Effectiveness of self-financing patient-led support groups in the management of hypertension and diabetes in low- and middle-income countries: Systematic review

OBJECTIVE

There is insufficient evidence on the role of self-financing patient support groups in the control of blood pressure (BP) and/or diabetes in low- and middle-income countries (LMICs). We conducted a systematic review to investigate the effectiveness of these groups in BP and glycaemic control.

METHODS

We searched PubMed, Embase, SCOPUS, Web of Science, Global Health, African Journals Online, CINAHL and African Index Medicus for published peer-reviewed articles from inception up to November 2021. Grey literature was obtained from OpenGrey. Studies on patient support groups for hypertension and/or diabetes with a component of pooling financial resources, conducted in LMICs, were included. Narrative reviews, commentaries, editorials and articles published in languages other than English and French were excluded. Study quality and risk of bias were assessed using the National Institutes of Health Quality assessment tool and the revised Cochrane risk-of-bias tool. Results are reported according to PRISMA guidelines.

RESULTS

Of 724 records screened, three studies met the criteria: two trials conducted in Kenya and a retrospective cohort study conducted in Cambodia. All studies reported improvement in BP control after 12 months follow-up with reductions in systolic BP of 23, 14.8, and 16.9 mmHg, respectively. Two studies reported diabetes parameters. The first reported improvement in HbA1c (reduction from baseline 10.8%, to 10.6% at 6 months) and random blood sugar (baseline 8.9 mmol/L, to 8.5 mmol/L at 6 months) but these changes did not achieve statistical significance. The second reported a reduction in fasting blood glucose (baseline-216 mg/dl, 12 months-159 mg/dl) in diabetic patients on medication.

CONCLUSION

Self-financing patient support groups for diabetes and hypertension are potentially effective in the control of BP and diabetes in LMICs. More studies are needed to add to the scarce evidence base on the role of self-financing patient support groups.

An experiment of health services and additional microcredit in 128 villages of Bangladesh

Background

Studies in the literature have found mixed results on the effect of microcredit on health outcomes. Of the five previous experimental studies that included microcredit and a health intervention, three reported no significant changes in health status or behaviors. The purpose of this study was to test for marginal and interactive effects of increased microcredit and provision of basic health services.

Methods

This study had a 4-celled experimental design in 128 villages in rural Bangladesh. For villages in one cell, an additional microcredit worker was assigned. For those in a second cell, a health assistant visited households each month, provided simple medicines and announced a satellite clinic held monthly in each village. For a third cell, both interventions were combined, and villages in a fourth cell served as control. A baseline survey was completed and a follow-up survey was done three years later. Outcome measures were food security, contraceptive use, having a trained birth attendant at last birth, and measles immunization.

Results

Comparison of follow-up with baseline levels of the four outcome measures (for 3787 households (96% completeness) and 3687 women (94% completeness)) showed significant improvement in food security in all study arms and a significant increase in trained birth attendant at last birth in the health services villages. Due to confusion within Grameen Bank about which workers would provide the additional microcredit work, that intervention was poorly implemented so in multivariate analyses, the data for that intervention arm were grouped with data from the control arm. Logistic regression with values of the outcomes at follow-up as dependent variable and study arm and women’s schooling as covariates showed no significant effects of either separate or grouped study arms.

Conclusion

Two of the three health behaviors showed no significant changes over time but having a trained birth attendant at last delivery did increase significantly in the health services arm. Therefore, community health education can sometimes be effective in promoting healthy behaviors.

Trial registration

This was a field trial rather than a clinical trial, so trial registration was unnecessary.

Integrated community-based HIV and non-communicable disease care within microfinance groups in Kenya: study protocol for the Harambee cluster randomised trial

INTRODUCTION

In Kenya, distance to health facilities, inefficient vertical care delivery and limited financial means are barriers to retention in HIV care. Furthermore, the increasing burden of non-communicable diseases (NCDs) among people living with HIV complicates chronic disease treatment and strains traditional care delivery models. Potential strategies for improving HIV/NCD treatment outcomes are differentiated care, community-based care and microfinance (MF).

METHODS AND ANALYSIS

We will use a cluster randomised trial to evaluate integrated community-based (ICB) care incorporated into MF groups in medium and high HIV prevalence areas in western Kenya. We will conduct baseline assessments with n=900 HIV positive members of 40 existing MF groups. Group clusters will be randomised to receive either (1) ICB or (2) standard of care (SOC). The ICB intervention will include: (1) clinical care visits during MF group meetings inclusive of medical consultations, NCD management, distribution of antiretroviral therapy (ART) and NCD medications, and point-of-care laboratory testing; (2) peer support for ART adherence and (3) facility referrals as needed. MF groups randomised to SOC will receive regularly scheduled care at a health facility. Findings from the two trial arms will be compared with follow-up data from n=300 matched controls. The primary outcome will be VS at 18 months. Secondary outcomes will be retention in care, absolute mean change in systolic blood pressure and absolute mean change in HbA1c level at 18 months. We will use mediation analysis to evaluate mechanisms through which MF and ICB care impact outcomes and analyse incremental cost-effectiveness of the intervention in terms of cost per HIV suppressed person-time, cost per patient retained in care and cost per disability-adjusted life-year saved.

ETHICS AND DISSEMINATION

The Moi University Institutional Research and Ethics Committee approved this study (IREC#0003054). We will share data via the Brown University Digital Repository and disseminate findings via publication.

TRIAL REGISTRATION NUMBER

NCT04417127.

Microcredit as a public health initiative? Exploring mechanisms and pathways to health and wellbeing

The widening health gap between the best and worst-off in the UK requires innovative solutions that act upon the social, economic and environmental causes of ill-health. Initiatives such as microcredit have been conceptualised as having the potential to act on the social determinants of health. However, pathways that lead to this impact have yet to be empirically explored. People living on low incomes, who are financially-excluded, require access to credit to cope with everyday financial needs. While research shows the connections between debt and health, this link is often focused on over-indebtedness and negative health outcomes. In this paper, we investigate the impact of responsibly-delivered credit on the health and wellbeing of borrowers. In 2016-17, in-depth, semi-structured interviews were undertaken with fourteen borrowers from two microcredit providers offering personal and business microloans, operating in Glasgow, United Kingdom. Findings are presented, using social determinants of health as an analytic lens, and illustrated in a conceptual model explaining the loan mechanisms and pathways connecting microcredit to health and wellbeing. Microcredit, and the mechanisms through which it is delivered, were perceived by participants as positively impacting on their health and wellbeing. Access to flexible, responsibly-delivered, microloans enabled participants to plan and feel secure when faced with (un)expected financial events, reducing the associated stress, sustaining social relationships and empowering borrowers to take greater control over their lives. For some, receiving microcredit was stressful, as it is still a debt that needs to be repaid. Such stress can also be exacerbated by particular aspects of the lending model; for example, group lending. Our results contribute to growing evidence on the impact of financial inclusion approaches on health and wellbeing, highlighting the potential role of microcredit as a public health initiative and the need to support 'alternative' economic spaces in the UK to serve the financially-excluded.

