Boosting efficiency above 28% using effective charge transport layer with Sr3SbI3 based novel inorganic perovskite

Strontium antimony iodide (Sr3SbI3) is one of the emerging absorbers materials owing to its intriguing structural, electronic, and optical properties for efficient and cost-effective solar cell applications. A comprehensive investigation on the structural, optical, and electronic characterization of Sr3SbI3 and its subsequent applications in heterostructure solar cells have been studied theoretically. Initially, the optoelectronic parameters of the novel Sr3SbI3 absorber, and the possible electron transport layer (ETL) of tin sulfide (SnS2), zinc sulfide (ZnS), and indium sulfide (In2S3) including various interface layers were obtained by DFT study. Afterward, the photovoltaic (PV) performance of Sr3SbI3 absorber-based cell structures with SnS2, ZnS, and In2S3 as ETLs were systematically investigated at varying layer thickness, defect density bulk, doping density, interface density of active materials including working temperature, and thereby, optimized PV parameters were achieved using SCAPS-1D simulator. Additionally, the quantum efficiency (QE), current density-voltage (J-V), and generation and recombination rates of photocarriers were determined. The maximum power conversion efficiency (PCE) of 28.05% with JSC of 34.67 mA cm-2, FF of 87.31%, VOC of 0.93 V for SnS2 ETL was obtained with Al/FTO/SnS2/Sr3SbI3/Ni structure, while the PCE of 24.33%, and 18.40% in ZnS and In2S3 ETLs heterostructures, respectively. The findings of this study contribute to in-depth understanding of the physical, electronic, and optical properties of Sr3SbI3 absorber perovskite and SnS2, ZnS, and In2S3 ETLs. Additionally, it provides valuable insights into the potential of Sr3SbI3 in heterostructure perovskite solar cells (PSCs), paving the pathway for further experimental design of an efficient and stable PSC devices.

High efficiency Cu2MnSnS4 thin film solar cells with SnS BSF and CdS ETL layers: A numerical simulation

The quaternary compound copper manganese tin sulfide Cu₂MnSnS₄ is a potential absorber semiconductor material for fabricating thin film solar cells (TFSC) thanks to their promising optoelectronic parameters. This article numerically investigated the performance of Cu₂MnSnS₄ (CMTS)-based TFSC without and with tin sulphide (SnS) back surface field (BSF) thin-film layer. First, the impact of several major influential parameters such as the active material's thickness, doping concentration of photoactive materials, density of bulk and interface defect, working temperature, and metal contact, were studied systematically without a BSF layer. Thereafter, the photovoltaic performance of the optimized pristine cell was further investigated with an SnS as BSF inserted between the absorber (CMTS) with a Platinum back metal of an optimized heterostructure of Cu/ZnO:Al/i-ZnO/n-CdS/p-Cu₂MnSnS₄/Pt. Thus, the photoconversion efficiency (PCE) of 25.43% with a J _SC of 34.41nullmA/cm² and V _OC of 0.883 V was achieved under AM1.5G solar spectrum without SnS BSF layer. Furthermore, an improved PCE of 31.4% with a J _SC of 36.21nullmA/cm² and V _OC of 1.07 V was achieved with a quantum efficiency of over 85% in the wavelengths of 450-1000 nm by the addition of SnS BSF layer. Thus, this obtained systematic and consistent outcomes reveal immense potential of CMTS with SnS as absorber and BSF, respectively and provide imperious guidance for fabricating highly a massive potential efficient solar cell.

Stakeholder perceptions on scaling-up community-led interventions for prevention and control of non-communicable diseases in Bangladesh: a qualitative study

BACKGROUND

Engaging communities is an important component of multisectoral action to address the growing burden of non-communicable diseases (NCDs) in low- and middle-income countries. We conducted research with non-communicable disease stakeholders in Bangladesh to understand how a community-led intervention which was shown to reduce the incidence of type 2 diabetes in rural Bangladesh could be scaled-up.

METHODS

We purposively sampled any actor who could have an interest in the intervention, or that could affect or be affected by the intervention. We interviewed central level stakeholders from donor agencies, national health policy levels, public, non-governmental, and research sectors to identify scale-up mechanisms. We interviewed community health workers, policy makers, and non-governmental stakeholders, to explore the feasibility and acceptability of implementing the suggested mechanisms. We discussed scale-up options in focus groups with community members who had attended a community-led intervention. We iteratively developed our data collection tools based on our analysis and re-interviewed some participants. We analysed the data deductively using a stakeholder analysis framework, and inductively from codes identified in the data.

RESULTS

Despite interest in addressing NCDs, there was a lack of a clear community engagement strategy at the government level, and most interventions have been implemented by non-governmental organisations. Many felt the Ministry of Health and Family Welfare should lead on community engagement, and NCD screening and referral has been added to the responsibilities of community health workers and health volunteers. Yet there remains a focus on reproductive health and NCD diagnosis and referral instead of prevention at the community level. There is potential to engage health volunteers in community-led interventions, but their present focus on engaging women for reproductive health does not fit with community needs for NCD prevention.

CONCLUSIONS

Research highlighted the need for a preventative community engagement strategy to address NCDs, and the potential to utilise existing cadres to scale-up community-led interventions. It will be important to work with key stakeholders to address gender issues and ensure flexibility and responsiveness to community concerns. We indicate areas for further implementation research to develop scaled-up models of community-led interventions to address NCDs.

Community participatory learning and action cycle groups to reduce type 2 diabetes in Bangladesh (D:Clare): an updated study protocol for a parallel arm cluster randomised controlled trial

The "Diabetes: Community-led Awareness, Response and Evaluation" (D:Clare) trial aims to scale up and replicate an evidence-based participatory learning and action cycle intervention in Bangladesh, to inform policy on population-level T2DM prevention and control.The trial was originally designed as a stepped-wedge cluster randomised controlled trial, with the interventions running from March 2020 to September 2022. Twelve clusters were randomly allocated (1:1) to implement the intervention at months 1 or 12 in two steps, and evaluated through three cross-sectional surveys at months 1, 12 and 24. However, due to the COVID-19 pandemic, we suspended project activities on the 20th of March 2020. As a result of the changed risk landscape and the delays introduced by the COVID-19 pandemic, we changed from the stepped-wedge design to a wait-list parallel arm cluster RCT (cRCT) with baseline data. We had four key reasons for eventually agreeing to change designs: equipoise, temporal bias in exposure and outcomes, loss of power and time and funding considerations.Trial registration ISRCTN42219712 . Registered on 31 October 2019.

Intermediate hyperglycaemia, diabetes and blood pressure in rural Bangladesh: five-year post-randomisation follow-up of the DMagic cluster-randomised controlled trial

Background

The DMagic trial showed that participatory learning and action (PLA) community mobilisation delivered through facilitated community groups, and mHealth voice messaging interventions improved diabetes knowledge in Bangladesh and the PLA intervention reduced diabetes occurrence. We assess intervention effects three years after intervention activities stopped.

Methods

Five years post-randomisation, we conducted a cross-sectional survey among a random sample of adults aged ≥30-years living in the 96 DMagic villages, and a cohort of individuals identified with intermediate hyperglycaemia at the start of the DMagic trial in 2016. Primary outcomes were: 1) the combined prevalence of intermediate hyperglycaemia and diabetes; 2) five-year cumulative incidence of diabetes among the 2016 cohort of individuals with intermediate hyperglycaemia. Secondary outcomes were: weight, BMI, waist and hip circumferences, blood pressure, knowledge and behaviours. Primary analysis compared outcomes at the cluster level between intervention arms relative to control.

Findings

Data were gathered from 1623 (82%) of the randomly selected adults and 1817 (87%) of the intermediate hyperglycaemia cohort. 2018 improvements in diabetes knowledge in mHealth clusters were no longer observable in 2021. Knowledge remains significantly higher in PLA clusters relative to control but no difference in primary outcomes of intermediate hyperglycaemia and diabetes prevalence (OR (95%CI) 1.23 (0.89, 1.70)) or five-year incidence of diabetes were observed (1.04 (0.78, 1.40)). Hypertension (0.73 (0.54, 0.97)) and hypertension control (2.77 (1.34, 5.75)) were improved in PLA clusters relative to control.

Interpretation

PLA intervention effect on intermediate hyperglycaemia and diabetes was not sustained at 3 years after intervention end, but benefits in terms of blood pressure reduction were observed.

Funding

Medical Research Council UK: MR/M016501/1 (DMagic trial); MR/T023562/1 (DClare study), under the Global Alliance for Chronic Diseases (GACD) Diabetes and Scale-up Programmes, respectively.

