HIV-sensitive social protection for unemployed and out-of-school young women in Botswana: An exploratory study of barriers and solutions.

Promotive social protection programs aim to increase income and capabilities and could help address structural drivers of HIV-vulnerability like poverty, lack of education and gender inequality. Unemployed and out-of-school young women bear the brunt of HIV infection in Botswana, but rarely benefit from such economic empowerment programs. Using a qualitative exploratory study design and a participatory research approach, we explored factors affecting perceived program benefit and potential solutions to barriers. Direct stakeholders (n = 146) included 87 unemployed and out-of-school young women and 59 program and technical officers in five intervention districts. Perceived barriers were identified in 20 semi-structured interviews (one intervention district) and 11 fuzzy cognitive maps. Co-constructed improvement recommendations were generated in deliberative dialogues. Analysis relied on Framework and the socioecological model. Overall, participants viewed existing programs in Botswana as ineffective and inadequate to empower vulnerable young women socially or economically. Factors affecting perceived program benefit related to programs, program officers, the young women, and their social and structural environment. Participants perceived barriers at every socioecological level. Young women's lack of life and job skills, unhelpful attitudes, and irresponsible behaviors were personal-level barriers. At an interpersonal level, competing care responsibilities, lack of support from boyfriends and family, and negative peer influence impeded program benefit. Traditional venues for information dissemination, poverty, inequitable gender norms, and lack of coordination were community- and structural-level barriers. Improvement recommendations focused on improved outreach and peer approaches to implement potential solutions. Unemployed and out-of-school young women face multidimensional, interacting barriers that prevent benefit from available promotive social protection programs in Botswana. To become HIV-sensitive, these socioeconomic empowerment programs would need to accommodate or preferentially attract this key population. This requires more generous and comprehensive programs, a more client-centered program delivery, and improved coordination. Such structural changes require a holistic, intersectoral approach to HIV-sensitive social protection.

Perinatal morbidity among women with a previous caesarean delivery (PRISMA trial): a cluster-randomised trial.

BACKGROUND: Women with a previous caesarean delivery face a difficult choice in their next pregnancy: planning another caesarean or attempting vaginal delivery, both of which are associated with potential maternal and perinatal complications. This trial aimed to assess whether a multifaceted intervention, which promoted person-centred decision making and best practices, would reduce the risk of major perinatal morbidity among women with one previous caesarean delivery. METHODS: We conducted an open, multicentre, cluster-randomised, controlled trial of a multifaceted 2-year intervention in 40 hospitals in Quebec among women with one previous caesarean delivery, in which hospitals were the units of randomisation and women the units of analysis. Randomisation was stratified according to level of care, using blocked randomisation. Hospitals were randomly assigned (1:1) to the intervention group (implementation of best practices and provision of tools that aimed to support decision making about mode of delivery, including an estimation of the probability of vaginal delivery and an ultrasound estimation of the risk of uterine rupture), or the control group (no intervention). The primary outcome was a composite risk of major perinatal morbidity. This trial was registered with ISRCTN, ISRCTN15346559. FINDINGS: 21 281 eligible women delivered during the study period, from April 1, 2016 to Dec 13, 2019 (10 514 in the intervention group and 10 767 in the control group). None were lost to follow-up. There was a significant reduction in the rate of major perinatal morbidity from the baseline period to the intervention period in the intervention group as compared with the control group (adjusted odds ratio [OR] for incremental change over time, 0·72 [95% CI 0·52-0·99]; p=0·042; adjusted risk difference -1·2% [95% CI -2·0 to -0·1]). Major maternal morbidity was significantly reduced in the intervention group as compared with the control group (adjusted OR 0·54 [95% CI 0·33-0·89]; p=0·016). Minor perinatal and maternal morbidity, caesarean delivery, and uterine rupture rates did not differ significantly between groups. INTERPRETATION: A multifaceted intervention supporting women in their choice of mode of delivery and promoting best practices resulted in a significant reduction in rates of major perinatal and maternal morbidity, without an increase in the rate of caesarean or uterine rupture. FUNDING: Canadian Institutes of Health Research (CIHR, MOP-142448).

Vulnerable young women and frontline service providers identify options to improve the HIV-sensitivity of social protection programmes in Botswana: A modified Policy Delphi approach.

Poverty, lack of education and gender inequality make unemployed and out-of-school young women extremely vulnerable to HIV infection. Promotive social protection programmes aim to increase livelihood and capabilities and could empower this priority population to act on HIV prevention choices. In Botswana, they rarely benefit from such programmes.A modified Policy Delphi engaged a panel of 22 unemployed and out-of-school young women and eight frontline service providers to consider alternative policy and practice options, and tailor available programmes to their own needs and social situation. The panel assessed the desirability and feasibility of improvement proposals and, in a second round, ranked them for relative importance.Nearly all 40 improvement proposals were considered very desirable and definitely, or possibly, feasible, and panellists prioritised a wide range of proposals. Frontline service providers stressed foundational skills, like life skills and second chance education. Young women preferred options with more immediate benefits. Overall, panellists perceived positive role models for programme delivery, access to land and water, job skills training, and stipends as most important to empower HIV-vulnerable young women. Results suggest ample policy space to make existing social protection programmes in Botswana more inclusive of unemployed and out-of-school young women, hence more HIV-sensitive.

