Delivering development? Evidence on self-help groups as development intermediaries in South Asia and Africa

Equity and empowerment effects: Multiple styles of 'voluntarism' in community-based health projects

Community health workers (CHW) are individuals with no formal health training who perform various roles to address health disparities. There are long-sustained debates over how different forms of incentives shape CHW programs, which are often staffed with volunteer or minimally remunerated women. These debates are complicated by the diversity of CHW roles and contexts in which they work. Evidence is particularly scant around "change-agent" style CHWs, who shape health knowledge and norms within their community. This paper addresses this gap through an analysis of a change agent-staffed program that provided nutrition participatory education through women's groups in three eastern Indian sites. We examine how contextual factors across sites shaped change-agent management, and analyze the implications of each approach for efficacy, empowerment, and equity. Analyzing 68 interviews and 10 focus groups this study advances a typology of 'varieties' of voluntarism that we name laissez faire, active-cultivation, and honorarium-accountability, and uses comparative analysis to examine the equity and empowerment effects within selection, management, and payment. First, we find tensions in the community-based selection of volunteers because rather than selecting highly motivated women, groups selected women in the most favorable socioeconomic position to volunteer. Second, there is a tension around responsibility and expectations in that greater training and responsibility leads women to see more psychosocial empowerment (e.g., knowledge, confidence), but also may create more 'costs' to participation and leads to wider economic inequities in change-agent ranks. Third, we observe a misplaced focus on payments as central to change-agent motivation. While the two volunteer-only sites see payment as 'the answer' to motivation problems, the honorarium site sees payments as 'the problem' because they attract less intrinsically motivated individuals. We conclude that while payments may not make an unmotivated volunteer into a motivated one, this analysis suggests payments would potentially allow more marginalized women to participate, which may be key to making more equitable and efficacious impacts.

"Here, I am More than Just Symptoms Combined": Mental Health Services from the Perspective of Community Rehabilitation Groups

In response to the rise in mental disorders, psychosocial and community approaches have been proposed, complementing traditional clinical services. The present research aimed to understand the perception of individuals attending community-based strategies regarding mental health services as part of the approach to mental disorders in Colombia. Two workshops were conducted with 30 individuals with mental disorders (depression, anxiety and bipolar disorder), who were members of community strategies. A thematic analysis was conducted. The theme resulting from the analysis shows Community mental health within the healthcare system, which consisted of categories such as Group Amplifying Actions for Health and Groups as Complementary to Other Forms of Care. It is emphasized that the healthcare system should establish bridges with community mental health strategies and actively engage in their strengthening processes to enhance the outcomes of pharmacological interventions and even psychotherapeutic interventions. Bidirectional learning approach is proposed between community-based mental health services and clinical settings within the healthcare system. Community strategies can make an important contribution to complex processes in the health system.

Livelihood support for caregivers of children with developmental disabilities: findings from a scoping review and stakeholder survey

PURPOSE

Poverty amongst families with a child with disability adversely impacts child and family quality of life. We aimed to identify existing approaches to livelihood support for caregivers of children with developmental disabilities in low- and middle-income countries.

METHODS

This mixed-method study incorporated a scoping literature review and online stakeholder survey. We utilised the World Health Organization community-based rehabilitation (CBR) matrix as a guiding framework for knowledge synthesis and descriptively analysed the included articles and survey responses.

RESULTS

We included 11 peer-reviewed publications, 6 grey literature articles, and 49 survey responses from stakeholders working in 22 countries. Identified programmes reported direct and indirect strategies for livelihood support targeting multiple elements of the CBR matrix; particularly skills development, access to social protection measures, and self-employment; frequently in collaboration with specialist partners, and as one component of a wider intervention. Self-help groups were also common. No publications examined effectiveness of livelihood support approaches in mitigating poverty, with most describing observational studies at small scale.

CONCLUSION

Whilst stakeholders describe a variety of direct and indirect approaches to livelihood support for caregivers of children with disabilities, there is a lack of published literature on content, process, and impact to inform future programme development and delivery.

