Reducing inequities in maternal and child health in rural Guatemala through the CBIO+ Approach of Curamericas: 8. Impact on women's empowerment.

BACKGROUND: Indigenous Maya women in the rural highlands of Guatemala have traditionally faced constraints to decision-making and participation in community affairs. Anecdotal experiences from previous Curamericas Global projects in Guatemala and Liberia have suggested that interventions using the CBIO+ Approach (which consists of implementing together the Census-Based, Impact-Oriented Approach, the Care Group Approach, and Community Birthing Centers), can be empowering and can facilitate improvements in maternal and child health. This paper, the eighth in a series of 10 papers examining the effectiveness of CBIO+ in improving the health and well-being of mothers and children in an isolated mountainous rural area of the Department of Huehuetenango, explores changes in women's empowerment among mothers of young children associated with the Curamericas/Guatemala Maternal and Child Health Project, 2011-2015. METHODS: Knowledge, practice, and coverage (KPC) surveys and focus group discussions (FGDs) were used to explore six indicators of women's empowerment focusing on participation in health-related decision-making and participation in community meetings. KPC surveys were conducted at baseline (January 2012) and endline (June 2015) using standard stratified cluster sampling. Seventeen FGDs (9 with women, 3 with men, 2 with mothers-in-law, and 3 with health committees), approximately 120 people in all, were conducted to obtain opinions about changes in empowerment and to identify and assess qualitative factors that facilitate and/or impede women's empowerment. RESULTS: The KPC surveys revealed statistically significant increases in women's active participation in community meetings. Women also reported statistically significant increases in rates of participation in health-related decision-making. Further, the findings show a dose-response effect for two of the six empowerment indicators. The qualitative findings from FGDs show that the Project accelerated progress in increasing women's empowerment though women still face major barriers in accessing needed health care services for themselves and their children. CONCLUSION: The Project achieved some notable improvements in women's decision-making autonomy and participation in community activities. These improvements often translated into making decisions to practice recommended health behaviors. Traditional cultural norms and the barriers to accessing needed health services are not easily overcome, even when empowerment strategies are effective.

Reducing inequities in maternal and child health in rural Guatemala through the CBIO+ Approach of Curamericas: 7. The empowering effect of Care Groups.

BACKGROUND: While there is extensive published evidence regarding the effectiveness of the Care Group Approach in promoting community-wide health behavior change, there is no published evidence regarding its empowering effect on its participants. Our study aimed to understand if the Care Group Approach as applied in the Curamericas/Guatemala Maternal and Child Health Project in isolated rural mountainous communities in Guatemala produced evidence of empowerment among the female participants. This is the seventh of 10 papers describing the expanded Census-Based, Impact-Oriented (CBIO+) Approach in improving the health and well-being of mothers and children in the rural highlands of the Department of Huehuetenango, Guatemala. METHODS: We conducted semi-structured individual and group interviews with 96 female Care Group participants -including Level-1 Care Group Promoters, Care Group Volunteers, and Self-Help Group participants. The participants were from six communities - two from each of the three municipalities making up the Project Area. Data were analyzed both using deductive thematic and by exploring the following social constructs: perceived social status, self-efficacy, decision-making autonomy, and formation of social capital. RESULTS: The findings supported the hypothesis that Care Group participation was an empowering process. The primary themes that emerged included increased respect accorded to women in the community, women's willingness and ability to make decisions and their confidence in making those decisions, and the development of stronger bonds among Care Group members, with other community members, and with community leaders. CONCLUSION: Through increased theoretical and practical knowledge about important maternal and child health matters and through the social experience of obtaining this knowledge and sharing it with other community members, participation in the Care Group Approach empowered participants to make positive health behavior changes for themselves and for their children and families. This, in turn, led many participants to become more engaged in community activities for improved health and beyond, thereby enhancing social capital in the community. We conclude that the Care Group Approach, as applied in this setting, has made it possible for marginalized indigenous women living in a male-dominated society to become more empowered.

Assessing the relationship between domestic work experience and musculoskeletal health among rural Nigerian women.

