Layering of a health, nutrition and sanitation programme onto microfinance-oriented self-help groups in rural India: results from a process evaluation.

BACKGROUND: The state of Bihar has been lagging behind Indian national averages on indicators related to maternal and child health, primarily due to lack of knowledge among mothers of young children on lifesaving practices and on where to seek services when healthcare is needed. Hence, the JEEViKA Technical Support Programme was established in 101 blocks to support the state rural livelihood entity, JEEViKA, in order to increase demand for and link rural families to existing health, nutrition and sanitation services. Programme activities were geared to those engaged in JEEViKA's microfinance-oriented self-help groups. These groups were facilitated by a village-based community mobilizer who was trained on health, nutrition and sanitation-related topics which she later shared in self-help group meetings monthly and during ad hoc home visits. Further, a block-level health, nutrition and sanitation integrator was introduced within JEEViKA to support community mobilizers. Also, indicators were added into the existing monitoring system to routinely capture the layering of health, nutrition and sanitation activities. METHODS: A process evaluation was conducted from August-November 2017 which comprised of conducting 594 quantitative surveys with community mobilizers, from program and non-programme intervention blocks. Linear and logistic regressions were done to capture the association of at least one training that the community mobilizers received on knowledge of the topics learned and related activities they carried out. RESULTS: Community mobilizers who had received at least one training were more likely to have higher levels of knowledge on the topics they learned and were also more likely to carry out related activities, such as interacting with block-level integrators for guidance and support, routinely collect data on health, nutrition and sanitation indicators and spend time weekly on related activities. CONCLUSIONS: Successful integration of health, nutrition and sanitation programming within a non-health programme such as JEEViKA is possible through trainings provided to dedicated staff in decentralized positions, such as community mobilizers. The findings of this evaluation hold great promise for engaging existing non-health, nutrition and sanitation systems that are serving vulnerable communities to become partners in working towards ensuring stronger health, nutrition and sanitation outcomes for all.

The role of gender empowerment on reproductive health outcomes in urban Nigeria.

To date, limited evidence is available for urban populations in sub-Saharan Africa, specifically research into the association between urban women's empowerment and reproductive health outcomes. The objective of this study is to investigate whether women's empowerment in urban Nigerian settings is associated with family planning use and maternal health behaviors. Moreover, we examine whether different effects of empowerment exist by region of residence. This study uses baseline household survey data from the Measurement, Learning and Evaluation Project for the Nigerian Urban Reproductive Health Initiative being implemented in six major cities. We examine four dimensions of empowerment: economic freedom, attitudes towards domestic violence, partner prohibitions and decision-making. We determine if the empowerment dimensions have different effects on reproductive health outcomes by region of residence using multivariate analyses. Results indicate that more empowered women are more likely to use modern contraception, deliver in a health facility and have a skilled attendant at birth. These trends vary by empowerment dimension and by city/region in Nigeria. We conclude by discussing the implications of these findings on future programs seeking to improve reproductive health outcomes in urban Nigeria and beyond.

Key learnings from an outcome and embedded process evaluation of a direct to beneficiary mobile health intervention among marginalised women in rural Bihar, India.

INTRODUCTION: Mobile Vaani was implemented as a pilot programme across six blocks of Nalanda district in Bihar state, India to increase knowledge of rural women who were members of self-help groups on proper nutrition for pregnant or lactating mothers and infants, family planning and diarrhoea management. Conveners of self-help group meetings, community mobilisers, introduced women to the intervention by giving them access to interactive voice response informational and motivational content. A mixed methods outcome and embedded process evaluation was commissioned to assess the reach and impact of Mobile Vaani. METHODS: The outcome evaluation, conducted from January 2017 to November 2018, used a quasi-experimental pre-post design with a sample of 4800 married women aged 15-49 from self-help group households, who had a live birth in the past 24 months. Surveys with community mobilisers followed by meeting observations (n=116), in-depth interviews (n=180) with self-help group members and secondary analyses of system generated data were conducted to assess exposure and perceptions of the intervention. RESULTS: From the outcome evaluation, 23% of women interviewed had heard about Mobile Vaani. Women in the intervention arm had significantly higher knowledge than women in the comparison arm for two of seven focus outcomes: knowledge of how to make child's food nutrient and energy dense (treatment-on-treated: 18.8% (95% CI 0.4% to 37.2%, p<0.045)) and awareness of at least two modern spacing family planning methods (treatment-on-treated: 17.6% (95% CI 4.7% to 30.5%, p<0.008)). Women with any awareness of Mobile Vaani were happy with the programme and appreciated the ability to call in and listen to the content. CONCLUSION: Low population awareness and programme exposure are underpinned by broader population level barriers to mobile phone access and use among women and missed opportunities by the programme to improve targeting and programme promotion. Further research is needed to assess programmatic linkages with changes in health practices.

