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Grewal G, Fuller SS, Rababeh A, Maina M, English M, Paton C, Papoutsi C. Scoping review of interventions to improve continuity of postdischarge care for newborns in LMICs. BMJ Glob Health 2024; 9:e012894. [PMID: 38199778 PMCID: PMC10806884 DOI: 10.1136/bmjgh-2023-012894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 11/12/2023] [Indexed: 01/12/2024] Open
Abstract
INTRODUCTION Neonatal mortality remains significant in low-income and middle-income countries (LMICs) with in-hospital mortality rates similar to those following discharge from healthcare facilities. Care continuity interventions have been suggested as a way of reducing postdischarge mortality by better linking care between facilities and communities. This scoping review aims to map and describe interventions used in LMICs to improve care continuity for newborns after discharge and examine assumptions underpinning the design and delivery of continuity. METHODS We searched seven databases (MEDLINE, CINAHL, Scopus, Web of Science, EMBASE, Cochrane library and (Ovid) Global health). Publications with primary data on interventions focused on continuity of care for newborns in LMICs were included. Extracted data included year of publication, study location, study design and type of intervention. Drawing on relevant theoretical frameworks and classifications, we assessed the extent to which interventions adopted participatory methods and how they attempted to establish continuity. RESULTS A total of 65 papers were included in this review; 28 core articles with rich descriptions were prioritised for more in-depth analysis. Most articles adopted quantitative designs. Interventions focused on improving continuity and flow of information via education sessions led by community health workers during home visits. Extending previous frameworks, our findings highlight the importance of interpersonal continuity in LMICs where communication and relationships between family members, healthcare workers and members of the wider community play a vital role in creating support systems for postdischarge care. Only a small proportion of studies focused on high-risk babies. Some studies used participatory methods, although often without meaningful engagement in problem definition and intervention implementation. CONCLUSION Efforts to reduce neonatal mortality and morbidity should draw across multiple continuity logics (informational, relational, interpersonal and managerial) to strengthen care after hospital discharge in LMIC settings and further focus on high-risk neonates, as they often have the worst outcomes.
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Affiliation(s)
- Gulraj Grewal
- Nuffield Department of Medicine, Center for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Sebastian S Fuller
- Nuffield Department of Medicine, Center for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Asma Rababeh
- Nuffield Department of Medicine, Center for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Michuki Maina
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
| | - Mike English
- Nuffield Department of Medicine, Center for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
| | - Chris Paton
- Nuffield Department of Medicine, Center for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Department of Information Science, University of Otago, Dunedin, New Zealand
| | - Chrysanthi Papoutsi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
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Blanchard AK, Ansari S, Rajput R, Colbourn T, Houweling TAJ, Lorway R, Isac S, Prost A, Anthony J. 'That is because we are alone': A relational qualitative study of socio-spatial inequities in maternal and newborn health programme coverage in rural Uttar Pradesh, India. Glob Public Health 2024; 19:2348640. [PMID: 38716491 DOI: 10.1080/17441692.2024.2348640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 04/22/2024] [Indexed: 05/15/2024]
Abstract
This qualitative study was conducted in Uttar Pradesh state, India to explore how interrelated socio-economic position and spatial characteristics of four diverse villages may have influenced equity in coverage of community-based maternal and newborn health (MNH) services. We conducted social mapping and three focus group discussions in each village, among women of lower and higher socio-economic position who recently gave birth, and with community health workers (n = 134). Data were analysed in NVivo 11.0 using thematic framework analysis. The extent of socio-economic hierarchies and spatial disparateness within the village, combined with distance to larger centers, together shaped villages' level of socio-spatial remoteness. Disadvantaged socio-economic groups expressed being more often spatially isolated, with less access to infrastructure, resources or services, which was heightened if the village was physically distant from larger centers. In more socio-spatially remote villages, inequities in coverage of MNH services that disadvantaged lower socio-economic position groups were compounded as these groups more often experienced ASHA vacancies, as well as greater distance to and poorer perceived quality of health services nearest the village. The results inform a conceptual framework of 'socio-spatial remoteness' that can guide public health research and programmes to more comprehensively address health inequities within India and beyond.
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Affiliation(s)
- Andrea K Blanchard
- Institute for Global Public Health, University of Manitoba, Winnipeg, Canada
| | | | | | - Tim Colbourn
- Institute for Global Health, University College London, London, UK
| | | | - Robert Lorway
- Institute for Global Public Health, University of Manitoba, Winnipeg, Canada
| | - Shajy Isac
- Institute for Global Public Health, University of Manitoba, Winnipeg, Canada
- India Health Action Trust, Lucknow, India
| | - Audrey Prost
- Institute for Global Health, University College London, London, UK
| | - John Anthony
- Institute for Global Public Health, University of Manitoba, Winnipeg, Canada
- India Health Action Trust, Lucknow, India
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Dada S, Aivalli P, De Brún A, Barreix M, Chelwa N, Mutunga Z, Vwalika B, Gilmore B. Understanding communication in community engagement for maternal and newborn health programmes in low- and middle-income countries: a realist review. Health Policy Plan 2023; 38:1079-1098. [PMID: 37650702 PMCID: PMC10566325 DOI: 10.1093/heapol/czad078] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 08/20/2023] [Accepted: 08/29/2023] [Indexed: 09/01/2023] Open
Abstract
As community engagement (CE) is implemented for sustainable maternal and newborn health (MNH) programming, it is important to determine how these approaches work. Low- and middle-income countries (LMICs) have become a particular focus for MNH CE activities due to their high burden of maternal and neonatal deaths. MNH messaging and communication to engage communities are likely to differ by context, but how these approaches are actually developed and implemented within CE is not well understood. Understanding how communications in CE actually work is vital in the translation of learnings across programmes and to inform future projects. The purpose of this realist review is to describe how, why, to what extent and for whom communications in CE contribute to MNH programming in LMICs. After searching academic databases, grey literature and literature suggested by the expert advisory committee, documents were included if they described the CE communication processes/activities used for MNH programming in an LMIC. Relevant documents were assessed for richness (depth of insight) and rigor (trustworthiness and coherence of data/theories). Data were extracted as context-mechanism-outcome configurations (CMOCs) and synthesized into demi-regularities to contribute to theory refinement. After screening 416 records, 45 CMOCs were extracted from 11 documents. This informed five programme theories explaining that communications in CE for an MNH programme work when: communities are actively involved throughout the programme, the messaging and programme are acceptable, communication sources are trusted, the community has a reciprocal relationship with the programme and the community sees value in the programme. While these findings reflect what is often anecdotally known in CE or acknowledged in communications theory, they have implications for policy, practice and research by highlighting the importance of centring the community's needs and priorities throughout the stages of developing and implementing communications for CE in MNH.
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Affiliation(s)
- Sara Dada
- UCD Centre for Interdisciplinary Research Education and Innovation in Health Systems (UCD IRIS Centre), University College Dublin, School of Nursing Midwifery and Health Systems , Belfield, Dublin 4, Ireland
- School of Nursing Midwifery and Health Systems, University College Dublin, Belfield, Dublin 4, Ireland
| | - Praveenkumar Aivalli
- UCD Centre for Interdisciplinary Research Education and Innovation in Health Systems (UCD IRIS Centre), University College Dublin, School of Nursing Midwifery and Health Systems , Belfield, Dublin 4, Ireland
- School of Nursing Midwifery and Health Systems, University College Dublin, Belfield, Dublin 4, Ireland
| | - Aoife De Brún
- UCD Centre for Interdisciplinary Research Education and Innovation in Health Systems (UCD IRIS Centre), University College Dublin, School of Nursing Midwifery and Health Systems , Belfield, Dublin 4, Ireland
- School of Nursing Midwifery and Health Systems, University College Dublin, Belfield, Dublin 4, Ireland
| | - Maria Barreix
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1211, Geneva 27, Switzerland
| | | | | | - Bellington Vwalika
- Department of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia
| | - Brynne Gilmore
- UCD Centre for Interdisciplinary Research Education and Innovation in Health Systems (UCD IRIS Centre), University College Dublin, School of Nursing Midwifery and Health Systems , Belfield, Dublin 4, Ireland
- School of Nursing Midwifery and Health Systems, University College Dublin, Belfield, Dublin 4, Ireland
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Saville NM, Kharel C, Morrison J, Harris-Fry H, James P, Copas A, Giri S, Arjyal A, Beard BJ, Haghparast-Bidgoli H, Skordis J, Richter A, Baral S, Hillman S. Comprehensive Anaemia Programme and Personalized Therapies (CAPPT): protocol for a cluster-randomised controlled trial testing the effect women's groups, home counselling and iron supplementation on haemoglobin in pregnancy in southern Nepal. Trials 2022; 23:183. [PMID: 35232469 PMCID: PMC8886560 DOI: 10.1186/s13063-022-06043-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 01/19/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Anaemia in pregnancy remains prevalent in Nepal and causes severe adverse health outcomes. METHODS This non-blinded cluster-randomised controlled trial in the plains of Nepal has two study arms: (1) Control: routine antenatal care (ANC); (2) Home visiting, iron supplementation, Participatory Learning and Action (PLA) groups, plus routine ANC. Participants, including women in 54 non-contiguous clusters (mean 2582; range 1299-4865 population) in Southern Kapilbastu district, are eligible if they consent to menstrual monitoring, are resident, married, aged 13-49 years and able to respond to questions. After 1-2 missed menses and a positive pregnancy test, consenting women < 20 weeks' gestation, who plan to reside locally for most of the pregnancy, enrol into trial follow-up. Interventions comprise two home-counselling visits (at 12-21 and 22-26 weeks' gestation) with iron folic acid (IFA) supplement dosage tailored to women's haemoglobin concentration, plus monthly PLA women's group meetings using a dialogical problem-solving approach to engage pregnant women and their families. Home visits and PLA meetings will be facilitated by auxiliary nurse midwives. The hypothesis is as follows: Haemoglobin of women at 30 ± 2 weeks' gestation is ≥ 0.4 g/dL higher in the intervention arm than in the control. A sample of 842 women (421 per arm, average 15.6 per cluster) will provide 88% power, assuming SD 1.2, ICC 0.09 and CV of cluster size 0.27. Outcomes are captured at 30 ± 2 weeks gestation. Primary outcome is haemoglobin concentration (g/dL). Secondary outcomes are as follows: anaemia prevalence (%), mid-upper arm circumference (cm), mean probability of micronutrient adequacy (MPA) and number of ANC visits at a health facility. Indicators to assess pathways to impact include number of IFA tablets consumed during pregnancy, intake of energy (kcal/day) and dietary iron (mg/day), a score of bioavailability-enhancing behaviours and recall of one nutrition knowledge indicator. Costs and cost-effectiveness of the intervention will be estimated from a provider perspective. Using constrained randomisation, we allocated clusters to study arms, ensuring similarity with respect to cluster size, ethnicity, religion and distance to a health facility. Analysis is by intention-to-treat at the individual level, using mixed-effects regression. DISCUSSION Findings will inform Nepal government policy on approaches to increase adherence to IFA, improve diets and reduce anaemia in pregnancy. TRIAL REGISTRATION ISRCTN 12272130 .
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Affiliation(s)
- Naomi M Saville
- Institute for Global Health, University College London (UCL), London, UK.
| | | | - Joanna Morrison
- Institute for Global Health, University College London (UCL), London, UK
| | - Helen Harris-Fry
- Department of Population Health, London School of Hygiene & Tropical Medicine (LSHTM), London, UK
| | - Philip James
- Department of Population Health, London School of Hygiene & Tropical Medicine (LSHTM), London, UK
| | - Andrew Copas
- Institute for Global Health, University College London (UCL), London, UK
| | - Santosh Giri
- HERD International, Thapathali, Kathmandu, Nepal
| | | | | | | | - Jolene Skordis
- Institute for Global Health, University College London (UCL), London, UK
| | - Adam Richter
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Sushil Baral
- HERD International, Thapathali, Kathmandu, Nepal.,Health Research and Social Development Forum (HERD), Kathmandu, Nepal
| | - Sara Hillman
- Institute for Women's Health, University College London (UCL), London, UK
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Canuto K, Preston R, Rannard S, Felton-Busch C, Geia L, Yeomans L, Turner N, Thompson Q, Carlisle K, Evans R, Passey M, Larkins S, Redman-MacLaren M, Farmer J, Muscat M, Taylor J. How and why do women's groups (WGs) improve the quality of maternal and child health (MCH) care? A systematic review of the literature. BMJ Open 2022; 12:e055756. [PMID: 35190438 PMCID: PMC8862452 DOI: 10.1136/bmjopen-2021-055756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND This systematic review was undertaken to assist the implementation of the WOmen's action for Mums and Bubs (WOMB) project which explores Aboriginal and Torres Strait Islander community women's group (WG) action to improve maternal and child health (MCH) outcomes. There is now considerable international evidence that WGs improve MCH outcomes, and we were interested in understanding how and why this occurs. The following questions guided the review: (1) What are the characteristics, contextual influences and group processes associated with the MCH outcomes of WGs? (2) What are the theoretical and conceptual approaches to WGs? (3) What are the implications likely to inform Aboriginal and Torres Strait Islander WGs? METHODS We systematically searched electronic databases (MEDLINE (Ovid); CINAHL (Ebsco); Informit health suite, Scopus, Emcare (Ovid) and the Cochrane Library and Informit), online search registers and grey literature using the terms mother, child, group, participatory and community and their variations during all time periods to January 2021. The inclusion criteria were: (1) Population: studies involving community WGs in any country. (2) Intervention: a program/intervention involving any aspect of community WGs planning, acting, learning and reviewing MCH improvements. (3) Outcome: studies with WGs reported a component of: (i) MCH outcomes; or (ii) improvements in the quality of MCH care or (iii) improvements in socioemotional well-being of mothers and/or children. (4) Context: the primary focus of initiatives must be in community-based or primary health care settings. (5) Process: includes some description of the process of WGs or any factors influencing the process. (6) Language: English. (7) Study design: all types of quantitative and qualitative study designs involving primary research and data collection.Data were extracted under 14 headings and a narrative synthesis identified group characteristics and analysed the conceptual approach to community participation, the use of theory and group processes. An Australian typology of community participation, concepts from Aboriginal and Torres Strait Islander group work and an adapted framework of Cohen and Uphoff were used to synthesise results. Risk of bias was assessed using Joanna Briggs Institute Critical Appraisal Tools. RESULTS Thirty-five (35) documents were included with studies conducted in 19 countries. Fifteen WGs used participatory learning and action cycles and the remainder used cultural learning, community development or group health education. Group activities, structure and who facilitated groups was usually identified. Intergroup relationships and decision-making were less often described as were important concepts from an Aboriginal or Torres Strait Islander perspective (the primacy of culture, relationships and respect). All but two documents used an explicit theoretical approach. Using the typology of community participation, WGs were identified as predominantly developmental (22), instrumental (10), empowerment (2) and one was unclear. DISCUSSION A framework to categorise links between contextual factors operating at micro, meso and macro levels, group processes and MCH improvements is required. Currently, despite a wealth of information about WGs, it was difficult to determine the methods through which they achieved their outcomes. This review adds to existing systematic reviews about the functioning of WGs in MCH improvement in that it covers WGs in both high-income and low-income settings, identifies the theory underpinning the WGs and classifies the conceptual approach to participation. It also introduces an Australian Indigenous perspective into analysis of WGs used to improve MCH. PROSPERO REGISTRATION NUMBER CRD42019126533.