Mapping of Pro-Equity Interventions Proposed by Immunisation Programs in Gavi Health Systems Strengthening Grants.

Reaching zero-dose (ZD) children, operationally defined as children who have not received a first dose of the diphtheria, tetanus, and pertussis (DTP1) vaccine, is crucial to increase equitable immunisation coverage and access to primary health care. However, little is known about the approaches already taken by countries to improve immunisation equity. We reviewed all Health System Strengthening (HSS) proposals submitted by Gavi-supported countries from 2014 to 2021 inclusively and extracted information on interventions favouring equity. Pro-equity interventions were mapped to an analytical framework representing Gavi 5.0 programmatic guidance on reaching ZD children and missed communities. Data from keyword searches and manual screening were extracted into an Excel database. Open format responses were analysed using inductive and deductive thematic coding. Data analysis was conducted using Excel and R. Of the 56 proposals included, 51 (91%) included at least one pro-equity intervention. The most common interventions were conducting outreach sessions, tailoring the location of service delivery, and partnerships. Many proposals had "bundles" of interventions, most often involving outreach, microplanning and community-level education activities. Nearly half prioritised remote-rural areas and only 30% addressed gender-related barriers to immunisation. The findings can help identify specific interventions on which to focus future evidence syntheses, case studies and implementation research and inform discussions on what may or may not need to change to better reach ZD children and missed communities moving forward.

An Equity Analysis of Zero-Dose Children in India Using the National Family Health Survey Data: Status, Challenges, and Next Steps.

Background While immunization programs across the world have made considerable progress, children and communities continue to be beyond the reach of healthcare services. Globally, they are now referred to as zero-dose (ZD) children (those who have not received a single dose of diphtheria, pertussis, and tetanus-containing vaccine). Pre-COVID-19 pandemic analyses suggest that nearly 50% of vaccine-preventable deaths occur among ZD children. Two-thirds of these children live in extremely poor households suffering from multiple deprivations including lack of access to reproductive health services, water, and sanitation. Hence, ZD children have now been prioritized as a key cohort for identification and integration with the health systems as we build back from the pandemic. Methodology Extracting data from the last two National Family Health Survey (NFHS) rounds (NFHS 4, 2015-2016 and NFHS 5, 2019-2021), this study aims to ascertain the status of ZD children aged 12-23 months in India, the challenges, and the necessary action agenda going forward. Data were analyzed for equity determinants such as gender, place of residence, religion, birth order, caste, and mother's schooling. Key determinants included the change in ZD prevalence at the national, state, and district levels; variations across equity parameters and states with maximum improvements; and disparity across these indicators. A correlation analysis was also conducted to understand the nature of the association between ZD prevalence and critical maternal and child health indicators. Results The overall ZD prevalence between the two rounds was reduced by 4.1% (10.5-6.4%). A total of 26 states in the country reported a ZD prevalence of <10% in NFHS 5 compared to 18 in NFHS 4. In total, 324 districts reported a ZD prevalence of <5%, and 145 districts reported a prevalence of >10%. The equity parameters reflected a slow-footed reduction among ZD for girl children, across urban geographies, firstborn children, mothers with 12 or more years of schooling, and children in families with the highest wealth quintiles. A negative correlation accentuated between the two NFHS rounds was established between first-trimester registration, four or more antenatal visits, institutional deliveries, and ZD prevalence. Conclusions The findings point toward sustained improvement across key equity parameters, however, challenges do exist. Moreover, the impact of the pandemic on immunization programs across the globe and in India is bound to halt and reverse the progress and potentiate further inequities. It is thus imperative that continued and augmented efforts are continued to identify, integrate, and immunize ZD children, families, and communities.

Socioeconomic and geographic inequities in vaccination among children 12 to 59 months in Mexico, 2012 to 2021.