An extensive study on multiple ETL and HTL layers to design and simulation of high-performance lead-free CsSnCl3-based perovskite solar cells

Cesium tin chloride (CsSnCl₃) is a potential and competitive absorber material for lead-free perovskite solar cells (PSCs). The full potential of CsSnCl₃ not yet been realized owing to the possible challenges of defect-free device fabrication, non-optimized alignment of the electron transport layer (ETL), hole transport layer (HTL), and the favorable device configuration. In this work, we proposed several CsSnCl₃-based solar cell (SC) configurations using one dimensional solar cell capacitance simulator (SCAPS-1D) with different competent ETLs like indium-gallium-zinc-oxide (IGZO), tin-dioxide (SnO₂), tungsten disulfide (WS₂), ceric dioxide (CeO₂), titanium dioxide (TiO₂), zinc oxide (ZnO), C₆₀, PCBM, and HTLs of cuprous oxide (Cu₂O), cupric oxide (CuO), nickel oxide (NiO), vanadium oxide (V₂O₅), copper iodide (CuI), CuSCN, CuSbS₂, Spiro MeOTAD, CBTS, CFTS, P3HT, PEDOT:PSS. Simulation results revealed that ZnO, TiO₂, IGZO, WS₂, PCBM, and C₆₀ ETLs-based halide perovskites with ITO/ETLs/CsSnCl₃/CBTS/Au heterostructure exhibited outstanding photoconversion efficiency retaining nearest photovoltaic parameters values among 96 different configurations. Further, for the six best-performing configurations, the effect of the CsSnCl₃ absorber and ETL thickness, series and shunt resistance, working temperature, impact of capacitance, Mott-Schottky, generation and recombination rate, current-voltage properties, and quantum efficiency on performance were assessed. We found that ETLs like TiO₂, ZnO, and IGZO, with CBTS HTL can act as outstanding materials for the fabrication of CsSnCl₃-based high efficiency (η ≥ 22%) heterojunction SCs with ITO/ETL/CsSnCl₃/CBTS/Au structure. The simulation results obtained by the SCAPS-1D for the best six CsSnCl₃-perovskites SC configurations were compared by the wxAMPS (widget provided analysis of microelectronic and photonic structures) tool for further validation. Furthermore, the structural, optical and electronic properties along with electron charge density, and Fermi surface of the CsSnCl₃ perovskite absorber layer were computed and analyzed using first-principle calculations based on density functional theory. Thus, this in-depth simulation paves a constructive research avenue to fabricate cost-effective, high-efficiency, and lead-free CsSnCl₃ perovskite-based high-performance SCs for a lead-free green and pollution-free environment.

Equity impact of participatory learning and action community mobilisation and mHealth interventions to prevent and control type 2 diabetes and intermediate hyperglycaemia in rural Bangladesh: analysis of a cluster randomised controlled trial

Background

A cluster randomised trial of mHealth and participatory learning and action (PLA) community mobilisation interventions showed that PLA significantly reduced the prevalence of intermediate hyperglycaemia and type 2 diabetes mellitus (T2DM) and the incidence of T2DM among adults in rural Bangladesh; mHealth improved knowledge but showed no effect on glycaemic outcomes. We explore the equity of intervention reach and impact.

Methods

Intervention reach and primary outcomes of intermediate hyperglycaemia and T2DM were assessed through interview surveys and blood fasting glucose and 2-hour oral glucose tolerance tests among population-based samples of adults aged ≥30 years. Age-stratified, gender-stratified and wealth-stratified intervention effects were estimated using random effects logistic regression.

Results

PLA participants were similar to non-participants, though female participants were younger and more likely to be married than female non-participants. Differences including age, education, wealth and marital status were observed between individuals exposed and those not exposed to the mHealth intervention.

PLA reduced the prevalence of T2DM and intermediate hyperglycaemia in all age, gender and wealth strata. Reductions in 2-year incidence of T2DM of at least 51% (0.49, 95% CI 0.26 to 0.92) were observed in all strata except among the oldest and least poor groups. mHealth impact on glycaemic outcomes was observed only among the youngest group, where a 47% reduction in the 2-year incidence of T2DM was observed (0.53, 95% CI 0.28 to 1.00).

Conclusion

Large impacts of PLA across all strata indicate a highly effective and equitable intervention. mHealth may be more suitable for targeting higher risk, younger populations.

Trial registration number

ISRCTN41083256.

Changes in non-communicable diseases, diet and exercise in a rural Bangladesh setting before and after the first wave of COVID-19

Prevalence of non-communicable diseases (NCDs) is high in rural Bangladesh. Given the complex multi-directional relationships between NCDs, COVID-19 infections and control measures, exploring pandemic impacts in this context is important. We conducted two cross-sectional surveys of adults ≥30-years in rural Faridpur district, Bangladesh, in February to March 2020 (survey 1, pre-COVID-19), and January to March 2021 (survey 2, post-lockdown). A new random sample of participants was taken at each survey. Anthropometric measures included: blood pressure, weight, height, hip and waist circumference and fasting and 2-hour post-glucose load blood glucose. An interviewer-administered questionnaire included: socio-demographics; lifestyle and behavioural risk factors; care seeking; self-rated health, depression and anxiety assessments. Differences in NCDs, diet and exercise were compared between surveys using chi2 tests, logistic and linear regression; sub-group analyses by gender, age and socio-economic tertiles were conducted. We recruited 950 (72.0%) participants in survey 1 and 1392 (87.9%) in survey 2. The percentage of the population with hypertension increased significantly from 34.5% (95% CI: 30.7, 38.5) to 41.5% (95% CI: 38.2, 45.0; p-value = 0.011); the increase was more pronounced in men. Across all measures of self-reported health and mental health, there was a significant improvement between survey 1 and 2. For self-rated health, we observed a 10-point increase (71.3 vs 81.2, p-value = 0.005). Depression reduced from 15.3% (95% CI: 8.4, 26.1) to 6.0% (95% CI: 2.7, 12.6; p-value = 0.044) and generalised anxiety from 17.9% (95% CI: 11.3, 27.3) to 4.0% (95% CI: 2.0, 7.6; p-value<0.001). No changes in fasting blood glucose, diabetes status, BMI or abdominal obesity were observed. Our findings suggest both positive and negative health outcomes following COVID-19 lockdown in a rural Bangladeshi setting, with a concerning increase in hypertension. These findings need to be further contextualised, with prospective assessments of indirect effects on physical and mental health and care-seeking.

Mist chemical vapor deposition of crystalline MoS2atomic layer films using sequential mist supply mode and its application in field-effect transistors

Molybdenum disulfide (MoS₂) mono/bilayer have been systematically investigated using atmospheric-pressure mist chemical vapor deposition (mist CVD) from (NH₄)₂MoS₄dissolved in N-methyl-2-pyrrolidone as a precursor. Film deposition was performed by alternating MoS₂mist storage within a closed chamber and mist exhaust, i.e. sequential mist supply mode at different furnace temperatures, storage times of precursor, and repetition cycles of mist supply on thermally grown SiO₂(th-SiO₂) and mist-CVD grown Al_1-xTi_xO_y(ATO) layers coated on p⁺-Si substrates. The average size of the MoS₂flake and their number of stack layers could be controlled by tuning the deposition parameters combined with substrate pretreatment. Field-effect transistors with MoS₂atomic mono/bilayer as a channel layer exhibited mobility up to 31-40 (43-55) cm²V^-1s^-1with a threshold voltage of -1.6 (-0.5) V, subthreshold slope of 0.8 (0.11) V dec.^-1, and on/off ratio of 3.2 × 10⁴(3.6 × 10⁵) onth-SiO₂(ATO) layers as gate dielectric layers without mechanical exfoliation. These findings imply that mist CVD is available for the synthesis of metal transition metal dichalcogenide and metal oxide layers as channel and gate dielectric layers, respectively.

Care-seeking and managing diabetes in rural Bangladesh: a mixed methods study

Background

Type 2 diabetes mellitus poses a major health challenge worldwide and in low-income countries such as Bangladesh, however little is known about the care-seeking of people with diabetes. We sought to understand the factors that affect care-seeking and diabetes management in rural Bangladesh in order to make recommendations as to how care could be better delivered.

Methods

Survey data from a community-based random sample of 12,047 adults aged 30 years and above identified 292 individuals with a self-reported prior diagnosis of diabetes. Data on health seeking practices regarding testing, medical advice, medication and use of non-allopathic medicine were gathered from these 292 individuals. Qualitative semi-structured interviews and focus group discussions with people with diabetes and semi-structured interviews with health workers explored care-seeking behaviour, management of diabetes and perceptions on quality of care. We explore quality of care using the WHO model with the following domains: safe, effective, patient-centred, timely, equitable and efficient.

Results

People with diabetes who are aware of their diabetic status do seek care but access, particularly to specialist diabetes services, is hindered by costs, time, crowded conditions and distance. Locally available services, while more accessible, lack infrastructure and expertise. Women are less likely to be diagnosed with diabetes and attend specialist services. Furthermore costs of care and dissatisfaction with health care providers affect medication adherence.

Conclusion

People with diabetes often make a trade-off between seeking locally available accessible care and specialised care which is more difficult to access. It is vital that health services respond to the needs of patients by building the capacity of local health providers and consider practical ways of supporting diabetes care.