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Affiliation(s)
- Karla Canuto
- Aboriginal Health Equity, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Naghir Tribe of the Kulkagul Clan, Torres Strait, Queensland, Australia
| | - Robyn Preston
- School of Health, Medical and Applied Sciences, Central Queensland University, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Bebegu Yumba,Townsville, Queensland, Australia
| | - Sam Rannard
- Library and Information Services, James Cook University, Bebegu Yumba, Townsville, Queensland, Australia
| | - Catrina Felton-Busch
- Murtupuni Centre Rural and Remote Health, James Cook University, Mount Isa, Queensland, Australia
- Yangkaal and Gangaidda, Mount Isa, Queensland, Australia
| | - Lynore Geia
- College of Healthcare Sciences, James Cook University, Bebegu Yumba, Townsville, Queensland, Australia
- Bwgcolman, Palm Island, Queensland, Australia
| | - Lee Yeomans
- Queensland Aboriginal and Islander Health Council, Brisbane, Queensland, Australia
| | - Nalita Turner
- College of Medicine and Dentistry, James Cook University, Bebegu Yumba,Townsville, Queensland, Australia
- Anmatyerre/Jaru, Northern Territory, Northern Territory, Australia
| | - Quitaysha Thompson
- Gurindji Aboriginal Corporation, Kalkaringi, Northern Territory, Australia
- Gurindji woman, Kalkaringi, Northern Territory, Australia
| | - Karen Carlisle
- College of Medicine and Dentistry, James Cook University, Bebegu Yumba,Townsville, Queensland, Australia
| | - Rebecca Evans
- College of Medicine and Dentistry, James Cook University, Bebegu Yumba,Townsville, Queensland, Australia
| | - Megan Passey
- University Centre for Rural Health, University of Sydney, Lismore, New South Wales, Australia
| | - Sarah Larkins
- College of Medicine and Dentistry, James Cook University, Bebegu Yumba,Townsville, Queensland, Australia
| | - Michelle Redman-MacLaren
- College of Medicine and Dentistry, James Cook University, Nguma-bada, Cairns, Queensland, Australia
| | - Jane Farmer
- Swinburne Social Innovation Research Institute, Centre for Social Impact, Swinburne University of Technology, Melbourne, Victoria, Australia
| | - Melody Muscat
- College of Medicine and Dentistry, James Cook University, Bebegu Yumba,Townsville, Queensland, Australia
- Bijara, Charleville, Queensland, Australia
| | - Judy Taylor
- College of Medicine and Dentistry, James Cook University, Bebegu Yumba,Townsville, Queensland, Australia
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Harris-Fry H, Saville NM, Paudel P, Manandhar DS, Cortina-Borja M, Skordis J. Relative power: Explaining the effects of food and cash transfers on allocative behaviour in rural Nepalese households. JOURNAL OF DEVELOPMENT ECONOMICS 2022; 154:102784. [PMID: 34824488 PMCID: PMC7612026 DOI: 10.1016/j.jdeveco.2021.102784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
We estimate the effects of antenatal food and cash transfers with women's groups on household allocative behaviour and explore whether these effects are explained by intergenerational bargaining among women. Interventions were tested in randomised-controlled trial in rural Nepal, in a food-insecure context where pregnant women are allocated the least adequate diets. We show households enrolled in a cash transfer intervention allocated pregnant women with 2-3 pp larger shares of multiple foods (versus their mothers-in-law and male household heads) than households in a control group. Households in a food transfer intervention only increased pregnant women's allocation of staple foods (by 2 pp). Intergenerational bargaining power may partly mediate the effects of the cash transfers but not food transfers, whereas household food budget and nutrition knowledge do not mediate any effects. Our findings highlight the role of intergenerational bargaining in determining the effectiveness of interventions aiming to reach and/or empower junior women.
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Affiliation(s)
- Helen Harris-Fry
- Department of Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Corresponding author. London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Naomi M. Saville
- UCL Institute for Global Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Puskar Paudel
- Mother and Infant Research Activities, PO Box 921, Thapathali, Kathmandu, Nepal
| | - Dharma S. Manandhar
- Mother and Infant Research Activities, PO Box 921, Thapathali, Kathmandu, Nepal
| | - Mario Cortina-Borja
- Population, Policy and Practice Research and Teaching Department, University College London Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Jolene Skordis
- UCL Institute for Global Health, 30 Guilford Street, London, WC1N 1EH, UK
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Irani L, Schooley J, Supriya, Chaudhuri I. Layering of a health, nutrition and sanitation programme onto microfinance-oriented self-help groups in rural India: results from a process evaluation. BMC Public Health 2021; 21:2131. [PMID: 34801003 PMCID: PMC8605516 DOI: 10.1186/s12889-021-12049-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 10/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The state of Bihar has been lagging behind Indian national averages on indicators related to maternal and child health, primarily due to lack of knowledge among mothers of young children on lifesaving practices and on where to seek services when healthcare is needed. Hence, the JEEViKA Technical Support Programme was established in 101 blocks to support the state rural livelihood entity, JEEViKA, in order to increase demand for and link rural families to existing health, nutrition and sanitation services. Programme activities were geared to those engaged in JEEViKA's microfinance-oriented self-help groups. These groups were facilitated by a village-based community mobilizer who was trained on health, nutrition and sanitation-related topics which she later shared in self-help group meetings monthly and during ad hoc home visits. Further, a block-level health, nutrition and sanitation integrator was introduced within JEEViKA to support community mobilizers. Also, indicators were added into the existing monitoring system to routinely capture the layering of health, nutrition and sanitation activities. METHODS A process evaluation was conducted from August-November 2017 which comprised of conducting 594 quantitative surveys with community mobilizers, from program and non-programme intervention blocks. Linear and logistic regressions were done to capture the association of at least one training that the community mobilizers received on knowledge of the topics learned and related activities they carried out. RESULTS Community mobilizers who had received at least one training were more likely to have higher levels of knowledge on the topics they learned and were also more likely to carry out related activities, such as interacting with block-level integrators for guidance and support, routinely collect data on health, nutrition and sanitation indicators and spend time weekly on related activities. CONCLUSIONS Successful integration of health, nutrition and sanitation programming within a non-health programme such as JEEViKA is possible through trainings provided to dedicated staff in decentralized positions, such as community mobilizers. The findings of this evaluation hold great promise for engaging existing non-health, nutrition and sanitation systems that are serving vulnerable communities to become partners in working towards ensuring stronger health, nutrition and sanitation outcomes for all.
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Affiliation(s)
- Laili Irani
- Population Council, Zone 5A, Ground Floor, India Habitat Centre, Lodi Road, New Delhi, 110003, India.
| | - Janine Schooley
- Project Concern International, 5151 Murphy Canyon Rd, Suite 320, San Diego, CA, 92123, USA
| | - Supriya
- Population Council, Zone 5A, Ground Floor, India Habitat Centre, Lodi Road, New Delhi, 110003, India
| | - Indrajit Chaudhuri
- Project Concern International, 38, Okhla Phase 3 Rd, Okhla Phase III, Okhla Industrial Area, New Delhi, 110020, India
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Schleiff MJ, Aitken I, Alam MA, Damtew ZA, Perry HB. Community health workers at the dawn of a new era: 6. Recruitment, training, and continuing education. Health Res Policy Syst 2021; 19:113. [PMID: 34641898 PMCID: PMC8506097 DOI: 10.1186/s12961-021-00757-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This is the sixth of our 11-paper supplement entitled "Community Health Workers at the Dawn of New Era". Expectations of community health workers (CHWs) have expanded in recent years to encompass a wider array of services to numerous subpopulations, engage communities to collaborate with and to assist health systems in responding to complex and sometimes intensive threats. In this paper, we explore a set of key considerations for training of CHWs in response to their enhanced and changing roles and provide actionable recommendations based on current evidence and case examples for health systems leaders and other stakeholders to utilize. METHODS We carried out a focused review of relevant literature. This review included particular attention to a 2014 book chapter on training of CHWs for large-scale programmes, a systematic review of reviews about CHWs, the 2018 WHO guideline for CHWs, and a 2020 compendium of 29 national CHW programmes. We summarized the findings of this latter work as they pertain to training. We incorporated the approach to training used by two exemplary national CHW programmes: for health extension workers in Ethiopia and shasthya shebikas in Bangladesh. Finally, we incorporated the extensive personal experiences of all the authors regarding issues in the training of CHWs. RESULTS The paper explores three key themes: (1) professionalism, (2) quality and performance, and (3) scaling up. Professionalism: CHW tasks are expanding. As more CHWs become professionalized and highly skilled, there will still be a need for neighbourhood-level voluntary CHWs with a limited scope of work. Quality and performance: Training approaches covering relevant content and engaging CHWs with other related cadres are key to setting CHWs up to be well prepared. Strategies that have been recently integrated into training include technological tools and provision of additional knowledge; other strategies emphasize the ongoing value of long-standing approaches such as regular home visitation. Scale-up: Scaling up entails reaching more people and/or adding more complexity and quality to a programme serving a defined population. When CHW programmes expand, many aspects of health systems and the roles of other cadres of workers will need to adapt, due to task shifting and task sharing by CHWs. CONCLUSION Going forward, if CHW programmes are to reach their full potential, ongoing, up-to-date, professionalized training for CHWs that is integrated with training of other cadres and that is responsive to continued changes and emerging needs will be essential. Professionalized training will require ongoing monitoring and evaluation of the quality of training, continual updating of pre-service training, and ongoing in-service training-not only for the CHWs themselves but also for those with whom CHWs work, including communities, CHW supervisors, and other cadres of health professionals. Strong leadership, adequate funding, and attention to the needs of each cadre of CHWs can make this possible.
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Affiliation(s)
- Meike J. Schleiff
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Iain Aitken
- Management Sciences for Health, Ministry of Public Health, Kabul, Afghanistan
| | | | | | - Henry B. Perry
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
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Pant PR, Deave T, Banstola A, Bhatta S, Joshi E, Adhikari D, Manandhar SR, Joshi SK, Mytton JA. Home-related and work-related injuries in Makwanpur district, Nepal: a household survey. Inj Prev 2021; 27:450-455. [PMID: 33148799 PMCID: PMC8461414 DOI: 10.1136/injuryprev-2020-043986] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 10/01/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To describe the epidemiology of home-related and work-related injuries, their mechanisms, inequalities and costs associated with these injuries. METHODS A household survey was undertaken in three palikas of Makwanpur district between April and June 2019. Data were collected electronically on non-fatal injuries that occurred in the previous 3 months and fatal injuries that occurred in the previous 5 years. FINDINGS 17 593 individuals were surveyed from 3327 households. Injury rates were 8.0 per 1000 population for home injuries and 6.4 per 1000 for work-related injuries; 61.0% of home injuries were among women and 69.9% of work-related injuries among men. Falls were the cause of 48% home injuries, affecting 50.9% of men and 46.5% of women. Burns/scalds were higher in women than men, affecting 17.4% of women reporting home injuries. Cuts and piercings accounted for 39.8% of all work-related injuries and 36.3% were falls. Injury incidence varied by ethnic group: home injuries were highest in Brahmin (12.0 per 1000) and work-related injuries highest in Rai groups (21.0 per 1000). The total mean costs (transport and treatment) of work-related injury was US$143.3 (SD 276.7), higher than for home injuries (US$130.4, SD 347.6). The number of home (n=74, 64.9%) and work-related (n=67, 77.9%) injuries were higher in families below the poverty line than families in the next income bracket (home: n=22, 19.3%; work: n=11, 12.8%). CONCLUSIONS Home-related and work-related fall injuries are common. The inequalities in injury identified in our study by rurality, age, sex, income level and ethnic group can help target injury prevention interventions for vulnerable groups.
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Affiliation(s)
- Puspa Raj Pant
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Toity Deave
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Amrit Banstola
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Sumiksha Bhatta
- Kathmandu Medical College Public Limited, Nepal Injury Research Centre, Kathmandu, Nepal
| | - Elisha Joshi
- Kathmandu Medical College Public Limited, Nepal Injury Research Centre, Kathmandu, Nepal
| | - Dhruba Adhikari
- Mother and Infant Research Activities (MIRA), Kathmandu, Nepal
| | - Sunil Raja Manandhar
- Mother and Infant Research Activities (MIRA), Kathmandu, Nepal
- Department of Paediatrics, Kathmandu Medical College Public Limited, Kathmandu, Nepal
| | - Sunil Kumar Joshi
- Department of Community Medicine, Kathmandu Medical College Public Limited, Kathmandu, Nepal
| | - Julie A Mytton
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
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10
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Gram L, Desai S, Prost A. Classroom, club or collective? Three types of community-based group intervention and why they matter for health. BMJ Glob Health 2021; 5:bmjgh-2020-003302. [PMID: 33328198 PMCID: PMC7745328 DOI: 10.1136/bmjgh-2020-003302] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 10/06/2020] [Accepted: 10/08/2020] [Indexed: 12/12/2022] Open
Abstract
Interventions involving groups of laywomen, men and adolescents to promote health are increasingly popular, but past research has rarely distinguished between different types of intervention with groups. We introduce a simple typology that distinguishes three ideal types: classrooms, clubs and collectives. Classrooms treat groups as a platform for reaching a population with didactic behaviour change strategies. Clubs seek to build, strengthen and leverage relationships between group members to promote health. Collectives engage whole communities in assuming ownership over a health problem and taking action to address it. We argue that this distinction goes a long way towards explaining differences in achievable health outcomes using interventions with groups. First, classrooms and clubs are appropriate when policymakers primarily care about improving the health of group members, but collectives are better placed to achieve population-level impact. Second, classroom interventions implicitly assume bottleneck behaviours preventing a health outcome from being achieved can be reliably identified by experts, whereas collectives make use of local knowledge, skill and creativity to tackle complexity. Third, classroom interventions assume individual participants can address health issues largely on their own, while clubs and collectives are required to engender collective action in support of health. We invite public health researchers and policymakers to use our framework to align their own and communities’ ambitions with appropriate group-based interventions to test and implement for their context. We caution that our typology is meant to apply to groups of laypeople rather than professionalised groups such as whole civil society organisations.
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Affiliation(s)
- Lu Gram
- Institute for Global Health, Department of Population Health Sciences, University College London, London, UK
| | - Sapna Desai
- Population Council India, New Delhi, Delhi, India
| | - Audrey Prost
- Institute for Global Health, Department of Population Health Sciences, University College London, London, UK
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11
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Louart S, Bonnet E, Ridde V. Is patient navigation a solution to the problem of "leaving no one behind"? A scoping review of evidence from low-income countries. Health Policy Plan 2021; 36:101-116. [PMID: 33212491 PMCID: PMC7938515 DOI: 10.1093/heapol/czaa093] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2020] [Indexed: 12/25/2022] Open
Abstract
Patient navigation interventions, which are designed to enable patients excluded from health systems to overcome the barriers they face in accessing care, have multiplied in high-income countries since the 1990s. However, in low-income countries (LICs), indigents are generally excluded from health policies despite the international paradigm of universal health coverage (UHC). Fee exemption interventions have demonstrated their limits and it is now necessary to act on other dimensions of access to healthcare. However, there is a lack of knowledge about the interventions implemented in LICs to support the indigents throughout their care pathway. The aim of this paper is to synthesize what is known about patient navigation interventions to facilitate access to modern health systems for vulnerable populations in LICs. We therefore conducted a scoping review to identify all patient navigation interventions in LICs. We found 60 articles employing a total of 48 interventions. Most of these interventions targeted traditional beneficiaries such as people living with HIV, pregnant women and children. We utilized the framework developed by Levesque et al. (Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health 2013;12:18) to analyse the interventions. All acted on the ability to perceive, 34 interventions on the ability to reach, 30 on the ability to engage, 8 on the ability to pay and 6 on the ability to seek. Evaluations of these interventions were encouraging, as they often appeared to lead to improved health indicators and service utilization rates and reduced attrition in care. However, no intervention specifically targeted indigents and very few evaluations differentiated the impact of the intervention on the poorest populations. It is therefore necessary to test navigation interventions to enable those who are worst off to overcome the barriers they face. It is a major ethical issue that health policies leave no one behind and that UHC does not benefit everyone except the poorest.