Examining the evidence of microfinance on non-communicable disease health indicators and outcomes: A systematic literature review

Microfinance has emerged as an effective approach to address health outcomes, particularly infectious diseases and maternal and child health. However, there remains a significant knowledge gap about microfinance and Non-Communicable Diseases (NCDs). This review synthesises current evidence on microfinance and NCDs, including NCD-specific modifiable risks, health-seeking behaviour, and financing mechanisms of adults using microfinance services. Studies were identified through a systematic search of seven electronic databases, extracted for full-text screening, and analysed using a narrative analysis. A total of twelve articles that covered thirteen countries and four global regions were included in the review. Variations in study designs and reporting in the articles limited the ability to draw strong conclusions about microfinance and NCDs. However, the review revealed that microfinance may reduce modifiable risk factors, promote health-seeking behaviour, and reduce out-of-pocket health expenditure and catastrophic health expenditure related to NCDs. One study, however, found microfinance to be associated with negative effects of higher waist circumference, BMI and obesity rates. Overall, the review helped to identify the current gaps in knowledge, and highlighted the need to focus future research and publication on the use of microfinance to target NCDs of the poor.

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

BACKGROUND

Self-help group (SHG) interventions have been widely studied in low and middle income countries. However, there is little data on specific impacts of health layering, or adding health education modules upon existing SHGs which were formed primarily for economic empowerment. We examined three SHG interventions from 2012-2017 in Bihar, India to test the hypothesis that health-layering of SHGs would lead to improved health-related behaviours of women in SHGs.

METHODS

A model for health layering of SHGs - Parivartan - was developed by the non-governmental organisation (NGO), Project Concern International, in 64 blocks of eight districts. Layering included health modules, community events and review mechanisms. The health layering model was adapted for use with government-led SHGs, called JEEViKA+HL, in 37 other blocks of Bihar. Scale-up of government-led SHGs without health layering (JEEViKA) occurred contemporaneously in 433 other blocks, providing a natural comparison group. Using Community-based Household Surveys (CHS, rounds 6-9) by CARE India, 62 reproductive, maternal, newborn and child health and nutrition (RMNCHN) and sanitation indicators were examined for SHGs with health layering (Pavivartan SHGs and JEEViKA+HL SHGs) compared to those without. We calculated mean, standard deviation and odds ratios of indicators using surveymeans and survey logistic regression.

RESULTS

In 2014, 64% of indicators were significantly higher in Parivartan members compared to non-members residing in the same blocks. During scale up, from 2015-17, half (50%) of indicators had significantly higher odds in health layered SHG members (Parivartan or JEEViKA+HL) in 101 blocks compared to SHG members without health layering (JEEViKA) in 433 blocks.

CONCLUSIONS

Health layering of SHGs was demonstrated by an NGO-led model (Parivartan), adapted and scaled up by a government model (JEEViKA+HL), and associated with significant improvements in health compared to non-health-layered SHGs (JEEViKA). These results strengthen the evidence base for further layering of health onto the SHG platform for scale-level health change.

STUDY REGISTRATION

ClinicalTrials.gov number NCT02726230.

The relationship between a microfinance-based healthcare delivery platform, health insurance coverage, health screenings, and disease management in rural Western Kenya

BACKGROUND

Structural barriers often prevent rural Kenyans from receiving healthcare and diagnostic testing. The Bridging Income Generation through grouP Integrated Care (BIGPIC) Family intervention facilitates microfinance groups, provides health screenings and treatment, and delivers education about health insurance coverage to address some of these barriers. This study evaluated the association between participation in BIGPIC microfinance groups and health screening/disease management outcomes.

METHODS

From November 2018 to March 2019, we interviewed a sample of 300 members of two rural communities in Western Kenya, 100 of whom were BIGPIC microfinance members. We queried participants about their experiences with health screening and disease management for HIV, diabetes, hypertension, tuberculosis, and cervical cancer. We used log-binomial regression models to estimate the association between microfinance membership and each health outcome, adjusting for key covariates.

RESULTS

Microfinance members were more likely to be screened for most of the health conditions we queried, including those provided by BIGPIC [e.g. diabetes: aPR (95% CI): 3.46 (2.60, 4.60)] and those not provided [e.g. cervical cancer: aPR (95% CI): 2.43 (1.21, 4.86)]. Microfinance membership was not significantly associated with health insurance uptake and disease management outcomes.

CONCLUSIONS

In rural Kenya, a microfinance program integrated with healthcare delivery may be effective at increasing health screening. Interventions designed to thoughtfully and sustainably address structural barriers to healthcare will be critical to improving the health of those living in low-resource settings.

Human-centered design as a guide to intervention planning for non-communicable diseases: the BIGPIC study from Western Kenya

BACKGROUND

Non-communicable disease (NCD) care in Sub-Saharan Africa is challenging due to barriers including poverty and insufficient health system resources. Local culture and context can impact the success of interventions and should be integrated early in intervention design. Human-centered design (HCD) is a methodology that can be used to engage stakeholders in intervention design and evaluation to tailor-make interventions to meet their specific needs.

METHODS

We created a Design Team of health professionals, patients, microfinance officers, community health workers, and village leaders. Over 6 weeks, the Design Team utilized a four-step approach of synthesis, idea generation, prototyping, and creation to develop an integrated microfinance-group medical visit model for NCD. We tested the intervention with a 6-month pilot and conducted a feasibility evaluation using focus group discussions with pilot participants and community members.

RESULTS

Using human-centered design methodology, we designed a model for NCD delivery that consisted of microfinance coupled with monthly group medical visits led by a community health educator and a rural clinician. Benefits of the intervention included medication availability, financial resources, peer support, and reduced caregiver burden. Critical concerns elicited through iterative feedback informed subsequent modifications that resulted in an intervention model tailored to the local context.

CONCLUSIONS

Contextualized interventions are important in settings with multiple barriers to care. We demonstrate the use of HCD to guide the development and evaluation of an innovative care delivery model for NCDs in rural Kenya. HCD can be used as a framework to engage local stakeholders to optimize intervention design and implementation. This approach can facilitate the development of contextually relevant interventions in other low-resource settings.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT02501746, registration date: July 17, 2015.

Economic evaluation in implementation science: Making the business case for implementation strategies

Implementation researchers have made notable progress in developing and testing implementation strategies (i.e., highly-specified methods used to help providers improve uptake of mental health evidence-based practices: EBPs). Yet, implementation strategies are not widely applied in healthcare organizations to improve delivery of EBPs. Economic considerations are a key factor influencing the use of implementation strategies to deliver and sustain mental health evidence-based practices, in part because many health care leaders are reluctant to invest in ongoing implementation strategy support without knowing the return-on-investment. Comparative economic evaluation of implementation strategies provides critical information for payers, policymakers, and providers to make informed decisions if specific strategies are an efficient use of scarce organizational resources. Currently, few implementation studies include implementation cost data and even fewer conduct comparative economic analyses of implementation strategies. This summary will introduce clinicians, researchers and other health professionals to the economic evaluation in implementation science. We provide an overview of different economic evaluation methods, discuss differences between economic evaluation in health services and implementation science. We also highlight approaches and frameworks to guide economic evaluation of implementation, provide an example for a cognitive-behavioral therapy program and discuss recommendations.