Objective: To document the evolution of socioeconomic and geographical inequalities in childhood vaccination in Mexico from 2012 to 2021. Methods: Repeated cross-sectional analysis using three rounds of National Health and Nutrition Surveys (2012, 2018, and 2021). Dichotomous variables were created to identify the proportion of children who received no dose of each vaccine included in the national immunization schedule (BCG; diphtheria, pertussis, and tetanus-containing; rotavirus; pneumococcal conjugate; and measles, mumps, and rubella [MMR]), and the proportion completely unvaccinated. The distribution of unvaccinated children was analyzed by state, and by socioeconomic status using the concentration index. Results: The prevalence of completely unvaccinated children in Mexico was low, with 0.3% children in 2012 and 0.8% children in 2021 receiving no vaccines (p = 0.070). Notwithstanding, for each vaccine, an important proportion of children missed receiving any dose. Notably, the prevalence of MMR unvaccinated children was 10.2% (95% CI 9.2-11.1) in 2012, 22.3% (95% CI 20.9-23.8) in 2018, and 29.1% (95% CI 26.3-31.8) in 2021 (p < 0.001 for the difference between 2012 and 2021). The concentration index indicated pro-rich inequalities in non-vaccination for 2 of 5 vaccines in 2012, 3 of 5 vaccines in 2018, and 4 of 5 vaccines in 2021. There were marked subnational variations. The percentage of MMR unvaccinated children ranged from 3.3% to 17.9% in 2012, 5.5% to 36.5% in 2018, and 13.1% to 72.5% in 2021 across the 32 states of Mexico. Conclusions: Equitable access to basic childhood vaccines in Mexico has deteriorated over the past decade. Vigilant equity monitoring coupled with tailored strategies to reach those left out is urgently required.

Patterns in the Prevalence of Unvaccinated Children Across 36 States and Union Territories in India, 1993-2021.

Importance: Children who do not receive any routine vaccinations (ie, who have 0-dose status) are at elevated risk of death, morbidity, and socioeconomic vulnerabilities that limit their development over the life course. India has the world's highest number of children with 0-dose status; analysis of national and subnational patterns is the first important step to addressing this problem. Objectives: To examine the patterns among children with 0-dose immunization status across all 36 states and union territories (UTs) in India over 29 years, from 1993 to 2021, and to elucidate the relative share of multiple geographic regions in the total geographic variation in 0-dose immunization. Design, Setting, and Participants: This repeated cross-sectional study analyzed all 5 rounds of India's National Family Health Survey (1992-1993, 1998-1999, 2005-2006, 2015-2016, and 2019-2021) to compare the prevalence of children with 0-dose status across time-space and geographic regions. The Integrated Public Use of Microdata Series was used to construct comparable geographic boundaries for states and UTs across surveys. The study included a total of 125 619 live children aged 12 to 23 months who were born to participating women. Main Outcomes and Measures: The outcome was a binary indicator of children's 0-dose vaccination status, coded as children aged 12 to 23 months at the time of the survey who had not received the first dose of the diphtheria-tetanus-pertussis-containing vaccine. The significance of each geographic unit was computed using the variance partition coefficient (VPC). Results: Among 125 619 children, the national prevalence of those with 0-dose status in India decreased from 33.4% (95% CI, 32.5%-34.2%) in 1993 to 6.6% (95% CI, 6.4%-6.8%) in 2021. A substantial reduction in the IQR of 0-dose prevalence across states from 30.1% in 1993 to 3.1% in 2021 suggested a convergence in state disparities. The prevalence in the northeastern states of Meghalaya (17.0%), Nagaland (16.1%), Mizoram (14.3%), and Arunachal Pradesh (12.6%) remained relatively high in 2021. Prevalence increased between 2016 and 2021 in 10 states, including several traditionally high-performing states and UTs, such as Telangana (1.16 percentage points) and Sikkim (0.92 percentage points). In 2021, 53.0% of children with 0-dose status resided in the populous states of Uttar Pradesh, Bihar, and Maharashtra. A multilevel analysis comparing the share of variation at the state, district, and cluster (primary sampling unit) levels revealed that clusters accounted for the highest share of the total variation in 2016 (44.7%; VPC [SE], 1.04 [0.32]) and 2021 (64.3%; VPC [SE], 0.38 [0.12]). Conclusions and Relevance: In this cross-sectional study, findings from approximately 3 decades of analysis suggest the need for sustained efforts to target populous states like Uttar Pradesh and Bihar and northeastern parts of India. The resurgence of 0-dose prevalence in 10 states highlights the importance of programs like Intensified Mission Indradhanush 4.0, a major national initiative to improve immunization coverage. Prioritizing small administrative units will be important to strengthening India's efforts to bring every child into the immunization regime.

Advancing Immunization Coverage and Equity: A Structured Synthesis of Pro-Equity Strategies in 61 Gavi-Supported Countries.