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Affiliation(s)
- Sarah Louart
- Univ. Lille, CNRS, UMR 8019 - CLERSE - Centre Lillois d’Études et de Recherches sociologiques et Économiques, F-59000 Lille, France
| | - Emmanuel Bonnet
- Institute for Research on Sustainable Development, UMI Résiliences 236, Bondy, France
| | - Valéry Ridde
- Institute for Research on Sustainable Development, CEPED (IRD-Université de Paris), Université de Paris, ERL INSERM SAGESUD, 45 Rue des Saints-Pères, Paris 75006, France
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12
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Blanchard AK, Ansari S, Rajput R, Colbourn T, Houweling TAJ, Isac S, Anthony J, Prost A. Understanding the roles of community health workers in improving perinatal health equity in rural Uttar Pradesh, India: a qualitative study. Int J Equity Health 2021; 20:63. [PMID: 33622337 PMCID: PMC7901073 DOI: 10.1186/s12939-021-01406-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 02/09/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite substantial reductions in perinatal deaths (stillbirths and early neonatal deaths), India's perinatal mortality rates remain high, both nationally and in individual states. Rates are highest among disadvantaged socio-economic groups. To address this, India's National Health Mission has trained community health workers called Accredited Social Health Activists (ASHAs) to counsel and support women by visiting them at home before and after childbirth. We conducted a qualitative study to explore the roles of ASHAs' home visits in improving equity in perinatal health between socio-economic position groups in rural Uttar Pradesh (UP), India. METHODS We conducted social mapping in four villages of two districts in UP, followed by three focus group discussions in each village (12 in total) with ASHAs and women who had recently given birth belonging to 'higher' and 'lower' socio-economic position groups (n = 134 participants). We analysed the data in NVivo and Dedoose using a thematic framework approach. RESULTS Home visits enabled ASHAs to build trusting relationships with women, offer information about health services, schemes and preventive care, and provide practical support for accessing maternity care. This helped many women and families prepare for birth and motivated them to deliver in health facilities. In particular, ASHAs encouraged women who were poorer, less educated or from lower caste groups to give birth in public Community Health Centres (CHCs). However, women who gave birth at CHCs often experienced insufficient emergency obstetric care, mistreatment from staff, indirect costs, lack of medicines, and referrals to higher-level facilities when complications occurred. Referrals often led to delays and higher fees that placed the greatest burden on families who were considered of lower socio-economic position or living in remote areas, and increased their risk of experiencing perinatal loss. CONCLUSIONS The study found that ASHAs built relationships, counselled and supported many pregnant women of lower socio-economic positions. Ongoing inequities in health facility births and perinatal mortality were perpetuated by overlapping contextual issues beyond the ASHAs' purview. Supporting ASHAs' integration with community organisations and health system strategies more broadly is needed to address these issues and optimise pathways between equity in intervention coverage, processes and perinatal health outcomes.
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Affiliation(s)
- Andrea K Blanchard
- Institute for Global Public Health, University of Manitoba, R070 Medical Rehabilitation Building, 771 McDermot Avenue, Winnipeg, R3E 0T6, Canada.
| | - Shahnaz Ansari
- India Health Action Trust, 404, 4th Floor Ratan Square, Vidhan Sabha Marg, Lucknow, 226001, India
| | - Rajni Rajput
- India Health Action Trust, 404, 4th Floor Ratan Square, Vidhan Sabha Marg, Lucknow, 226001, India
| | - Tim Colbourn
- Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK
| | - Tanja A J Houweling
- Department of Public Health, Erasmus MC, Dr. Molewaterplein 40, 3015 GD, Rotterdam, Netherlands
| | - Shajy Isac
- Institute for Global Public Health, University of Manitoba, R070 Medical Rehabilitation Building, 771 McDermot Avenue, Winnipeg, R3E 0T6, Canada
- India Health Action Trust, 404, 4th Floor Ratan Square, Vidhan Sabha Marg, Lucknow, 226001, India
| | - John Anthony
- Institute for Global Public Health, University of Manitoba, R070 Medical Rehabilitation Building, 771 McDermot Avenue, Winnipeg, R3E 0T6, Canada
- India Health Action Trust, 404, 4th Floor Ratan Square, Vidhan Sabha Marg, Lucknow, 226001, India
| | - Audrey Prost
- Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK
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Belaid L, Ochola E, Bayo P, Alii GW, Ogwang M, Greco D, Zarowsky C. Exploring the impact of a community participatory intervention on women's capability: a qualitative study in Gulu Northern Uganda. BMC WOMENS HEALTH 2021; 21:28. [PMID: 33461541 PMCID: PMC7812725 DOI: 10.1186/s12905-020-01170-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 12/29/2020] [Indexed: 11/28/2022]
Abstract
Background Community participatory interventions mobilizing women of childbearing age are an effective strategy to promote maternal and child health. In 2017, we implemented this strategy in Gulu Northern Uganda. This study explored the perceived impact of this approach on women's capability. Methods We conducted a qualitative study based on three data collection methods: 14 in-depth individual interviews with participating women of childbearing age, five focus group discussions with female facilitators, and document analysis. We used the Sen capability approach as a conceptual framework and undertook a thematic analysis. Results Women adopted safe and healthy behaviors for themselves and their children. They were also able to respond to some of their family's financial needs. They reported a reduction in domestic violence and in mistreatment towards their children. The facilitators perceived improved communication skills, networking, self-confidence, and an increase in their social status. Nevertheless, the women still faced unfreedoms that deprived them of living the life they wanted to lead. These unfreedoms are related to their lack of access to economic opportunities and socio-cultural norms underlying gender inequalities. Conclusion To expand women's freedoms, we need more collective political actions to tackle gender inequalities and need to question the values underlying women's social status.
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Affiliation(s)
- Loubna Belaid
- Family Medicine Department, McGill University, 5858 Chemin de la Côte des Neiges, Montreal, QC, Canada.
| | | | - Pontius Bayo
- St. Mary's Lacor Hospital, P.O. Box 180, Gulu, Uganda
| | | | - Martin Ogwang
- St. Mary's Lacor Hospital, P.O. Box 180, Gulu, Uganda
| | - Donato Greco
- International Prevention Research Institute, Allée Claude Debussy, 69130, Écully, Lyon, France
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14
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Mueller S, Soriano D, Boscor A, Saville NM, Arjyal A, Baral S, Fordham M, Hearn G, Kayastha R, Kostkova P. MANTRA: Improving Knowledge of Maternal Health, Neonatal Health, and Geohazards in Women in Rural Nepal Using a Mobile Serious Game. Front Public Health 2020; 8:584375. [PMID: 33363082 PMCID: PMC7759478 DOI: 10.3389/fpubh.2020.584375] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 11/19/2020] [Indexed: 11/13/2022] Open
Abstract
Serious games, conveying educational knowledge rather than merely entertainment, are a rapidly expanding research domain for cutting-edge educational technology. Digital interventions like serious games are great opportunities to overcome challenges in low-and-middle-income countries that limit access to health information, such as social barriers like low-literacy and gender. MANTRA: Increasing maternal and child health resilience before, during and after disasters using mobile technology in Nepal takes on these challenges with a novel digital health intervention; a serious mobile game aimed at vulnerable low-literacy female audiences in rural Nepal. The serious game teaches 28 learning objectives of danger signs in geohazards, maternal, and neonatal health to improve knowledge and self-assessment of common conditions and risks to inform healthcare-seeking behavior. Evaluations consisted of recruiting 35 end users to participate in a pre-test assessment, playing the game, post-test assessment, and focus groups to elicit qualitative feedback. Assessments analyzed knowledge gain in two ways; by learning objective with McNemar tests for each learning objective, and by participant scores with paired t-tests of overall scores and by module. Results of assessments of knowledge gain by learning objective (McNemar tests) indicate participants had sufficient prior knowledge to correctly interpret and respond to 26% of pictograms (coded AA), which is a desirable result although without the possibility of improvement through the intervention. The geohazard module had greatest impact as 16% of responses showed knowledge gain (coded BA). The two most successful learning objectives showing statistically significant positive change were evidence of rockfalls and small cracks in the ground (p = < 0.05). Assessment of knowledge gain by participant scores (paired t-tests) showed the 35 participants averaged a 7.7 point improvement (p < 0.001) in the assessment (28 learning objectives). Average change in knowledge of subdivided module scores (each module normalized to 100 points for comparison) was greatest in the geohazard module (9.5 points, p < 0.001), then maternal health (7.4 points, p = 0.0067), and neonatal health (6.0 points, p = 0.013). This evaluation demonstrated that carefully designed digital health interventions with pictograms co-authored by experts and users can teach complex health and geohazard situations. Significant knowledge gain was demonstrated for several learning objectives while those with non-significant or negative change will be re-designed to effectively convey information.
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Affiliation(s)
- Sonja Mueller
- Institute for Risk and Disaster Reduction, University College London, London, United Kingdom.,Institute for Risk and Disaster Reduction Centre for Digital Public Health in Emergencies (dPHE), University College London, London, United Kingdom
| | - Delphine Soriano
- Institute for Risk and Disaster Reduction, University College London, London, United Kingdom.,Institute for Risk and Disaster Reduction Centre for Digital Public Health in Emergencies (dPHE), University College London, London, United Kingdom
| | - Andrei Boscor
- Institute for Risk and Disaster Reduction, University College London, London, United Kingdom.,Institute for Risk and Disaster Reduction Centre for Digital Public Health in Emergencies (dPHE), University College London, London, United Kingdom
| | - Naomi M Saville
- Institute for Global Health, University College London, London, United Kingdom
| | - Abriti Arjyal
- Health Research and Social Development Forum, Kathmandu, Nepal
| | - Sushil Baral
- Health Research and Social Development Forum, Kathmandu, Nepal
| | - Maureen Fordham
- Institute for Risk and Disaster Reduction, University College London, London, United Kingdom.,Institute for Risk and Disaster Reduction Centre for Gender and Disaster, University College London, London, United Kingdom
| | | | - Rachya Kayastha
- Institute for Risk and Disaster Reduction, University College London, London, United Kingdom.,Institute for Global Health, University College London, London, United Kingdom
| | - Patty Kostkova
- Institute for Risk and Disaster Reduction, University College London, London, United Kingdom.,Institute for Risk and Disaster Reduction Centre for Digital Public Health in Emergencies (dPHE), University College London, London, United Kingdom
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15
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Lee M. Engaging female community health volunteers in maternal health services and its satisfaction among village mothers in Hill and Mountain Regions, Nepal. AIMS Public Health 2020; 7:778-791. [PMID: 33294481 PMCID: PMC7719561 DOI: 10.3934/publichealth.2020060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 09/23/2020] [Indexed: 11/18/2022] Open
Abstract
Background Female Community Health Volunteers (FCHVs) are service providers and educators for maternal health at the village level (in the hill and Terai district) in Nepal. At present, there are insufficient data and little is understood about the maternal health service (MHS) of FCHVs from Nepali mothers' perspective. Methodology The research was undertaken in three hill and mountain regions where there should be at least one FCHVs per ward, Thulo sirubari, Sano sirubari and Jalkeni in Chautara Sangachowkgadi in Nepal, during five days from 5 April to 9 April 2019. The study worked with a local partner organisation, Green Tara Nepal (GTN). The study took the form of a qualitative approach with a community-based snowball approach (seed-and-recruit approach), which consisted of interviews with six key informants and 11 village mothers who have a child aged under five. Results The study found that all participated mothers recognised FCHVs and that it was easy to contact them within walking distance. They were happy with FCHV's existence and had a close relationship between them. They were all satisfied with MHS from FCHVs. In particular, accessibility of FCHVs, frequent home visits, monthly mothers' meetings, and regular ANC were the main points of satisfaction. Moreover, NGO intervention increased their satisfaction and contributed significantly to FCHV activities. However, the lack of meeting place and sustainable incentives are challenging to implement monthly mothers' meetings. Sufficient regular refresher training for FCHVs is also required to educate them better. Furthermore, the local government's unequally distributed budget for FCHVs programmes, small incentives, and benefits for FCHVs are challenges. Conclusion This study offered various views with vivid memories into the satisfaction of FCHV's MHS among village mothers in three hill and mountain regions of Nepal. FCHVs are essential assets for MHS in rural communities. The FCHVs programme should be complemented by (1) supporting suitable meeting place of mother's meeting, (2) providing sustainable and sufficient budget for mother's meeting and FCHVs, (3) distributing the budget equally in each ward, (4) offering frequent FCHVs training to improve the MHS for village mothers.
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Affiliation(s)
- Mina Lee
- STOP-TB Partnership KOREA, Korean National Tuberculosis Association, Siem Reap, Cambodia
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16
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Zuurmond M, Seeley J, Shakespeare T, Nyante GG, Bernays S. Illuminating the empowerment journey of caregivers of children with disabilities: Understanding lessons learnt from Ghana. Afr J Disabil 2020; 9:705. [PMID: 33354533 PMCID: PMC7736676 DOI: 10.4102/ajod.v9i0.705] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 09/23/2020] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Empowerment is an increasingly popular goal, considered core to a transformative agenda for children with disabilities and their families. However, it can still be a poorly understood concept in practice. OBJECTIVE This article is an empirical analysis of the 'empowerment journeys' of caregivers participating in a community-based training programme in Ghana. METHOD In-depth interviews were conducted with 18 caregivers at three time points over 14 months. Thematic analysis was conducted on the full data set, with three representative case studies selected for more detailed analysis to illustrate the dynamism of time and context in shaping the empowerment journey. RESULTS Our findings illuminate the complexity and non-linearity of the caregiver empowerment journey. There were important gains in individual dimensions of power and the nascent emergence of collective power, through improved knowledge and valuable peer support from group membership. However, further gains were impeded by their limited influence over wider economic and sociopolitical structural issues that perpetuated their experiences of poverty, stigma and the gendered nature of caregiving. The support group facilitator often played a valuable brokering role to help traverse individual agency and structural issues. CONCLUSION A richer and more nuanced understanding of caregiver empowerment in the community and family context can inform the wider discourse on disability. Guidelines on working with people with disabilities, and the role of empowerment, should not neglect the pivotal role of caregivers. There are important lessons to be learnt if we want to improve family-centred interventions and transform the lives of children with disabilities.
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Affiliation(s)
- Maria Zuurmond
- International Centre for Evidence in Disability, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Janet Seeley
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Tom Shakespeare
- International Centre for Evidence in Disability, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Gifty G. Nyante
- Department of Physiotherapy, Faculty Biomedical and Health Sciences, University of Ghana, Accra, Ghana
| | - Sarah Bernays
- School of Public Health, Faculty Medicine and Health, University of Sydney, Sydney, Australia
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Mueller S, Soriano D, Boscor A, Saville N, Arjyal A, Baral S, Fordham M, Hearn G, Le Masson V, Kayastha R, Kostkova P. MANTRA: development and localization of a mobile educational health game targeting low literacy players in low and middle income countries. BMC Public Health 2020; 20:1171. [PMID: 32723317 PMCID: PMC7385876 DOI: 10.1186/s12889-020-09246-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 07/12/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mobile technology is increasingly important for delivering public health interventions to remote populations. This research study developed, piloted, and assessed a serious game for mobile devices that teaches geohazard, maternal, and neonatal health messages. This unique mHealth intervention aimed at low-literacy audiences in low resource settings is part of the Maternal and Neonatal Technologies in Rural Areas (MANTRA) project: Increasing maternal and child health resilience before, during, and after disasters using mobile technology in Nepal. METHODS The serious game was developed through a co-creation process between London and Kathmandu based researchers by email and video-calling, and face-to-face with local stakeholders in Nepal. The process identified core needs, developed appropriate pictograms and mechanics, and tailored the pilot serious game to the local cultural context. Evaluations and feedback from end users took place in rural villages and suburban Kathmandu in Province Three. Field evaluation sessions used mixed methods. Researchers observed game play and held focus group discussions to elicit qualitative feedback and understand engagement, motivation, and usability, and conducted a paired pre- and post-game knowledge assessment. RESULTS The MANTRA serious game is contextualized to rural Nepal. The game teaches 28 learning objectives in three modules: maternal health, neonatal health, and geohazards, through picture matching with immediate audio and visual feedback. User feedback from focus groups demonstrated high engagement, motivation, and usability of the game. CONCLUSIONS This MANTRA study is a unique mHealth intervention of a serious game to teach core health and geohazards messages to low-literacy audiences in rural Nepal. Although the mobile game is tailored for this specific context, the developmental process and insights could be transferable to the development of other games-based interventions and contextualized for any part of the world. Successfully targeting this low-literacy and illiterate audience makes the MANTRA development process the first of its kind and a novel research endeavor with potential for widespread impact and adoption following further game development. TRIAL REGISTRATION This project was approved by the University College London Ethics Committee in London, United Kingdom [10547/001], and the Nepal Health Research Council in Kathmandu, Nepal [Reg. No. 105/2017]. All participants provided informed written consent.