Health Education Training Embedded in a Microfinance Platform Associated with Safer Sexual Behavior in Haitian Women

Sexual health education interventions have generally yielded modest impact, but may be more successful when integrated into programs designed to alleviate poverty and empower women. Between December 2017 and February 2018, we interviewed 304 Haitian female microfinance clients, 75 of whom had received health education training delivered within their regular meetings. Participants reported six key sexual health outcomes. We used log-binomial models to estimate the association between health education training and each outcome, and tested for interaction by age and literacy status. Women with health education training reported more condom use with unfaithful partners [PR (95% CI) 1.78 (1.04, 3.02)], more HIV testing [PR (95% CI) 1.56 (1.28, 1.90)], and fewer STI symptoms [PR (95% CI) 0.37 (0.19, 0.73)], compared to women with no training. Some of the associations were stronger among older women [e.g. HIV testing: PR (95% CI) 2.09 (1.49, 2.82)] and illiterate women [e.g. condom use: PR (95% CI) 3.46 (1.05, 11.38)]. These findings add to the growing body of evidence demonstrating the potential to use microfinance programs as platforms for health education delivery, and provide the first evidence for the association in Haiti.

Measuring coordination between women's self-help groups and local health systems in rural India: a social network analysis

OBJECTIVES

To assess how the health coordination and emergency referral networks between women's self-help groups (SHGs) and local health systems have changed over the course of a 2-year learning phase of the Uttar Pradesh Community Mobilization Project, India.

DESIGN

A pretest, post-test programme evaluation using social network survey to analyse changes in network structure and connectivity between key individuals and groups.

SETTING

The study was conducted in 18 villages located in three districts in Uttar Pradesh, India.

INTERVENTION

To improve linkages and coordination between SHGs and government health providers by building capacity in leadership, management and community mobilisation skills of the SHG federation.

PARTICIPANTS

A purposeful sampling that met inclusion criteria. 316 respondents at baseline and 280 respondents at endline, including SHG members, village-level and block-level government health workers, and other key members of the community (traditional birth attendants, drug sellers, unqualified rural medical providers, pradhans or elected village heads, and religious leaders).

MAIN OUTCOME MEASURES

Social network analysis measured degree centrality, density and centralisation to assess changes in health services coordination networks at the village and block levels.

RESULTS

The health services coordination and emergency referral networks increased in density and the number of connections between respondents as measured by average degree centrality have increased, along with more diversity of interaction between groups. The network expanded relationships at the village and block levels, reflecting the rise of bridging social capital. The accredited social health activist, a village health worker, occupied the central position in the network, and her role expanded to sharing information and coordinating services with the SHG members.

CONCLUSIONS

The creation of new partnerships between traditionally under-represented communities and local government can serve as vehicle for building social capital that can lead to a more accountable and accessible community health delivery system.

Improving the evidence for integrated family planning and economic growth programming: a synthesis of the evidence

Background:Integrated family planning and economic growth programming has the potential to be more equitable and cost-effective, to garner high levels of support from communities, and to support countries on their journey to self-reliance. The available evidence is limited, but demonstrates that such integrated programming can catalyze improved outcomes in both sectors. We reviewed available program evidence to explore what information is available to implementers regarding potential best practices.Methods:Economic growth is a broad sector; we focused specifically on the need for evidence related to integration of family planning with microfinance and livelihood programs. We conducted an extensive literature search and reviewed both published and gray literature according to two criteria: whether the papers explicitly focused on FP/EG integration and whether they included program descriptions, including discussions of what specific interventions were implemented.Results:We find that only limited information exists regarding how best to design and implement such programs for FP/RH and economic growth. We provide ideas drawn from the identified program evidence about potential best practices for FP/RH and economic growth integrated programs, and find an increasing need for tools and resources on related best practices.Conclusions:Both family planning and economic growth programs should consider strengthening linkages between the two sectors, to accelerate the achievement of global family planning goals as well as to improve economic growth outcomes. We call for additional research and improved documentation to clarify the apparent contributions and effectiveness of FP/EG integration, as well as to confirm promising practices. The integration of family planning and economic growth sectors is particularly important as the global community works toward achieving broader global and country-level development goals.

Evaluating an MFI Community Health Worker Program: How microfinance group networks influence intervention outreach and impact

BACKGROUND

Community Health Workers (CHWs) are considered to be a cost-effective and inclusive solution to address the persistent health workforce shortage in many low and middle-income countries. In recent years, microfinance institutions (MFIs) got increasingly engaged in providing health services delivered by CHWs. Despite their growing importance, little is known about the impacts and implementation barriers of these mostly small-scale initiatives. This paper evaluates an MFI-led CHW program in the Philippines and studies the role of microfinance group networks in influencing program outreach and impact. The intervention aims at disseminating information in poor communities, improving health monitoring through increased check-ups and raising social support.

METHODS

Clustered randomized controlled trial in 70 communities in the greater area of Metro Manila, the Philippines. The main data was collected in a baseline and follow-up survey and is complemented with extensive sociometric network and geographical data. The main outcome variable is a composite health index based on 10 indicators. The role of the health worker's embeddedness and connectedness in the community for program success is tested using tools of social network analysis.

RESULTS

The intervention led to a 3.8% (95% confidence interval (CI) = 1.3, 6.4) improvement in the composite health outcome. Effects across indicators are mixed and mainly driven by changes in immediate health monitoring behavior: The probability for routine examinations increased in the treatment group by 10.6% (95% CI = 3.2, 18.1), for regular blood pressure checks by 9.6% (95% CI = 3.3, 15.9), and for having access to a health care provider by 7.2% (95% CI = 0.93, 13.5). No statistical effects on general knowledge and social support are observable. Social networks are a key driver of program outreach and impact. Close friends and acquaintances of health workers used and benefited substantially more from the program than more distant ties.

CONCLUSIONS

Despite the promising immediate behavioral impacts, it remains questionable to what extent such small-scale MFI initiatives can bring transformative and sustainable changes without external support. Microfinance group networks played an important role for the success of the health intervention and further research is needed to better understand how these affect the health care utilization decisions of the clients.

A review of organizational arrangements in microfinance and health programs

BACKGROUND

Combining health programs with microfinance is gaining more recognition as a pathway for improving health and increasing access to health services among the poor, especially women living in low-income countries. Recently published reviews have summarized the changes in health behaviors and health outcomes due to the effective layering of health interventions with microfinance initiatives. However, a large gap remains in defining and understanding the organizational strategies for implementing effective health programs and services that improve the health and social well-being of women and their families.

METHOD

As microfinance organizations and the global health community recognize the largely untapped potential of developing effective multidimensional channels of providing access to a variety of health interventions through a microfinance platform, there is a need for more evidence to guide organizational strategies that are feasible, sustainable and produce results. We developed a framework and classification scheme for identifying organizational arrangements between microfinance and health, outlined the criteria for article identification and selection, and reviewed original articles that included a discussion on organizational strategies published in peer-reviewed journals to better inform future research and effective program development.

RESULTS

Our review found that most MFIs operate in cooperative and collaborative partnerships for expanding health and social services with health education as the leading intervention. The extreme ends of the integration-partnership continuum, ie, no partnership on one end and complete merger on the other, are rare if they exist.