BACKGROUND: Women performing strenuous domestic tasks (especially those in developing countries) are at risk of experiencing musculoskeletal pain (MSP). Physical, psychosocial, and social conditions of work in rural environments contribute to women's domestic work experiences (DWEs) and the risk of MSP. The impact of DWEs on women's health is especially severe in water-insecure countries like Nigeria. This study examines the relationship between a recently developed measure of DWEs and self-reported pain in the lower back (LBP), neck/shoulder (NSP), and elbow/hand/wrist regions (EHWP) among rural Nigerian women. METHODS: Interviewer-administered survey data were collected from 356 women in four rural communities of Ibadan, Nigeria. Binary and ordinal logistic regression models were used to examine the relationship between DWE factor scores, sociodemographic characteristics, and musculoskeletal pain symptoms and severity after controlling for sociodemographic covariates. Effect estimates of association were presented using the odds ratio (OR), and the corresponding 95% confidence interval (CI) at p-value of 0.05. FINDINGS: Among 356 participants, the 2-month prevalence of LBP was 58%, NSP was 30%, and EWHP 30%. High DWE scores were significantly associated with higher odds of experiencing and having more severe LBP, NSP, and EHWP. Specifically, the odds of LBP [(OR = 2.88; 95% CI = 1.64-5.11), NSP (OR = 4.58; 95% CI = 2.29-9.40) and EHWP (OR = 1.88; 95% CI = 1.26-3.77)] were significantly higher among women who perceived their domestic work responsibilities as very stressful (i.e., 'high stress appraisal') compared to those with lower stress appraisal scores. Those who were time-pressured and had less autonomy over familial duties (i.e., 'high demand/low control') had significantly higher odds of LBP [(OR = 2.58; 95% CI = 1.64-4.09) and NSP (OR = 1.49; 95% CI = 1.24-2.58)]. Frequently fetching and carrying water over long distances and time (i.e., 'high water sourcing and carriage') was also associated with higher odds of LBP [(OR = 1.31; 95% CI = 1.09-1.79) and NSP (OR = 1.20; 95% CI = 1.08-1.76). CONCLUSION: Strenuous and stressful DWEs were associated with MSP among rural Nigerian women. This study provides new evidence on how the physical, social, and psychosocial factors of domestic work can increase women's risk of MSP.

Understanding Rural Women's Domestic Work Experiences (DWE) in Ibadan, Nigeria: Development of a Measurement Tool Using Confirmatory Factor Analysis.

Gender norms prescribe domestic labor as primarily a female's responsibility in developing countries. Many domestic tasks depend on access to water, so the physical, emotional, and time demands of domestic labor may be exacerbated for women living in water-insecure environments. We developed a set of domestic work experience (DWE) measures tailored to work in rural areas in developing countries, assessed rural Nigerian women's DWE, and examined relationships among the measures. Interviewer-administered survey data were collected between August and September from 256 women in four rural Nigerian communities. Latent factors of DWE were identified by analyzing survey items using confirmatory factor analysis. Pearson's correlation was used to examine relationships among latent factor scores, and multivariate linear regression models were used to determine if factor scores significantly differed across socio-demographic characteristics. The DWE measures consisted of latent factors of the physical domain (frequency of common domestic tasks, water sourcing and carriage, experience of water scarcity), the psychosocial domain (stress appraisal and demand-control), and the social domain (social support). Significant correlations were observed among the latent factors within and across domains. Results revealed the importance of measuring rural Nigerian women's DWE using multiple and contextual approaches rather than relying solely on one exposure measure. Multiple inter-related factors contributed to women's DWE. Water insecurity exacerbated the physical and emotional demands of domestic labor DWE varied across age categories and pregnancy status among rural Nigerian women.

Does social capital increase healthcare financing's projection? Results from the rural household of Uttar Pradesh, India.