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Affiliation(s)
- Sonja Mueller
- Institute for Risk and Disaster Reduction, University College London, Gower Street, London, WC1E 6BT, UK.
- Centre for Digital Public Health in Emergencies (dPHE), University College London, Gower Street, London, WC1E 6BT, UK.
| | - Delphine Soriano
- Institute for Risk and Disaster Reduction, University College London, Gower Street, London, WC1E 6BT, UK
- Centre for Digital Public Health in Emergencies (dPHE), University College London, Gower Street, London, WC1E 6BT, UK
| | - Andrei Boscor
- Institute for Risk and Disaster Reduction, University College London, Gower Street, London, WC1E 6BT, UK
- Centre for Digital Public Health in Emergencies (dPHE), University College London, Gower Street, London, WC1E 6BT, UK
| | - Naomi Saville
- Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK
| | - Abriti Arjyal
- Health Research and Social Development Forum, Prasuti Griha Marg, Kathmandu, 44600, Nepal
| | - Sushil Baral
- Health Research and Social Development Forum, Prasuti Griha Marg, Kathmandu, 44600, Nepal
| | - Maureen Fordham
- Institute for Risk and Disaster Reduction, University College London, Gower Street, London, WC1E 6BT, UK
- Centre for Gender and Disaster, University College London, Gower Street, London, WC1E 6BT, UK
| | | | - Virginie Le Masson
- Overseas Development Institute, 203 Blackfriars Road, London, SE1 8NJ, UK
| | - Rachya Kayastha
- Institute for Risk and Disaster Reduction, University College London, Gower Street, London, WC1E 6BT, UK
- Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK
| | - Patty Kostkova
- Institute for Risk and Disaster Reduction, University College London, Gower Street, London, WC1E 6BT, UK
- Centre for Digital Public Health in Emergencies (dPHE), University College London, Gower Street, London, WC1E 6BT, UK
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Laurenzi CA, Skeen S, Coetzee BJ, Gordon S, Notholi V, Tomlinson M. How do pregnant women and new mothers navigate and respond to challenges in accessing health care? Perspectives from rural South Africa. Soc Sci Med 2020; 258:113100. [PMID: 32534304 DOI: 10.1016/j.socscimed.2020.113100] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 05/13/2020] [Accepted: 05/30/2020] [Indexed: 11/30/2022]
Abstract
Women in low- and middle-income countries and in contexts characterized by inequality face various interpersonal and structural barriers when accessing formal maternal and child health (MCH) services. These barriers persist even in contexts where programs to increase access to services, such as community health worker (CHW) interventions, have been implemented. However, while barriers to accessing care have been extensively documented, less is known about the diverse ways that women respond to, and navigate, these situations. This study explores strategies pregnant women and new mothers use to navigate and respond to health care barriers in a rural district in the Eastern Cape, South Africa. Twenty-six pregnant or recently delivered clients of the Enable Mentor Mother program were interviewed about their experiences of accessing formal MCH services. Interviews were conducted between February-March 2018 by an experienced isiXhosa-speaking research assistant, translated and transcribed into English, with transcripts coded and organized by themes using ATLAS.ti software. Facing resource shortages, inconsistent communication, and long travel times to clinics, participants employed diverse, innovative strategies to navigate interpersonal and structural barriers to care. While some participants chose to respond to barriers more passively-citing endurance and acceptance as practices of health system engagement-those participants who focused more on active responses tended to leverage their education, existing relationships, and available community resources to overcome barriers. Nevertheless, most participants described feelings of frustration and dejection. While CHW interventions may alleviate some of the burdens facing fragile health care systems in these contexts, these programs still rely on an underlying infrastructure of care that primary health care clinics and hospitals should be providing. Future programming should work in tandem with formal health systems and should support staff to improve quality of care provided to pregnant women, new mothers, and their infants to prioritize their health at a time of vulnerability.
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Affiliation(s)
- Christina A Laurenzi
- Institute for Life Course Health Research, Department of Global Health, 4009 Education Building, Faculty of Medical and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Western Cape, 7505, South Africa; Department of Psychology, Willcocks Building, Stellenbosch University, Stellenbosch, Western Cape, 7600, South Africa.
| | - Sarah Skeen
- Institute for Life Course Health Research, Department of Global Health, 4009 Education Building, Faculty of Medical and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Western Cape, 7505, South Africa
| | - Bronwyne J Coetzee
- Department of Psychology, Willcocks Building, Stellenbosch University, Stellenbosch, Western Cape, 7600, South Africa
| | - Sarah Gordon
- Institute for Life Course Health Research, Department of Global Health, 4009 Education Building, Faculty of Medical and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Western Cape, 7505, South Africa
| | - Vuyolwethu Notholi
- Institute for Life Course Health Research, Department of Global Health, 4009 Education Building, Faculty of Medical and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Western Cape, 7505, South Africa
| | - Mark Tomlinson
- Institute for Life Course Health Research, Department of Global Health, 4009 Education Building, Faculty of Medical and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Western Cape, 7505, South Africa; School of Nursing and Midwifery, Queens University, Medical Biology Centre, 97 Lisburn Road, Belfast, Northern Ireland BT9 7BL, United Kingdom
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19
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Evaluation of a health promotion intervention associated with birthing centres in rural Nepal. PLoS One 2020; 15:e0233607. [PMID: 32442234 PMCID: PMC7244127 DOI: 10.1371/journal.pone.0233607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 05/10/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Birthing centres (BC) in Nepal are mostly situated in rural areas and provide care for women without complications. However, they are often bypassed by women and their role in providing good quality maternity services is overlooked. This study evaluated an intervention to increase access and utilisation of perinatal care facilities in community settings. METHODS This longitudinal cross-sectional study was conducted over five years in four villages in Nepal and included two BCs. An intervention was conducted in 2014-2016 that involved supporting the BCs and conducting a health promotion programme with local women. Population-based multi-stage sampling of women of reproductive age with a child below 24 months of age was undertaken. Household surveys were conducted (2012 and 2017) employing trained enumerators and using a structured validated questionnaire. The collected data were entered into SPSS and analysed comparing pre- and post-intervention surveys. RESULTS The intervention was associated with an increase in uptake in facility birth, with an increase in utilisation of perinatal services available from BCs. The post-intervention survey provided evidence that women were more likely to give birth at primary care facilities (OR 5.60, p-value <0.001) than prior to the intervention. Similarly, the likelihood of giving birth at a health facility increased if decision for birthplace was made jointly by women and family members for primary care facilities (OR 1.76, p-value 0.023) and hospitals/tertiary care facilities (OR 1.78, p-value 0.020. If women had less than four ANC visits, then they were less likely to give birth at primary care facilities (OR 0.39, p-value <0.001) or hospitals/tertiary care facilities (OR 0.63, p-value 0.014). Finally, women were less likely to give birth at primary care facilities if they had only primary level of education (OR 0.49, p-value 0.014). CONCLUSION BCs have the potential to increase the births at health facilities and decrease home births if their services are promoted by the local health promoters. In addition, socio-economic factors including women's education, the level of women's autonomy and having four or more ANC visits affect the utilisation of perinatal services at the health facility.
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20
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Morrison J, Tumbahangphe K, Sen A, Gram L, Budhathoki B, Neupane R, Thapa R, Dahal K, Thapa B, Manandhar D, Costello A, Osrin D. Health management committee strengthening and community mobilisation through women's groups to improve trained health worker attendance at birth in rural Nepal: a cluster randomised controlled trial. BMC Pregnancy Childbirth 2020; 20:268. [PMID: 32375684 PMCID: PMC7201973 DOI: 10.1186/s12884-020-02960-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 04/21/2020] [Indexed: 12/02/2022] Open
Abstract
Background Engaging citizens and communities to make services accountable is vital to achieving health development goals. Community participation in health management committees can increase public accountability of health services. We conducted a cluster randomised controlled trial to test the impact of strengthened health management committees (HMCs) and community mobilisation through women’s groups on institutional deliveries and deliveries by trained health workers in rural Nepal. Methods The study was conducted in all Village Development Committee clusters in the hills district of Makwanpur (population of 420,500). In 21 intervention clusters, we conducted three-day workshops with HMCs to improve their capacity for planning and action and supported female community health volunteers to run women’s groups. These groups met once a month and mobilised communities to address barriers to institutional delivery through participatory learning and action cycles. We compared this intervention with 22 control clusters. Prospective surveillance from October 2010 to the end of September 2012 captured complete data on 13,721 deliveries in intervention and control areas. Analysis was by intention to treat. Results The women’s group intervention was implemented as intended, but we were unable to support HMCs as planned because many did not meet regularly. The activities of community based organisations were systematically targeted at control clusters, which meant that there were no true ‘control’ clusters. 39% (5403) of deliveries were in health institutions and trained health workers attended most of them. There were no differences between trial arms in institutional delivery uptake (1.45, 0.76–2.78) or attendance by trained health workers (OR 1.43, 95% CI 0.74–2.74). Conclusions The absence of a true counterfactual and inadequate coverage of the HMC strengthening intervention impedes our ability to draw conclusions. Further research is needed to test the effectiveness of strengthening public accountability mechanisms on increased utilisation of services at delivery. Trial registration Current Controlled Trials ISRCTN99834806. Date of registration:28/09/10.
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Affiliation(s)
- Joanna Morrison
- Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK.
| | - Kirti Tumbahangphe
- Mother and Infant Research Activities, PO Box 921, Thapathali, Kathmandu, Nepal
| | - Aman Sen
- Mother and Infant Research Activities, PO Box 921, Thapathali, Kathmandu, Nepal
| | - Lu Gram
- Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK
| | - Bharat Budhathoki
- Mother and Infant Research Activities, PO Box 921, Thapathali, Kathmandu, Nepal
| | - Rishi Neupane
- Mother and Infant Research Activities, PO Box 921, Thapathali, Kathmandu, Nepal
| | - Rita Thapa
- Mother and Infant Research Activities, PO Box 921, Thapathali, Kathmandu, Nepal
| | - Kunta Dahal
- Mother and Infant Research Activities, PO Box 921, Thapathali, Kathmandu, Nepal
| | - Bidur Thapa
- Mother and Infant Research Activities, PO Box 921, Thapathali, Kathmandu, Nepal
| | - Dharma Manandhar
- Mother and Infant Research Activities, PO Box 921, Thapathali, Kathmandu, Nepal
| | - Anthony Costello
- Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK
| | - David Osrin
- Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK
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21
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Carlisle K, Felton-Busch C, Cadet-James Y, Taylor J, Bailie R, Farmer J, Passey M, Matthews V, Callander E, Evans R, Kelly J, Preston R, Redman-MacLaren M, Fox H, Esterman A, Zwarenstein M, Larkins S. WOmen's Action for Mums and Bubs (WOMB) Trial Protocol: A Non-randomized Stepped Wedge Implementation Trial of Participatory Women's Groups to Improve the Health of Aboriginal and Torres Strait Islander Mothers and Children in Australia. Front Public Health 2020; 8:73. [PMID: 32257990 PMCID: PMC7093577 DOI: 10.3389/fpubh.2020.00073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 02/25/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: In Australia, there have been improvements in Aboriginal and Torres Strait Islander maternal health, however inequities remain. There is increasing international evidence illustrating the effectiveness of Participatory Women's Groups (PWGs) in improving Maternal and Child Health (MCH) outcomes. Using a non-randomized, cluster stepped-wedge implementation of a complex intervention with mixed methods evaluation, this study aims to test the effectiveness of PWGs in improving MCH within Indigenous primary care settings in Australia and how they operate in various contexts. Methods: This study takes place in ten primary health care services across Australia and involves the recruitment of existing PWGs or the setting up of new PWGs. Services are paired based on geography for practical reasons and two services commence the PWG intervention at three monthly intervals, with the initial four services being those with existing women's groups. Implementation of the PWGs as an intervention involves training local facilitators of PWG groups, supported engagement with local MCH data through workshops, PWGs identifying and prioritizing issues and strengths and co-implementing solutions with health services. Outcomes are measured with yearly MCH audits, a cost-effectiveness study, and process evaluation of community participation and empowerment. Discussion: This study is the first to formally implement and quantitatively, yet with contextual awareness, measure the effect of applying a community participation intervention to improve the quality of Aboriginal and Torres Strait Islander MCH in Australia. Findings from this work, including detailed theory-producing qualitative analysis, will produce new knowledge of how to facilitate improved quality of MCH care in Indigenous PHC settings and how to best engage community in driving health care improvements. Trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12618000945224. Web address: http://www.ANZCTR.org.au/ACTRN12618000945224.aspx.
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Affiliation(s)
- Karen Carlisle
- College of Medicine and Dentistry, James Cook University, Douglas, QLD, Australia.,Anton Breinl Research Centre for Health Systems Strengthening, James Cook University, Townsville, QLD, Australia.,Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, QLD, Australia
| | - Catrina Felton-Busch
- Anton Breinl Research Centre for Health Systems Strengthening, James Cook University, Townsville, QLD, Australia.,Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, QLD, Australia.,Centre for Rural and Remote Health, James Cook University, Mount Isa, QLD, Australia
| | - Yvonne Cadet-James
- Anton Breinl Research Centre for Health Systems Strengthening, James Cook University, Townsville, QLD, Australia.,Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, QLD, Australia.,Indigenous Education and Research Centre, James Cook University, Douglas, QLD, Australia
| | - Judy Taylor
- College of Medicine and Dentistry, James Cook University, Douglas, QLD, Australia.,Anton Breinl Research Centre for Health Systems Strengthening, James Cook University, Townsville, QLD, Australia.,Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, QLD, Australia
| | - Ross Bailie
- University Centre for Rural Health, University of Sydney, Lismore, NSW, Australia
| | - Jane Farmer
- Social Innovation Research Unit, Swinburne University of Technology, Hawthorn, VIC, Australia
| | - Megan Passey
- University Centre for Rural Health, University of Sydney, Lismore, NSW, Australia
| | - Veronica Matthews
- University Centre for Rural Health, University of Sydney, Lismore, NSW, Australia
| | - Emily Callander
- School of Medicine, Griffith University, Gold Coast, QLD, Australia
| | - Rebecca Evans
- College of Medicine and Dentistry, James Cook University, Douglas, QLD, Australia.,Anton Breinl Research Centre for Health Systems Strengthening, James Cook University, Townsville, QLD, Australia.,Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, QLD, Australia
| | - Janet Kelly
- Adelaide Nursing School, University of Adelaide, Adelaide, SA, Australia
| | - Robyn Preston
- School of Health, Medical and Applied Science, CQUniversity, Townsville, QLD, Australia
| | - Michelle Redman-MacLaren
- Anton Breinl Research Centre for Health Systems Strengthening, James Cook University, Townsville, QLD, Australia.,Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, QLD, Australia.,College of Medicine and Dentistry, James Cook University, Smithfied, QLD, Australia
| | - Haylee Fox
- School of Medicine, Griffith University, Gold Coast, QLD, Australia
| | - Adrian Esterman
- Australian Institute of Tropical Health and Medicine, James Cook University, Smithfield, QLD, Australia
| | - Merrick Zwarenstein
- Centre for Studies in Family Medicine, Department of Family Medicine and Schulich School of Medicine & Dentistry, Western Centre for Public Health and Family Medicine, Western University, London, ON, Canada
| | - Sarah Larkins
- College of Medicine and Dentistry, James Cook University, Douglas, QLD, Australia.,Anton Breinl Research Centre for Health Systems Strengthening, James Cook University, Townsville, QLD, Australia.,Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, QLD, Australia
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22
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Harsha Bangura A, Nirola I, Thapa P, Citrin D, Belbase B, Bogati B, B K N, Khadka S, Kunwar L, Halliday S, Choudhury N, Schwarz R, Adhikari M, Kalaunee SP, Rising S, Maru D, Maru S. Measuring fidelity, feasibility, costs: an implementation evaluation of a cluster-controlled trial of group antenatal care in rural Nepal. Reprod Health 2020; 17:5. [PMID: 31952543 PMCID: PMC6967133 DOI: 10.1186/s12978-019-0840-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 12/02/2019] [Indexed: 12/04/2022] Open
Abstract
Background Access to high-quality antenatal care services has been shown to be beneficial for maternal and child health. In 2016, the WHO published evidence-based recommendations for antenatal care that aim to improve utilization, quality of care, and the patient experience. Prior research in Nepal has shown that a lack of social support, birth planning, and resources are barriers to accessing services in rural communities. The success of CenteringPregnancy and participatory action women’s groups suggests that group care models may both improve access to care and the quality of care delivered through women’s empowerment and the creation of social networks. We present a group antenatal care model in rural Nepal, designed and implemented by the healthcare delivery organization Nyaya Health Nepal, as well as an assessment of implementation outcomes. Methods The study was conducted at Bayalata Hospital in Achham, Nepal, via a public private partnership between the Nepali non-profit, Nyaya Health Nepal, and the Ministry of Health and Population, with financial and technical assistance from the American non-profit, Possible. We implemented group antenatal care as a prospective non-randomized cluster-controlled, type I hybrid effectiveness-implementation study in six village clusters. The implementation approach allows for iterative improvement in design, making changes to improve the quality of the intervention. Assessments of implementation process and model fidelity were undertaken using a mobile checklist completed by nurse supervisors, and observation forms completed by program leadership. We evaluated data quarterly using descriptive statistics to identify trends. Qualitative interviews and team communications were analyzed through immersion crystallization to identify major themes that evolved during the implementation process. Results A total of 141 group antenatal sessions were run during the study period. This paper reports on implementation results, whereas we analyze and present patient-level effectiveness outcomes in a complementary paper in this journal. There was high process fidelity to the model, with 85.7% (95% CI 77.1–91.5%) of visits completing all process elements, and high content fidelity, with all village clusters meeting the minimum target frequency for 80% of topics. The annual per capita cost for group antenatal care was 0.50 USD. Qualitative analysis revealed the compromise of stable gestation-matched composition of the group members in order to make the intervention feasible. Major adaptations were made in training, documentation, feedback and logistics. Conclusion Group antenatal care provided in collaboration with local government clinics has the potential to provide accessible and high quality antenatal care to women in rural Nepal. The intervention is a feasible and affordable alternative to individual antenatal care. Our experience has shown that adaptation from prior models was important for the program to be successful in the local context within the national healthcare system. Trial registration ClinicalTrials.gov Identifier: NCT02330887, registered 01/05/2015, retroactively registered.