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

Background

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

Methods

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

Results

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

Conclusions

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

Economic evaluation of self-help group interventions for health in LMICs: a scoping review

This scoping review aims to identify and critically appraise published economic evaluations of self-help group (SHG) interventions in low- and middle-income countries (LMICs) that seek to improve health and potentially also non-health outcomes. Through a systematic search of MEDLINE ALL (Ovid), EMBASE Ovid, PsychINFO, EconLit (Ovid) and Global Index Medicus, we identified studies published between 2014 and 2020 that were based in LMICs, included at least a health outcome, estimated intervention costs and reported the methods used. We critically analysed whether the methods employed can meaningfully inform decisions by ministries of health and other sectors, including donors, regarding whether to fund such interventions, and prioritized the aspects of evaluations that support decision-making and cross-sectoral decision-making especially. Nine studies met our inclusion criteria. Randomized controlled trials were the most commonly used vehicle to collect data and to establish a causal effect across studies. While all studies clearly stated one or more perspectives justifying the costs and effects that are reported, few papers clearly laid out the decision context or the decision maker(s) informed by the study. The latter is required to inform which costs, effects and opportunity costs are relevant to the decision and should be included in the analysis. Costs were typically reported from the provider or health-care sector perspective although other perspectives were also employed. Four papers reported outcomes in terms of a generic measure of health. Contrary to expectation, no studies reported outcomes beyond health. Our findings suggest limitations in the extent to which published studies are able to inform decision makers around the value of implementing SHG interventions in their particular context. Funders can make better informed decisions when evidence is presented using a cross-sectoral framework.

PROTOCOL: Effects of interventions to improve access to financial services for micro-, small- and medium-sized enterprises in low- and middle-income countries: An evidence and gap map

Background

Micro-, small-, and medium-sized enterprises (MSMEs) account for the vast majority of firms in most economies, particularly in developing nations, and are key contributors to job creation and global economic development. However, the most significant impediment to MSME development in low- and middle-income countries is a lack of access to both investment and working capital financing. Due to a lack of essential track record, appropriate collateral, and credit history, MSMEs are frequently denied business loans by traditional lending institutions. In addition, SMEs' inability to access funding is hindered by institutional, structural, and non-financial factors. To address this, both the public and private sectors employ indirect and direct finance interventions to help MSMEs in developing and emerging economies enhance and increase their financing needs. Given the importance of MSMEs in the economy, a comprehensive overview of and systematic synthesizing of the evidence of the effects of financial access interventions for MSMEs, capturing a wide variety of outcome variables, is useful.

Objectives

The objective of this evidence and gap map (EGM) is to describe the existing evidence on the effects of various interventions dedicated to supporting and improving MSMEs' access to credit, as well as the corresponding firm performance and/or welfare outcomes.

Methods

An EGM is a systematic evidence product that displays the existing evidence relevant to a specific research question. An EGM's end product is a research article or report, but it can also be shared via an interactive map drawn as a matrix of included studies and their corresponding interventions and outcomes. Interventions in low- and middle-income countries that target specific population subgroups are included on the map. The EGM considers five types of interventions: (i) strategy, legislation and regulatory; (ii) systems and institutions; (iii) facilitate access; (iv) lending instruments or financial products; and (v) demand-side interventions. The map, on the other hand, covers outcome domains for policy environment, financial inclusion, firm performance, and welfare. Impact evaluations or systematic reviews of relevant interventions for a previously defined target population are included in the EGM. Studies using experimental or non-experimental designs, as well as systematic reviews, are eligible. The EGM excludes before-and-after study designs with no suitable comparison group. Furthermore, the map excludes literature reviews, key informant interviews, focus group discussions, and descriptive analyses. Search strings were used to conduct electronic searches in databases. To ensure that the research team had identified a significant portion of relevant research works, the search strategy was supplemented with gray literature searches and systematic review citation tracking. We have compiled studies that are either completed or in progress. For practical reasons, studies are limited to papers written in English and are not restricted by publication date.

Selection Criteria

We included studies that examined interventions to enhance MSMEs' access to finance in low- and middle-income countries targeting MSMEs including households, smallholder farmers and single person enterprise as well as financial institutions/agencies and their staff. The EGM considers five types of interventions that aim to: (i) deliver strategy, legislation, and regulatory aspects; (ii) systems and institutions that enable financing; (iii) facilitate access to finance; (iv) deliver different lending instruments or financial products, including traditional forms of microcredit; and (v) demand-side interventions such as programs on financial literacy. The map includes outcome domains surrounding policy environment, financial inclusion, firm performance, and welfare. Eligible studies must be experimental, non-experimental, or systematic reviews. In addition, the study designs must have a suitable comparison group before and after the implementation of interventions.

