Impact of the Ananya program on reproductive, maternal, newborn and child health and nutrition in Bihar, India: early results from a quasi-experimental study

Strengthening theories of change in women's group interventions to improve learning

Background

Supporting women's groups is increasingly seen as an important intervention strategy for advancing women's empowerment, economic outcomes, and family health in low- and middle-income countries. We argue that learning from investments in women's group platforms is often limited by the lack of a well-articulated, evaluable theory of change (ToC) developed by those designing the programmes.

Methods

We first identify a simple set of steps important to specifying a ToC that is evaluable and supports learning (what could be done). We then propose a framework in which we hope social scientists can find a common starting point (reconciling what could be and is being done). The framework emphasises identifying untested assumptions around pathways for introducing and adopting new knowledge, opportunities, technologies, interventions or implementation approaches, and pathways from group participation to behaviour change. Finally, we apply this framework to a portfolio of 46 women's groups investments made by the Bill and Melinda Gates Foundation between 2005 and 2017 to understand the prevalence and clarity of their grantees' theories of change (some of what is done).

Results

The majority of the investment documents reviewed did not make clear the embedded assumptions or hypothesised pathways from decisions to join a group, to women's group participation, to behaviour change and and whether pathways are connected or work independently.

Conclusions

We use an example from an actual investment to illustrate how this framework can support accounting for assumptions in the ToC used to guide the evaluation, the testing and measuring of mechanisms assumed to be driving behaviour change and disentangling the effects of implementationfrom context. A ToC for group-based programmes should specify in what capacities the group-based model is essential to the hypothesised pathways of impact vs. its role as an efficient delivery mechanism for programmes that would potentially generate impacts even if delivered directly to individuals. In addition, without fully specifying the motivation for individuals to change behaviour in terms of their risk/return calculus and testing underlying assumptions, we miss an opportunity to better understand the pathways for how the programme influences or fails to influence individuals' health behaviours. However, fully specifying (and measuring) every link in the programme's ToC is not costless. We present suggestions for developing ToCs with testable hypotheses that foster learning about why a women's group intervention achieved or failed to achieve its intended impact.

Association of BCC Module Roll-Out in SHG meetings with changes in complementary feeding and dietary diversity among children (6-23 months)? Evidence from JEEViKA in Rural Bihar, India

OBJECTIVES

Child dietary diversity is very low across rural communities in Bihar. Based on the experience of behavior change communication (BCC) module roll out in self-help group (SHG) sessions in rural Bihar, this study aims to assess the impact of the intervention on child dietary diversity levels in the beneficiary groups.

METHODS

The study is based on a pre-post study design whereby child dietary diversity is examined for a sample of 300 children (6-23 months old from 60 village organizations) during both pre-intervention as well as post-intervention phase. The latter consists of two types of group viz. a) children whose mothers were directly exposed to BCC module in SHGs sessions and b) those who were non-participants but may have indirect exposure through spillovers of BCC activities. Econometric analysis including logistic regression as well as propensity score matching techniques are applied for estimating the changes in dietary diversity in the post-intervention phase.

RESULTS

During the pre-intervention phase, 19% of the children (6-23 months) had adequate dietary diversity (eating from at least 4 out of 7 different food groups) and this increased to 49% among the exposed group and to 28% among the non-exposed group in the post-intervention phase. The exposed group have an odds ratio of 3.81 (95% CI: 2.03, 7.15) for consuming diverse diet when compared to the pre-intervention group. The propensity score matching analysis finds a 33% average treatment effect on the treated (ATT) for the group participating in BCC sessions at SHG events.

CONCLUSION

BCC roll out among SHG members is an effective mode to increase dietary diversity among infants and young children. The impact on child dietary diversity was significantly higher among mothers directly exposed to BCC modules. The BCC module also improved knowledge and awareness levels on complementary feeding and child dietary diversity.

Improving the precision of maternal, newborn, and child health impact through geospatial analysis of the association of contextual and programmatic factors with health trends in Bihar, India

Background

There is a scarcity of research that comprehensively examines programme impact from a context-specific perspective. We aimed to determine the conditions under which the Bihar Technical Support Programme led to more favourable outcomes for maternal and child health in Bihar.

Methods

We obtained block-level data on maternal and child health indicators during the state-wide scale-up of the pilot Ananya programme and data on health facility readiness, along with geographical and sociodemographic variables. We examined the associations of these factors with increases in the levels of indicators using multilevel logistic regression, and the associations with rates of change in the indicators using Bayesian Hierarchical modelling.

Results

Frontline worker (FLW) visits between 2014-2017 were more likely to increase in blocks with better night lighting (odds ratio (OR) = 1.23, 95% confidence interval (CI) = 1.01-1.51). Birth preparedness increased in blocks with increasing FLW visits (OR = 3.43, 95% CI = 1.15-10.21), while dry cord care practice increased in blocks where satisfaction with FLW visits was increasing (OR = 1.52, 95% CI = 1.10-2.11). Age-appropriate frequency of complementary feeding increased in blocks with higher development index (OR = 1.55, 95% CI = 1.16-2.06) and a higher percentage of scheduled caste or tribe (OR = 3.21, 95% CI = 1.13-9.09). An increase in most outcomes was more likely in areas with lower baseline levels.

Conclusions

Contextual factors (eg, night lighting and development) not targeted by the programme and FLW visits were associated with favourable programme outcomes. Intervention design, including intervention selection for a particular geography, should be modified to fit the local context in the short term. Expanding collaborations beyond the health sector to influence modifiable contextual factors in the long term can result in a higher magnitude and more sustainable impact.

Registration

ClinicalTrials.gov: NCT02726230.