Effect of sharing health messages on antenatal care behavior among women involved in microfinance-based self-help groups in Bihar India.

Background: Bihar state in India has one of the highest rates of maternal and infant mortality in South Asia. Microfinance-based self-help groups (SHGs), involving rural women, are being utilized to improve maternal and child health practice and reduce mortality. SHG members receive information on key maternal and child health practices as well as encouragement for their practice. This study measures the association of health messaging to SHG members with their antenatal care (ANC) behaviors. Methods: The study was conducted in eight districts of Bihar in 2016. A three-stage cluster sampling design (with a random selection of blocks, villages, and SHGs) selected the sample of 1204 SHG members who had an infant child; of these, 597 women were members of SHGs that received dedicated sessions on health messages, while 607 women belonged to SHGs that did not. To examine the impact of the health intervention on ANC practice, radius caliper method of propensity score matching controlled for various socio-demographic characteristics between the two groups. Results: Most of the interviewed women (91.5%) belonged to a scheduled caste or tribe. Nearly 44% of SHG members exposed to the health intervention were engaged in some occupation, compared to 35% of those not exposed to the intervention. After matching unexposed SHG women with exposed SHG women, no significant differences were found in their socio-demographic characteristics. Findings suggest that exposure to a health intervention is associated with increased likelihood of at least four ANC visits by SHG women (ATE = 7.2, 95% CI: 0.76-13.7, p < 0.05), consumption of iron-folic acid for at least 100 days (ATE = 8.7, 95% CI: 5.0-12.5, p < 0.001) and complete ANC (ATE = 3.6, 95% CI: 2.3-4.9, p < 0.001), when compared to women not exposed to the health intervention. Conclusions: The study shows that sharing health messages in microfinance-based SHGs is associated with significant increase in ANC practice. While the results suggest the potential of microfinance-based SHGs for improved maternal health services, the approach's sustainability needs to be further examined.

Participation in microfinance based Self Help Groups in India: Who becomes a member and for how long?

INTRODUCTION: Microfinance is a widely promoted developmental initiative to provide poor women with affordable financial services for poverty alleviation. One popular adaption in South Asia is the Self-Help Group (SHG) model that India adopted in 2011 as part of a federal poverty alleviation program and as a secondary approach of integrating health literacy services for rural women. However, the evidence is limited on who joins and continues in SHG programs. This paper examines the determinants of membership and staying members (outcomes) in an integrated microfinance and health literacy program from one of India's poorest and most populated states, Uttar Pradesh across a range of explanatory variables related to economic, socio-demographic and area-level characteristics. METHOD: Using secondary survey data from the Uttar Pradesh Community Mobilization project comprising of 15,300 women from SHGs and Non-SHG households in rural India, we performed multivariate logistic and hurdle negative binomial regression analyses to model SHG membership and duration. RESULTS: While in general poor women are more likely to be SHG members based on an income threshold limit (government-sponsored BPL cards), women from poorest households are more likely to become members, but less likely to stay members, when further classified using asset-based wealth quintiles. Additionally, poorer households compared to the marginally poor are less likely to become SHG members when borrowing for any reason, including health reasons. Only women from moderately poor households are more likely to continue as members if borrowing for health and non-income-generating reasons. The study found that an increasing number of previous pregnancies is associated with a higher membership likelihood in contrast to another study from India reporting a negative association. CONCLUSION: The study supports the view that microfinance programs need to examine their inclusion and retention strategies in favour of poorest household using multidimensional indicators that can capture poverty in its myriad forms.