BACKGROUND: Global immunization inequities persist, reflected in the 25 million underimmunized and 18 million zero-dose children in 2021. To identify country approaches to reach underimmunized and zero-dose children, we undertook a structured synthesis of pro-equity strategies across 61 countries receiving programmatic support from Gavi, the Vaccine Alliance. METHODS: We extracted data from 174 Country Joint Appraisals and Multi-Stakeholder Dialogue reports (2016-2020). We identified strategies via a targeted keyword search, informed by a determinants of immunization coverage framework. Strategies were synthesized into themes consolidated from UNICEF's Journey to Health and Immunization (JTHI) and the Global Routine Immunization Strategies and Practices (GRISP) frameworks. RESULTS: We found 607 unique strategies across 61 countries and 24 themes. Strategies to improve care at the point of service (44%); to improve knowledge, awareness and beliefs (25%); and to address preparation, cost and effort barriers (13%) were common. Fewer strategies targeted experience of care (8%), intent, (7%) and after-service (3%). We also identified strategies addressing gender-related barriers to immunization and targeting specific types of communities. CONCLUSIONS: We summarize the range of pro-equity immunization strategies employed in Gavi-supported countries and interpret them thematically. Findings are incorporated into a searchable database which can be used to inform equity-driven immunization programs, policies and decision-making which target underimmunized and zero-dose communities.

Socioeconomic and geographic inequities in vaccination among children 12 to 59 months in Mexico, 2012 to 2021 / Inequidades socioeconómicas y geográficas en la vacunación infantil entre los 12 y 59 meses de edad, México, 2012-2021 / Iniquidades socioeconômicas e geográficas na vacinação de crianças entre 12 e 59 meses no México, 2012 a 2021

ABSTRACT Objective. To document the evolution of socioeconomic and geographical inequalities in childhood vaccination in Mexico from 2012 to 2021. Methods. Repeated cross-sectional analysis using three rounds of National Health and Nutrition Surveys (2012, 2018, and 2021). Dichotomous variables were created to identify the proportion of children who received no dose of each vaccine included in the national immunization schedule (BCG; diphtheria, pertussis, and tetanus-containing; rotavirus; pneumococcal conjugate; and measles, mumps, and rubella [MMR]), and the proportion completely unvaccinated. The distribution of unvaccinated children was analyzed by state, and by socioeconomic status using the concentration index. Results. The prevalence of completely unvaccinated children in Mexico was low, with 0.3% children in 2012 and 0.8% children in 2021 receiving no vaccines (p = 0.070). Notwithstanding, for each vaccine, an important proportion of children missed receiving any dose. Notably, the prevalence of MMR unvaccinated children was 10.2% (95% CI 9.2-11.1) in 2012, 22.3% (95% CI 20.9-23.8) in 2018, and 29.1% (95% CI 26.3-31.8) in 2021 (p < 0.001 for the difference between 2012 and 2021). The concentration index indicated pro-rich inequalities in non-vaccination for 2 of 5 vaccines in 2012, 3 of 5 vaccines in 2018, and 4 of 5 vaccines in 2021. There were marked subnational variations. The percentage of MMR unvaccinated children ranged from 3.3% to 17.9% in 2012, 5.5% to 36.5% in 2018, and 13.1% to 72.5% in 2021 across the 32 states of Mexico. Conclusions. Equitable access to basic childhood vaccines in Mexico has deteriorated over the past decade. Vigilant equity monitoring coupled with tailored strategies to reach those left out is urgently required.

RESUMEN Objetivo. Documentar la evolución de las inequidades socioeconómicas y geográficas en la vacunación infantil en México del 2012 al 2021. Métodos. Se llevó a cabo un análisis transversal repetido con tres rondas (2012, 2018 y 2021) de la Encuesta Nacional de Salud y Nutrición (ENSANUT). Se crearon variables dicotómicas para determinar la proporción de la población infantil que no había recibido cada una de las vacunas incluidas en el calendario nacional de vacunación (BCG; difteria, tos ferina y tétanos; rotavirus; conjugado neumocócico; y sarampión, parotiditis y rubéola [triple viral]) y la proporción de la población infantil completamente sin vacunar. La distribución de la población infantil sin vacunar se analizó por estado y nivel socioeconómico mediante el índice de concentración. Resultados. La prevalencia de la población infantil completamente sin vacunar en México fue baja, con 0,3% en el 2012 y 0,8% en el 2021 de la población infantil que no recibió ninguna vacuna (p = 0,070). No obstante, en relación con cada vacuna, una gran proporción de población infantil no recibió ninguna dosis. En particular, la prevalencia de la población infantil sin vacunarse con la triple viral fue de 10,2% (IC del 95% 9,2-11,1) en el 2012, 22,3% (IC del 95% 20,9-23,8) en el 2018 y 29,1% (IC del 95 % 26,3-31,8) en el 2021 (p < 0,001 para la diferencia entre el 2012 y el 2021). El índice de concentración reveló desigualdades que favorecen a los estratos más ricos en la probabilidad de no estar vacunado para 2 de las 5 vacunas en 2012, en 3 de las 5 vacunas en 2018, y en 4 de las 5 vacunas en el 2021. Asimismo, hubo marcadas variaciones subnacionales: el porcentaje de la población infantil que no recibió la vacuna triple viral osciló entre 3,3% y 17,9% en el 2012, entre 5,5% y 36,5% en el 2018 y entre 13,1% y 72,5% en el 2021 en los 32 estados de México. Conclusiones. El acceso equitativo a las vacunas infantiles básicas en México se ha deteriorado en el último decenio. Es urgentemente necesario un monitoreo vigilante de la equidad, así como estrategias adaptadas, para poder vacunar a la población al margen.