CONCLUSIONS

The drivers of organizational strategy are related to the context, health needs of the clients, and individual capacities of MFIs to develop effective services. However, approaches to establishing these processes and decision-making for effectively structuring and delivering health and microfinance services is an inadequately explored area. Future progress depends on bridging public health, microfinance, and organizational research silos to study how different organizational arrangements affect implementation and outcomes.

Perceived Social Networks and Newborn Health: Evidence from Self-Help Group Communities in Northern India

The limitations of individual level interventions in changing behaviors to improve global maternal, newborn and child health have generated more interest in the patterns of social influence and decision making embedded in families, friends and communities. The purpose of this study is to expand the understanding of village dynamics in India and how first degree social and advice networks and cognitive perceptions of 185 recently delivered women (RDW) in areas with and without women's Self-Help Groups (SHGs) affect immediate breastfeeding. Data was collected in 6 blocks and 36 villages in Uttar Pradesh, India. The expansion of RDW's social worlds and creation of social capital through the organization of Self-Help Groups in their villages allowed us to examine basic relationships and advice formation as well as perceptions of interconnectedness of known groups. RDW living in SHG villages and blocks had consistently higher numbers of relationship ties, health advice ties and higher density of health advice networks than RDW living in the non-SHG areas. RDW's perceived knowing ties were also significantly higher between family and health workers in the SHG areas with related higher immediate breastfeeding rates. These results suggest that SHGs can accelerate community social capital and promote more accountability in the health system to engage with families and support the change from traditional to more evidence-based health practices.

Microfinance Institutions' Successful Delivery Of Micronutrient Powders: A Randomized Trial In Rural Haiti

Globally, two-thirds of child deaths could be prevented by increased provision of health interventions such as vaccines, micronutrient supplements, and water purification tablets. We report the results from a randomized controlled trial in Haiti during 2012 that tested whether microfinance institutions-which reach 200 million households worldwide-can effectively deliver health products. These institutions provide loans to underserved entrepreneurs, primarily poor women in rural areas. In the intervention group, micronutrient powders to improve the nutrition of young children were distributed at regularly occurring microfinance meetings by a trained borrower. In both the control and the intervention groups, nurses led seminars on nutrition and extended breastfeeding during microfinance meetings. At three-month follow-up, the mean difference in hemoglobin concentration between children in the intervention group and those in the control group was 0.28 grams per deciliter (g/dL)-with a subsample of younger children (under two years of age) showing greater relative improvement (0.46 g/dL)-and the odds ratio for children in the intervention group meeting the diagnostic criteria for anemia was 0.64. The results are similar to those of previous studies that evaluated micronutrient powder distribution through dedicated health institutions. Our findings suggest that microfinance institutions are a promising platform for the large-scale delivery of health products in low-income countries.

Effectiveness of educational interventions conducted by telephone to promote breastfeeding: a systematic review of the literature

OBJECTIVE

To assess the effectiveness of telephone educational interventions on the duration and exclusiveness of breastfeeding.

METHOD

A systematic review of the literature was conducted including only Randomized Clinical Trials. The exposure factor was an educational intervention via telephone, and the outcomes were duration and exclusiveness of breastfeeding. Literature in Portuguese, English and Spanish published between 2010 and 2016 were searched for in the Cochrane, Lilacs, Medline and Scopus databases. The articles were analyzed through a results synthesis.

RESULTS

241 articles were identified, of which 231 did not meet the inclusion criteria. Therefore, only 10 articles were reviewed. Four studies showed no efficacy related to breastfeeding. Regarding common characteristics, these studies were performed in short periods and in pairs. The others revealed efficacy regarding duration and/or exclusiveness of breastfeeding. The latter were mostly studies with long-term interventions and carried out by nurse lactation consultants.

CONCLUSION

The evidence demonstrates that the telephone is a viable technology for promoting breastfeeding, representing an alternative for the health units and health professionals that can contribute to mother-baby care.

Microfinance and health interventions: Factors influencing loan repayment success with young men in Dar es Salaam, Tanzania

Poverty is associated with numerous poor health outcomes. Youth unemployment in Tanzania is approximately 13.7%, and concentrates in urban areas. These youth lack relevant job skills and access to financial capital. Microfinance continues to be implemented globally to address poverty, and increasingly has been linked to health interventions. Men less frequently are recipients of microfinance loans. We offered microcredit to young men in an area of Dar es Salaam with high poverty as part of a randomised controlled-trial to assess the efficacy of a microfinance and health leadership intervention in preventing STI acquisition. We used mixed methods to understand predictors of successful loan repayment. Our qualitative sub-study showed that leader influence, prior business experience, personal motivation, and planning facilitated repayment. Using a modified Poisson approach, our quantitative analysis showed that successful repayment was associated with business experience, education, increasing number of children, community of residence, percentage of network members trained in business, and repayment success of peer leaders. Our results suggest that enforcing group accountability and repayment rules, offering ongoing training, and using successful entrepreneurs as role models could increase repayment success in similar populations. These strategies could provide financial opportunity for men while minimising risk for microfinance institutions.

Beyond Infrastructure: Understanding Why Patients Decline Surgery in the Developing World: An Observational Study in Cameroon

OBJECTIVE

The aim of this study was to quantify and describe a population of patients in rural Cameroon who present with a surgically treatable illness but ultimately decline surgery, and to understand the patient decision-making process and identify key socioeconomic factors that result in barriers to care.

BACKGROUND

An estimated 5 billion people lack access to safe, affordable surgical care and anesthesia when needed, and this unmet need resides disproportionally in low-income countries (LICs). An understanding of the socioeconomic factors underlying decision-making is key to future efforts to expand surgical care delivery in this population. We assessed patient decision-making in a LIC with a cash-based health care economy.

METHODS

Standardized interviews were conducted of a random sample of adult patients with treatable surgical conditions over a 7-week period in a tertiary referral hospital in rural Cameroon. Main outcome measures included participant's decision to accept or decline surgery, source of funding, and the relative importance of various factors in the decision-making process.

RESULTS

Thirty-four of 175 participants (19.4%) declined surgery recommended by their physician. Twenty-six of 34 participants declining surgery (76.4%) cited procedure cost, which on average equaled 6.4 months' income, as their primary decision factor. Multivariate analysis revealed female gender [odds ratio (OR) 3.35, 95% confidence interval (95% CI) 2.14-5.25], monthly earnings (OR 0.83, 95% CI, 0.77-0.89), supporting children in school (OR 1.22, 95% CI 1.13-1.31), and inability to borrow funds from family or the community (OR 6.49, 95% CI 4.10-10.28) as factors associated with declining surgery.

CONCLUSION

Nearly one-fifth of patients presenting to a surgical clinic with a treatable condition did not ultimately receive needed surgery. Both financial and sociocultural factors contribute to the decision to decline care.

Bridging Income Generation with Group Integrated Care for cardiovascular risk reduction: Rationale and design of the BIGPIC study

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of mortality worldwide, with >80% of CVD deaths occurring in low and middle income countries (LMICs). Diabetes mellitus and pre-diabetes are risk factors for CVD, and CVD is the major cause of morbidity and mortality among individuals with DM. There is a critical period now during which reducing CVD risk among individuals with diabetes and pre-diabetes may have a major impact. Cost-effective, culturally appropriate, and context-specific approaches are required. Two promising strategies to improve health outcomes are group medical visits and microfinance.