Trial registration

ISRCTN41083256. Registered on 30/03/2016.

Learning from a diabetes mHealth intervention in rural Bangladesh: what worked, what did not and what next?

There is an urgent need for population-based interventions to slow the growth of the diabetes epidemic in low-and middle-income countries. We tested the effectiveness of a population-based mHealth voice messaging intervention for T2DM prevention and control in rural Bangladesh through a cluster randomised controlled trial. mHealth improved knowledge and awareness about T2DM but there was no detectable effect on T2DM occurrence. We conducted mixed-methods research to understand this result. Exposure to messages was limited by technological faults, high frequency of mobile phone number changes, message fatigue and (mis)perceptions that messages were only for those who had T2DM. Persistent social norms, habits and desires made behaviour change challenging, and participants felt they would be more motivated by group discussions than mHealth messaging alone. Engagement with mHealth messages for T2DM prevention and control can be increased by (1) sending identifiable messages from a trusted source (2) using participatory design of mHealth messages to inform modelling of behaviours and increase relevance to the general population (3) enabling interactive messaging. mHealth messaging is likely to be most successful if implemented as part of a multi-sectoral, multi-component approach to address T2DM and non-communicable disease risk factors.

Community participatory learning and action cycle groups to reduce type 2 diabetes in Bangladesh (D:Clare trial): study protocol for a stepped-wedge cluster randomised controlled trial

BACKGROUND

An estimated 463 million people globally have diabetes, with the prevalence growing in low-and middle-income settings, such as Bangladesh. Given the need for context-appropriate interventions to prevent type 2 diabetes mellitus (T2DM), the 'Diabetes: Community-led Awareness, Response and Evaluation' (D:Clare) trial will rigorously evaluate the replication and scale-up of a participatory learning and action (PLA) cycle intervention in Bangladesh, to inform policy on population-level T2DM prevention and control.

METHODS

This is a stepped-wedge cluster randomised controlled trial, with integrated process and economic evaluations, conducted from March 2020 to September 2022. The trial will evaluate a community-based four-phase PLA cycle intervention focused on prevention and control of T2DM implemented over 18 months, against a control of usual care. Twelve clusters will be randomly allocated (1:1) to implement the intervention at project month 1 or 12. The intervention will be evaluated through three cross-sectional surveys at months 1, 12 and 24. The trial will be conducted in Alfadanga Upazila, Faridpur district, with an estimated population of 120,000. Clusters are defined as administrative geographical areas, with approximately equal populations. Each of the six unions in Alfadanga will be divided into two clusters, forming 12 clusters in total. Given the risk of inter-cluster contamination, evaluation surveys will exclude villages in border areas. Participants will be randomly sampled, independently for each survey, from a population census conducted in January 2020. The primary outcome is the combined prevalence of intermediate hyperglycaemia and T2DM, measured through fasting and 2-h post-glucose load blood tests. A total of 4680 participants provide 84% power to detect a 30% reduction in the primary outcome, assuming a baseline of 30% and an ICC of 0.07. The analysis will be by intention-to-treat, comparing intervention and control periods across all clusters, adjusting for geographical clustering.

DISCUSSION

This study will provide further evidence of effectiveness for community-based PLA to prevent T2DM at scale in a rural Bangladesh setting. However, we encountered several challenges in applying the stepped-wedge design to our research context, with particular consideration given to balancing seasonality, timing and number of steps and estimation of partial versus full effect.

TRIAL REGISTRATION

ISRCTN: ISRCTN42219712 . Registered on 31 October 2019.

Participatory learning and action to address type 2 diabetes in rural Bangladesh: a qualitative process evaluation

BACKGROUND

Diabetes is 7th largest cause of death worldwide, and prevalence is increasing rapidly in low-and middle-income countries. There is an urgent need to develop and test interventions to prevent and control diabetes and develop the theory about how such interventions can be effective. We conducted a participatory learning and action (PLA) intervention with community groups in rural Bangladesh which was evaluated through a cluster randomised controlled trial. There was a large reduction in the combined prevalence of type 2 diabetes and intermediate hyperglycaemia in the PLA group compared with the control group. We present findings from qualitative process evaluation research to explore how this intervention was effective.

METHODS

We conducted group interviews and focus group discussions using photovoice with purposively sampled group attenders and non-attenders, and intervention implementers. Data were collected before the trial analysis. We used inductive content analysis to generate theory from the data.

RESULTS

The intervention increased the health literacy of individuals and communities - developing their knowledge, capacity and self-confidence to enact healthy behaviours. Community, household and individual capacity increased through social support and social networks, which then created an enabling community context, further strengthening agency and enabling community action. This increased opportunities for healthy behaviour. Community actions addressed lack of awareness about diabetes, gendered barriers to physical activity and lack of access to blood glucose testing. The interaction between the individual, household, and community contexts amplified change, and yet there was limited engagement with macro level, or 'state', barriers to healthy behaviour.

CONCLUSIONS

The participatory approach enabled groups to analyse how context affected their ability to have healthy behaviours and participants engaged with issues as a community in the ways that they felt comfortable. We suggest measuring health literacy and social networks in future interventions and recommend specific capacity strengthening to develop public accountability mechanisms and health systems strengthening to complement community-based interventions.

TRIAL REGISTRATION

Registered at ISRCTN on 30th March 2016 (Retrospectively Registered) Registration number: ISRCTN41083256 .

Developing a theory-driven contextually relevant mHealth intervention

Background: mHealth interventions have huge potential to reach large numbers of people in resource poor settings but have been criticised for lacking theory-driven design and rigorous evaluation. This paper shares the process we developed when developing an awareness raising and behaviour change focused mHealth intervention, through applying behavioural theory to in-depth qualitative research. It addresses an important gap in research regarding the use of theory and formative research to develop an mHealth intervention.

Objectives: To develop a theory-driven contextually relevant mHealth intervention aimed at preventing and managing diabetes among the general population in rural Bangladesh.

Methods: In-depth formative qualitative research (interviews and focus group discussions) were conducted in rural Faridpur. The data were analysed thematically and enablers and barriers to behaviour change related to lifestyle and the prevention of and management of diabetes were identified. In addition to the COM-B (Capability, Opportunity, Motivation-Behaviour) model of behaviour change we selected the Transtheoretical Domains Framework (TDF) to be applied to the formative research in order to guide the development of the intervention.

Results: A six step-process was developed to outline the content of voice messages drawing on in-depth qualitative research and COM-B and TDF models. A table to inform voice messages was developed and acted as a guide to scriptwriters in the production of the messages.

Conclusions: In order to respond to the local needs of a community in Bangladesh, a process of formative research, drawing on behavioural theory helped in the development of awareness-raising and behaviour change mHealth messages through helping us to conceptualise and understand behaviour (for example by categorising behaviour into specific domains) and subsequently identify specific behavioural strategies to target the behaviour.

Gendered perceptions of physical activity and diabetes in rural Bangladesh: a qualitative study to inform mHealth and community mobilization interventions

Background Diabetes prevalence is increasing rapidly in Bangladesh, and there is an urgent need to promote preventive behaviours for type 2 diabetes, such as maintaining a healthy body weight, eating healthily, avoiding tobacco and being active for 150 minutes per week. Methods We used a qualitative methodology informed by the capability, opportunity, motivation theory of behaviour change to explore the factors affecting physical activity among men and women in rural Bangladesh. We conducted semi-structured interviews and focus group discussions with 64 purposively sampled participants with and without diabetes, and five health workers. From the results of descriptive content analysis, we identified key capabilities, opportunities and motivations to engage with in our mHealth and community mobilization interventions. Results Men and women without diabetes lacked awareness about the need to remain physically active to prevent diabetes, and most felt that their activity levels were sufficient. Housework was not commonly perceived as physical activity among all respondents. These knowledge and capability gaps could be addressed through mHealth messaging and community mobilization providing information on sufficiency and types of physical activity to prevent and control diabetes. Men were physically active while working outside the home, whereas women felt unsafe and conspicuous, and were constrained by family commitments and social expectations of appropriate behaviour. Women engaged in strategies to protect their own and their family’s reputations. These opportunity factors affecting physical activity indicated the need for strategies developed through participatory processes to challenge unhealthy gender norms and increase women’s safety. Conclusion Formative research data can enable the development of contextually relevant interventions. Data show that mHealth interventions should consider gendered barriers to physical activity, tailoring information to meet men’s and women’s needs, and that community mobilization interventions should enable unhealthy, gendered community norms to be challenged. Participatory interventions can enable communities to push the boundaries of socially acceptable behaviours to increase physical activity, helping to prevent and control diabetes.

Implementation and fidelity of a participatory learning and action cycle intervention to prevent and control type 2 diabetes in rural Bangladesh

Introduction

There is an urgent need to address the growing type 2 diabetes disease burden. 20–30% of adults in rural areas of Bangladesh have intermediate hyperglycaemia and about 10% have diabetes. We report on the implementation and fidelity of a Participatory Learning and Action (PLA) intervention, evaluated through a three-arm cluster randomised controlled trial which reduced the incidence of diabetes and intermediate hyperglycaemia in rural Bangladesh. PLA interventions have been effective in addressing population level health problems in low income country contexts, and therefore we sought to use this approach to engage communities to identify and address community barriers to prevention and control of type 2 diabetes.