RESUMO Objetivo. Documentar a evolução das desigualdades socioeconômicas e geográficas na vacinação infantil no México, no período entre 2012 e 2021. Métodos. Foi realizada a análise repetida de dados transversais obtidos em três ciclos da Pesquisa Nacional de Saúde e Nutrição do México (2012, 2018 e 2021). Variáveis dicotômicas foram elaboradas para estimar o percentual de crianças que não receberam nenhuma dose de cada uma das vacinas do calendário nacional de vacinação (a saber: vacina BCG, vacina contra difteria, coqueluche e tétano, vacina contra rotavírus, vacina pneumocócica conjugada e vacina contra sarampo, caxumba e rubéola [SCR]) e a proporção de crianças totalmente não vacinadas. O índice de concentração foi usado para analisar a distribuição das crianças não vacinadas por estado e condição socioeconômica. Resultados. A prevalência de crianças totalmente não vacinadas foi baixa no país (0,3% em 2012 e 0,8% em 2021, p = 0,070). Porém, um percentual significativo deixou de receber alguma dose de vacina. A prevalência de crianças não vacinadas com a vacina SCR foi 10,2% (IC 95% 9,2-11,1) em 2012, 22,3% (IC 95% 20,9-23,8) em 2018 e 29,1% (IC 95% 26,3-31,8) em 2021 (p < 0,001 para a diferença entre 2012 e 2021). O índice de concentração indicou desigualdade de renda entre vacinados e não vacinados com relação a 2 das 5 vacinas em 2012, 3 das 5 vacinas em 2018 e 4 das 5 vacinas em 2021. Houve uma grande variação geográfica na vacinação infantil. Em particular, o percentual de não vacinados com a vacina SCR nos 32 estados do país variou de 3,3% a 17,9% em 2012, 5,5% a 36,5% em 2018 e 13,1% a 72,5% em 2021. Conclusões. Ocorreu uma piora no acesso equitativo à vacinação básica infantil na última década no México. É imprescindível monitorar atentamente a equidade e implementar estratégias específicas para garantir a cobertura vacinal de todos.

Progress in reaching unvaccinated (zero-dose) children in India, 1992-2016: a multilevel, geospatial analysis of repeated cross-sectional surveys.

BACKGROUND: Reaching zero-dose children (infants who receive no routine vaccinations) is a global strategic priority. We studied zero-dose children in India over 24 years to clarify aggregate trends and the contribution of large-scale social, economic, and geographical inequalities to these. METHODS: We did a multilevel, geospatial analysis of repeated cross-sectional surveys of all four rounds (1992-2016) of India's National Family Health Survey to study the prevalence, distribution, and drivers of zero-dose (no first dose of diphtheria, tetanus, and pertussis) vaccination status. We included all children born to participating women who were aged 12-23 months at the time of the survey, as this is the standard age at which immunisation data are assessed. Children who died before the survey and those missing data on key outcomes or correlates were excluded. The outcome was child zero-dose vaccination status. We also compared the prevalence of nutritional deficits among zero-dose versus vaccinated children. For the most recent survey, we produced geospatial estimates identifying the prevalence of zero-dose children across states and districts and used these to project head count. FINDINGS: We examined 393 167 children for eligibility. 72 848 children were included in the final analytic data set. The proportion of zero-dose children in India declined from 33·4% (95% CI 32·5-34·2) in 1992 to 10·1% (9·8-10·4) in 2016. Progress notwithstanding, in 2016, zero-dose children remained concentrated among disadvantaged groups (prevalence in the bottom wealth quintile 15·3%, 95% CI 14·6-16·0; prevalence among mothers with no education 16·8%, 16·1-17·4). Compared with vaccinated children, zero-dose children were more likely to suffer from malnutrition in all survey rounds (prevalence of severe stunting in 1992: zero dose 41·3%, 95% CI 39·2-43·8 vs vaccinated 28·5%, 27·2-29·7; 2016: zero dose 24·9%, 23·6-26·2 vs vaccinated 18·7%, 18·3-19·1). In 2016, there were an estimated 2·88 (95% CI 2·86-2·89) million zero-dose children in India, concentrated in less developed states and districts and several urban areas. INTERPRETATION: Over a 24-year period in India, child zero-dose status was shaped by large-scale social inequalities and remained a consistent marker of generalised vulnerability. Interventions that address this cycle of intergenerational inequities should be prioritised. FUNDING: None. TRANSLATIONS: For the French, Spanish, and Hindi translations of the abstract see Supplementary Materials section.