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Affiliation(s)
| | - Isha Nirola
- Harvard T.H, Chan School of Public Health, Boston, MA, USA
| | - Poshan Thapa
- University of New South Wales, School of Public Health and Community Medicine, Sydney, NSW, Australia
| | - David Citrin
- Nyaya Health Nepal, Kathmandu, Nepal.,Department of Anthropology, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA.,University of Washington, Henry M. Jackson School of International Studies, Seattle, WA, USA.,Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, 1216 Fifth Avenue Fifth Floor, Room 556, New York, NY, 10029, USA.,Possible, New York, NY, USA
| | | | - Bhawana Bogati
- Nyaya Health Nepal, Kathmandu, Nepal.,Possible, New York, NY, USA
| | - Nirmala B K
- Om Health Science Campus, Purbanchal University, Kathmandu, VA, Nepal
| | - Sonu Khadka
- Nyaya Health Nepal, Kathmandu, Nepal.,Possible, New York, NY, USA
| | - Lal Kunwar
- Nyaya Health Nepal, Kathmandu, Nepal.,Possible, New York, NY, USA
| | - Scott Halliday
- Nyaya Health Nepal, Kathmandu, Nepal.,Department of Global Health, University of Washington, Seattle, WA, USA.,University of Washington, Henry M. Jackson School of International Studies, Seattle, WA, USA.,Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, 1216 Fifth Avenue Fifth Floor, Room 556, New York, NY, 10029, USA.,Possible, New York, NY, USA
| | - Nandini Choudhury
- Nyaya Health Nepal, Kathmandu, Nepal.,Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, 1216 Fifth Avenue Fifth Floor, Room 556, New York, NY, 10029, USA.,Possible, New York, NY, USA
| | - Ryan Schwarz
- Nyaya Health Nepal, Kathmandu, Nepal.,Department of Medicine, Brigham and Women's Hospital, Division of Global Health Equity, Boston, MA, USA.,Department of Medicine, Massachusetts General Hospital, Division of General Internal Medicine, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA.,Possible, New York, NY, USA
| | | | - S P Kalaunee
- Nyaya Health Nepal, Kathmandu, Nepal.,Eastern University, College of Business and Leadership, St. Davids, PA, USA.,Possible, New York, NY, USA
| | | | - Duncan Maru
- Nyaya Health Nepal, Kathmandu, Nepal.,Department of Health Systems Design and Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, 1216 Fifth Avenue Fifth Floor, Room 556, New York, NY, 10029, USA.,Icahn School of Medicine at Mount Sinai, Department of Pediatrics, New York, NY, USA.,Icahn School of Medicine at Mount Sinai, Department of Internal Medicine, New York, NY, USA.,Possible, New York, NY, USA
| | - Sheela Maru
- Nyaya Health Nepal, Kathmandu, Nepal. .,Department of Health Systems Design and Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA. .,Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, 1216 Fifth Avenue Fifth Floor, Room 556, New York, NY, 10029, USA. .,Icahn School of Medicine at Mount Sinai, Department of Obstetrics, Gynecology and Reproductive Science, New York, NY, USA. .,Possible, New York, NY, USA.
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23
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Gram L, Fitchett A, Ashraf A, Daruwalla N, Osrin D. Promoting women's and children's health through community groups in low-income and middle-income countries: a mixed-methods systematic review of mechanisms, enablers and barriers. BMJ Glob Health 2019; 4:e001972. [PMID: 31908874 PMCID: PMC6936553 DOI: 10.1136/bmjgh-2019-001972] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 10/23/2019] [Accepted: 11/10/2019] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Community mobilisation through group activities has been used to improve women's and children's health in a range of low-income and middle-income contexts, but the mechanisms through which it works deserve greater consideration. We did a mixed-methods systematic review of mechanisms, enablers and barriers to the promotion of women's and children's health in community mobilisation interventions. METHODS We searched for theoretical and empirical peer-reviewed articles between January 2000 and November 2018. First, we extracted and collated proposed mechanisms, enablers and barriers into categories. Second, we extracted and synthesised evidence for them using narrative synthesis. We assessed risk of bias with adapted Downs and Black and Critical Appraisal Skills Programme checklists. We assigned confidence grades to each proposed mechanism, enabler and barrier. RESULTS 78 articles met the inclusion criteria, of which 39 described interventions based on a participatory group education model, 19 described community-led structural interventions to promote sexual health in marginalised populations and 20 concerned other types of intervention or multiple interventions at once. We did not have high confidence in any mechanism, enabler or barrier. Two out of 15 proposed mechanisms and 10 out of 12 proposed enablers and barriers reached medium confidence. A few studies provided direct evidence relating proposed mechanisms, enablers or barriers to health behaviours or health outcomes. Only two studies presented mediation or interaction analysis for a proposed mechanism, enabler or barrier. CONCLUSION We uncovered multiple proposed mechanisms, enablers and barriers to health promotion through community groups, but much work remains to provide a robust evidence base for proposed mechanisms, enablers and barriers. PROSPERO REGISTRATION NUMBER CRD42018093695.
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Affiliation(s)
- Lu Gram
- Institute for Global Health, University College London, London, UK
| | - Adam Fitchett
- Faculty of Life Sciences, University College London, London, UK
| | - Asma Ashraf
- Institute for Global Health, University College London, London, UK
| | - Nayreen Daruwalla
- Society for Nutrition, Education & Health Action (SNEHA), Mumbai, Maharashtra, India
| | - David Osrin
- Institute for Global Health, University College London, London, UK
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24
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Morrison J, Akter K, Jennings HM, Nahar T, Kuddus A, Shaha SK, Ahmed N, King C, Haghparast-Bidgoli H, Costello A, Khan AKA, Azad K, Fottrell E. Participatory learning and action to address type 2 diabetes in rural Bangladesh: a qualitative process evaluation. BMC Endocr Disord 2019; 19:118. [PMID: 31684932 PMCID: PMC6830002 DOI: 10.1186/s12902-019-0447-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 10/18/2019] [Indexed: 12/24/2022] Open
Abstract
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 .
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Affiliation(s)
- Joanna Morrison
- University College London Institute for Global Health, London, UK
| | | | | | - Tasmin Nahar
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Abdul Kuddus
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | - Naveed Ahmed
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Carina King
- University College London Institute for Global Health, London, UK
| | | | - Anthony Costello
- University College London Institute for Global Health, London, UK
| | | | - Kishwar Azad
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Edward Fottrell
- University College London Institute for Global Health, London, UK
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25
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Sondaal AEC, Tumbahangphe KM, Neupane R, Manandhar DS, Costello A, Morrison J. Sustainability of community-based women's groups: reflections from a participatory intervention for newborn and maternal health in Nepal. COMMUNITY DEVELOPMENT JOURNAL 2019; 54:731-749. [PMID: 31885401 PMCID: PMC6924535 DOI: 10.1093/cdj/bsy017] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 03/19/2018] [Indexed: 05/25/2023]
Abstract
Participatory community-based women's group interventions have been successful in improving maternal and newborn survival. In rural Makwanpur, Nepal, exposure to these Participatory Learning and Action groups resulted in a thirty-percent reduction in neonatal mortality rate and significantly fewer maternal deaths. It is often theorised that participatory approaches are more likely to be sustained than top-down approaches, but this is rarely evaluated after the withdrawal of external support. We sought to understand how participatory learning and action (PLA) groups in Makwanpur fared after the supporting non-governmental organisation withdrew their support as well as factors affecting their sustainability. We used mixed methods, conducting a cross-sectional survey of 239 groups, thirty focus group discussions with group members and thirty key informant interviews within twelve-seventeen months after support was withdrawn. Eighty percent of groups were still active which suggests that PLA groups have a high chance of being sustained over time. Groups were more likely to be sustained if the group had local importance and members continued to acquire new knowledge. However, the participatory nature of the group and local embeddedness were not enough to sustain all groups. They also needed leadership capacity, a unifying activity such as a fund, and a strong belief in the value of their meeting to sustain. These key factors should be considered when seeking to enable sustainability of participatory interventions.
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Affiliation(s)
- Annemijn E C Sondaal
- Address for correspondence: Annemijn E.C. Sondaal, Institute for Global Health, University College London, London WC1N 1EH, UK;
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Indravudh PP, Fielding K, Kumwenda MK, Nzawa R, Chilongosi R, Desmond N, Nyirenda R, Johnson CC, Baggaley RC, Hatzold K, Terris-Prestholt F, Corbett EL. Community-led delivery of HIV self-testing to improve HIV testing, ART initiation and broader social outcomes in rural Malawi: study protocol for a cluster-randomised trial. BMC Infect Dis 2019; 19:814. [PMID: 31533646 PMCID: PMC6751650 DOI: 10.1186/s12879-019-4430-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 08/30/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Prevention of new HIV infections is a critical public health issue. The highest HIV testing gaps are in men, adolescents 15-19 years old, and adults 40 years and older. Community-based HIV testing services (HTS) can contribute to increased testing coverage and early HIV diagnosis, with HIV self-testing (HIVST) strategies showing promise. Community-based strategies, however, are resource intensive, costly and not widely implemented. A community-led approach to health interventions involves supporting communities to plan and implement solutions to improve their health. This trial aims to determine if community-led delivery of HIVST can improve HIV testing uptake, ART initiation, and broader social outcomes in rural Malawi. METHODS The trial uses a parallel arm, cluster-randomised design with group village heads (GVH) and their defined catchment areas randomised (1:1) to community-led HIVST or continue with the standard of the care (SOC). As part of the intervention, informal community health cadres are supported to plan and implement a seven-day HIVST campaign linked to HIV treatment and prevention. Approximately 12 months after the initial campaign, intervention GVHs are randomised to lead a repeat HIVST campaign. The primary outcome includes the proportion of adolescents 15-19 years old who have tested for HIV in their lifetime. Secondary outcomes include recent testing in adults 40 years and older and men; ART initiation; knowledge of HIV prevention; and HIV testing stigma. Outcomes will be measured through cross-sectional surveys and clinic registers. Economic evaluation will determine the cost per person tested, cost per person diagnosed, and incremental cost effectiveness ratio. DISCUSSION To the best of our knowledge, this is the first trial to assess the effectiveness of community-led HTS, which has only recently been enabled by the introduction of HIVST. Community-led delivery of HIVST is a promising new strategy for providing periodic HIV testing to support HIV prevention in rural communities. Further, introduction of HIVST through a community-led framework seems particularly apt, with control over healthcare concurrently devolved to individuals and communities. TRIAL REGISTRATION Clinicaltrials.gov registry ( NCT03541382 ) registered 30 May 2018.
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Affiliation(s)
- Pitchaya P. Indravudh
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Katherine Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Moses K. Kumwenda
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Rebecca Nzawa
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Nicola Desmond
- Clinical Sciences Department, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Rose Nyirenda
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - Cheryl C. Johnson
- Department of HIV/AIDS, World Health Organisation, Geneva, Switzerland
| | | | - Karin Hatzold
- Population Services International, Johannesburg, South Africa
| | - Fern Terris-Prestholt
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Elizabeth L. Corbett
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
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Blanchard AK, Prost A, Houweling TAJ. Effects of community health worker interventions on socioeconomic inequities in maternal and newborn health in low-income and middle-income countries: a mixed-methods systematic review. BMJ Glob Health 2019; 4:e001308. [PMID: 31275619 PMCID: PMC6577316 DOI: 10.1136/bmjgh-2018-001308] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 04/30/2019] [Accepted: 05/04/2019] [Indexed: 12/02/2022] Open
Abstract
Introduction Community health worker (CHW) interventions are promoted to improve maternal and newborn health in low-income and middle-income countries. We reviewed the evidence on their effectiveness in reducing socioeconomic inequities in maternal and newborn health outcomes, how they achieve these effects, and contextual processes that shape these effects. Methods We conducted a mixed-methods systematic review of quantitative and qualitative studies published between 1996 and 2017 in Medline, Embase, Web of Science and Scopus databases. We included studies examining the effects of CHW interventions in low-income and middle-income countries on maternal and newborn health outcomes across socioeconomic groups (wealth, occupation, education, class, caste or tribe and religion). We then conducted a narrative synthesis of evidence. Results We identified 1919 articles, of which 22 met the inclusion criteria. CHWs facilitated four types of interventions: home visits, community-based groups, cash transfers or combinations of these. Four studies found that CHWs providing home visits or facilitating women’s groups had equitable coverage. Four others found that home visits and cash transfer interventions had inequitable coverage. Five studies reported equitable effects of CHW interventions on antenatal care, skilled birth attendance and/or essential newborn care. One study found that a CHW home visit intervention did not reduce wealth inequities in skilled birth attendance. A study of women’s groups reported greater reductions in neonatal mortality among lower compared with higher socioeconomic groups. Equity was most improved when CHWs had relevant support for assisting women to improve health practices and access health care within community contexts. Conclusion While current evidence remains limited, particularly for mortality, existing studies suggest that CHW interventions involving home visits, cash transfers, participatory women’s groups or multiple components can improve equity in maternal and newborn health. Future mixed-methods research should explore intervention strategies and contextual processes shaping such effects on equity to optimise these efforts.