Methods

We used a mixed methods approach collecting quantitative data through field reports and qualitative data through observations and focus group discussions. Through descriptive analysis, we considered fidelity to the participatory approach and implementation plans.

Results

One hundred twenty-two groups per month were convened by 16 facilitators and supervised by two coordinators. Groups worked through a four phase PLA cycle of problem identification, planning together, implementation and evaluation to address the risk factors for diabetes – diet, physical activity, smoking and stress. Groups reported a lack of awareness about diabetes prevention and control, the prohibitive cost of care and healthy eating, and gender barriers to exercise for women. Groups set targets to encourage physical activity, kitchen-gardening, cooking with less oil, and reduced tobacco consumption. Anti-tobacco committees operated in 90 groups. One hundred twenty-two groups arranged blood glucose testing and 74 groups organized testing twice. Forty-one women’s groups established funds, and 61 communities committed not to ridicule women exercising. Experienced and committed supervisors enabled fidelity to a participatory methodology. A longer intervention period and capacity building could enable engagement with systems barriers to behaviour change.

Conclusion

Our complex intervention was implemented as planned and is likely to be valid in similar contexts given the flexibility of the participatory approach to contextually specific barriers to prevention and control of type 2 diabetes. Fidelity to the participatory approach is key to implementing the intervention and effectively addressing type 2 diabetes in a low-income country.

Exploring the equity impact of a maternal and newborn health intervention: a qualitative study of participatory women's groups in rural South Asia and Africa

BACKGROUND

A consensus is developing on interventions to improve newborn survival, but little is known about how to reduce socioeconomic inequalities in newborn mortality in low- and middle-income countries. Participatory learning and action (PLA) through women's groups can improve newborn survival and home care practices equitably across socioeconomic strata, as shown in cluster randomised controlled trials. We conducted a qualitative study to understand the mechanisms that led to the equitable impact of the PLA approach across socioeconomic strata in four trial sites in India, Nepal, Bangladesh, and Malawi.

METHODS

We conducted 42 focus group discussions (FGDs) with women who had attended groups and women who had not attended, in poor and better-off communities. We also interviewed six better-off women and nine poor women who had delivered babies during the trials and had demonstrated recommended behaviours. We conducted 12 key informant interviews and five FGDs with women's group facilitators and fieldworkers.

RESULTS

Women's groups addressed a knowledge deficit in poor and better-off women. Women were engaged through visual learning and participatory tools, and learned from the facilitator and each other. Facilitators enabled inclusion of all socioeconomic strata, ensuring that strategies were low-cost and that discussions and advice were relevant. Groups provided a social support network that addressed some financial barriers to care and gave women the confidence to promote behaviour change. Information was disseminated through home visits and other strategies. The social process of learning and action, which led to increased knowledge, confidence to act, and acceptability of recommended practices, was key to ensuring behaviour change across social strata. These equitable effects were enabled by the accessibility, relevance, and engaging format of the intervention.

CONCLUSIONS

Participatory learning and action led to increased knowledge, confidence to act, and acceptability of recommended practices. The equitable behavioural effects were facilitated by the accessibility, relevance, and engaging format of the intervention across socioeconomic groups, and by reaching-out to parts of the population usually not accessed. A PLA approach improved health behaviours across socioeconomic strata in rural communities, around issues for which there was a knowledge deficit and where simple changes could be made at home.

Community groups or mobile phone messaging to prevent and control type 2 diabetes and intermediate hyperglycaemia in Bangladesh (DMagic): a cluster-randomised controlled trial

BACKGROUND

Strategies are needed to prevent and control type 2 diabetes and intermediate hyperglycaemia, which together affect roughly a third of adults in Bangladesh. We aimed to assess the effects of mHealth and community mobilisation on the prevalence of intermediate hyperglycaemia and diabetes among the general adult population in rural Bangladesh, and to assess the effect of these interventions on the incidence of type 2 diabetes among people with intermediate hyperglycaemia within the study population.

METHODS

DMagic was a three-arm, cluster-randomised trial of participatory community mobilisation, mHealth mobile phone messaging, and usual care (control) in 96 villages (population roughly 125 000) in Bangladesh. Community mobilisation involved 18 monthly group meetings, led by lay facilitators, applying a participatory learning and action (PLA) cycle focused on diabetes prevention and control. mHealth involved twice-weekly voice messages over 14 months promoting behaviour change to reduce diabetes risk. The primary outcomes were the combined prevalence of type 2 diabetes and intermediate hyperglycaemia in the overall population at the end of the intervention implementation period, and 2-year cumulative incidence of type 2 diabetes in a cohort with intermediate hyperglycaemia at baseline. Primary outcomes were assessed through fasting blood glucose concentrations and 2-h oral glucose tolerance tests among a cross-section of adults aged 30 years and older and a cohort of individuals identified with intermediate hyperglycaemia. Prevalence findings are based on a cross-sectional survey at the end of the study; incidence findings are based on 2-year follow-up survey of a cohort of individuals identified with intermediate hyperglycaemia through a cross-sectional survey at baseline. We also assessed the cost-effectiveness of the interventions. This trial is registered with the ISRCTN registry, number ISRCTN41083256, and is completed.

FINDINGS

The study took place between June 27, 2015, and June 28, 2018, with the PLA intervention running in 32 villages from June, 2016, to December, 2017, and the mHealth intervention running in 32 villages from Oct 21, 2016, to Dec 24, 2017. End-of study prevalence was assessed in 11 454 individuals and incidence in 2100 individuals. There was a large reduction in the combined prevalence of type 2 diabetes and intermediate hyperglycaemia in the PLA group compared with the control group at the end of the study (adjusted [for stratification, clustering, and wealth] odds ratio [aOR] 0·36 [0·27-0·48]), with an absolute reduction of 20·7% (95% CI 14·6-26·7). Among 2470 adults with intermediate hyperglycaemia at baseline, 2100 (85%) were followed-up at 2 years. The 2-year cumulative incidence of diabetes in this cohort was significantly lower in the PLA group compared with control (aOR 0·39, 0·24-0·65), representing an absolute incidence reduction of 8·7% (3·5-14·0). There was no evidence of effect of mHealth on combined prevalence of intermediate hyperglycaemia and diabetes (aOR 0·93, 0·74-1·16) or the incidence of diabetes (1·02, 0·73-1·43). The incremental cost-effectiveness ratios for PLA were INT$316 per case of intermediate hyperglycaemia or type 2 diabetes prevented and $6518 per case of type 2 diabetes prevented among individuals with intermediate hyperglycaemia.

INTERPRETATION

Our data provide strong evidence to support the use of community mobilisation based on PLA to prevent type 2 diabetes in this rural Bangladeshi population. Despite raising knowledge and awareness of diabetes, the mHealth intervention did not change disease outcomes in our population. Replication studies in other populations should be a priority.

FUNDING

UK Medical Research Council.

The equity impact of community women's groups to reduce neonatal mortality: a meta-analysis of four cluster randomized trials

BACKGROUND

Socioeconomic inequalities in neonatal mortality are substantial in many developing countries. Little is known about how to address this problem. Trials in Asia and Africa have shown strong impacts on neonatal mortality of a participatory learning and action intervention with women's groups. Whether this intervention also reduces mortality inequalities remains unknown. We describe the equity impact of this women's groups intervention on the neonatal mortality rate (NMR) across socioeconomic strata.

METHODS

We conducted a meta-analysis of all four participatory women's group interventions that were shown to be highly effective in cluster randomized trials in India, Nepal, Bangladesh and Malawi. We estimated intervention effects on NMR and health behaviours for lower and higher socioeconomic strata using random effects logistic regression analysis. Differences in effect between strata were tested.

RESULTS

Analysis of 69120 live births and 2505 neonatal deaths shows that the intervention strongly reduced the NMR in lower (50-63% reduction depending on the measure of socioeconomic position used) and higher (35-44%) socioeconomic strata. The intervention did not show evidence of 'elite-capture': among the most marginalized populations, the NMR in intervention areas was 63% lower [95% confidence interval (CI) 48-74%] than in control areas, compared with 35% (95% CI: 15-50%) lower among the less marginalized in the last trial year (P-value for difference between most/less marginalized: 0.009). The intervention strongly improved home care practices, with no systematic socioeconomic differences in effect.

CONCLUSIONS

Participatory women's groups with high population coverage benefit the survival chances of newborns from all socioeconomic strata, and perhaps especially those born into the most deprived households.

Distribution of diabetes, hypertension and non-communicable disease risk factors among adults in rural Bangladesh: a cross-sectional survey

Background

Non-communicable diseases (NCDs) are increasing in low-income settings. We conducted a survey of risk factors, blood pressure and blood glucose in rural Bangladesh and assessed variations by age, sex and wealth.