Effects of health behaviour change intervention through women's self-help groups on maternal and newborn health practices and related inequalities in rural india: A quasi-experimental study.

BACKGROUND: Despite the health system efforts, health disparities exist across sub-populations in India. We assessed the effects of health behaviour change interventions through women's self-help groups (SHGs) on maternal and newborn health (MNH) behaviours and socio-economic inequalities. METHODS: We did a quasi-experimental study of a large-scale SHG program in Uttar Pradesh, India, where 120 geographic blocks received, and 83 blocks did not receive health intervention. Data comes from two cross-sectional surveys with 4,615 recently delivered women in 2015, and 4,250 women in 2017. The intervention included MNH discussions in SHG meetings and community outreach activities. The outcomes included antenatal, natal and postnatal care, contraceptive use, cord care, skin-to-skin care, and breastfeeding practices. Effects were assessed using multilevel mixed-effects regression adjusted difference-in-differences (DID) analysis adjusting for geographic clustering and potential covariates, for all, most-marginalised and least-marginalised women. Concentration indices examined the socio-economic inequality in health practices over time. FINDINGS: The net improvements (5-11 percentage points [pp]) in correct MNH practices were significant in the intervention areas. The improvements over time were higher among the most-marginalised than least-marginalised for antenatal check-ups (DID: 20pp, p<0•001 versus DID: 6pp, p = 0•093), consumption of iron folic acid tablets for 100 days (DID: 7pp, p = 0•036 versus DID: -1pp, p = 0•671), current use of contraception (DID: 12pp, p = 0•046 versus DID: 10pp, p = 0•021), cord care (DID: 12pp, p = 0•051 versus DID: 7pp, p = 0•210), and timely initiation of breastfeeding (DID: 29pp, p = 0•001 versus DID: 1pp, p = 0•933). Lorenz curves and concentration indices indicated reduction in rich-poor gap in health practices over time in the intervention areas. INTERPRETATION: Disparities in MNH behaviours declined with the efforts by SHGs through behaviour change communication intervention.

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.

Health impact of self-help groups scaled-up statewide in Bihar, India.

BACKGROUND: The objective of this study was to assess the impact of self-help groups (SHGs) and subsequent scale-up on reproductive, maternal, newborn, child health, and nutrition (RMNCHN) and sanitation outcomes among marginalised women in Bihar, India from 2014-2017. METHODS: We examined RMNCHN and sanitation behaviors in women who were members of any SHGs compared to non-members, without differentiating between types of SHGs. We analysed annual surveys across 38 districts of Bihar covering 62 690 women who had a live birth in the past 12 months. All analyses utilised data from Community-based Household Surveys (CHS) rounds 6-9 collected in 2014-2017 by CARE India as part of the Bihar Technical Support Program funded by the Bill & Melinda Gates Foundation. We examined 66 RMNCHN and sanitation indicators using survey logistic regression; the comparison group in all cases was age-comparable women from the geographic contexts of the SHG members but who did not belong to SHGs. We also examined links between discussion topics in SHGs and changes in relevant behaviours, and stratification of effects by parity and mother's age. RESULTS: SHG members had higher odds compared to non-SHG members for 60% of antenatal care indicators, 22% of delivery indicators, 70% of postnatal care indicators, 50% of nutrition indicators, 100% of family planning and sanitation indicators and no immunisation indicators measured. According to delivery platform, most FLW performance indicators (80%) had increased odds, followed by maternal behaviours (57%) and facility care and outreach service delivery (22%) compared to non-SHG members. Self-report of discussions within SHGs on specific topics was associated with increased related maternal behaviours. Younger SHG members (<25 years) had attenuated health indicators compared to older group members (≥25 years), and women with more children had more positive indicators compared to women with fewer children. CONCLUSIONS: SHG membership was associated with improved RMNCHN and sanitation indicators at scale in Bihar, India. Further work is needed to understand the specific impacts of health layering upon SHGs. Working through SHGs is a promising vehicle for improving primary health care. STUDY REGISTRATION: ClinicalTrials.gov number NCT02726230.