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Affiliation(s)
| | - Audrey Prost
- Institute for Global Health, University College London, London, UK
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Morrison J, Osrin D, Alcock G, Azad K, Bamjan J, Budhathoki B, Kuddus A, Mala MA, Manandhar D, Nkhata A, Pathak S, Phiri T, Rath S, Tripathy P, Costello A, Houweling TAJ. 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. Int J Equity Health 2019; 18:55. [PMID: 30971254 PMCID: PMC6458781 DOI: 10.1186/s12939-019-0957-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 04/02/2019] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Joanna Morrison
- Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH UK
| | - David Osrin
- Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH UK
| | - Glyn Alcock
- Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH UK
| | - Kishwar Azad
- BADAS, Room No-390, BIRDEM Building 122,Kazi Nazrul Islam Avenue,Shahbagh, Dhaka, 1000 Bangladesh
| | | | | | - Abdul Kuddus
- BADAS, Room No-390, BIRDEM Building 122,Kazi Nazrul Islam Avenue,Shahbagh, Dhaka, 1000 Bangladesh
| | | | | | | | | | | | | | | | - Anthony Costello
- Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH UK
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Zuurmond M, Nyante G, Baltussen M, Seeley J, Abanga J, Shakespeare T, Collumbien M, Bernays S. A support programme for caregivers of children with disabilities in Ghana: Understanding the impact on the wellbeing of caregivers. Child Care Health Dev 2019; 45:45-53. [PMID: 30259548 PMCID: PMC7379711 DOI: 10.1111/cch.12618] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 07/09/2018] [Accepted: 08/12/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Four fifths of the estimated 150 million children with disability in the world live in resource poor settings where the role of the family is crucial in ensuring that these children survive and thrive. Despite their critical role, evidence is lacking on how to provide optimal support to these families. This study explores the impact of a participatory training programme for caregivers delivered through a local support group, with a focus on understanding caregiver wellbeing. METHODS A qualitative longitudinal study was conducted to investigate the impact of a training programme, "getting to know cerebral palsy," with caregivers on their wellbeing. Eighteen caregivers, from four districts, were interviewed up to three times over 14 months, to assess impact and the reasons for any changes. RESULTS Low levels of knowledge, high levels of stigma, physical and emotional exhaustion, and often difficult family relationships with social exclusion of the child and caregiver were common themes at the outset. Caregivers struggled to combine their caring and economic activities. This was exacerbated by the common absence of the father. Two months after completion of the training, their reported wellbeing had improved. The reasons for this were an improved understanding about their child's condition, positive attitudinal change towards their child, feelings of hope, and through the group support, a profound realisation that they are "not on their own." While relationships within the family remained complex in many cases, the support group offered an important and alternative social support network. CONCLUSIONS This study illustrates the many benefits of a relatively simple caregiver intervention, which has the potential to offer a mechanism to provide sustainable social support for caregivers and children with cerebral palsy. Any future programme needs to also address more structural issues, including stigma and discrimination, and strengthen approaches to family engagement.
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Affiliation(s)
- Maria Zuurmond
- International Centre for Evidence in DisabilityLondon School of Hygiene and Tropical MedicineLondonUK
| | | | | | - Janet Seeley
- London School of Hygiene and Tropical MedicineLondonUK
| | | | | | - Martine Collumbien
- Faculty of Public Health and PolicyLondon School of Hygiene & Tropical MedicineLondonUK
| | - Sarah Bernays
- Sydney School of Public Health, Sydney Medical SchoolLondon School of Hygiene and Tropical MedicineLondonUK
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Gram L, Morrison J, Saville N, Yadav SS, Shrestha B, Manandhar D, Costello A, Skordis-Worrall J. Do Participatory Learning and Action Women's Groups Alone or Combined with Cash or Food Transfers Expand Women's Agency in Rural Nepal? THE JOURNAL OF DEVELOPMENT STUDIES 2019; 55:1670-1686. [PMID: 31218298 PMCID: PMC6540743 DOI: 10.1080/00220388.2018.1448069] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 02/15/2018] [Indexed: 05/07/2023]
Abstract
Participatory learning and action women's groups (PLA) have proven effective in reducing neonatal mortality in rural, high-mortality settings, but their impacts on women's agency in the household remain unknown. Cash transfer programmes have also long targeted female beneficiaries in the belief that this empowers women. Drawing on data from 1309 pregnant women in a four-arm cluster-randomised controlled trial in Nepal, we found little evidence for an impact of PLA alone or combined with unconditional food or cash transfers on women's agency in the household. Caution is advised before assuming PLA women's groups alone or with resource transfers necessarily empower women.
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Affiliation(s)
- Lu Gram
- Institute for Global Health, University College London, London, UK
- Correspondence Address: Lu Gram Institute of Global Health, University College London, 30 Guilford Street, WC1N 1EH, UK.
| | - Joanna Morrison
- Institute for Global Health, University College London, London, UK
| | - Naomi Saville
- Institute for Global Health, University College London, London, UK
| | | | | | | | - Anthony Costello
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
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Sikorski C, Van Hees S, Lakhanpaul M, Benton L, Martin J, Costello A, Heys M. Could Postnatal Women's Groups Be Used to Improve Outcomes for Mothers and Children in High-Income Countries? A Systematic Review. Matern Child Health J 2018; 22:1698-1712. [PMID: 30155582 PMCID: PMC6245133 DOI: 10.1007/s10995-018-2606-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Introduction Participatory postnatal women’s groups have been shown to have a significant impact on maternal and neonatal mortality in low-income countries. However, it is not clear whether this approach can be translated to high-income countries (HICs). We conducted a systematic review to answer the question: “Can postnatal women’s groups improve health outcomes for mothers and children in high-income countries?” Methods MEDLINE, EMBASE and Cochrane databases were searched for randomised controlled trials testing any group-based intervention during the postnatal period, in HICs. No limitations were applied to stated outcomes. Results Nine trials, including 3029 women, fulfilled the criteria. Group-based interventions, facilitated by health professionals, ranged from didactic to participant-led. Three trials addressed postnatal depression, one addressed physical activity, whilst the remainder looked at multiple health or social outcomes. Three trials reported a significant association between their intervention and at least one outcome measure. Study limitations included poor and inequitable intervention uptake, low participant retention, small sample size and incomplete intervention description. Discussion This review found limited and incompletely described evidence testing the use of postnatal group-based interventions to improve health outcomes in HICs. Promising results were reported when the obstacles of sample size and group attendance were overcome. Studies reporting positive impacts on primary outcomes reported higher attendance rates and involved a psychoeducational or cognitive behavioural component in their group approaches. Further research should design and evaluate implementation strategies, assess the use of lay support workers in community settings to improve attendance and retention, and examine the effect of the group environment on outcomes.
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Affiliation(s)
| | | | - Monica Lakhanpaul
- Population, Policy and Practice, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Lorna Benton
- Population, Policy and Practice, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Jennifer Martin
- Population, Policy and Practice, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Anthony Costello
- Institute for Global Health, University College, London, UK.,Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Michelle Heys
- Institute for Global Health, University College, London, UK. .,Population, Policy and Practice, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK.
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Gram L, Daruwalla N, Osrin D. Understanding participation dilemmas in community mobilisation: can collective action theory help? J Epidemiol Community Health 2018; 73:90-96. [PMID: 30377247 PMCID: PMC6839791 DOI: 10.1136/jech-2018-211045] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 08/28/2018] [Accepted: 10/12/2018] [Indexed: 11/24/2022]
Abstract
Community mobilisation interventions have been used to promote health in many low-income and middle-income settings. They frequently involve collective action to address shared determinants of ill-health, which often requires high levels of participation to be effective. However, the non-excludable nature of benefits produced often generates participation dilemmas: community members have an individual interest in abstaining from collective action and free riding on others’ contributions, but no benefit is produced if nobody participates. For example, marches, rallies or other awareness-raising activities to change entrenched social norms affect the social environment shared by community members whether they participate or not. This creates a temptation to let other community members invest time and effort. Collective action theory provides a rich, principled framework for analysing such participation dilemmas. Over the past 50 years, political scientists, economists, sociologists and psychologists have proposed a plethora of incentive mechanisms to solve participation dilemmas: selective incentives, intrinsic benefits, social incentives, outsize stakes, intermediate goals, interdependency and critical mass theory. We discuss how such incentive mechanisms might be used by global health researchers to produce new questions about how community mobilisation works and conclude with theoretical predictions to be explored in future quantitative or qualitative research.
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Affiliation(s)
- Lu Gram
- Institute for Global Health, University College London, London, UK
| | - Nayreen Daruwalla
- SNEHA (Society for Nutrition, Education and Health Action), Mumbai, India
| | - David Osrin
- Institute for Global Health, University College London, London, UK
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A cluster randomized controlled trial to assess the impact of SAFE on spousal violence against women and girls in slums of Dhaka, Bangladesh. PLoS One 2018; 13:e0198926. [PMID: 29902217 PMCID: PMC6001962 DOI: 10.1371/journal.pone.0198926] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 05/29/2018] [Indexed: 11/19/2022] Open
Abstract
Background Bangladesh reports one of the highest rates of intimate partner violence (IPV) in the world. Despite wide recognition of IPV as an important public health and human rights issue, evidence for IPV prevention is still inadequate. Lack of guidance on effective IPV prevention in Bangladesh resulted in targeting only women in most of the programmes. Methods This paper assesses impact of SAFE, a 20-month intervention (March 2012 to October 2013) in slums of Dhaka on IPV and tests effectiveness of female only groups vs. no groups; and female + male groups vs. female only groups on IPV in the community using a three-arm cluster randomized controlled trial. SAFE’s core activities included interactive group sessions, community mobilisation, and services. The last two activities were common across arms. Findings Regression analyses (female survey: baseline n = 2,666; endline n = 2,670) showed no effect of SAFE on IPV against women aged 15–29. However, sub-group analyses demonstrated 21% risk reduction of physical IPV against adolescent girls aged 15–19 in the female + male group intervention arm. A consistent reduction in sexual violence was observed in both female and female + male arms for both groups of women, but the results were not statistically significant. Interpretation The findings emphasise the importance of combining male and female interventions for reducing physical IPV against adolescent girls. Implications for future research have been discussed.
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Kumar N, Scott S, Menon P, Kannan S, Cunningham K, Tyagi P, Wable G, Raghunathan K, Quisumbing A. Pathways from women's group-based programs to nutrition change in South Asia: A conceptual framework and literature review. GLOBAL FOOD SECURITY-AGRICULTURE POLICY ECONOMICS AND ENVIRONMENT 2018; 17:172-185. [PMID: 29930896 PMCID: PMC6004534 DOI: 10.1016/j.gfs.2017.11.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 11/24/2017] [Accepted: 11/25/2017] [Indexed: 11/17/2022]
Abstract
Improving the nutritional status of women and children in South Asia remains a high public health and development priority. Women's groups are emerging as platforms for delivering health- and nutrition-oriented programs and addressing gender and livelihoods challenges. We propose a framework outlining pathways through which women's group participation may facilitate improvements in nutrition. Evidence is summarized from 36 studies reporting on 24 nutritional indicators across infant and young child feeding (IYCF) practices, intake/diet, and anthropometry. Our findings suggest that women's group-based programs explicitly triggering behavior change pathways are most successful in improving nutrition outcomes, with strongest evidence for IYCF practices. Future investigators should link process and impact evaluations to better understand the pathways from women's group participation to nutritional impact. Women’s group programs in South Asia are starting to promote health and nutrition. Achieving nutritional impacts is complex and operates through multiple pathways. We outline income, agriculture, health behavior change, and rights pathways. Evidence is strongest for programs triggering the health behavior change pathway.
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Affiliation(s)
- Neha Kumar
- International Food Policy Research Institute, Poverty Health and Nutrition Division, Washington DC, USA
| | - Samuel Scott
- International Food Policy Research Institute, Poverty Health and Nutrition Division, Washington DC, USA
| | - Purnima Menon
- International Food Policy Research Institute, Poverty Health and Nutrition Division, Washington DC, USA
| | - Samyuktha Kannan
- International Food Policy Research Institute, Poverty Health and Nutrition Division, Washington DC, USA
| | | | | | - Gargi Wable
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA
| | - Kalyani Raghunathan
- International Food Policy Research Institute, Poverty Health and Nutrition Division, Washington DC, USA
| | - Agnes Quisumbing
- International Food Policy Research Institute, Poverty Health and Nutrition Division, Washington DC, USA
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Gram L, Skordis-Worrall J, Manandhar DS, Strachan D, Morrison J, Saville N, Osrin D, Tumbahangphe KM, Costello A, Heys M. The long-term impact of community mobilisation through participatory women's groups on women's agency in the household: A follow-up study to the Makwanpur trial. PLoS One 2018; 13:e0197426. [PMID: 29758071 PMCID: PMC5951552 DOI: 10.1371/journal.pone.0197426] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 05/02/2018] [Indexed: 11/19/2022] Open
Abstract
Women's groups practicing participatory learning and action (PLA) in rural areas have been shown to improve maternal and newborn survival in low-income countries, but the pathways from intervention to impact remain unclear. We assessed the long-term impact of a PLA intervention in rural Nepal on women's agency in the household. In 2014, we conducted a follow-up study to a cluster randomised controlled trial on the impact of PLA women's groups from 2001-2003. Agency was measured using the Relative Autonomy Index (RAI) and its subdomains. Multi-level regression analyses were performed adjusting for baseline socio-demographic characteristics. We additionally adjusted for potential exposure to subsequent PLA groups based on women's pregnancy status and conduct of PLA groups in areas of residence. Sensitivity analyses were performed using two alternative measures of agency. We analysed outcomes for 4030 mothers (66% of the cohort) who survived and were recruited to follow-up at mean age 39.6 years. Across a wide range of model specifications, we found no association between exposure to the original PLA intervention with women's agency in the household approximately 11.5 years later. Subsequent exposure to PLA groups was not associated with greater agency in the household at follow-up, but some specifications found evidence for reduced agency. Household agency may be a prerequisite for actualising the benefits of PLA groups rather than a consequence.
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Affiliation(s)
- Lu Gram
- Institute for Global Health, University College London, London, United Kingdom
- * E-mail:
| | | | | | - Daniel Strachan
- Institute for Global Health, University College London, London, United Kingdom
| | - Joanna Morrison
- Institute for Global Health, University College London, London, United Kingdom
| | - Naomi Saville
- Institute for Global Health, University College London, London, United Kingdom
| | - David Osrin
- Institute for Global Health, University College London, London, United Kingdom
| | | | - Anthony Costello
- Institute for Global Health, University College London, London, United Kingdom
- Department of Maternal, Newborn, Child and Adolescent Health (MCA), World Health Organization, Geneva, Switzerland
| | - Michelle Heys
- Institute for Global Health, University College London, London, United Kingdom
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
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Gram L, Morrison J, Saville N, Yadav SS, Shrestha B, Manandhar D, Costello A, Skordis-Worrall J. Do Participatory Learning and Action Women's Groups Alone or Combined with Cash or Food Transfers Expand Women's Agency in Rural Nepal? THE JOURNAL OF DEVELOPMENT STUDIES 2018; 55:1670-1686. [PMID: 31218298 DOI: 10.1080/00220388.2018.14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Grants] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 02/15/2018] [Indexed: 05/25/2023]
Abstract
Participatory learning and action women's groups (PLA) have proven effective in reducing neonatal mortality in rural, high-mortality settings, but their impacts on women's agency in the household remain unknown. Cash transfer programmes have also long targeted female beneficiaries in the belief that this empowers women. Drawing on data from 1309 pregnant women in a four-arm cluster-randomised controlled trial in Nepal, we found little evidence for an impact of PLA alone or combined with unconditional food or cash transfers on women's agency in the household. Caution is advised before assuming PLA women's groups alone or with resource transfers necessarily empower women.