Results

The EGM includes 413 studies. The majority of the studies (379 studies) analyzed microenterprises, such as households and smallholder farmers; 7 studies analyzed community groups; while 109 studies analyzed small and medium enterprises. There were 147 studies on interventions that targeted multiple firm sizes. Lending instruments/financial products are the most common intervention across all firm types. When it comes to the types of firms that receive the said financial intervention, the data is overwhelmingly in favor of microenterprises (278 studies), followed by systems and organizations (138 studies) that support better access to such financial products and services. Welfare outcomes have the most evidence out of all of the outcomes of interest, followed by firm performance and financial inclusion. Among all firm types, welfare outcomes are primarily targeted at microenterprises. With 59 studies, we can say that small businesses have a significantly large number of enterprise performance outcomes. of the 413 studies, 243 used non-experimental or quasi-experimental designs (mainly propensity score matching and instrumental variable approaches), 136 used experimental methods, and 34 were systematic reviews. 175 studies (43%) provided evidence from Sub-Saharan Africa, 142 studies (35%) from South Asia, 86 studies (21%) from East Asia and the Pacific, 66 studies (16%) from Latin America and the Caribbean, 28 studies (7%), Europe and Central Asia, and 21 studies (5%) from the Middle East and North Africa. Most of the included evidence covers low-income (26%) and lower-middle income countries (66%), and to a lesser extent upper-middle-income countries (26%).

Conclusion

This map depicts the existing evidence and gaps on the effects of interventions to enhance MSMEs' access to financial services in low and middle-income countries. Interventions directed at microenterprises with welfare outcomes have a significant number of research outcomes in the literature. SME evaluations have looked at firm performance, with less focus to employment and the welfare effects on owners and employees, including poverty reduction. Microcredit/loans have been the focus of a large number of research papers (238 studies), indicating the field's growing popularity. However, emerging financial interventions such as facilitating access to digital financial services are relatively under-studied. Several studies also investigate rural or population in remote areas with 192 studies, 126 studies on poor and disadvantaged, and 114 papers on women. Most of the research is conducted in Sub-Saharan Africa (175 studies) and South Asia (142 studies) so further research in other regions could be conducted to allow a more holistic understanding of the effects of financial inclusion interventions. Credit lines, supply chain finance, and trade financing, which are some of the ADB's financial tools have limited evidence. Future studies should look into strategy, law, and regulation interventions, as well as interventions targeted at SMEs, and examine policy and regulatory environment outcomes as well as welfare outcomes. Interventions on the demand side and their impact on the policy and regulatory environment, as well as facilitating access are relatively understudied.

Cash plus programming and intimate partner violence: a qualitative evaluation of the benefits of group-based platforms for delivering activities in support of the Ethiopian government's Productive Safety Net Programme (PSNP)

OBJECTIVES

Intimate partner violence (IPV) is a public health challenge but there is evidence that cash and cash 'plus' interventions reduce IPV. An increasingly popular design feature of these kind of interventions is the group-based modality for delivering plus activities, however, evidence of the mechanisms through which this modality of delivery impacts IPV is limited. We explore how the group-based modality of delivering plus activities that complemented the Government of Ethiopia's Productive Safety Net Programme contributed to modifying intermediate outcomes on the pathway to IPV.

DESIGN

Qualitative study using in-depth interviews and focus group discussions between February and March 2020. Data were analysed using a thematic content and gender lens approach. Findings were interpreted, refined and drafted in collaboration with our local research partners.

SETTING

Amhara and Oromia regions in Ethiopia.

PARTICIPANTS

In total 115 men and women beneficiaries from the Strengthen PSNP4 Institutions and Resilience (SPIR) programme took part in the study. Fifty-eight were interviewed and 57 took part in 7 focus group discussions.

RESULTS

We found that Village Economic and Social Associations-through which SPIR activities were delivered-improved financial security and increased economic resilience against income shocks. The group-based delivery of plus activities to couples appeared to enhance individual agency, collective power and social networks, which in turn strengthened social support, gender relations and joint decision-making. Critical reflective dialogues provided a reference group to support the shift away from social norms that condone IPV. Finally, there appeared to be gender differences, with men highlighting the financial benefits and enhanced social status afforded by the groups, whereas women's accounts focused primarily on strengthened social networks and social capital.

CONCLUSION

Our study offers important insights into the mechanisms by which the group-based delivery of plus activities affects intermediate outcomes on the pathway to IPV. It underscores the importance of the modality of delivery in such programmes, and suggests that policy-makers should consider gender-specific needs as men and women might differentially benefit from interventions that enhance social capital to generate gender transformative impacts.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Health Mothers' Groups in Nepal: Barriers, Facilitators, and Recommendations

Background

Nepal's female community health volunteers (FCHVs) each lead a monthly health mothers' group (HMG) to share health-related information and engage communities in the health system. Suaahara II (SII), a US Agency for International Development-funded multisectoral nutrition program, uses social and behavior change interventions to promote HMG participation and uses its health systems interventions to strengthen HMG quality.