Improving primary health care delivery in Bihar, India: Learning from piloting and statewide scale-up of Ananya.

In 2010, the Bill and Melinda Gates Foundation (BMGF) partnered with the Government of Bihar (GoB), India to launch the Ananya program to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) outcomes. The program sought to address supply- and demand-side barriers to the adoption, coverage, quality, equity and health impact of select RMNCHN interventions. Approaches included strengthening frontline worker service delivery; social and behavior change communications; layering of health, nutrition and sanitation into women's self-help groups (SHGs); and quality improvement in maternal and newborn care at primary health care facilities. Ananya program interventions were piloted in approximately 28 million population in eight innovation districts from 2011-2013, and then beginning in 2014, were scaled up by the GoB across the rest of the state's population of 104 million. A Bihar Technical Support Program provided techno-managerial support to governmental Health as well as Integrated Child Development Services, and the JEEViKA Technical Support Program supported health layering and scale-up of the GoB's SHG program. The level of support at the block level during statewide scale-up in 2014 onwards was approximately one-fourth that provided in the pilot phase of Ananya in 2011-2013. This paper - the first manuscript in an 11-manuscript and 2-viewpoint collection on Learning from Ananya: Lessons for primary health care performance improvement - seeks to provide a broad description of Ananya and subsequent statewide adaptation and scale-up, and capture the background and context, key objectives, interventions, delivery approaches and evaluation methods of this expansive program. Subsequent papers in this collection focus on specific intervention delivery platforms. For the analyses in this series, Stanford University held key informant interviews and worked with the technical support and evaluation grantees of the Ananya program, as well as leadership from the India Country Office of the BMGF, to analyse and synthesise data from multiple sources. Capturing lessons from the Ananya pilot program and statewide scale-up will assist program managers and policymakers to more effectively design and implement RMNCHN programs at scale through technical assistance to governments.

Inconsistent fertility motivations and contraceptive use behaviors among women in Honduras.

BACKGROUND: Recent studies have demonstrated that it is common for women to report inconsistent fertility motivations and family planning behaviors. This study examines these inconsistencies among urban Honduran women interviewed at two points in time and presents reasons for inconsistent fertility motivations and contraceptive behaviors at follow-up. METHODS: Data come from a one-year panel study conducted in Honduras from October 2006 to December 2007. A total of 633 women aged 15-44 years were interviewed at baseline and follow-up and have non-missing information on the key variables of interest. At baseline and follow-up, women were asked how much of a problem it would be (no problem/small problem/big problem) if they got pregnant in the next couple of weeks. At follow-up, women were asked an open-ended question on reasons it would be no problem, a small problem, or a big problem. The open-ended question was recoded into a smaller set of response categories. Univariate and bivariate analyses are presented to examine inconsistencies and reasons for stated inconsistencies. RESULTS: At follow-up, over half the women using a contraceptive method said that it would be no problem if they got pregnant. Nearly half of the women changed their perceptions between baseline and follow-up. Common reasons for reporting no problem among contraceptive users were that they accepted a child as God's will or that children are a blessing, their last child was old enough and they wanted another child. Common reasons for reporting a big/small problem among non-users of family planning (who have an unmet need for family planning) were that they were not in a stable relationship, the husband was not present, and they would expect a negative response from their family. CONCLUSION: Inconsistent fertility motivations and contraceptive behaviors are common among effective contraceptive users. Women who are using contraception and become pregnant will not necessarily report the pregnancy as unintended, given the widespread acceptance of unintended pregnancies in Honduras. Family planning providers need to recognize that fertility motivations vary over time and that women may not have firm motivations to avoid a pregnancy.