HIV-sensitive social protection for vulnerable young women in East and Southern Africa: a systematic review.

INTRODUCTION: Social protection programmes are considered HIV-sensitive when addressing risk, vulnerability or impact of HIV infection. Socio-economic interventions, like livelihood and employability programmes, address HIV vulnerabilities like poverty and gender inequality. We explored the HIV-sensitivity of socio-economic interventions for unemployed and out-of-school young women aged 15 to 30 years, in East and Southern Africa, a key population for HIV infection. METHODS: We conducted a systematic review using a narrative synthesis method and the Mixed Methods Appraisal Tool for quality appraisal. Interventions of interest were work skills training, microfinance, and employment support. Outcomes of interest were socio-economic outcomes (income, assets, savings, skills, (self-) employment) and HIV-related outcomes (behavioural and biological). We searched published and grey literature (January 2005 to November 2019; English/French) in MEDLINE, Scopus, Web of Science and websites of relevant international organizations. RESULTS: We screened 3870 titles and abstracts and 188 full-text papers to retain 18 papers, representing 12 projects. Projects offered different combinations of HIV-sensitive social protection programmes, complemented with mentors, safe space and training (HIV, reproductive health and gender training). All 12 projects offered work skills training to improve life and business skills. Six offered formal (n = 2) or informal (n = 5) livelihood training. Eleven projects offered microfinance, including microgrants (n = 7), microcredit (n = 6) and savings (n = 4). One project offered employment support in the form of apprenticeships. In general, microgrants, savings, business and life skills contributed improved socio-economic and HIV-related outcomes. Most livelihood training contributed positive socio-economic outcomes, but only two projects showed improved HIV-related outcomes. Microcredit contributed little to either outcome. Programmes were effective when (i) sensitive to beneficiaries' age, needs, interests and economic vulnerability; (ii) adapted to local implementation contexts; and (iii) included life skills. Programme delivery through mentorship and safe space increased social capital and may be critical to improve the HIV-sensitivity of socio-economic programmes. CONCLUSIONS: A wide variety of livelihood and employability programmes were leveraged to achieve improved socio-economic and HIV-related outcomes among unemployed and out-of-school young women. To be HIV-sensitive, programmes should be designed around their interests, needs and vulnerability, adapted to local implementation contexts, and include life skills. Employment support received little attention in this literature.

The first 100 days: how has COVID-19 affected poor and vulnerable groups in India?

In India, strict public health measures to suppress COVID-19 transmission and reduce burden have been rapidly adopted. Pandemic containment and confinement measures impact societies and economies; their costs and benefits must be assessed holistically. This study provides an evolving portrait of the health, economic and social consequences of the COVID-19 pandemic on vulnerable populations in India. Our analysis focuses on 100 days early in the pandemic from 13 March to 20 June 2020. We developed a conceptual framework based on the human right to health and the UN Sustainable Development Goals (SDGs). We analysed people's experiences recorded and shared via mobile phone on the voice platforms operated by the Gram Vaani COVID-19 response network, a service for rural and low-income populations now being deployed to support India's COVID-19 response. Quantitative and visual methods were used to summarize key features of the data and explore relationships between factors. In its first 100 days, the platform logged over 1.15 million phone calls, of which 793 350 (69%) were outbound calls related largely to health promotion in the context of COVID-19. Analysis of 6636 audio recordings by network users revealed struggles to secure the basic necessities of survival, including food (48%), cash (17%), transportation (10%) and employment or livelihoods (8%). Themes were mapped to shortfalls in 10 SDGs and their associated targets. Pre-existing development deficits and weak social safety nets are driving vulnerability during the COVID-19 crisis. For an effective pandemic response and recovery, these must be addressed through inclusive policy design and institutional reforms.

Implementation fidelity and acceptability of an intervention to improve vaccination uptake and child health in rural India: a mixed methods evaluation of a pilot cluster randomized controlled trial.