METHODS/DESIGN

This study tests whether group medical visits integrated into microfinance groups are effective and cost-effective in reducing CVD risk among individuals with diabetes or at increased risk for diabetes in western Kenya. An initial phase of qualitative inquiry will assess contextual factors, facilitators, and barriers that may impact integration of group medical visits and microfinance for CVD risk reduction. Subsequently, we will conduct a four-arm cluster randomized trial comparing: (1) usual clinical care, (2) usual clinical care plus microfinance groups only, (3) group medical visits only, and (4) group medical visits integrated into microfinance groups. The primary outcome measure will be 1-year change in systolic blood pressure, and a key secondary outcome measure is 1-year change in overall CVD risk as measured by the QRISK2 score. We will conduct mediation analysis to evaluate the influence of changes in social network characteristics on intervention outcomes, as well as moderation analysis to evaluate the influence of baseline social network characteristics on effectiveness of the interventions. Cost-effectiveness analysis will be conducted in terms of cost per unit change in systolic blood pressure, percent change in CVD risk score, and per disability-adjusted life year saved.

DISCUSSION

This study will provide evidence regarding effectiveness and cost-effectiveness of interventions to reduce CVD risk. We aim to produce generalizable methods and results that can provide a model for adoption in low-resource settings worldwide.

Evaluating the effect of integrated microfinance and health interventions: an updated review of the evidence

BACKGROUND

Solutions delivered within firm sectoral boundaries are inadequate in achieving income security and better health for poor populations. Integrated microfinance and health interventions leverage networks of women to promote financial inclusion, build livelihoods, and safeguard against high cost illnesses. Our understanding of the effect of integrated interventions has been limited by variability in intervention, outcome, design, and methodological rigour. This systematic review synthesises the literature through 2015 to understand the effect of integrated microfinance and health programs.

METHODS

We searched PubMed, Scopus, Embase, EconLit, and Global Health databases and sourced bibliographies, identifying 964 articles exclusive of duplicates. Title, abstract, and full text review yielded 35 articles. Articles evaluated the effect of intentionally integrated microfinance and health programs on client outcomes. We rated the quality of evidence for each article.

RESULTS

Most interventions combined microfinance with health education, which demonstrated positive effects on health knowledge and behaviours, though not health status. Among programs that integrated microfinance with other health components ( i.e. health micro-insurance, linkages to health providers, and access to health products), results were generally positive but mixed due to the smaller number and quality of studies. Interventions combining multiple health components in a given study demonstrated positive effects, though it was unclear which component was driving the effect. Most articles (57%) were moderate in quality.

DISCUSSION

Integrated microfinance and health education programs were effective, though longer intervention periods are necessary to measure more complex pathways to health status. The effect of microfinance combined with other health components was less clear. Stronger randomized research designs with multiple study arms are required to improve evidence and disentangle the effects of multiple component microfinance and health interventions. Few studies attempted to understand changes in economic outcomes, limiting our understanding of the relationship between health and income effects.

"You Are Not Alone" Strategies for Addressing Mental Health and Health Promotion with a Refugee Women's Sewing Group

Resettlement can be an uncertain time for refugees as they have often suffered life-threatening circumstances prior to flight from their countries, yet few resettlement programs screen for mental health. The purpose of this study was to pilot the Refugee Health Screener-15 (RHS-15) to assess mental health and the Pathways to Wellness intervention to identify internal and structural barriers affecting resettlement with a refugee women's sewing group. Community collaborations that create healthy social and physical environments through access to resources, economic opportunities, and social support promote a holistic approach to health and can improve quality of life for this vulnerable population.

Adult and adolescent livestock productive asset transfer programmes to improve mental health, economic stability and family and community relationships in rural South Kivu Province, Democratic Republic of Congo: a protocol of a randomised controlled trial

INTRODUCTION

People living in poverty have limited access to traditional financial institutions. Microfinance programmes are designed to meet this gap and show promise in improving income, economic productivity and health. Our Congolese-US community academic research partnership developed two livestock productive asset transfer programmes, Pigs for Peace (PFP) and Rabbits for Resilience (RFR), to address the interlinked health, social and economic well-being of individuals, their families and communities. The community-based randomised controlled trials examine the effectiveness of PFP and RFR to improve health, economic stability, and family and community relationships among male and female adults and adolescents living in 10 rural, postconflict villages of eastern Democratic Republic of Congo.

METHODS AND ANALYSIS

PFP participants include adult permanent residents of rural villages; adolescent participants in RFR include male and female adolescents 10-15 years old living in the selected rural villages. Participants were randomised to intervention or delayed control group. Participants in PFP completed baseline interview prior to intervention and follow-up interview at 6, 12 and 18 months postintervention. In RFR, participants completed baseline interview prior to intervention and follow-up interview at 6, 12 and 18 months postbaseline. The primary outcome of both trials, the change in baseline mental health distress at 18 months in the intervention group (adults, adolescents) compared to control group, is used to calculate sample size.

ETHICS AND DISSEMINATION

The Johns Hopkins Medical Institute Internal Review Board approved this protocol. A committee of respected Congolese educators and community members (due to lack of local ethics review board) approved the study. The findings will provide important information on the potential for community-led sustainable development initiatives to build on traditional livelihood (livestock raising, agriculture) to have a sustained health, economic and social impact on the individual, family and community.

TRIAL REGISTRATION NUMBER

NCT02008708, NCT02008695.

Credit with Health Education in Benin: A Cluster Randomized Trial Examining Impacts on Knowledge and Behavior

We evaluate whether health education integrated into microcredit lending groups reduces health risks by improving health knowledge and self-reported behaviors among urban and rural borrowers in eastern Benin. In 2007, we randomly assigned 138 villages in the Plateau region of Benin to one of four variations of a group liability credit product, varying lending groups' gender composition and/or inclusion of health education using a 2 × 2 design. Women in villages receiving health education, regardless of gender composition of the groups, showed improved knowledge of malaria and of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), but not of childhood illness danger signs. No significant changes in health behavior were observed except an increase in HIV/AIDS prevention behavior, a result predominantly driven by an increase in respondents' self-reported ability to procure a condom, likely an indicator of increased perceived access rather than improved preventative behavior. Women in villages assigned to mixed-gender groups had significantly lower levels of social capital, compared with villages assigned to female-only groups. This suggests there may be an important trade-off to consider for interventions seeking improved health outcomes and social capital through provision of services to mixed-gender groups. Although bundling health education with microcredit can expand health education coverage and lower service-delivery costs, the approach may not be sufficient to improve health behaviors.

Group-based microfinance for collective empowerment: a systematic review of health impacts

Objective

To assess the impact on health-related outcomes, of group microfinance schemes based on collective empowerment.

Methods

We searched the databases Social Sciences Citation Index, Embase, MEDLINE, MEDLINE In-Process, PsycINFO, Social Policy & Practice and Conference Proceedings Citation Index for articles published between 1 January 1980 and 29 February 2016. Articles reporting on health impacts associated with group-based microfinance were included in a narrative synthesis.

