Health layering of self-help groups: impacts on reproductive, maternal, newborn and child health and nutrition in Bihar, India

Preliminary impact of an mHealth education and social support intervention on maternal health knowledge and outcomes among postpartum mothers in Punjab, India

BACKGROUND

Significant disruptions in the perinatal continuum of care occur postpartum in India, despite it being a critical time to optimize maternal health and wellbeing. Group-oriented mHealth approaches may help mitigate the impact of limited access to care and the lack of social support that characterize this period. Our team developed and pilot tested a provider-moderated group intervention to increase education, communication with providers, to refer participants to in-person care, and to connect them with a virtual social support group of other mothers with similarly aged infants through weekly calls and text chat.

METHODS

We analyzed the preliminary effectiveness of the pilot intervention on maternal health knowledge through 6 months postpartum among 135 participants in Punjab, India who responded to baseline and endline surveys. We described change in knowledge of maternal danger signs, birth preparedness, postpartum care use, postpartum physical and mental health, and family planning use over time between individuals in group call (synchronous), other intervention (asynchronous), and control groups.

RESULTS

Participant knowledge regarding danger signs was low overall regarding pregnancy, childbirth and the postpartum period (mean range of 1.13 to 2.05 at baseline and 0.79 to 2.10 at endline). Synchronous participants had a significantly higher increase over time in knowledge of danger signs than asynchronous and control group participants. Birth preparedness knowledge ranged from mean 0.89-1.20 at baseline to 1.31-2.07 at follow-up, with synchronous participants having significantly greater increases in comparison to the control group. Synchronous participants had nearly three-fold increased odds of postpartum health check with a clinical provider than asynchronous participants (OR 2.88, 95% CI 1.07-7.74). No differences were noted in postpartum depressive and anxiety symptoms.

CONCLUSIONS

Preliminary effectiveness results are promising, yet further robust testing of the MeSSSSage intervention effectiveness is needed. Further development of strategies to support health knowledge and behaviors and overcoming barriers to postpartum care access can improve maternal health among this population.

Effectiveness of an Information, Motivation and Behavior skills intervention on knowledge, practices, skills, and health-seeking behaviors on reproductive tract infections among married women - A quasi-experimental study

BACKGROUND

Reproductive tract infections (RTIs) are a major health problem among women of the reproductive age group in India. Most of them are incompetent to handle their sexual and reproductive health needs. Enabling them with the knowledge and ability to recognize their own symptoms will prompt them to seek treatment and lessen the complications. This study determined the effectiveness of an Information, Motivation, and Behavior skills (IMB) program on the knowledge, practices, skills, and health-seeking behaviors of RTIs among women of reproductive age.

MATERIALS AND METHODS

A quasi-experimental design was used. Ninety-nine married women who had experienced any two symptoms of RTIs in the last 3 months preceding data collection were selected using a disproportionate random sampling technique. Knowledge, practices, skills, and health-seeking behaviors were assessed before and at the end of the third and sixth months following the administration of the IMB program in the intervention group. SPSS version 16 was used for data analysis, and the effectiveness was determined using repeated measures ANOVA.

RESULTS

Both the intervention and comparison groups were homogenous with regard to the socio-personal variables and baseline scores of the outcome variables. Significant improvement was observed in the knowledge (P < 0.001), practice (P = 0.002), and skill (P < 0.001) scores of the women in the intervention group and not in their health-seeking behavior scores (P = 0.830).

CONCLUSION

The IMB program is an effective strategy for improving the knowledge, practice, and skills of the women on RTIs and can be utilized by nursing officers.

Effectiveness of a technical support program with women's self-help groups in catalyzing health and nutrition behaviors in Bihar-a multicomponent analysis

Introduction

Bihar Rural Livelihoods Promotion Society launched the JEEViKA program in 2007 to improve livelihoods through the Self-Help Group (SHG) platform. Women's SHGs have shown members' health improvements by promoting awareness, practices and access to services. This study investigates whether Health & Nutrition (HN) interventions delivered by JEEViKA Technical Support Program (JTSP) via SHG platforms could improve maternal and newborn health and nutritional behaviors in rural Bihar.

Methods

Annual Household Survey and Married Women of Reproductive Age (MWRA) studies of Bihar Technical Support Unit were used to analyze the effectiveness of JTSP on HN behaviors for mother and their infants in Bihar during 2016-21. Descriptive analysis followed by multivariable (binary and multinomial) logistic regressions were conducted to determine the distribution of and associations between various individual/community and programmatic exposures and outcomes of interest.