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Affiliation(s)
- Lu Gram
- Institute for Global Health, University College London, London, UK
| | - Joanna Morrison
- Institute for Global Health, University College London, London, UK
| | - Naomi Saville
- Institute for Global Health, University College London, London, UK
| | | | | | | | - Anthony Costello
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
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Kadiyala S, Prost A, Harris-Fry H, O’Hearn M, Pradhan R, Pradhan S, Mishra NK, Rath S, Nair N, Rath S, Tripathy P, Krishnan S, Koniz-Booher P, Danton H, Elbourne D, Sturgess J, Beaumont E, Haghparast-Bidgoli H, Skordis-Worrall J, Mohanty S, Upadhay A, Allen E. Upscaling Participatory Action and Videos for Agriculture and Nutrition (UPAVAN) trial comparing three variants of a nutrition-sensitive agricultural extension intervention to improve maternal and child nutritional outcomes in rural Odisha, India: study protocol for a cluster randomised controlled trial. Trials 2018; 19:176. [PMID: 29523173 PMCID: PMC5845188 DOI: 10.1186/s13063-018-2521-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 02/02/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Maternal and child undernutrition have adverse consequences for pregnancy outcomes and child morbidity and mortality, and they are associated with low educational attainment, economic productivity as an adult, and human wellbeing. 'Nutrition-sensitive' agriculture programs could tackle the underlying causes of undernutrition. METHODS/DESIGN This study is a four-arm cluster randomised controlled trial in Odisha, India. Interventions are as follows: (1) an agricultural extension platform of women's groups viewing and discussing videos on nutrition-sensitive agriculture (NSA) practices, and follow-up visits to women at home to encourage the adoption of new practices shown in the videos; (2) women's groups viewing and discussing videos on NSA and nutrition-specific practices, with follow-up visits; and (3) women's groups viewing and discussing videos on NSA and nutrition-specific practices combined with a cycle of Participatory Learning and Action meetings, with follow-up visits. All arms, including the control, receive basic nutrition training from government community frontline workers. Primary outcomes, assessed at baseline and 32 months after the start of the interventions, are (1) percentage of children aged 6-23 months consuming ≥ 4 out of 7 food groups per day and (2) mean body mass index (BMI) (kg/m2) of non-pregnant, non-postpartum (gave birth > 42 days ago) mothers or female primary caregivers of children aged 0-23 months. Secondary outcomes are percentage of mothers consuming ≥ 5 out of 10 food groups per day and percentage of children's weight-for-height z-score < -2 standard deviations (SD). The unit of randomisation is a cluster, defined as one or more villages with a combined minimum population of 800 residents. There are 37 clusters per arm, and outcomes will be assessed in an average of 32 eligible households per cluster. For randomisation, clusters are stratified by distance to nearest town (< 10 km or ≥ 10 km), and low (< 30%), medium (30-70%), or high (> 70%) proportion of Scheduled Tribe or Scheduled Caste (disadvantaged) households. A process evaluation will assess the quality of implementation and mechanisms behind the intervention effects. A cost-consequence analysis will compare incremental costs and outcomes of the interventions. DISCUSSION This trial will contribute evidence on the impacts of NSA extension through participatory, low-cost, video-based approaches on maternal and child nutrition and on whether integration with nutrition-specific goals and enhanced participatory approaches can increase these impacts. TRIAL REGISTRATION ISRCTN , ISRCTN65922679 . Registered on 21 December 2016.
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Affiliation(s)
- Suneetha Kadiyala
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Audrey Prost
- University College London, Institute for Global Health, 30 Guilford Street, London, WC1N 1EH UK
| | - Helen Harris-Fry
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Meghan O’Hearn
- Digital Green, S-26 to 28, 3rd Floor, Green Park Extension Market, New Delhi, 110016 India
| | - Ronali Pradhan
- Digital Green, S-26 to 28, 3rd Floor, Green Park Extension Market, New Delhi, 110016 India
| | - Shibananth Pradhan
- VARRAT (Voluntary Association for Rural Reconstruction and Appropriate Technology), Boulakani Baradang, Mahakalpara Kendrapad, Keonjhar, 754224 Odisha India
| | - Naba Kishore Mishra
- VARRAT (Voluntary Association for Rural Reconstruction and Appropriate Technology), Boulakani Baradang, Mahakalpara Kendrapad, Keonjhar, 754224 Odisha India
| | - Suchitra Rath
- Ekjut, 556 B, Ward No. 17, Potka, Chakradharpur, 833102 Jharkhand India
| | - Nirmala Nair
- Ekjut, 556 B, Ward No. 17, Potka, Chakradharpur, 833102 Jharkhand India
| | - Shibanand Rath
- Ekjut, 556 B, Ward No. 17, Potka, Chakradharpur, 833102 Jharkhand India
| | | | - Sneha Krishnan
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Peggy Koniz-Booher
- Strengthening Partnerships, Results, and Innovations in Nutrition Globally, JSI Research & Training Institute, Inc., 1616 Fort Myer Drive, 16th Floor, Arlington, 22209 VA USA
| | - Heather Danton
- Strengthening Partnerships, Results, and Innovations in Nutrition Globally, JSI Research & Training Institute, Inc., 1616 Fort Myer Drive, 16th Floor, Arlington, 22209 VA USA
| | - Diana Elbourne
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Joanna Sturgess
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Emma Beaumont
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | | | - Jolene Skordis-Worrall
- University College London, Institute for Global Health, 30 Guilford Street, London, WC1N 1EH UK
| | - Satyanarayan Mohanty
- Development Corner Consulting Pvt. Ltd. (DCOR), 131(P), Punjabi Chhak, Satyanagar, Near Hotel Sungreen, Bhubaneshwar, 751007 India
| | - Avinash Upadhay
- Digital Green, S-26 to 28, 3rd Floor, Green Park Extension Market, New Delhi, 110016 India
| | - Elizabeth Allen
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
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Thapa S. Women helping women prevent HIV in resource-limited settings. Lancet 2018; 391:738-739. [PMID: 29486941 DOI: 10.1016/s0140-6736(18)30307-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 01/05/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Subash Thapa
- Department of Public Health and Primary care, KU Leuven, 3000 Leuven, Belgium; Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.
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Lama TP, Khatry SK, Katz J, LeClerq SC, Mullany LC. Illness recognition, decision-making, and care-seeking for maternal and newborn complications: a qualitative study in Sarlahi District, Nepal. JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2017; 36:45. [PMID: 29297386 PMCID: PMC5764053 DOI: 10.1186/s41043-017-0123-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Identification of maternal and newborn illness and the decision-making and subsequent care-seeking patterns are poorly understood in Nepal. We aimed to characterize the process and factors influencing recognition of complications, the decision-making process, and care-seeking behavior among families and communities who experienced a maternal complication, death, neonatal illness, or death in a rural setting of Nepal. METHODS Thirty-two event narratives (six maternal/newborn deaths each and 10 maternal/newborn illnesses each) were collected using in-depth interviews and small group interviews. We purposively sampled across specific illness and complication definitions, using data collected prospectively from a cohort of women and newborns followed from pregnancy through the first 28 days postpartum. The event narratives were coded and analyzed for common themes corresponding to three main domains of illness recognition, decision-making, and care-seeking; detailed event timelines were created for each. RESULTS While signs were typically recognized early, delays in perceiving the severity of illness compromised prompt care-seeking in both maternal and newborn cases. Further, care was often sought initially from informal health providers such as traditional birth attendants, traditional healers, and village doctors. Key decision-makers were usually female family members; husbands played limited roles in decisions related to care-seeking, with broader family involvement in decision-making for newborns. Barriers to seeking care at any type of health facility included transport problems, lack of money, night-time illness events, low perceived severity, and distance to facility. Facility care was often sought only after referral or following treatment failure from an informal provider and private facilities were sought for newborn care. Respondents characterized government facility-based care as low quality and reported staff rudeness and drug type and/or supply stock shortages. CONCLUSION Delaying the decision to seek skilled care was common in both newborn and maternal cases. Among maternal cases, delays in receiving appropriate care when at a facility were also seen. Improved recognition of danger signs and increased demand for skilled care, motivated through community level interventions and health worker mobilization, needs to be encouraged. Engaging informal providers through training in improved danger sign identification and prompt referral, especially for newborn illnesses, is recommended.
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Affiliation(s)
- Tsering P. Lama
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, W5009, Baltimore, MD 21205 USA
| | - Subarna K. Khatry
- Nepal Nutrition Intervention Project—Sarlahi (NNIPS), Kathmandu, Nepal
| | - Joanne Katz
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, W5009, Baltimore, MD 21205 USA
| | - Steven C. LeClerq
- Nepal Nutrition Intervention Project—Sarlahi (NNIPS), Kathmandu, Nepal
| | - Luke C. Mullany
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, W5009, Baltimore, MD 21205 USA
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Seward N, Neuman M, Colbourn T, Osrin D, Lewycka S, Azad K, Costello A, Das S, Fottrell E, Kuddus A, Manandhar D, Nair N, Nambiar B, Shah More N, Phiri T, Tripathy P, Prost A. 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. PLoS Med 2017; 14:e1002467. [PMID: 29206833 PMCID: PMC5716527 DOI: 10.1371/journal.pmed.1002467] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 11/01/2017] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Nadine Seward
- Institute for Global Health, University College London, London, United Kingdom
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Melissa Neuman
- Institute for Global Health, University College London, London, United Kingdom
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Tim Colbourn
- Institute for Global Health, University College London, London, United Kingdom
| | - David Osrin
- Institute for Global Health, University College London, London, United Kingdom
| | - Sonia Lewycka
- Nuffield Department of Medicine, Centre for Tropical Medicine, University of Oxford, Oxford, United Kingdom
| | - Kishwar Azad
- Perinatal Care Project, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Anthony Costello
- Institute for Global Health, University College London, London, United Kingdom
| | - Sushmita Das
- Society for Nutrition, Education & Health Action, Mumbai, India
| | - Edward Fottrell
- Institute for Global Health, University College London, London, United Kingdom
| | - Abdul Kuddus
- Perinatal Care Project, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | | | - Bejoy Nambiar
- Institute for Global Health, University College London, London, United Kingdom
| | - Neena Shah More
- Society for Nutrition, Education & Health Action, Mumbai, India
| | - Tambosi Phiri
- Parent and Child Health Initiative Trust, Lilongwe, Malawi
| | | | - Audrey Prost
- Institute for Global Health, University College London, London, United Kingdom
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Formative qualitative research to develop community-based interventions addressing low birth weight in the plains of Nepal. Public Health Nutr 2017; 21:377-384. [PMID: 29032790 DOI: 10.1017/s1368980017002646] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To explore the factors affecting intra-household food allocation practices to inform the development of interventions to prevent low birth weight in rural plains of Nepal. DESIGN Qualitative methodology using purposive sampling to explore the barriers and facilitating factors to improved maternal nutrition. SETTING Rural Dhanusha District, Nepal. SUBJECTS We purposively sampled twenty-five young daughters-in-law from marginalised groups living in extended families and conducted semi-structured interviews with them. We also conducted one focus group discussion with men and one with female community health volunteers who were mothers-in-law. RESULTS Gender and age hierarchies were important in household decision making. The mother-in-law was responsible for ensuring that a meal was provided to productive household members. The youngest daughter-in-law usually cooked last and ate less than other family members, and showed respect for other family members by cooking only when permitted and deferring to others' choice of food. There were limited opportunities for these women to snack between main meals. Daughters-in-law' movement outside the household was restricted and therefore family members perceived that their nutritional need was less. Poverty affected food choice and families considered cost before nutritional value. CONCLUSIONS It is important to work with the whole household, particularly mothers-in-law, to improve maternal nutrition. We present five barriers to behaviour change: poverty; lack of knowledge about cheap nutritional food, the value of snacking, and cheap nutritional food that does not require cooking; sharing food; lack of self-confidence; and deference to household guardians. We discuss how we have targeted our interventions to develop knowledge, discuss strategies to overcome barriers, engage mothers-in-law, and build the confidence and social support networks of pregnant women.
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Morrison J, Colbourn T, Budhathoki B, Sen A, Adhikari D, Bamjan J, Pathak S, Basnet A, Trani JF, Costello A, Manandhar D, Groce N. Disabled women's attendance at community women's groups in rural Nepal. Health Promot Int 2017; 32:464-474. [PMID: 26519006 PMCID: PMC5455254 DOI: 10.1093/heapro/dav099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
There is strong evidence that participatory approaches to health and participatory women's groups hold great potential to improve the health of women and children in resource poor settings. It is important to consider if interventions are reaching the most marginalized, and therefore we examined disabled women's participation in women's groups and other community groups in rural Nepal. People with disabilities constitute 15% of the world's population and face high levels of poverty, stigma, social marginalization and unequal access to health resources, and therefore their access to women's groups is particularly important. We used a mixed methods approach to describe attendance in groups among disabled and non-disabled women, considering different types and severities of disability. We found no significant differences in the percentage of women that had ever attended at least one of our women's groups, between non-disabled and disabled women. This was true for women with all severities and types of disability, except physically disabled women who were slightly less likely to have attended. Barriers such as poverty, lack of family support, lack of self-confidence and attendance in many groups prevented women from attending groups. Our findings are particularly significant because disabled people's participation in broader community groups, not focused on disability, has been little studied. We conclude that women's groups are an important way to reach disabled women in resource poor communities. We recommend that disabled persons organizations help to increase awareness of disability issues among organizations running community groups to further increase their effectiveness in reaching disabled women.
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Affiliation(s)
- J. Morrison
- Institute ofGlobal Health, University College London, 30 Guilford Street, London WC1N 1EH, UK
| | - T. Colbourn
- Institute ofGlobal Health, University College London, 30 Guilford Street, London WC1N 1EH, UK
| | - B. Budhathoki
- Mother Infant Research Activities (MIRA) Nepal, PO Box 921, Thapathali, Kathmandu, Nepal
| | - A. Sen
- Mother Infant Research Activities (MIRA) Nepal, PO Box 921, Thapathali, Kathmandu, Nepal
| | - D. Adhikari
- Mother Infant Research Activities (MIRA) Nepal, PO Box 921, Thapathali, Kathmandu, Nepal
| | - J. Bamjan
- Mother Infant Research Activities (MIRA) Nepal, PO Box 921, Thapathali, Kathmandu, Nepal
| | - S. Pathak
- Mother Infant Research Activities (MIRA) Nepal, PO Box 921, Thapathali, Kathmandu, Nepal
| | - A. Basnet
- Mother Infant Research Activities (MIRA) Nepal, PO Box 921, Thapathali, Kathmandu, Nepal
| | - J. F. Trani
- Leonard Cheshire Centre for Disability and Inclusive Development, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London WC1E 6BT, UK
| | - A. Costello
- Institute ofGlobal Health, University College London, 30 Guilford Street, London WC1N 1EH, UK
| | - D. Manandhar
- Mother Infant Research Activities (MIRA) Nepal, PO Box 921, Thapathali, Kathmandu, Nepal
| | - N. Groce
- Leonard Cheshire Centre for Disability and Inclusive Development, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London WC1E 6BT, UK
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George AS, Scott K, Mehra V, Sriram V. Synergies, strengths and challenges: findings on community capability from a systematic health systems research literature review. BMC Health Serv Res 2016; 16:623. [PMID: 28185589 PMCID: PMC5123247 DOI: 10.1186/s12913-016-1860-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Community capability is the combined influence of a community’s social systems and collective resources that can address community problems and broaden community opportunities. We frame it as consisting of three domains that together support community empowerment: what communities have; how communities act; and for whom communities act. We sought to further understand these domains through a secondary analysis of a previous systematic review on community participation in health systems interventions in low and middle income countries (LMICs). Methods We searched for journal articles published between 2000 and 2012 related to the concepts of “community”, “capability/participation”, “health systems research” and “LMIC.” We identified 64 with rich accounts of community participation involving service delivery and governance in health systems research for thematic analysis following the three domains framing community capability. Results When considering what communities have, articles reported external linkages as the most frequently gained resource, especially when partnerships resulted in more community power over the intervention. In contrast, financial assets were the least mentioned, despite their importance for sustainability. With how communities act, articles discussed challenges of ensuring inclusive participation and detailed strategies to improve inclusiveness. Very little was reported about strengthening community cohesiveness and collective efficacy despite their importance in community initiatives. When reviewing for whom communities act, the importance of strong local leadership was mentioned frequently, while conflict resolution strategies and skills were rarely discussed. Synergies were found across these elements of community capability, with tangible success in one area leading to positive changes in another. Access to information and opportunities to develop skills were crucial to community participation, critical thinking, problem solving and ownership. Although there are many quantitative scales measuring community capability, health systems research engaged with community participation has rarely made use of these tools or the concepts informing them. Overall, the amount of information related to elements of community capability reported by these articles was low and often of poor quality. Conclusions Strengthening community capability is critical to ensuring that community participation leads to genuine empowerment. Our simpler framework to define community capability may help researchers better recognize, support and assess it.