Objectives

This study aimed to explore HMG functionality and variation across Nepal, including barriers and facilitators to attending HMG meetings.

Methods

SII's cross-sectional annual survey data from 16 districts (n = 192 FCHVs and 1850 mothers with children <2 y) were used. Descriptive and logistic regression analyses were conducted where the outcome variable was whether mothers were active HMG members or not, with FCHV and maternal characteristics as explanatory variables. Qualitative data were obtained from 3 of 16 survey districts (n = 30 observations, n = 30 in-depth interviews with mothers, and n = 16 focus group discussions with mothers, family members, FCHVs, health workers, and SII staff).

Results

Among FCHVs, 90% reported facilitating HMG meetings, whereas 64% of mothers reported HMG availability, and only 25% reported participating actively in meetings. Household head sex, maternal age, maternal education, maternal self-efficacy, and engagement with an FCHV and SII were associated with whether mothers were active participants in HMG meetings. Qualitative findings highlighted systems-level barriers, including lack of FCHV skills, demotivation, and heavy workload. Mothers noted time as the major constraint and family support, the HMG's savings component, and active FCHVs as facilitators to participation.

Conclusions

Findings suggest that both supply- and demand-side solutions are needed to improve HMG performance and uptake in Nepal. These solutions need to include improving FCHV skills and motivating them to provide high-quality HMG services, as well as encouraging family members to support women so that they have time to participate in the HMGs.

Self-help groups as platforms for development: The role of social capital

Women-led self-help groups (SHGs) are increasingly being utilized as platforms for delivering development activities by funding agencies and governmental bodies. However, there is currently little understanding as to whether SHGs are effective or equitable platforms for delivering health or livelihoods interventions. Social capital is hypothesized as a comparative advantage when utilizing SHGs as development platforms, however the specific mechanisms have yet to be explored. This paper investigates the efficacy and equity of SHGs as platforms for development programs through analyzing 64 interviews and 6 focus group discussions collected from an agriculture and behavior change intervention delivered through SHGs in eastern India. We find that while, theoretically, SHGs are a promising platform for health messaging this is largely dependent on SHG norms of attendance, which itself is closely tied to socioeconomic conditions and social capital. Social capital is important both within SHGs as well as between SHGs and the implementing organization. Sites with more mature SHGs had greater economic security allowing more active participation in the intervention than sites with more poverty and young SHGs. The former sites also had greater norms of trust and reciprocity (social capital) with the implementing organization that led them to accept additional interventions. In the latter sites, SHG members had competing demands on their time and less trust in the implementers, making it difficult to attend both SHG meetings and health sessions. We put forth a materialist understanding of social capital formation, where SHG members must have already received substantive benefit from membership for new activities to be successfully incorporated into their agenda. Further, using SHGs as a nutrition message delivery platform should not detract from individual engagement with more vulnerable members of the community.

Spaces for women: Rethinking behavior change communication in the context of women's groups and nutrition-sensitive agriculture

Recently, nutrition-sensitive agriculture programs have taken aim at malnutrition's multi-sectoral roots through re-diversifying agricultural production while integrating women's empowerment and nutrition behavior-change communication components. For these integrated nutrition-sensitive agricultural programs, women-led self-help groups have emerged as promising platforms for program delivery. Yet, while well-designed nutrition behavior-change communication has been successfully used in self-help groups, and is central to nutrition-sensitive agriculture, it can take many forms. These vary widely in their theoretical and ethical underpinnings, communication strategies, and theory of change. As nutrition-sensitive agriculture continues to proliferate, it is critical to better understand how women interact with different behavior-change messages and how to engage individuals in ethical, effective ways. This paper analyzes qualitative data collected from a nutrition-sensitive agricultural project in India that used participatory storytelling to generate knowledge and awareness about malnutrition among women. Drawing from data across two sites, the paper analyzes why certain messages generated more discussion among women then others. We find self-help group women were drawn to topics of early marriage and diet diversity because they emotionally connected to them, and felt they were relevant to their lives with high perceived pay-off and actionability. While other topics on gender and health also provoked emotional, lively discussions, the stories were less effective due to their complexity, which were difficult for volunteer facilitators to communicate. We conclude that there is unmet demand among women in rural India for structured spaces to discuss gendered aspects of health and diet, and nutrition-sensitive agricultural programs could benefit from focusing attention here.