Methods

We surveyed a random sample of 12 280 adults aged >30 years in 96 villages in rural Bangladesh. Fieldworkers measured blood glucose and conducted an glucose tolerance test with a repeat blood test 120 min post glucose ingestion. Blood pressure, anthropometric, socioeconomic, lifestyle and behavioural risk factors data were also collected. Data were analysed to describe the prevalence of diabetes, intermediate hyperglycaemia, hypertension and NCD risk factors by age, sex and wealth.

Results

Women had higher levels of overweight or obesity and lower levels of physical activity and fruit and vegetable consumption than men; 63% of men used tobacco compared with 41.3% of women. Overweight or obesity and abdominal obesity (waist to hip ratio) increased with socioeconomic status (least poor vs most poor: OR (95% CI) 3.21 (2.51 to 4.11) for men and 2.83 (2.28 to 3.52) for women). Tobacco use, passive smoke exposure and salt consumption fell with increasing socioeconomic status in both sexes. Clustering of risk factors showed more than 70% of men and women reported at least three risk factors. Women in the least poor group were 33% more likely to have three or more risk factors compared with women in the most poor group (1.33 (95% CI 1.17 to 1.58)). The combined prevalence of impaired fasting glucose, impaired glucose tolerance and diabetes was 26.1% among men and 34.9% among women, and increased with age. The prevalence of prehypertension and hypertension was 30.7% and 15.9% among men and 27.2% and 22.5% among women, with similar rising prevalence with age.

Conclusion

NCD risk factors, hyperglycaemia and raised blood pressure are an immediate health threat in rural Bangladesh. Initiatives to improve detection, treatment and prevention strategies are needed.

Growth and body composition of children aged 2-4 years after exposure to community mobilisation women's groups in Bangladesh

BACKGROUND

Women's groups interventions in Bangladesh reduced neonatal deaths by 38% and improved hygienic delivery, newborn care practices and breast feeding. We explore the longer-term impact of exposure to women's groups during pregnancy on child growth at 2-4 years.

METHODS

We performed a cross-sectional survey of child anthropometric measures (analysed as z-scores) among children born to women who had participated in the women's groups interventions while pregnant, compared with an age-matched and sex-matched sample of children born to control mothers. Results were stratified by maternal body mass index (BMI) and adjusted for possible confounding effects of maternal education, household asset ownership and, in a separate model, mother-child height difference, a proxy for improved survival of small babies in intervention groups.

RESULTS

Data were obtained from 2587 mother-child pairs (91% response). After adjustment for asset ownership, maternal education and potential survival effects, children whose mothers were exposed to the women's group intervention had higher head (0.16 (0.04 to 0.28)), mid-upper arm (0.11 (0.04 to 0.19)), abdominal (0.13 (0.00 to 0.26)) and chest (0.18 (0.08 to 0.29)) circumferences than their control counterparts. No significant differences in subcutaneous fat (subscapular and triceps skinfold thickness) were observed. When stratified by maternal BMI, intervention children had higher weight, BMI and circumferences, and these effects decreased with increasing maternal BMI category.

CONCLUSIONS

Women's groups appear to have had a lasting, positive impact on child anthropometric outcomes, with most significant results clustering in children of underweight mothers. Observed differences are likely to be of public health significance in terms of the nutritional and metabolic development of children.

Protocol of economic evaluation and equity impact analysis of mHealth and community groups for prevention and control of diabetes in rural Bangladesh in a three-arm cluster randomised controlled trial

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is one of the leading causes of death and disability worldwide, generating substantial economic burden for people with diabetes and their families, and to health systems and national economies. Bangladesh has one of the largest numbers of adults with diabetes in the South Asian region. This paper describes the planned economic evaluation of a three-arm cluster randomised control trial of mHealth and community mobilisation interventions to prevent and control T2DM and non-communicable diseases' risk factors in rural Bangladesh (D-Magic trial).

METHODS AND ANALYSIS

The economic evaluation will be conducted as a within-trial analysis to evaluate the incremental costs and health outcomes of mHealth and community mobilisation interventions compared with the status quo. The analyses will be conducted from a societal perspective, assessing the economic impact for all parties affected by the interventions, including implementing agencies (programme costs), healthcare providers, and participants and their households. Incremental cost-effectiveness ratios (ICERs) will be calculated in terms of cost per case of intermediate hyperglycaemia and T2DM prevented and cost per case of diabetes prevented among individuals with intermediate hyperglycaemia at baseline and cost per mm Hg reduction in systolic blood pressure. In addition to ICERs, the economic evaluation will be presented as a cost-consequence analysis where the incremental costs and all statistically significant outcomes will be listed separately. Robustness of the results will be assessed through sensitivity analyses. In addition, an analysis of equity impact of the interventions will be conducted.

ETHICS AND DISSEMINATION

The approval to conduct the study was obtained by the University College London Research Ethics Committee (4766/002) and by the Ethical Review Committee of the Diabetic Association of Bangladesh (BADAS-ERC/EC/t5100246). The findings of this study will be disseminated through different means within academia and the wider policy sphere.

TRIAL REGISTRATION NUMBER

ISRCTN41083256; Pre-results.

Socioeconomic inequalities in newborn care during facility and home deliveries: a cross sectional analysis of data from demographic surveillance sites in rural Bangladesh, India and Nepal

Background

In Bangladesh, India and Nepal, neonatal outcomes of poor infants are considerably worse than those of better-off infants. Understanding how these inequalities vary by country and place of delivery (home or facility) will allow targeting of interventions to those who need them most. We describe socio-economic inequalities in newborn care in rural areas of Bangladesh, Nepal and India for all deliveries and by place of delivery.

Methods

We used data from surveillance sites in Bangladesh, India and from Makwanpur and Dhanusha districts in Nepal, covering periods from 2001 to 2011. We used literacy (ability to read a short text) as indicator of socioeconomic status. We developed a composite score of nine newborn care practices (score range 0–9 indicating infants received no newborn care to all nine newborn care practices). We modeled the effect of literacy and place of delivery on the newborn care score and on individual practices.

Results

In all study sites (60,078 deliveries in total), use of facility delivery was higher among literate mothers. In all sites, inequalities in newborn care were observed: the difference in new born care between literate and illiterate ranged 0.35–0.80. The effect of literacy on the newborn care score reduced after adjusting for place of delivery (range score difference literate-illiterate: 0.21–0.43).

Conclusion

Socioeconomic inequalities in facility care greatly contribute to inequalities in newborn care. Improving newborn care during home deliveries and improving access to facility care are a priority for addressing inequalities in newborn care and newborn mortality.

Electronic supplementary material

The online version of this article (10.1186/s12939-018-0834-9) contains supplementary material, which is available to authorized users.

Diabetes knowledge and care practices among adults in rural Bangladesh: a cross-sectional survey

Background

Population knowledge of how to prevent, detect and control diabetes is critical to public health initiatives to tackle the disease. We undertook a cross-sectional survey of adults in rural Bangladesh to estimate knowledge and practices related to diabetes.

Methods

In 96 villages in Faridpur district, trained fieldworkers surveyed 12 140 randomly selected men and women aged ≥30. They collected data on sociodemographic status, knowledge of diabetes and history of blood and urine glucose testing. Fasting and 2-hour post-glucose load capillary blood tests ascertained the diabetic status of respondents. Levels of knowledge and practices were analysed by sociodemographic characteristics and diabetic status.

Results

The population showed low levels of diabetes knowledge overall, with only one in three adults able to report any valid causes of the disease. Knowledge of diabetes causes, symptoms, complications, prevention and control was significantly associated with age, education, wealth and employment. Only 14% of respondents reported ever having had a blood glucose test and strong associations with wealth were observed (least poor relative to most poor 2.91 (2.32–3.66)). 78.4% of known diabetics (ie, with a prior diagnosis) reported that they did not monitor their blood glucose levels on at least a monthly basis. However, they had better knowledge of the causes (odds relative to normoglycaemic individuals 1.62 (1.23–2.09)), symptoms (5.17 (3.41–7.82)), complications (5.18 (3.75–7.14)), prevention (4.18 (3.04–5.74)) and control (8.43 (4.83–14.71)).

Conclusion

Knowledge of diabetes among rural adults in Faridpur is extremely poor. Levels of diabetes testing are low and monitoring of blood glucose among known diabetics infrequent. Diabetes prevention and control efforts in this population must include large-scale awareness initiatives which focus not only on high-risk individuals but the whole population.

Trial registration number

ISRCTN41083256; Pre-results.

Effects of women's groups practising participatory learning and action on preventive and care-seeking behaviours to reduce neonatal mortality: A meta-analysis of cluster-randomised trials

BACKGROUND

The World Health Organization recommends participatory learning and action (PLA) in women's groups to improve maternal and newborn health, particularly in rural settings with low access to health services. There have been calls to understand the pathways through which this community intervention may affect neonatal mortality. We examined the effect of women's groups on key antenatal, delivery, and postnatal behaviours in order to understand pathways to mortality reduction.