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Affiliation(s)
- Asha S George
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. .,South African Research Chair in Health Systems, Complexity and Social Change, School of Public Health, University of Western Cape, Cape Town, South Africa.
| | - Kerry Scott
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Global health consultant, Bangalore, India
| | - Vrinda Mehra
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Veena Sriram
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Saville NM, Shrestha BP, Style S, Harris-Fry H, Beard BJ, Sengupta A, Jha S, Rai A, Paudel V, Pulkki-Brannstrom AM, Copas A, Skordis-Worrall J, Bhandari B, Neupane R, Morrison J, Gram L, Sah R, Basnet M, Harthan J, Manandhar DS, Osrin D, Costello A. Protocol of the Low Birth Weight South Asia Trial (LBWSAT), a cluster-randomised controlled trial testing impact on birth weight and infant nutrition of Participatory Learning and Action through women's groups, with and without unconditional transfers of fortified food or cash during pregnancy in Nepal. BMC Pregnancy Childbirth 2016; 16:320. [PMID: 27769191 PMCID: PMC5073870 DOI: 10.1186/s12884-016-1102-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 10/08/2016] [Indexed: 11/16/2022] Open
Abstract
Background Low birth weight (LBW, < 2500 g) affects one third of newborn infants in rural south Asia and compromises child survival, infant growth, educational performance and economic prospects. We aimed to assess the impact on birth weight and weight-for-age Z-score in children aged 0–16 months of a nutrition Participatory Learning and Action behaviour change strategy (PLA) for pregnant women through women’s groups, with or without unconditional transfers of food or cash to pregnant women in two districts of southern Nepal. Methods The study is a cluster randomised controlled trial (non-blinded). PLA comprises women’s groups that discuss, and form strategies about, nutrition in pregnancy, low birth weight and hygiene. Women receive up to 7 monthly transfers per pregnancy: cash is NPR 750 (~US$7) and food is 10 kg of fortified sweetened wheat-soya Super Cereal per month. The unit of randomisation is a rural village development committee (VDC) cluster (population 4000–9200, mean 6150) in southern Dhanusha or Mahottari districts. 80 VDCs are randomised to four arms using a participatory ‘tombola’ method. Twenty clusters each receive: PLA; PLA plus food; PLA plus cash; and standard care (control). Participants are (mostly Maithili-speaking) pregnant women identified from 8 weeks’ gestation onwards, and their infants (target sample size 8880 birth weights). After pregnancy verification, mothers may be followed up in early and late pregnancy, within 72 h, after 42 days and within 22 months of birth. Outcomes pertain to the individual level. Primary outcomes include birth weight within 72 h of birth and infant weight-for-age Z-score measured cross-sectionally on children born of the study. Secondary outcomes include prevalence of LBW, eating behaviour and weight during pregnancy, maternal and newborn illness, preterm delivery, miscarriage, stillbirth or neonatal mortality, infant Z-scores for length-for-age and weight-for-length, head circumference, and postnatal maternal BMI and mid-upper arm circumference. Exposure to women’s groups, food or cash transfers, home visits, and group interventions are measured. Discussion Determining the relative importance to birth weight and early childhood nutrition of adding food or cash transfers to PLA women’s groups will inform design of nutrition interventions in pregnancy. Trial registration ISRCTN75964374, 12 Jul 2013 Electronic supplementary material The online version of this article (doi:10.1186/s12884-016-1102-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Naomi M Saville
- University College London, Institute for Global Health, London, UK.
| | - Bhim P Shrestha
- Mother and Infant Research Activities (MIRA), PO Box 921, Thapathali, Kathmandu, Nepal
| | - Sarah Style
- University College London, Institute for Global Health, London, UK
| | - Helen Harris-Fry
- University College London, Institute for Global Health, London, UK
| | - B James Beard
- University College London, Institute for Global Health, London, UK
| | - Aman Sengupta
- Mother and Infant Research Activities (MIRA), PO Box 921, Thapathali, Kathmandu, Nepal
| | - Sonali Jha
- Mother and Infant Research Activities (MIRA), PO Box 921, Thapathali, Kathmandu, Nepal
| | - Anjana Rai
- Mother and Infant Research Activities (MIRA), PO Box 921, Thapathali, Kathmandu, Nepal
| | - Vikas Paudel
- Mother and Infant Research Activities (MIRA), PO Box 921, Thapathali, Kathmandu, Nepal
| | | | - Andrew Copas
- University College London, Institute for Global Health, London, UK
| | | | - Bishnu Bhandari
- Mother and Infant Research Activities (MIRA), PO Box 921, Thapathali, Kathmandu, Nepal
| | - Rishi Neupane
- Mother and Infant Research Activities (MIRA), PO Box 921, Thapathali, Kathmandu, Nepal
| | - Joanna Morrison
- University College London, Institute for Global Health, London, UK
| | - Lu Gram
- University College London, Institute for Global Health, London, UK
| | - Raghbendra Sah
- Mother and Infant Research Activities (MIRA), PO Box 921, Thapathali, Kathmandu, Nepal
| | - Machhindra Basnet
- Mother and Infant Research Activities (MIRA), PO Box 921, Thapathali, Kathmandu, Nepal
| | - Jayne Harthan
- University College London, Institute for Global Health, London, UK
| | - Dharma S Manandhar
- Mother and Infant Research Activities (MIRA), PO Box 921, Thapathali, Kathmandu, Nepal
| | - David Osrin
- University College London, Institute for Global Health, London, UK
| | - Anthony Costello
- University College London, Institute for Global Health, London, UK
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Oguro M, Horiuchi S. A Cross-Sectional Study of Community-Based Maternal and Child Health Interventions Involving Women's Health Volunteer Groups in Rural Myanmar. Public Health Nurs 2016; 33:449-59. [PMID: 27283211 DOI: 10.1111/phn.12275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study identified the relationship between interventions with women's health volunteer groups in two Myanmar villages and maternal and child health outcomes. DESIGN AND SAMPLE This cross-sectional study included 188 women aged 15-49 years old with at least one ≤5-year-old child. The women were randomly selected from two control and two experimental villages. MEASURES Data were collected via structured interview with a questionnaire based on the UNICEF Multiple Indicator Cluster Survey. RESULTS Logistic regression analyses confirmed that women's health volunteer group intervention was related to the participants' receiving any antenatal care (OR: 6.99, p < .01) and having knowledge regarding danger signs during the perinatal period (OR: 15.08, p < .001), modern contraceptive methods (OR: 44.52, p < .001), acceptable first aid (OR: 14.04, p < .001), and malaria prevention (OR: 40.30, p < .001). A skilled midwife had the most significant relationship with patients' receiving any antenatal care (OR: 65.18, p < .001). Distance from urban area negatively related to appropriate disposal of the child's stool (i.e., flushed in a latrine; OR: 7.51, p < .05). CONCLUSIONS This study shows that women's health volunteer groups may positively affect the diffusion of the need to seek antenatal care and health knowledge in rural Myanmar. The importance of skilled midwives is also highlighted, especially in resource-limited settings.
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Affiliation(s)
- Michiko Oguro
- Women's Health and Midwifery, St. Luke's International University, Tokyo, Japan.
| | - Shigeko Horiuchi
- Women's Health and Midwifery, St. Luke's International University, Tokyo, Japan
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Downe S, Finlayson K, Tunçalp Ӧ, Metin Gülmezoglu A. What matters to women: a systematic scoping review to identify the processes and outcomes of antenatal care provision that are important to healthy pregnant women. BJOG 2015; 123:529-39. [PMID: 26701735 DOI: 10.1111/1471-0528.13819] [Citation(s) in RCA: 118] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Global uptake of antenatal care (ANC) varies widely and is influenced by the value women place on the service they receive. Identifying outcomes that matter to pregnant women could inform service design and improve uptake and effectiveness. OBJECTIVES To undertake a systematic scoping review of what women want, need and value in pregnancy. SEARCH STRATEGY Eight databases were searched (1994-2015) with no language restriction. Relevant journal contents were tracked via Zetoc. DATA COLLECTION AND ANALYSIS An initial analytic framework was constructed with findings from 21 papers, using data-mining techniques, and then developed using meta-ethnographic approaches. The final framework was tested with 17 more papers. MAIN RESULTS All continents except Australia were represented. A total of 1264 women were included. The final meta-theme was: Women want and need a positive pregnancy experience, including four subthemes: maintaining physical and sociocultural normality; maintaining a healthy pregnancy for mother and baby (including preventing and treating risks, illness and death); effective transition to positive labour and birth; and achieving positive motherhood (including maternal self-esteem, competence, autonomy). Findings informed a framework for future ANC provision, comprising three equally important domains: clinical practices (interventions and tests); relevant and timely information; and pyschosocial and emotional support; each provided by practitioners with good clinical and interpersonal skills within a high quality health system. CONCLUSIONS A positive pregnancy experience matters across all cultural and sociodemographic contexts. ANC guidelines and services should be designed to deliver it, and those providing ANC services should be aware of it at each encounter with pregnant women. TWEETABLE ABSTRACT Women around the world want ANC staff and services to help them achieve a positive pregnancy experience.
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Affiliation(s)
- S Downe
- Research in Childbirth and Health (ReaCH) group, University of Central Lancashire, Preston, UK
| | - K Finlayson
- Research in Childbirth and Health (ReaCH) group, University of Central Lancashire, Preston, UK
| | - Ӧ Tunçalp
- Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - A Metin Gülmezoglu
- Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
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George AS, Mehra V, Scott K, Sriram V. Community Participation in Health Systems Research: A Systematic Review Assessing the State of Research, the Nature of Interventions Involved and the Features of Engagement with Communities. PLoS One 2015; 10:e0141091. [PMID: 26496124 PMCID: PMC4619861 DOI: 10.1371/journal.pone.0141091] [Citation(s) in RCA: 153] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Accepted: 10/05/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Community participation is a major principle of people centered health systems, with considerable research highlighting its intrinsic value and strategic importance. Existing reviews largely focus on the effectiveness of community participation with less attention to how community participation is supported in health systems intervention research. OBJECTIVE To explore the extent, nature and quality of community participation in health systems intervention research in low- and middle-income countries. METHODOLOGY We searched for peer-reviewed, English language literature published between January 2000 and May 2012 through four electronic databases. Search terms combined the concepts of community, capability/participation, health systems research and low- and middle-income countries. The initial search yielded 3,092 articles, of which 260 articles with more than nominal community participation were identified and included. We further excluded 104 articles due to lower levels of community participation across the research cycle and poor description of the process of community participation. Out of the remaining 160 articles with rich community participation, we further examined 64 articles focused on service delivery and governance within health systems research. RESULTS Most articles were led by authors in high income countries and many did not consistently list critical aspects of study quality. Articles were most likely to describe community participation in health promotion interventions (78%, 202/260), even though they were less participatory than other health systems areas. Community involvement in governance and supply chain management was less common (12%, 30/260 and 9%, 24/260 respectively), but more participatory. Articles cut across all health conditions and varied by scale and duration, with those that were implemented at national scale or over more than five years being mainstreamed by government. Most articles detailed improvements in service availability, accessibility and acceptability, with fewer efforts focused on quality, and few designs able to measure impact on health outcomes. With regards to participation, most articles supported community's in implementing interventions (95%, n = 247/260), in contrast to involving communities in identifying and defining problems (18%, n = 46/260). Many articles did not discuss who in communities participated, with just over a half of the articles disaggregating any information by sex. Articles were largely under theorized, and only five mentioned power or control. Majority of the articles (57/64) described community participation processes as being collaborative with fewer describing either community mobilization or community empowerment. Intrinsic individual motivations, community-level trust, strong external linkages, and supportive institutional processes facilitated community participation, while lack of training, interest and information, along with weak financial sustainability were challenges. Supportive contextual factors included decentralization reforms and engagement with social movements. CONCLUSION Despite positive examples, community participation in health systems interventions was variable, with few being truly community directed. Future research should more thoroughly engage with community participation theory, recognize the power relations inherent in community participation, and be more realistic as to how much communities can participate and cognizant of who decides that.
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Affiliation(s)
- Asha S. George
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland, United States of America
| | - Vrinda Mehra
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland, United States of America
| | - Kerry Scott
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland, United States of America
| | - Veena Sriram
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland, United States of America
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Pant PR, Budhathoki B, Ellis M, Manandhar D, Deave T, Mytton J. The feasibility of community mobilisation for child injury prevention in rural Nepal: a programme for female community health volunteers. BMC Public Health 2015; 15:430. [PMID: 25928451 PMCID: PMC4418066 DOI: 10.1186/s12889-015-1783-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 04/22/2015] [Indexed: 11/10/2022] Open
Abstract
Background Injuries accounted for 23% of all deaths in children and adolescents in Nepal during 2010 (n = 3,700). Despite this, there is no national death registration or injury surveillance system. Non-fatal injuries are many times more common than fatal injuries and may leave the injured person with lifelong consequences. Children in low-income settings are exposed to widespread risks of injuries but there is little awareness of how they can be prevented. Community mobilisation has been shown to be effective to reduce maternal and neonatal morbidity. This study aimed to develop a child safety programme and assess the feasibility of delivering the programme through a community mobilisation approach. Methods We developed a culturally appropriate, educational programme for Female Community Health Volunteers that included both primary and secondary prevention materials for unintentional child injuries. We determined the feasibility of evaluating its effectiveness through the mobilisation of women’s groups in rural Nepal. Ten women’s groups across 9 wards in one village development committee area completed the programme during 6 monthly meetings. Parent-reported injuries were collected through a notification system established for this study. Experience of the programme by women’s group participants and leaders was assessed through a structured questionnaire and process measures assessed the delivery and reach of the programme. Results Programme resources were developed for this setting and adapted following feedback from users. Nine FCHVs received first-aid training and shown how to use the facilitation manual and injury prevention resources. The FCHVs convened 10 women’s groups to run over 6 months with 24–29 mothers attending each meeting (290 mothers participated in total). Each group presented their views on child injury risks and proposed prevention activities at local public meetings. Women reported 155 injuries to children under 18 years during 7 months of follow up using the notification system. Conclusions It is feasible to develop and implement a community mobilisation intervention where women’s groups work together with local FCHVs to prevent injuries in children. The intervention was well received by the women’s groups and by community members. The effectiveness and cost effectiveness of the intervention should now be evaluated through an experimental study. Electronic supplementary material The online version of this article (doi:10.1186/s12889-015-1783-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Puspa Raj Pant
- Centre for Child and Adolescent Health, University of the West of England, Bristol, UK.
| | | | - Matthew Ellis
- School of Social and Community Medicine, University of Bristol, Bristol, UK.
| | | | - Toity Deave
- Centre for Child and Adolescent Health, University of the West of England, Bristol, UK.
| | - Julie Mytton
- Centre for Child and Adolescent Health, University of the West of England, Bristol, UK.
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Mseu D, Nyasulu BM, Muheriwa SR. Evaluation of a Safe Motherhood project in Ntcheu district, Malawi. Int J Womens Health 2014; 6:1045-55. [PMID: 25540598 PMCID: PMC4270360 DOI: 10.2147/ijwh.s40109] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose This study evaluated knowledge and practices of childbearing women on key childcare practices within the Safe Motherhood project, administered by the Ntcheu District Health Office in the Republic of Malawi. The study excluded men and elderly women. Methods The design was cross-sectional, and utilized quantitative and qualitative data collection and analysis procedures. Data were also collected through review of participant health records. Results Although the findings showed that all participants (100%, n=400) had general knowledge on maternal and child health care, they did not have comprehensive information, and few mothers were practicing the recommended key child health care practices. Only 42.4% (n=170) knew the appropriate number of visits a woman should make to the antenatal clinic, and very few knew the appropriate time at which to access antenatal care. Only 55% (n=220) of participants breastfed their babies exclusively. Some participants introduced supplementary feeds as early as a month after birth, and not all women delivered at the health facility. Failure to actively involve men and elderly women in maternal and child health issues had a negative impact on women’s ability to fully implement key maternal and childcare practices. Conclusion and recommendations There is a need to actively involve men and elderly women in maternal and child health issues since, in the ideal Malawian context, a child is raised not just by the mother, but also by all who live in the village. Additionally, elderly women are the guardians of members of the childbearing group, and are a traditional reservoir of experience into which young women can tap. There is also a need to engage Community Nurse-Midwives in facilitating women’s groups that provide comprehensive antenatal information to mothers, who may then put knowledge into practice.
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Affiliation(s)
- Dennis Mseu
- Nurses and Midwives Council of Malawi, Lilongwe, Malawi
| | - Betty Mkwinda Nyasulu
- Basic Studies Department, Kamuzu College of Nursing, University of Malawi, Lilongwe, Malawi
| | - Sadandaula Rose Muheriwa
- Department of Maternal and Child Health, Kamuzu College of Nursing, University of Malawi, Lilongwe, Malawi
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