Findings

We identified one cluster-randomized control trial and 22 quasi-experimental studies. All of the included interventions targeted poor women living in low- or middle-income countries. Some included a health-promotion component. The results of the higher quality studies indicated an association between membership of a microfinance scheme and improvements in the health of women and their children. The observed improvements included reduced maternal and infant mortality, better sexual health and, in some cases, lower levels of interpersonal violence. According to the results of the few studies in which changes in empowerment were measured, membership of the relatively large and well-established microfinance schemes generally led to increased empowerment but this did not necessarily translate into improved health outcomes. Qualitative evidence suggested that increased empowerment may have contributed to observed improvements in contraceptive use and mental well-being and reductions in the risk of violence from an intimate partner.

Conclusion

Membership of the larger, well-established group-based microfinance schemes is associated with improvements in some health outcomes. Future studies need to be designed to cope better with bias and to assess negative as well as positive social and health impacts.

Using microfinance to facilitate household investment in sanitation in rural Cambodia

Improved sanitation access is extremely low in rural Cambodia. Non-governmental organizations have helped build local supply side latrine markets to promote household latrine purchase and use, but households cite inability to pay as a key barrier to purchase. To examine the extent to which microfinance can be used to facilitate household investment in sanitation, we applied a two-pronged assessment: (1) to address the gap between interest in and use of microfinance, we conducted a pilot study to assess microfinance demand and feasibility of integration with a sanitation marketing program and (2) using a household survey (n = 935) at latrine sales events in two rural provinces, we assessed attitudes about microfinance and financing for sanitation. We found substantial stated intent to use a microfinance institution (MFI) loan to purchase a latrine (27%). Five percent of current owners used an MFI loan for latrine purchase. Credit officers attended 159 events, with 4761 individuals attending. Actual loan applications were low, with 4% of sales events attendees applying for a loan immediately following the event (mean = 1.7 loans per event). Ongoing coordination was challenging, requiring management commitment from the sanitation marketing program and commitment to social responsibility from the MFI. Given the importance of improving sanitation coverage and concomitant health impacts, linking functional sanitation markets to already operational finance markets has the potential to give individuals and households more financial flexibility. Further product research and better integration of private vendors and financing modalities are necessary to create a scalable microfinance option for sanitation markets.

A systematic review of microfinance and women's health literature: Directions for future research

While growing evidence suggests that microfinance is an effective approach for improved women's health, a significant gap remains in our understanding. The objective of this review is to synthesise the findings from published literature focused on microfinance and health issues particularly affecting women, including HIV/AIDS, reproductive health, mental health, and violence. Forty-one articles that examine the impact of microfinance participation on women's health were identified through a systematic search of electronic databases, coded using a structured abstraction form, and synthesised. Review results indicate that the impact of microfinance on women's health is an area in great need of research and publication attention. Varied quality and reporting in the identified articles restricted the ability to draw concrete conclusions regarding the relationship between microfinance participation and women's health, but led to the identification of current gaps in existing published research. Future research should work to address the recommendations provided in order to offer additional evidence to better understand the use of microfinance programming as a structural intervention to improve women's health.

Group cell phones are feasible and acceptable for promoting optimal breastfeeding practices in a women's microcredit program in Nigeria

As part of a breastfeeding promotion intervention trial in Nigeria, we provided one cell phone per group of 5-7 microcredit clients and instructed the group's cell phone recipient to share weekly breastfeeding voice and text messages with group members. We measured the feasibility and acceptability of using group cell phones by conducting semi-structured exit interviews with 195 microcredit clients whose babies were born during the intervention (target group), in-depth interviews with eight phone recipients and nine non-phone recipients, and 16 focus group discussions with other microcredit clients. Women in the target group said the group phone worked well or very well (64%). They were motivated to try the recommended practices because they trusted the information (58%) and had support from others (35%). Approximately 44% of target women reported that their groups met and shared messages at least once a week. Women in groups that met at least weekly had higher odds of exclusive breastfeeding up to 6 months (OR 5.6, 95% CI 1.6, 19.7) than women in groups that never met. In-depth interviews and focus group discussions indicated that non-phone recipients had positive feelings towards phone recipients, the group phone met participants' needs, and messages were often shared outside the group. In conclusion, group cell phone messaging to promote breastfeeding among microcredit clients is feasible and acceptable and can be part of an effective behaviour change package.

Progress and remaining challenges for cancer control in Latin America and the Caribbean

Cancer is one of the leading causes of mortality worldwide, and an increasing threat in low-income and middle-income countries. Our findings in the 2013 Commission in The Lancet Oncology showed several discrepancies between the cancer landscape in Latin America and more developed countries. We reported that funding for health care was a small percentage of national gross domestic product and the percentage of health-care funds diverted to cancer care was even lower. Funds, insurance coverage, doctors, health-care workers, resources, and equipment were also very inequitably distributed between and within countries. We reported that a scarcity of cancer registries hampered the design of credible cancer plans, including initiatives for primary prevention. When we were commissioned by The Lancet Oncology to write an update to our report, we were sceptical that we would uncover much change. To our surprise and gratification much progress has been made in this short time. We are pleased to highlight structural reforms in health-care systems, new programmes for disenfranchised populations, expansion of cancer registries and cancer plans, and implementation of policies to improve primary cancer prevention.

Perceived Usefulness of a Microfinance Intervention on Health Awareness and Practices in Nepal

Background

Economic constraints may lead to poor health among people from the developing world. Microfinance has proven to be useful in improving health outcomes elsewhere, but it still remains a neglected issue in Nepal. This study aims to assess perceived usefulness of the microfinance on health awareness and practices among different ethnic groups of Nepal.

Method

A community-based cross-sectional study was conducted in four districts of western Nepal. A total of 500 microfinance clients representing different ethnic groups (upper caste, aadibasi and janajati, and dalit) were selected by using systemic random sampling. Health awareness and practices among different ethnic groups were compared by logistic regression after adjustment for age, level of education, sex of household heads, occupation, and place of residence. Since participants were asked about their health awareness and practices, before and after microfinance intervention, during a single interview, there was a strong possibility of recall bias with respect to their preintervention awareness and other measures.

Results

Microfinance intervention positively influenced self-reported health awareness and practices among different ethnic groups in Nepal, which was highest among the upper caste group (77–92%, rate ratios around 1.7–2.6), followed by the aadibasi/janajati (60–76%, rate ratios around 1.4–1.8) and dalit group (33–52%, reference group). Self-reported awareness about environment and sanitation, family planning methods, and available health services at local level improved from 11.2 to 69.2, 9.2 to 65.0, and 3.8 to 59.8%, respectively, among the clients after microfinance intervention (p < 0.001). Similarly, the practices of eating nutritious food/balanced diet, drinking safe water, using toilet, immunizing the children, and regularly visiting the healthcare facility were improved from 4.2 to 63.8, 12.6 to 66.8, 15.2 to 70.4, 15.8 to 73.8, and 3.6 to 61.4%, respectively (p < 0.001).

Conclusion

Despite lack of control group and potential recall bias, this study reports positive effect of microfinance on self-reported health awareness and practices among different ethnic groups of Nepal. This finding supports further implementation and evaluation of equity-based microfinance to improve health and economic conditions of Nepalese people.