METHODS AND FINDINGS

We conducted a meta-analysis using data from 7 cluster-randomised controlled trials that took place between 2001 and 2012 in rural India (2 trials), urban India (1 trial), rural Bangladesh (2 trials), rural Nepal (1 trial), and rural Malawi (1 trial), with the number of participants ranging between 6,125 and 29,901 live births. Behavioural outcomes included appropriate antenatal care, facility delivery, use of a safe delivery kit, hand washing by the birth attendant prior to delivery, use of a sterilised instrument to cut the umbilical cord, immediate wrapping of the newborn after delivery, delayed bathing of the newborn, early initiation of breastfeeding, and exclusive breastfeeding. We used 2-stage meta-analysis techniques to estimate the effect of the women's group intervention on behavioural outcomes. In the first stage, we used random effects models with individual patient data to assess the effect of groups on outcomes separately for the different trials. In the second stage of the meta-analysis, random effects models were applied using summary-level estimates calculated in the first stage of the analysis. To determine whether behaviour change was related to group attendance, we used random effects models to assess associations between outcomes and the following categories of group attendance and allocation: women attending a group and allocated to the intervention arm; women not attending a group but allocated to the intervention arm; and women allocated to the control arm. Overall, women's groups practising PLA improved behaviours during and after home deliveries, including the use of safe delivery kits (odds ratio [OR] 2.92, 95% CI 2.02-4.22; I2 = 63.7%, 95% CI 4.4%-86.2%), use of a sterile blade to cut the umbilical cord (1.88, 1.25-2.82; 67.6%, 16.1%-87.5%), birth attendant washing hands prior to delivery (1.87, 1.19-2.95; 79%, 53.8%-90.4%), delayed bathing of the newborn for at least 24 hours (1.47, 1.09-1.99; 68.0%, 29.2%-85.6%), and wrapping the newborn within 10 minutes of delivery (1.27, 1.02-1.60; 0.0%, 0%-79.2%). Effects were partly dependent on the proportion of pregnant women attending groups. We did not find evidence of effects on uptake of antenatal care (OR 1.03, 95% CI 0.77-1.38; I2 = 86.3%, 95% CI 73.8%-92.8%), facility delivery (1.02, 0.93-1.12; 21.4%, 0%-65.8%), initiating breastfeeding within 1 hour (1.08, 0.85-1.39; 76.6%, 50.9%-88.8%), or exclusive breastfeeding for 6 weeks after delivery (1.18, 0.93-1.48; 72.9%, 37.8%-88.2%). The main limitation of our analysis is the high degree of heterogeneity for effects on most behaviours, possibly due to the limited number of trials involving women's groups and context-specific effects.

CONCLUSIONS

This meta-analysis suggests that women's groups practising PLA improve key behaviours on the pathway to neonatal mortality, with the strongest evidence for home care behaviours and practices during home deliveries. A lack of consistency in improved behaviours across all trials may reflect differences in local priorities, capabilities, and the responsiveness of health services. Future research could address the mechanisms behind how PLA improves survival, in order to adapt this method to improve maternal and newborn health in different contexts, as well as improve other outcomes across the continuum of care for women, children, and adolescents.

Correction: Impact of a Participatory Intervention with Women's Groups on Psychological Distress among Mothers in Rural Bangladesh: Secondary Analysis of a Cluster-Randomised Controlled Trial

[This corrects the article DOI: 10.1371/journal.pone.0110697.].

The effect of community groups and mobile phone messages on the prevention and control of diabetes in rural Bangladesh: study protocol for a three-arm cluster randomised controlled trial

Background

Increasing rates of type 2 diabetes mellitus place a substantial burden on health care services, communities, families and individuals living with the disease or at risk of developing it. Estimates of the combined prevalence of intermediate hyperglycaemia and diabetes in Bangladesh vary, and can be as high as 30% of the adult population. Despite such high prevalence, awareness and control of diabetes and its risk factors are limited. Prevention and control of diabetes and its complications demand increased awareness and action of individuals and communities, with positive influences on behaviours and lifestyle choices. In this study, we will test the effect of two different interventions on diabetes occurrence and its risk factors in rural Bangladesh.

Methods/design

A three-arm cluster randomised controlled trial of mobile health (mHealth) and participatory community group interventions will be conducted in four rural upazillas in Faridpur District, Bangladesh. Ninety-six clusters (villages) will be randomised to receive either the mHealth intervention or the participatory community group intervention, or be assigned to the control arm. In the mHealth arm, enrolled individuals will receive twice-weekly voice messages sent to their mobile phone about prevention and control of diabetes. In the participatory community group arm, facilitators will initiate a series of monthly group meetings for men and women, progressing through a Participatory Learning and Action cycle whereby group members and communities identify, prioritise and tackle problems associated with diabetes and the risk of developing diabetes. Both interventions will run for 18 months. The primary outcomes of the combined prevalence of intermediate hyperglycaemia and diabetes and the cumulative 2-year incidence of diabetes among individuals identified as having intermediate hyperglycaemia at baseline will be evaluated through baseline and endline sample surveys of permanent residents aged 30 years or older in each of the study clusters. Data on blood glucose level, blood pressure, body mass index and hip-to-waist ratio will be gathered through physical measurements by trained fieldworkers. Demographic and socioeconomic data, as well as data on knowledge of diabetes, chronic disease risk factor prevalence and quality of life, will be gathered through interviews with sampled respondents.

Discussion

This study will increase our understanding of diabetes and other non-communicable disease burdens and risk factors in rural Bangladesh. By documenting and evaluating the delivery, impact and cost-effectiveness of participatory community groups and mobile phone voice messaging, study findings will provide evidence on how population-level strategies of community mobilisation and mHealth can be implemented to prevent and control noncommunicable diseases and risk factors in this population.

Trial registration

ISRCTN41083256. Registered on 30 Mar 2016 (Retrospectively Registered).

Trial acronym

D-Magic: Diabetes Mellitus – Action through Groups or mobile Information for better Control.

Institutional delivery in public and private sectors in South Asia: a comparative analysis of prospective data from four demographic surveillance sites

Background

Maternity care in South Asia is available in both public and private sectors. Using data from demographic surveillance sites in Bangladesh, Nepal and rural and urban India, we aimed to compare institutional delivery rates and public-private share.

Methods

We used records of maternity care collected in socio-economically disadvantaged communities between 2005 and 2011. Institutional delivery was summarized by four potential determinants: household asset index, maternal schooling, maternal age, and parity. We developed logistic regression models for private sector institutional delivery with these as independent covariates.

Results

The data described 52 750 deliveries. Institutional delivery proportion varied and there were differences in public-private split. In Bangladesh and urban India, the proportion of deliveries in the private sector increased with wealth, maternal education, and age. The opposite was observed in rural India and Nepal.

Conclusions

The proportion of institutional delivery increased with economic status and education. The choice of sector is more complex and provision and perceived quality of public sector services is likely to play a role. Choices for safe maternity are influenced by accessibility, quantity and perceived quality of care. Along with data linkage between private and public sectors, increased regulation should be part of the development of the pluralistic healthcare systems that characterize south Asia.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-1069-7) contains supplementary material, which is available to authorized users.

Formative evaluation of a participatory women's group intervention to improve reproductive and women's health outcomes in rural Bangladesh: a controlled before and after study

Background

Women's groups using participatory methods reduced newborn mortality in rural areas of low income countries. Our study assessed a participatory women's group intervention that focused on women's health, nutrition and family planning.

Methods

The study was conducted in three districts in Bangladesh between October 2011 and March 2013, covering a population of around 230 000. On the basis of allocation for the preceding cluster randomised trials, three unions per district were randomly allocated to receive a women's group intervention and three per district were control clusters. Outcomes included unmet need for family planning, morbidity, dietary diversity, night blindness, healthcare decision-making and knowledge of sexual and reproductive health, nutrition and anaemia. A difference-in-difference analysis was used to adjust for secular trends and baseline differences between women taking part in the intervention and a random sample from control clusters.

Results

We interviewed 5355 (91% response rate) women before the intervention and 5128 after (96% response rate). There were significant improvements in women's dietary diversity score (increase of 0.2 (95% CI 0.1 to 0.3)) and participation in healthcare decision-making (proportion increase (95% CI) 14.0% (10.6% to 17.4%)). There were also increases in knowledge about: contraception (4.2% (2.0% to 6.3%)), ways to treat (55.4% (52.2% to 58.5%)) and prevent (71.0% (68.0% to 74.1%)) sexually transmitted infections, nutrition (46.6% (43.6% to 49.6%)) and anaemia prevention (62.8% (60.9% to 64.6%)). There were no significant differences in unmet need for family planning, morbidity or night blindness.

Conclusions

Participatory women's groups have considerable potential to improve women's health knowledge, but evidence of impact on certain outcomes is lacking. Further formative work and intervention development is needed to optimise the impact of this approach for women's health.