Results

During 2016-2021, in Bihar, statewide increase (32 to 47%) in SHG membership across all population strata and expansion of HN layering of JTSP from 101 to 349 blocks corroborated with improvements in Maternal-Newborn-Child Health & Nutrition (MNCHN) indicators in JTSP blocks and SHG members. Substantial increase was observed in ≥3ANC visit (9% points), institutional delivery (10%), skin-to-skin-care (17%), dry cord-care (23%), early initiation of breastfeeding (19%) & complementary feeding (9%). Adjusting for socio-demographic factors and Front-Line Workers' (FLWs') advice/counseling, multivariable logistic regression revealed that SHG member in JTSP blocks delivering post-intervention (2021) were more likely (vs 2016) to practice: ≥3ANC visits (Adjusted Odds Ratio: aOR = 1.48, p < 0.0001), institutional delivery (aOR = 1.71, p < 0.0001), skin-to-skin care (aOR = 3.16, p < 0.0001) and dry cord-care (aOR = 2.64, p < 0.0001), early initiation of breastfeeding (aOR = 1.61, p < 0.0001), complementary feeding (aOR6-8 months = 1.48, p < 0.0001) and minimum dietary diversity (aOR6-8 months = 1.24). Better mobility, decision making, economic independence and overall empowerment were also evident among SHG member MWRA as opposed to non-members after both phases.

Discussion

The results highlight successful HN integration in JEEViKA by JTSP, demonstrating its effectiveness in integrating with State Rural Livelihoods Mission community platforms. JTSP showcases collaboration within a government system and emphasizes systematic introduction and strengthening at multiple levels. This integration has enabled JEEViKA systems to self-sustain its own HN implementation processes, paving the way for cross-sectoral comprehensive delivery mechanisms for social development.

Women improving nutrition through self-help groups in India: Does nutrition information help?

Women's self-help groups (SHGs) are an important platform for reaching poor women in India. Despite SHGs' women-focused programming, evidence of the impact of SHG-based interventions on nutrition outcomes is limited, and most evaluations of nutrition interventions have not examined intermediate outcomes along the impact pathways or outcomes for women themselves. This paper evaluates the effectiveness of an integrated agriculture-nutrition intervention delivered through women's SHGs in five states in central and eastern India. The interventions involved the delivery of nutrition behavior change communication to groups through participatory approaches, community engagement around key issues, and the strengthening of collective organizations. Our analysis is based on three rounds of rich panel data on close to 2700 rural women and their households from eight districts in these five states and qualitative work from an accompanying process evaluation. Using difference-in-difference models with nearest neighbor matching methods, we present results on women's anthropometry and diet-related outcomes. We do not observe any improvements in women's BMI or overall dietary diversity. Although more women in the nutrition intensification arm consumed animal source foods, nuts and seeds, and fruits, this was not enough to increase overall dietary diversity scores or the proportion of women achieving minimum dietary diversity. We measure intermediate outcomes along the program's impact pathways and find improvements in household incomes, cultivation of home gardens, and utilization of government schemes but not in women's empowerment. The lack of improvement in anthropometry and diets despite changes in some intermediate outcomes can be attributed to several factors such as low implementation intensity, poor facilitator capacity and incentives, the lack of relevance of the BCC topics to the average SHG member, and resource and agency constraints to adoption of recommended practices. Although we do not have data to test the parallel trends assumption and so do not interpret our results as causal, these findings do suggest that optimism about using group-based platforms needs to be tempered in resource-poor contexts.

Preliminary impact of an mHealth education and social support intervention on maternal health knowledge and outcomes among postpartum mothers in Punjab, India

Background

Significant disruptions in the perinatal continuum of care occur postpartum in India, despite it being a critical time to optimize maternal health and wellbeing. Group-oriented mHealth approaches may help mitigate the impact of limited access to care and the lack of social support that characterize this period. Our team developed and pilot tested a provider-moderated group intervention to increase education, communication with providers, to refer participants to in-person care, and to connect them with a virtual social support group of other mothers with similarly aged infants through weekly calls and text chat.

Methods

We analyzed the preliminary effectiveness of the pilot intervention on maternal health knowledge through 6 months postpartum among 135 participants in Punjab, India who responded to baseline and endline surveys. We described change in knowledge of maternal danger signs, birth preparedness, postpartum care use, postpartum physical and mental health, and family planning use over time between individuals in group call (synchronous), other intervention (asynchronous), and control groups.