Microcredit participation and women's health: results from a cross-sectional study in Peru

INTRODUCTION

Social and economic conditions are powerful determinants of women's health status. Microcredit, which involves the provision of small loans to low-income women in the hopes of improving their living conditions, is an increasingly popular intervention to improve women's socioeconomic status. Studies examining the health effects of microcredit programs have had mixed results.

METHODS

We conduct a cross-sectional study among female clients of a non-profit microcredit program in Peru (N = 1,593). The predictor variable is length of microcredit participation. We conduct bivariate and multivariate linear regressions to examine the associations between length of microcredit participation and a variety of measures of women's health. We control for participants' sociodemographic characteristics.

RESULTS

We find that longer participation is associated with decreased depressive symptoms, increased social support, and increased perceived control, but these differences are attenuated with the inclusion of covariates. We find no association between length of participation and contraception use, cancer screening, or self-reported days sick.

CONCLUSIONS

These results demonstrate a positive association between length of microcredit participation and measures of women's psychological health, but not physical health. These findings contribute to the discussion on the potential of microcredit programs to address the socioeconomic determinants of health, and suggest that addressing socioeconomic status may be a key way to improve women's health worldwide.

Factors influencing breastfeeding exclusivity during the first 6 months of life in developing countries: a quantitative and qualitative systematic review

Breastfeeding is the most advantageous feeding option for infants, and epidemiological studies provide evidence for its promotion. The objective of this review was to comprehensively delineate the barriers and facilitators of exclusive breastfeeding of infants aged 0-6 months old by mothers in developing countries. A search of CINAHL, MEDLINE and PsycINFO was carried out to retrieve studies from January 2001 to January 2014. Using our inclusion criteria, we selected studies that described barriers and facilitators of exclusive breastfeeding. Qualitative and quantitative studies were considered. Twenty-five studies involving 11 025 participants from 19 countries were included. Barriers and facilitators of exclusive/full breastfeeding were identified, analysed tabulated and summarised in this review. Maternal employment was the most frequently cited barrier to exclusive breastfeeding. Maternal perceptions of insufficient breast milk supply was pervasive among studies while medical barriers related to illness of mothers and/or infants as well as breast problems, rather than health care providers. Socio-cultural factors such as maternal and significant other's beliefs about infant nutrition also often constitute strong barriers to exclusive breastfeeding. Despite these barriers, mothers in developing countries often possess certain personal characteristics and develop strategic plans to enhance their success at breastfeeding. Health care providers should be informed about the determinants of exclusive breastfeeding and provide practical anticipatory guidance targeted at overcoming these barriers. In so doing, health care providers in developing countries can contribute to improving maternal and child health outcomes.

Where do the poorest go to seek outpatient care in Bangladesh: hospitals run by government or microfinance institutions?

Introduction

Health programs implemented by microfinance institutions (MFIs) aim to benefit the poor, but whether these services reach the poorest remains uncertain. This study intended to investigate the socioeconomic distribution of patients in hospitals operated by microfinance institutions (i.e. MFI hospitals) in Bangladesh and compare the differences with public hospitals to determine if the programs were consistent with their pro-poor mandate.

Methods

In this cross-sectional study, we used the convenience sampling method to conduct an interviewer-assisted questionnaire survey among 347 female outpatients, with 170 in public hospitals and 177 in MFI hospitals. Independent variables were patient characteristics categorized into predisposing factors (age, education, marital status, family size), enabling factors (microcredit membership, household income) and need factors (self-rated health, perceived needs for care). We employed Generalized Estimating Equations (GEE) to evaluate how these factors contributed to MFI hospital use.

Results

Use of MFI hospitals was associated with microcredit membership over 5 years (OR=2.9, p<.01), moderately poor household (OR=4.09, p<.001), non-poor household (OR=7.34, p<.01) and need for preventive care (OR=3.4, p<.01), compared with public hospitals. Combining membership and income, we found microcredit members had a higher tendency towards utilization but membership effect pertained to the non- and moderately-poor. Compared with the group who were non-members and the poorest, microcredit members who were non-poor had the highest likelihood (OR=7.46, p<.001) to visit MFI hospitals, followed by members with moderate income (OR=6.91, p<.001) and then non-members in non-poor households (OR=4.48, p<.01). Those who were members but the poorest had a negative association (OR=0.42), though not significant. Despite a higher utilization of preventive services in MFI hospitals, expenditure there was significantly higher.

Conclusion

Inequity was more pronounced in MFI hospitals than public ones. MFI hospitals appeared to miss their target population. We suggest that MFIs reorganize health programs toward primary health care to make care equitable and universally accessible. This study holds practical implications for governments, development agencies and microfinance practitioners working at the grassroots level.

Providing primary health care through integrated microfinance and health services in Latin America

The simultaneous burdens of communicable and chronic non-communicable diseases cause significant morbidity and mortality in middle-income countries. The poor are at particular risk, with lower access to health care and higher rates of avoidable mortality. Integrating health-related services with microfinance has been shown to improve health knowledge, behaviors, and access to appropriate health care. However, limited evidence is available on effects of fully integrating clinical health service delivery alongside microfinance services through large scale and sustained long-term programs. Using a conceptual model of health services access, we examine supply- and demand-side factors in a microfinance client population receiving integrated services. We conduct a case study using data from 2010 to 2012 of the design of a universal screening program and primary care services provided in conjunction with microfinance loans by Pro Mujer, a women's development organization in Latin America. The program operates in Argentina, Bolivia, Mexico, Nicaragua, and Peru. We analyze descriptive reports and administrative data for measures related to improving access to primary health services and management of chronic diseases. We find provision of preventive care is substantial, with an average of 13% of Pro Mujer clients being screened for cervical cancer each year, 21% receiving breast exams, 16% having a blood glucose measurement, 39% receiving a blood pressure measurement, and 46% having their body mass index calculated. This population, with more than half of those screened being overweight or obese and 9% of those screened having elevated glucose measures, has major risk factors for diabetes, high blood pressure, and cardiovascular disease without intervention. The components of the Pro Mujer health program address four dimensions of healthcare access: geographic accessibility, availability, affordability, and acceptability. Significant progress has been made to meet basic health needs, but challenges remain to ensure that health care provided is of reliable quality to predictably improve health outcomes over time.

Leveraging Community-Based Financing for Women’s Nonmaternal Health Care

Given the increasing need for mainstreaming household financing for women’s nonmaternal health care and evidences on community-based financing’s contribution to women’s health care in general, this study explored their scope for nonmaternal health care in Orissa. A qualitative assessment conducted focus group discussions with rural women who met the eligibility criteria. Community-based financing provided financial access and risk protection for women’s nonmaternal health care during the previous 1 year, though not adequately. Schemes covering outpatient care (or mild illnesses) provided relatively more financial access. The major determinants of their restricted financial access were limited sum assured, noncomprehensive coverage of services, exclusion of elderly women, and the lower priority households gave to nonmaternal health care. Community-based financing requires relevant structural changes along with demand-side behavioral modifications to ensure optimal attention to women’s nonmaternal health care.

Livestock/animal assets buffer the impact of conflict-related traumatic events on mental health symptoms for rural women

Background

In the context of multiple adversities, women are demonstrating resilience in rebuilding their futures, through participation in microfinance programs. In addition to the economic benefits of microfinance, there is evidence to suggest that it is an effective vehicle for improving health.