Classroom, club or collective? Three types of community-based group intervention and why they matter for health

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.

Community interventions with women's groups to improve women's and children's health in India: a mixed-methods systematic review of effects, enablers and barriers

INTRODUCTION

India is home to over 6 million women's groups, including self-help groups. There has been no evidence synthesis on whether and how such groups improve women's and children's health.

METHODS

We did a mixed-methods systematic review of quantitative and qualitative studies on women's groups in India to examine effects on women and children's health and to identify enablers and barriers to achieving outcomes. We searched 10 databases and included studies published in English from 2000 to 2019 measuring health knowledge, behaviours or outcomes. Our study population included adult women and children under 5 years. We appraised studies using standard risk of bias assessments. We compared intervention effects by level of community participation, scope of capability strengthening (individual, group or community), type of women's group and social and behaviour change techniques employed. We synthesised quantitative and qualitative studies to identify barriers and enablers related to context, intervention design and implementation, and outcome characteristics.

FINDINGS

We screened 21 380 studies and included 99: 19 randomised controlled trial reports, 25 quasi-experimental study reports and 55 non-experimental studies (27 quantitative and 28 qualitative). Experimental studies provided moderate-quality evidence that health interventions with women's groups can improve perinatal practices, neonatal survival, immunisation rates and women's and children's dietary diversity, and help control vector-borne diseases. Evidence of positive effects was strongest for community mobilisation interventions that built communities' capabilities and went beyond sharing information. Key enablers were inclusion of vulnerable community members, outcomes that could be reasonably expected to change through community interventions and intensity proportionate to ambition. Barriers included limited time or focus on health, outcomes not relevant to group members and health system constraints.

CONCLUSION

Interventions with women's groups can improve women's and children's health in India. The most effective interventions go beyond using groups to disseminate health information and seek to build communities' capabilities.

TRIAL REGISTRATION NUMBER

The review was registered with PROSPERO: CRD42019130633.

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.

Understanding the capacity of community-based groups to mobilise and engage in social action for health: Results from Avahan

Community mobilisation improves outcomes from HIV to maternal and child health. Yet, little health research has explored why some community groups are better able to mobilise than others. We address this gap by considering the case of Avahan, the India AIDS Initiative, which sought to foster community mobilisation, including the creation of community-based groups serving men who have sex with men (MSM), female sex workers (FSWs), and injection drug users (IDUs). Using quantitative and qualitative data collected from 58 community-based groups from 2009-2012 across six Indian states, we analyse variation in groups' action on behalf of their members. Based on a mixed effects logistic regression, we find that older groups and those with bank accounts, crisis committees, or strategic relationships were most likely to take action on behalf of members by demanding rights or confronting gatekeepers and opinion leaders. Analysis of qualitative data reveals the types of action organisations took on behalf of members (mediation, removal of community members from harm, and advocacy), but also that sometimes organisations refused to take action, or community members declined their assistance. These findings indicate that organisations formalising, creating structures for social action, and building networks are important strategies to foster community mobilisation.

A scoping review of the contributions of farmers’ organizations to smallholder agriculture

Farmers’ organizations (FOs), such as associations, cooperatives, self-help and women’s groups, are common in developing countries and provide services that are widely viewed as contributing to income and productivity for small-scale producers. Here, we conducted a scoping review of the literature on FO services and their impacts on small-scale producers in sub-Saharan Africa and India. Most reviewed studies (57%) reported positive FO impacts on farmer income, but much fewer reported positive impacts on crop yield (19%) and production quality (20%). Environmental benefits, such as resilience-building and improved water quality and quantity were documented in 24% of the studies. Our analysis indicates that having access to markets through information, infrastructure, and logistical support at the centre of FO design could help integrate FOs into policy. Natural resource management should also be more widely incorporated in the services provided by FOs to mitigate risks associated with environmental degradation and climate change. Finally, farmers who are already marginalized because of poor education, land access, social status and market accessibility may require additional support systems to improve their capacities, skills and resources before they are able to benefit from FO membership.

Development of self-help groups for caregivers of children with disabilities in Kilifi, Kenya: Process evaluation

Background

Caring for a child with disabilities in a resource-poor setting brings many challenges to the caregiver. We examined the development of self-help groups for caregivers in a rural part of Kenya.