BACKGROUND: The Tika Vaani intervention, an initiative to improve basic health knowledge and empower beneficiaries to improve vaccination uptake and child health for underserved rural populations in India, was assessed in a pilot cluster randomized trial. The intervention was delivered through two strategies: mHealth (using mobile phones to send vaccination reminders and audio-based messages) and community mobilization (face-to-face meetings) in rural Indian villages from January to September 2018. We assessed acceptability and implementation fidelity to determine whether the intervention delivered in the pilot trial can be implemented at a larger scale. METHODS: We adapted the Conceptual Framework for implementation fidelity to assess acceptability and fidelity of the pilot interventions using a mixed methods design. Quantitative data sources include a structured checklist, household surveys, and mobile phone call patterns. Qualitative data came from field observations, intervention records, semi-structured interviews and focus groups with project recipients and implementers. Quantitative analyses assessed whether activities were implemented as planned, using descriptive statistics to describe participant characteristics and the percentage distribution of activities. Qualitative data were analyzed using content analysis and in the light of the implementation fidelity model to explore moderating factors and to determine how well the intervention was received. RESULTS: Findings demonstrated high (86.7%) implementation fidelity. A total of 94% of the target population benefited from the intervention by participating in a face-to-face group meeting or via mobile phone. The participants felt that the strategies were useful means for obtaining information. The clarity of the intervention theory, the motivation, and commitment of the implementers as well as the periodic meetings of the supervisors largely explain the high level of fidelity obtained. Geographic distance, access to a mobile phone, level of education, and gender norms are contextual factors that contributed to heterogeneity in participation. CONCLUSIONS: Although the intervention was evaluated in the context of a randomized trial that could explain the high level of fidelity obtained, this evaluation provides confirmatory evidence that the results of the study reflect the underlying theory. The mobile platform coupled with community mobilization was well-received by the participants and could be a useful way to improve health knowledge and change behavior. TRIAL REGISTRATION: ISRCTN 44840759 (22 April 2018).

Social and Behavior Change Communication Interventions Delivered Face-to-Face and by a Mobile Phone to Strengthen Vaccination Uptake and Improve Child Health in Rural India: Randomized Pilot Study.

BACKGROUND: In resource-poor settings, lack of awareness and low demand for services constitute important barriers to expanding the coverage of effective interventions. In India, childhood immunization is a priority health strategy with suboptimal uptake. OBJECTIVE: To assess study feasibility and key implementation outcomes for the Tika Vaani model, a new approach to educate and empower beneficiaries to improve immunization and child health. METHODS: A cluster-randomized pilot trial with a 1:1 allocation ratio was conducted in rural Uttar Pradesh, India, from January to September 2018. Villages were randomly assigned to either the intervention or control group. In each participating village, surveyors conducted a complete enumeration to identify eligible households and requested participation before randomization. Interventions were designed through formative research using a social marketing approach and delivered over 3 months using strategies adapted to disadvantaged populations: (1) mobile health (mHealth): entertaining educational audio capsules (edutainment) and voice immunization reminders via mobile phone and (2) face-to-face: community mobilization activities, including 3 small group meetings offered to each participant. The control group received usual services. The main outcomes were prespecified criteria for feasibility of the main study (recruitment, randomization, retention, contamination, and adoption). Secondary endpoints tested equity of coverage and changes in intermediate outcomes. Statistical methods included descriptive statistics to assess feasibility, penalized logistic regression and ordered logistic regression to assess coverage, and generalized estimating equation models to assess changes in intermediate outcomes. RESULTS: All villages consented to participate. Gaps in administrative data hampered recruitment; 14.0% (79/565) of recorded households were nonresident. Only 1.4% (8/565) of households did not consent. A total of 387 households (184 intervention and 203 control) with children aged 0 to 12 months in 26 villages (13 intervention and 13 control) were included and randomized. The end line survey occurred during the flood season; 17.6% (68/387) of the households were absent. Contamination was less than 1%. Participation in one or more interventions was 94.0% (173/184), 78.3% (144/184) for the face-to-face strategy, and 67.4% (124/184) for the mHealth strategy. Determinants including place of residence, mobile phone access, education, and female empowerment shaped intervention use; factors operated differently for face-to-face and mHealth strategies. For 11 of 13 intermediate outcomes, regression results showed significantly higher basic health knowledge among the intervention group, supporting hypothesized causal mechanisms. CONCLUSIONS: A future trial of a new intervention model is feasible. The interventions could strengthen the delivery of immunization and universal primary health care. Social and behavior change communication via mobile phones proved viable and contributed to standardization and scalability. Face-to-face interactions remain necessary to achieve equity and reach, suggesting the need for ongoing health system strengthening to accompany the introduction of communication technologies. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN) 44840759; https://doi.org/10.1186/ISRCTN44840759.

Global research priorities for social, behavioural and community engagement interventions for maternal, newborn and child health.

BACKGROUND: Social, behavioural and community engagement (SBCE) interventions are essential for global maternal, newborn and child health (MNCH) strategies. Past efforts to synthesise research on SBCE interventions identified a need for clear priorities to guide future research. WHO led an exercise to identify global research priorities for SBCE interventions to improve MNCH. METHODS: We adapted the Child Health and Nutrition Research Initiative method and combined quantitative and qualitative methods to determine MNCH SBCE intervention research priorities applicable across different contexts. Using online surveys and meetings, researchers and programme experts proposed up to three research priorities and scored the compiled priorities against four criteria - health and social impact, equity, feasibility, and overall importance. Priorities were then ranked by score. A group of 29 experts finalised the top 10 research priorities for each of maternal, newborn or child health and a cross-cutting area. RESULTS: A total of 310 experts proposed 867 research priorities, which were consolidated into 444 priorities and scored by 280 experts. Top maternal and newborn health priorities focused on research to improve the delivery of SBCE interventions that strengthen self-care/family care practices and care-seeking behaviour. Child health priorities focused on the delivery of SBCE interventions, emphasising determinants of service utilisation and breastfeeding and nutrition practices. Cross-cutting MNCH priorities highlighted the need for better integration of SBCE into facility-based and community-based health services. CONCLUSIONS: Achieving global targets for MNCH requires increased investment in SBCE interventions that build capacities of individuals, families and communities as agents of their own health. Findings from this exercise provide guidance to prioritise investments and ensure that they are best directed to achieve global objectives. Stakeholders are encouraged to use these priorities to guide future research investments and to adapt them for country programmes by engaging with national level stakeholders.