Methods

The parent study is a community-based trial to evaluate the effectiveness of a livestock microfinance intervention, Pigs for Peace (PFP), on health and economic outcomes with households in 10 villages in eastern Democratic Republic of Congo. The analysis for this manuscript includes only baseline data from female participants enrolled in the ongoing parent study. Multiple regression analysis was used to examine if livestock/animal asset value moderates the relationship between conflict-related traumatic events and current mental health symptoms.

Findings

The majority of women are 25 years or older, married, have on average 4 children in the home and have never attended school. Nearly 50% of women report having at least one livestock/animal asset at baseline. Over the past 10 years, women report on average more than 4 (M = 4.31, SD 3·64) traumatic events (range 0–18). Women reported symptoms consistent with PTSD with a mean score of ·2.30 (SD = 0·66range 0–4) and depression with a mean score of 1.86 (SD  = 0·49, range 0–3.47). The livestock/animal asset value by conflict-related traumatic events interaction was significant for both the PTSD (p = 0·021) and depression (p = 0·002) symptom models.

Interpretation

The study provides evidence of the moderating affect of livestock/animal assets on mental health symptoms for women who have experienced conflict. The findings supports evidence about the importance of livestock/animal assets to economics in rural households but expands on previous research by demonstrating the psychosocial effects of these assets on women's health.

Trial Registration

clinicaltrials.gov NCT02008708

'More health for the money': an analytical framework for access to health care through microfinance and savings groups

The main contributors to inequities in health relates to widespread poverty. Health cannot be achieved without addressing the social determinants of health, and the answer does not lie in the health sector alone. One of the potential pathways to address vulnerabilities linked to poverty, social exclusion, and empowerment of women is aligning health programmes with empowerment interventions linked to access to capital through microfinance and self-help groups. This paper presents a framework to analyse combined health and financial interventions through microfinance programmes in reducing barriers to access health care. If properly designed and ethically managed such integrated programmes can provide more health for the money spent on health care.

Social determinants of mental health

A person's mental health and many common mental disorders are shaped by various social, economic, and physical environments operating at different stages of life. Risk factors for many common mental disorders are heavily associated with social inequalities, whereby the greater the inequality the higher the inequality in risk. The poor and disadvantaged suffer disproportionately, but those in the middle of the social gradient are also affected. It is of major importance that action is taken to improve the conditions of everyday life, beginning before birth and progressing into early childhood, older childhood and adolescence, during family building and working ages, and through to older age. Action throughout these life stages would provide opportunities for both improving population mental health, and for reducing risk of those mental disorders that are associated with social inequalities. As mental disorders are fundamentally linked to a number of other physical health conditions, these actions would also reduce inequalities in physical health and improve health overall. Action needs to be universal: across the whole of society and proportionate to need. Policy-making at all levels of governance and across sectors can make a positive difference.

Integrating group counseling, cell phone messaging, and participant-generated songs and dramas into a microcredit program increases Nigerian women's adherence to international breastfeeding recommendations

In northern Nigeria, interventions are urgently needed to narrow the large gap between international breastfeeding recommendations and actual breastfeeding practices. Studies of integrated microcredit and community health interventions documented success in modifying health behaviors but typically had uncontrolled designs. We conducted a cluster-randomized controlled trial in Bauchi State, Nigeria, with the aim of increasing early breastfeeding initiation and exclusive breastfeeding among female microcredit clients. The intervention had 3 components. Trained credit officers led monthly breastfeeding learning sessions during regularly scheduled microcredit meetings for 10 mo. Text and voice messages were sent out weekly to a cell phone provided to small groups of microcredit clients (5-7 women). The small groups prepared songs or dramas about the messages and presented them at the monthly microcredit meetings. The control arm continued with the regular microcredit program. Randomization occurred at the level of the monthly meeting groups. Pregnant clients were recruited at baseline and interviewed again when their infants were aged ≥6 mo. Logistic regression models accounting for clustering were used to estimate the odds of performing recommended behaviors. Among the clients who completed the final survey (n = 390), the odds of exclusive breastfeeding to 6 mo (OR: 2.4; 95% CI: 1.4, 4.0) and timely breastfeeding initiation (OR: 2.6; 95% CI: 1.6, 4.1) were increased in the intervention vs. control arm. Delayed introduction of water explained most of the increase in exclusive breastfeeding among clients receiving the intervention. In conclusion, a breastfeeding promotion intervention integrated into microcredit increased the likelihood that women adopted recommended breastfeeding practices. This intervention could be scaled up in Nigeria, where local organizations provide microcredit to >500,000 clients. Furthermore, the intervention could be adopted more widely given that >150 million women, many of childbearing age, are involved in microfinance globally.

Overcoming access barriers to health services through membership-based microfinance organizations: a review of evidence from South Asia

It is a challenge for the poor to overcome the barriers to accessing health services. Membership-based microfinance with associated health programmes can improve health outcomes for the poor. This study reviewed the evidence published between 1993 and 2013 on the role of membership-based microfinance with associated health programmes in improving health outcomes for the poor in South Asia. A total of 661 papers were identified and 26 selected for inclusion, based on the relevance and rigour of the research methods. Of these 26, five were evidence reviews. Of the remaining 21 papers, 12 were from India, seven from Bangladesh, and one each from Sri Lanka and Indonesia. Three papers addressed more than one theme. Five key themes emerged from the review: (i) the impact of microfinance programmes on the social and economic situation of the poor; (ii) the impact of microfinance programmes on community health; (iii) the impact of integrated microfinance health programmes on raising client awareness; (iv) the impact of integrated microfinance health programmes on financing health care; and (v) the impact of integrated microfinance health programmes on affordable health-care products and services. The review provides new evidence on the pathways through which microfinance helps to improve population health and value for money for such programmes. Among countries with large populations in the informal sector, there is a strong case for policy-makers to support these groups in providing access to life-saving health care among the poor.

Design and baseline findings of a multi-site non-randomized evaluation of the effect of a health programme on microfinance clients in India

Microfinance is the provision of financial services for the poor. Health program through microfinance has the potential to address several access barriers to health. We report the design and baseline findings of a multi-site non-randomized evaluation of the effect of a health program on the members of two microfinance organizations from Karnataka and Gujarat states of India. Villages identified for roll-out of health services with microfinance were pair-matched with microfinance only villages. A quantitative survey at inception and twelve months post health intervention compare the primary outcome (incidence of childhood diarrhea), and secondary outcome (place of last delivery, toilet at home, and out-of-pocket expenditure on treatment). At baseline, the intervention and comparison communities were similar except for out-of-pocket expenditure on health. Low reported use of toilet at home indicates the areas are heading towards a sanitation crisis. This should be an area of program priority for the microfinance organizations. While respondents primarily rely on their savings for meeting treatment expenditure, borrowing from friends, relatives, and money-lenders remains other important source of meeting treatment expenditure in the community. Programs need to prioritize steps to ensure awareness about national health insurance schemes, entitlement to increase service utilization, and developing additional health financing safety nets for financing outpatient care, that are responsible for majority of health-debt. Finally we discuss implications of such programs for national policy makers.