Reaching the poor with health interventions: programme-incidence analysis of seven randomised trials of women's groups to reduce newborn mortality in Asia and Africa

BACKGROUND

Efforts to end preventable newborn deaths will fail if the poor are not reached with effective interventions. To understand what works to reach vulnerable groups, we describe and explain the uptake of a highly effective community-based newborn health intervention across social strata in Asia and Africa.

METHODS

We conducted a secondary analysis of seven randomised trials of participatory women's groups to reduce newborn mortality in India, Bangladesh, Nepal and Malawi. We analysed data on 70,574 pregnancies. Socioeconomic and sociodemographic differences in group attendance were tested using logistic regression. Qualitative data were collected at each trial site (225 focus groups, 20 interviews) to understand our results.

RESULTS

Socioeconomic differences in women's group attendance were small, except for occasional lower attendance by elites. Sociodemographic differences were large, with lower attendance by young primigravid women in African as well as in South Asian sites. The intervention was considered relevant and interesting to all socioeconomic groups. Local facilitators ensured inclusion of poorer women. Embarrassment and family constraints on movement outside the home restricted attendance among primigravid women. Reproductive health discussions were perceived as inappropriate for them.

CONCLUSIONS

Community-based women's groups can help to reach every newborn with effective interventions. Equitable intervention uptake is enhanced when facilitators actively encourage all women to attend, organise meetings at the participants' convenience and use approaches that are easily understandable for the less educated. Focused efforts to include primigravid women are necessary, working with families and communities to decrease social taboos.

Generating Insights from Trends in Newborn Care Practices from Prospective Population-Based Studies: Examples from India, Bangladesh and Nepal

BACKGROUND

Delivery of essential newborn care is key to reducing neonatal mortality rates, yet coverage of protective birth practices remains incomplete and variable, with or without skilled attendance. Evidence of changes over time in newborn care provision, disaggregated by care practice and delivery type, can be used by policymakers to review efforts to reduce mortality. We examine such trends in four areas using control arm trial data.

METHODS AND FINDINGS

We analysed data from the control arms of cluster randomised controlled trials in Bangladesh (27 553 births), eastern India (8 939), Dhanusha, Nepal (15 344) and Makwanpur, Nepal (6 765) over the period 2001-2011. For each trial, we calculated the observed proportion of attended births and the coverage of WHO essential newborn care practices by year, adjusted for clustering and stratification. To explore factors contributing to the observed trends, we then analysed expected trends due only to observed shifts in birth attendance, accounted for stratification, delivery type and statistically significant interaction terms, and examined disaggregated trends in care practice coverage by delivery type. Attended births increased over the study periods in all areas from very low rates, reaching a maximum of only 30% of deliveries. Newborn care practice trends showed marked heterogeneity within and between areas. Adjustment for stratification, birth attendance and interaction revealed that care practices could change in opposite directions over time and/or between delivery types - e.g. in Bangladesh hygienic cord-cutting and skin-to-skin contact fell in attended deliveries but not home deliveries, whereas in India birth attendant hand-washing rose for institutional deliveries but fell for home deliveries.

CONCLUSIONS

Coverage of many essential newborn care practices is improving, albeit slowly and unevenly across sites and delivery type. Time trend analyses of birth patterns and essential newborn care practices can inform policy-makers about effective intervention strategies.

Socio-economic determinants of household food security and women's dietary diversity in rural Bangladesh: a cross-sectional study

BACKGROUND

There has been limited decline in undernutrition rates in South Asia compared with the rest of Asia and one reason for this may be low levels of household food security. However, the evidence base on the determinants of household food security is limited. To develop policies intended to improve household food security, improved knowledge of the determinants of household food security is required.

METHODS

Household data were collected in 2011 from a randomly selected sample of 2,809 women of reproductive age. The sample was drawn from nine unions in three districts of rural Bangladesh. Multinomial logistic regression was conducted to measure the relationship between selected determinants of household food security and months of adequate household food provisioning, and a linear regression to measure the association between the same determinants and women's dietary diversity score.

RESULTS

The analyses found that land ownership, adjusted relative risk ratio (RRR) 0.28 (CI 0.18, 0.42); relative wealth (middle tertile 0.49 (0.29, 0.84) and top tertile 0.18 (0.10, 0.33)); women's literacy 0.64 (0.46, 0.90); access to media 0.49 (0.33, 0.72); and women's freedom to access the market 0.56 (0.36, 0.85) all significantly reduced the risk of food insecurity. Larger households increased the risk of food insecurity, adjusted RRR 1.46 (CI 1.02, 2.09). Households with vegetable gardens 0.20 (0.11, 0.31), rich households 0.46 (0.24, 0.68) and literate women 0.37 (0.20, 0.54) were significantly more likely to have better dietary diversity scores.

CONCLUSION

Household food insecurity remains a key public health problem in Bangladesh, with households suffering food shortages for an average of one quarter of the year. Simple survey and analytical methods are able to identify numerous interlinked factors associated with household food security, but wealth and literacy were the only two determinants associated with both improved food security and dietary diversity. We cannot conclude whether improvements in all determinants are necessarily needed to improve household food security, but new and existing policies that relate to these determinants should be designed and monitored with the knowledge that they could substantially influence the food security and nutritional status of the population.

Prevalence and determinants of caesarean section in private and public health facilities in underserved South Asian communities: cross-sectional analysis of data from Bangladesh, India and Nepal

OBJECTIVES

To describe the prevalence and determinants of births by caesarean section in private and public health facilities in underserved communities in South Asia.

DESIGN

Cross-sectional study.

SETTING

81 community-based geographical clusters in four locations in Bangladesh, India and Nepal (three rural, one urban).

PARTICIPANTS

45,327 births occurring in the study areas between 2005 and 2012.

OUTCOME MEASURES

Proportion of caesarean section deliveries by location and type of facility; determinants of caesarean section delivery by location.

RESULTS

Institutional delivery rates varied widely between settings, from 21% in rural India to 90% in urban India. The proportion of private and charitable facility births delivered by caesarean section was 73% in Bangladesh, 30% in rural Nepal, 18% in urban India and 5% in rural India. The odds of caesarean section were greater in private and charitable health facilities than in public facilities in three of four study locations, even when adjusted for pregnancy and delivery characteristics, maternal characteristics and year of delivery (Bangladesh: adjusted OR (AOR) 5.91, 95% CI 5.15 to 6.78; Nepal: AOR 2.37, 95% CI 1.62 to 3.44; urban India: AOR 1.22, 95% CI 1.09 to 1.38). We found that highly educated women were particularly likely to deliver by caesarean in private facilities in urban India (AOR 2.10; 95% CI 1.61 to 2.75) and also in rural Bangladesh (AOR 11.09, 95% CI 6.28 to 19.57).

CONCLUSIONS

Our results lend support to the hypothesis that increased caesarean section rates in these South Asian countries may be driven in part by the private sector. They also suggest that preferences for caesarean delivery may be higher among highly educated women, and that individual-level and provider-level factors interact in driving caesarean rates higher. Rates of caesarean section in the private sector, and their maternal and neonatal health outcomes, require close monitoring.

The effect of participatory women's groups on infant feeding and child health knowledge, behaviour and outcomes in rural Bangladesh: a controlled before-and-after study

Background

Despite efforts to reduce under-5 mortality rates worldwide, an estimated 6.6 million under-5 children die every year. Community mobilisation through participatory women's groups has been shown to improve maternal and newborn health in rural settings, but little is known about the potential of this approach to improve care and health in children after the newborn period.

Methods

Following on from a cluster-randomised controlled trial to assess the effect of participatory women's groups on maternal and neonatal health outcomes in rural Bangladesh, 162 women's groups continued to meet between April 2010 and December 2011 to identify, prioritise and address issues that affect the health of children under 5 years. A controlled before-and-after study design and difference-in-difference analysis was used to assess morbidity outcomes and changes in knowledge and practices related to child feeding, hygiene and care-seeking behaviour.

Findings

Significant improvements were measured in mothers’ knowledge of disease prevention and management, danger signs and hand washing at critical times. Significant increases were seen in exclusive breast feeding for at least 6 months (15.3% (4.2% to 26.5%)), and mean duration of breast feeding (37.9 days (17.4 to 58.3)). Maternal reports of under-5 morbidities fell in intervention compared with control areas, including reports of fever (−10.5% (−15.1% to −6.0%)) and acute respiratory infections (−12.2% (−15.6% to −8.8%)). No differences were observed in dietary diversity scores or immunisation uptake.

Conclusions

Community mobilisation through participatory women's groups can be successfully adapted to address health knowledge and practice in relation to child's health, leading to improvements in a number of child health indicators and behaviours.