Objectives

To conduct a process evaluation on the development of self-help groups during a 10-month set-up period, focusing on implementation and mechanisms associated with their functional status.

Methods

Using a realist evaluation design, we set up 20 self-help groups for 254 caregivers. An evaluation was conducted to investigate implementation and mechanisms of impact. Implementation focused on caregiver registration, community group support and monitoring visit compliance. Data were collected from group registers, records of meetings and field notes. Mechanisms of impact employed a framework of strengths-weaknesses-opportunities-threats to review the groups at the end of the 10-month set-up period.

Results

Recruitment resulted in registration of 254 participants to 18 groups - two groups disbanded early. Post-evaluation included 11 active and 7 inactive groups. Compliance with the monitoring visits was consistent across the active groups. All groups engaged in 'merry-go-round' activities. The active groups were characterised by strong leadership and at least one successful income generation project; the inactive had inconsistent leadership and had dishonest behaviour both within the group and/or externally in the community. Mediators associated with functional status included the following: available literacy and numeracy skills, regular meetings with consistent attendance by the members, viable income generating projects, geographical proximity of membership and strong leadership for managing threats.

Conclusion

Self-help groups have the potential to progress in resource-poor settings. However, critical to group progression are literacy and numeracy skills amongst the members, their geographical proximity, regular meetings of the group, viable income generating projects and strong leadership.

Empowering self-help groups for caregivers of children with disabilities in Kilifi, Kenya: Impacts and their underlying mechanisms

Bringing up a child with disabilities in a low-income setting is challenged by inadequate resources, limited psycho-social support and poverty. Not surprisingly, many caregivers experience fatigue, distress and isolation. To address and investigate these issues, action was taken to set up twenty self-help groups focusing on caregiver empowerment. A realist evaluation design was adopted to evaluate impacts associated with the self-help process and to identify mechanisms determining the outcomes. Monthly monitoring visits were conducted to the groups during a ten-month set-up period, at the end of which eleven active groups remained, nine having dissolved due to disputes, corruption and extreme environmental conditions. A facilitated intervention was delivered to the active groups (N = 154) over a six-month period. The members were guided to review and discuss topics such as economic empowerment, personal situation, peer support, community inclusion, access to health and education. Evaluation employed mixed methods using questionnaires (n = 75) and semi-structured interviews (n = 36) pre- and post-intervention. At baseline, the burden of caregiving was characterised by aloneness, challenges, stigma and discrimination. Post-intervention, caregiver agency was defined by togetherness, capacity-building, acceptance and well-being. Significant impacts associated with caregiver perceptions included increased social support, reduced severity of child's disability and decreased effects of extrinsic factors affecting the caregiver's role. Mechanisms of 'handling goods and money' and 'social ties and support' appeared to underpin the outcomes. Caregiver empowerment was associated with newly developed skills, social connectedness and resource mobilisation. Documentation of group processes contributes to the evidence on community-based inclusive development.

More than credit: Exploring associations between microcredit programs and maternal and reproductive health service utilization in India

Microcredit programs are increasingly popular interventions aimed at enabling women's economic empowerment in low- and middle-income countries. Resultant improved income, and social support from co-members of microcredit programs, may lead to increased utilization of health services. But existing research is inconclusive. This study investigates the association of microcredit program awareness and participation, with maternal and postpartum reproductive health service utilization in India. We use data from a nationally representative survey, the National Family Health Survey (2015-16), and assess three indicators of maternal health service utilization: receipt of four or more antenatal check-ups, institutional delivery, and postnatal check-up among women who had a child less than 5 years of age (N = 32,880). Reproductive health service utilization is assessed via postpartum contraceptive use within 12 months of childbirth, among women who had a live birth in the 12-59 months preceding the survey (N = 24,258). We use binomial and multinomial logistic regression models to examine associations. Additionally, we use propensity score matching to account for self-selection bias. One-third of women are aware of microcredit programs in their community/village, but only 6% have ever taken a loan from these programs. Both microcredit program awareness and participation are associated with higher odds of antenatal care, postnatal check-ups, as well as use of a modern method of contraceptive within 12 months of childbirth, even after accounting for self-selection bias. Stratified analysis by household wealth show that significant associations seen in our primary analyses are significant only for the poorest women. Findings highlight the potential value of microcredit programs in improving health service utilization during and after pregnancy, particularly among poor women. Microcredit program benefits extend beyond their participants. Non-participants living close to the programs also have greater odds of maternal and reproductive health service utilization, suggesting a spillover effect of these programs at the community level.