Implementation fidelity of village health and nutrition days in Hardoi District, Uttar Pradesh, India: a cross-sectional survey.

BACKGROUND: Village Health and Nutrition Days (VHNDs) are a cornerstone of the Government of India's strategy to provide first-contact primary health care to rural areas. Recent government programmes such as the Janani Suraksha Yojana (JSY) and Mission Indradhanush (MI) have catalysed important changes impacting VHNDs. To learn how VHNDs are currently being delivered, we assessed the fidelity of services provided as compared to government norms in a priority district of Uttar Pradesh. METHODS: We fielded a cross-sectional study of VHNDs to provide a snapshot of health services functioning. Process evaluation data were collected via administrative sources, non-participant observation using a standardised form, and structured questionnaires. Questionnaires were designed using a framework to assess implementation fidelity. Key respondents were VHND participants, front-line workers involved in VHND delivery, and VHND non-participants (pregnant women due for antenatal care or children due for vaccination as per administrative records). Results were summarised as counts, frequencies, and proportions. RESULTS: In the 30 villages randomly selected for inclusion, 36 VHNDs were scheduled but four (11.1%) were cancelled and one VHND was not surveyed. Vaccination and antenatal care were offered at 96.8% (30/31) and child weighing at 83.9% (26/31) of VHNDs. Other normed services were infrequently provided or completely absent. Health education and promotion were particularly weak; institutional delivery was the only topic discussed in a majority of VHNDs. The true proportion of any serious problem impeding vaccine delivery was 47.2% (17/36), comprising 4 VHND cancellations and 13 VHNDs experiencing vaccine shortages. Of the 13 incidents of vaccine shortage, 11 related to an unexpected global shortage of injectable polio vaccine (IPV). Over the 31 VHNDs, 37.8% (171 of the 452 scheduled beneficiaries) did not participate. Analysis of missed opportunities for vaccination highlighted inaccuracies in beneficiary identification and tracking and demand side-factors. CONCLUSIONS: The transformative potential of VHNDs to improve population health is only partially being met. A core subset of high-priority services for antenatal care, institutional delivery, and vaccination associated with high-priority government programmes (JSY, MI) is now being provided quite successfully. Other basic health promotion and prevention services are largely not provided, constituting a critical missed opportunity.

Effects of improved drinking water quality on early childhood growth in rural Uttar Pradesh, India: A propensity-score analysis.

CONTEXT: Recent randomised controlled trials in Bangladesh and Kenya concluded that household water treatment, alone or in combination with upgraded sanitation and handwashing, did not reduce linear growth faltering or improve other child growth outcomes. Whether these results are applicable in areas with distinct constellations of water, sanitation and hygiene (WaSH) risks is unknown. Analysis of observational data offers an efficient means to assess the external validity of trial findings. We studied whether a water quality intervention could improve child growth in a rural Indian setting with higher levels of circulating pathogens than the original trial sites. METHODS: We analysed a cross-sectional dataset including a microbiological measure of household water quality. All households accessed water from an improved source. We applied propensity score methods to emulate a randomised trial investigating the hypothesis that receipt of drinking water meeting Sustainable Development Goal (SDG) 6.1 quality standards for absence of faecal contamination leads to improved growth. Growth outcomes (stunting, underweight, wasting, and their corresponding Z-scores) were assessed in children 12-23 months of age. For each outcome, we estimated the mean and 95% confidence interval of the absolute risk difference between treatment groups. FINDINGS: Of 1088 households, 442 (40.62%) received drinking water meeting SDG 6.1 standards. The adjusted risk of child underweight was 7.4% (1.3% to 13.4%) lower among those drinking water satisfying SDG 6.1 norms than among controls. Evidence concerning the relationship of drinking water meeting SDG 6.1 norms to length-for-age and weight-for-age was inconclusive, and there was no apparent relationship with stunting or wasting. CONCLUSIONS: In contexts characterised by high pathogen transmission, water quality improvements have the potential to reduce the proportion of underweight children, but are unlikely to impact stunting or wasting. Further research is required to assess how these modelled benefits can best be achieved in real world settings.