Impact of a participatory intervention with women's groups on psychological distress among mothers in rural Bangladesh: secondary analysis of a cluster-randomised controlled trial

Background

Perinatal common mental disorders (PCMDs) are a major cause of disability among women and disproportionately affect lower income countries. Interventions to address PCMDs are urgently needed in these settings, and group-based and peer-led approaches are potential strategies to increase access to mental health interventions. Participatory women’s health groups led by local women previously reduced postpartum psychological distress in eastern India. We assessed the effect of a similar intervention on postpartum psychological distress in rural Bangladesh.

Method

We conducted a secondary analysis of data from a cluster-randomised controlled trial with 18 clusters and an estimated population of 532,996. Nine clusters received an intervention comprising monthly meetings during which women’s groups worked through a participatory learning and action cycle to develop strategies for improving women’s and children’s health. There was one group for every 309 individuals in the population, 810 groups in total. Mothers in nine control clusters had access to usual perinatal care. Postpartum psychological distress was measured with the 20-item Self Reporting Questionnaire (SRQ-20) between six and 52 weeks after delivery, during the months of January to April, in 2010 and 2011.

Results

We analysed outcomes for 6275 mothers. Although the cluster mean SRQ-20 score was lower in the intervention arm (mean 5.2, standard deviation 1.8) compared to control (5.3, 1.2), the difference was not significant (β 1.44, 95% CI 0.28, 3.08).

Conclusions

Despite promising results in India, participatory women’s groups focused on women’s and children’s health had no significant effect on postpartum psychological distress in rural Bangladesh.

Is essential newborn care provided by institutions and after home births? Analysis of prospective data from community trials in rural South Asia

Background

Provision of essential newborn care (ENC) can save many newborn lives in poor resource settings but coverage is far from universal and varies by country and place of delivery. Understanding gaps in current coverage and where coverage is good, in different contexts and places of delivery, could make a valuable contribution to the future design of interventions to reduce neonatal mortality. We sought to describe the coverage of essential newborn care practices for births in institutions, at home with a skilled birth attendant, and at home without a skilled birth attendant (SBA) in rural areas of Bangladesh, Nepal, and India.

Methods

We used data from the control arms of four cluster randomised controlled trials in Bangladesh, Eastern India and from Makwanpur and Dhanusha districts in Nepal, covering periods from 2001 to 2011. We used these data to identify essential newborn care practices as defined by the World Health Organization. Each birth was allocated to one of three delivery types: home birth without an SBA, home birth with an SBA, or institutional delivery. For each study, we calculated the observed proportion of births that received each care practice by delivery type with 95% confidence intervals, adjusted for clustering and, where appropriate, stratification.

Results

After exclusions, we analysed data for 8939 births from Eastern India, 27 553 births from Bangladesh, 6765 births from Makwanpur and 15 344 births from Dhanusha. Across all study areas, coverage of essential newborn care practices was highest in institutional deliveries, and lowest in home non-SBA deliveries. However, institutional deliveries did not provide universal coverage of the recommended practices, with relatively low coverage (20%-70%) across all study areas for immediate breastfeeding and thermal care. Institutions in Bangladesh had the highest coverage for almost all care practices except thermal care. Across all areas, fewer than 20% of home non-SBA deliveries used a clean delivery kit, the use of plastic gloves was very low and coverage of recommended thermal care was relatively poor. There were large differences between study areas in handwashing, immediate breastfeeding and delayed bathing.

Conclusions

There remains substantial scope for health facilities to improve thermal care for the newborn and to encourage immediate and exclusive breastfeeding. For unattended home deliveries, increased handwashing, use of clean delivery kits and basic thermal care offer great scope for improvement.

The effect of increased coverage of participatory women's groups on neonatal mortality in Bangladesh: A cluster randomized trial

IMPORTANCE

Community-based interventions can reduce neonatal mortality when health systems are weak. Population coverage of target groups may be an important determinant of their effect on behavior and mortality. A women's group trial at coverage of 1 group per 1414 population in rural Bangladesh showed no effect on neonatal mortality, despite a similar intervention having a significant effect on neonatal and maternal death in comparable settings.

OBJECTIVE

To assess the effect of a participatory women's group intervention with higher population coverage on neonatal mortality in Bangladesh.

DESIGN

A cluster randomized controlled trial in 9 intervention and 9 control clusters.

SETTING

Rural Bangladesh.

PARTICIPANTS

Women permanently residing in 18 unions in 3 districts and accounting for 19 301 births during the final 24 months of the intervention.

INTERVENTIONS

Women's groups at a coverage of 1 per 309 population that proceed through a participatory learning and action cycle in which they prioritize issues that affected maternal and neonatal health and design and implement strategies to address these issues.

MAIN OUTCOMES AND MEASURES

Neonatal mortality rate.

RESULTS

Analysis included 19 301 births during the final 24 months of the intervention. More than one-third of newly pregnant women joined the groups. The neonatal mortality rate was significantly lower in the intervention arm (21.3 neonatal deaths per 1000 live births vs 30.1 per 1000 in control areas), a reduction in neonatal mortality of 38% (risk ratio, 0.62 [95% CI, 0.43-0.89]) when adjusted for socioeconomic factors. The cost-effectiveness was US $220 to $393 per year of life lost averted. Cause-specific mortality rates suggest reduced deaths due to infections and those associated with prematurity/low birth weight. Improvements were seen in hygienic home delivery practices, newborn thermal care, and breastfeeding practices.

CONCLUSIONS AND RELEVANCE

Women's group community mobilization, delivered at adequate population coverage, is a highly cost-effective approach to improve newborn survival and health behavior indicators in rural Bangladesh.

TRIAL REGISTRATION

isrctn.org Identifier: ISRCTN01805825.

Women's groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis

BACKGROUND

Maternal and neonatal mortality rates remain high in many low-income and middle-income countries. Different approaches for the improvement of birth outcomes have been used in community-based interventions, with heterogeneous effects on survival. We assessed the effects of women's groups practising participatory learning and action, compared with usual care, on birth outcomes in low-resource settings.

METHODS

We did a systematic review and meta-analysis of randomised controlled trials undertaken in Bangladesh, India, Malawi, and Nepal in which the effects of women's groups practising participatory learning and action were assessed to identify population-level predictors of effect on maternal mortality, neonatal mortality, and stillbirths. We also reviewed the cost-effectiveness of the women's group intervention and estimated its potential effect at scale in Countdown countries.

FINDINGS

Seven trials (119,428 births) met the inclusion criteria. Meta-analyses of all trials showed that exposure to women's groups was associated with a 37% reduction in maternal mortality (odds ratio 0.63, 95% CI 0.32-0.94), a 23% reduction in neonatal mortality (0.77, 0.65-0.90), and a 9% non-significant reduction in stillbirths (0.91, 0.79-1.03), with high heterogeneity for maternal (I(2)=58.8%, p=0.024) and neonatal results (I(2)=64.7%, p=0.009). In the meta-regression analyses, the proportion of pregnant women in groups was linearly associated with reduction in both maternal and neonatal mortality (p=0.026 and p=0.011, respectively). A subgroup analysis of the four studies in which at least 30% of pregnant women participated in groups showed a 55% reduction in maternal mortality (0.45, 0.17-0.73) and a 33% reduction in neonatal mortality (0.67, 0.59-0.74). The intervention was cost effective by WHO standards and could save an estimated 283,000 newborn infants and 41,100 mothers per year if implemented in rural areas of 74 Countdown countries.

INTERPRETATION

With the participation of at least a third of pregnant women and adequate population coverage, women's groups practising participatory learning and action are a cost-effective strategy to improve maternal and neonatal survival in low-resource settings.

FUNDING

Wellcome Trust, Ammalife, and National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Birmingham and the Black Country programme.

Scaling up community mobilisation through women's groups for maternal and neonatal health: experiences from rural Bangladesh

Background

Program coverage is likely to be an important determinant of the effectiveness of community interventions to reduce neonatal mortality. Rigorous examination and documentation of methods to scale-up interventions and measure coverage are scarce, however. To address this knowledge gap, this paper describes the process and measurement of scaling-up coverage of a community mobilisation intervention for maternal, child and neonatal health in rural Bangladesh and critiques this real-life experience in relation to available literature on scaling-up.

Methods

Scale-up activities took place in nine unions in rural Bangladesh. Recruitment and training of those who deliver the intervention, communication and engagement with the community and other stakeholders and active dissemination of intervention activities are described. Process evaluation and population survey data are presented and used to measure coverage and the success of scale-up.

Results

The intervention was scaled-up from 162 women's groups to 810, representing a five-fold increase in population coverage. The proportion of women of reproductive age and pregnant women who were engaged in the intervention increased from 9% and 3%, respectively, to 23% and 29%.

Conclusions

Examination and documentation of how scaling-up was successfully initiated, led, managed and monitored in rural Bangladesh provide a deeper knowledge base and valuable lessons.

Strong operational capabilities and institutional knowledge of the implementing organisation were critical to the success of scale-up. It was possible to increase community engagement with the intervention without financial incentives and without an increase in managerial staff. Monitoring and feedback systems that allow for periodic programme corrections and continued innovation are central to successful scale-up and require programmatic and operational flexibility.