Results

Participant knowledge regarding danger signs was low overall regarding pregnancy, childbirth and the postpartum period (mean range of 1.13 to 2.05 at baseline and 0.79 to 2.10 at endline). Group call participants had a significantly higher increase over time in knowledge of danger signs than other intervention and control group participants. Birth preparedness knowledge ranged from mean 0.89-1.20 at baseline to 1.31-2.07 at baseline, with group call participants having significantly greater increases in comparison to the control group. Group call participants had nearly three-fold increased odds of postpartum health check with a clinical provider than other intervention participants (OR 2.88, 95% CI 1.07-7.74). No differences were noted in postpartum depressive and anxiety symptoms.

Conclusions

Preliminary effectiveness results are promising, yet further robust testing of the MeSSSSage intervention effectiveness is needed. Further development of strategies to support health knowledge and behaviors and overcoming barriers to postpartum care access can improve maternal health among this population.

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.

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.

Adaptation of Water, Sanitation, and Hygiene Interventions: A Model and Scoping Review of Key Concepts and Tools

Background

Safe water, sanitation, and hygiene (WaSH) is important for health, livelihoods, and economic development, but WaSH programs have often underdelivered on expected health benefits. Underperformance has been attributed partly to poor ability to retain effectiveness following adaptation to facilitate WaSH programs' implementation in diverse contexts. Adaptation of WaSH interventions is common but often not done systematically, leading to poor outcomes. Models and frameworks from the adaptation literature have potential to improve WaSH adaptation to facilitate implementation and retain effectiveness. However, these models and frameworks were designed in a healthcare context, and WaSH interventions are typically implemented outside traditional health system channels. The purpose of our work was to develop an adaptation model tailored specifically to the context of WaSH interventions.

Methods

We conducted a scoping review to identify key adaptation steps and identify tools to support systematic adaptation. To identify relevant literature, we conducted a citation search based on three recently published reviews on adaptation. We also conducted a systematic database search for examples of WaSH adaptation. We developed a preliminary model based on steps commonly identified across models in adaptation literature, and then tailored the model to the WaSH context using studies yielded by our systematic search. We compiled a list of tools to support systematic data collection and decision-making throughout adaptation from all included studies.

Results and Conclusions

Our model presents adaptation steps in five phases: intervention selection, assessment, preparation, implementation, and sustainment. Phases for assessment through sustainment are depicted as iterative, reflecting that once an intervention is selected, adaptation is a continual process. Our model reflects the specific context of WaSH by including steps to engage non-health and lay implementers and to build consensus among diverse stakeholders with potentially competing priorities. We build on prior adaptation literature by compiling tools to support systematic data collection and decision-making, and we describe how they can be used throughout adaptation steps. Our model is intended to improve program outcomes by systematizing adaptation processes and provides an example of how systematic adaptation can occur for interventions with health goals but that are implemented outside conventional health system channels.

Matching Intent With Intensity: Implementation Research on the Intensity of Health and Nutrition Programs With Women's Self-Help Groups in India

Adding health interventions to women's groups primarily formed for financial purposes, such as self-help groups, is a widely used strategy to reach low-income women. An analysis of implementation intensity highlights the importance of ensuring that women's groups have sufficient time and population coverage to address health issues.

Introduction:

In India, a large network of self-help groups (SHGs) implements interventions to improve women's and children's health and nutrition. There is growing evidence on the effectiveness of women's group interventions to improve health but limited information on implementation intensity, including how often groups meet, for how long, and with whom, despite this often being cited as a key factor for success. We aimed to assess the implementation intensity of large SHG-based health and nutrition interventions with rural, low-income women, to inform program design, delivery, and measurement.

Methods:

We synthesized process data from surveys, meeting observations, and process evaluations across 8 maternal and child health and nutrition interventions in India. We examined the implementation intensity of 3 common intervention delivery channels: group meetings, home visits, and community-level activities.

Results:

SHG members spent approximately 30 minutes in monthly meetings discussing health or nutrition. SHG dissolution or limited participation in meetings was a common challenge. Beyond group meetings, home visits reached approximately 1 in 3 households with an SHG member. Pregnant and breastfeeding women's participation in community events varied across interventions.

Discussion:

Interventions that aim to capitalize on existing networks of financial women's groups not specifically formed for health and nutrition objectives, such as SHGs, will need to have an implementation intensity that matches the ambition of their health objectives: substantial changes in behavioral or mortality outcomes are unlikely to be achieved with relatively light intensity. Interventions that require sustained interactions with members to achieve health outcomes need to ensure adequate community and individual outreach to supplement group meetings, as well as improved participation through more intensive community mobilization approaches. Evaluations of group-based interventions should report on implementation intensity to support the interpretation of evaluation evidence and to inform further scale-up.