In the absence of adequate social security, out-of-pocket health expenditure compels households to adopt coping strategies, such as utilizing savings, selling assets, or acquiring external financial support (EFS) by borrowing with interest. Households' probability of acquiring EFS and its amount (intensity) depends on its social capital - the nature of social relationships and resources embedded within social networks. This study examines the effect of social capital on the probability and intensity of EFS during health events in Uttar Pradesh (UP), India. The analysis used data from a cross-sectional survey of 6218 households, reporting 3066 healthcare events, from two districts of UP. Household heads (HH) reported demographic, socioeconomic, and health-related information, including EFS, for each household member. Self-reported data from Shortened and Adapted Social Capital Assessment Tool in India (SASCAT-I) was used to generate four unique social capital measures (organizational participation, social support, trust, and social cohesion) at HH and community-level, using multilevel confirmatory factor analysis. After descriptive analysis, two-part mixed-effect models were implemented to estimate the probability and intensity of EFS as a function of social capital measures, where multilevel mixed-effects probit regression was used as the first-part and multilevel mixed-effects linear model with log link and gamma distribution as the second-part. Controlling for all covariates, the probability of acquiring EFS significantly increased (p = 0.04) with higher social support of the HH and significantly decreased (p = 0.02) with higher community social cohesion. Conditional to receiving any EFS, higher social trust of the HH resulted in higher intensity of EFS (p = 0.09). Social support and trust may enable households to cope up with financial stress. However, controlling for the other dimensions of social capital, high cohesiveness with the community might restrict a household's access to external resources demonstrating the unintended effect of social capital exerted by formal or informal social control.

Addressing Obstetric Health Disparities among Refugee Populations: Training the Next Generation of Culturally Humble OB/GYN Medical Providers.

Issue: The burden of increasing obstetric morbidity and mortality in the United States disproportionately affects marginalized and vulnerable populations, including refugees. Many factors have been attributed to this disparity in birth outcomes, such as linguistic, cultural, and health system limitations. However, refugee health disparities have received little attention in the U.S., especially as it relates to the training of healthcare providers. Evidence: Poor obstetric outcomes among refugee communities have been historically attributed to delayed initiation of prenatal care, failure to detect co-morbidities, as well as higher rates of Cesarean sections in comparison to host-country mothers. These inequities are often linked to poor communication due to cultural misunderstandings, which ultimately leads to mistrust and reduced utilization of healthcare services. In 2017, a Midwest academic hospital, refugee community, and health system came together to form the Congolese Health Partnership (CHP). The CHP was formed to improve access to quality healthcare for expecting Congolese mothers and their families experiencing poor quality of obstetric care. Discussions that arose from this partnership identified issues of mistrust in healthcare providers within the community, worry about misjudgment and overuse of C-sections, and a lack of understanding about health insurance during pregnancy and childbirth. Therefore, it is apparent that understanding the contextual nuances that play a role in these poor outcomes among refugee communities in the U.S. is critical in order to narrow the healthcare gap. Implications: Since pregnancy and its surrounding events are intricately tied to the ways in which different societies define culture, we argue for a focus on culture when training future healthcare providers to work with refugees in the U.S. Specifically, we focus on the necessity of cultural humility, rather than cultural competence, when caring for obstetric patients from diverse backgrounds. Cultural humility forces providers to think about power imbalances that exist between a patient and provider when cultural differences exist. We describe specific barriers to care among Congolese refugees living in eastern Iowa and explore ways to utilize community-provider partnership and cultural humility training to address obstetric morbidity. Finally, we propose ways to incorporate cultural humility training among OB/GYN residents to address community-identified barriers to improve overall health outcomes locally with implications for refugee communities across the U.S.

Changes in attitudes and behaviors supportive of maternal and newborn health in Ethiopia: an evaluative case study.

BACKGROUND: Ethiopia's high neonatal mortality rate led to the government's 2013 introduction of Community-Based Newborn Care (CBNC) to bring critical prevention and treatment interventions closer to communities in need. However, complex behaviors that are deeply embedded in social and cultural norms continue to prevent women and newborns from getting the care they need. A demand creation strategy was designed to create an enabling environment to support appropriate maternal, newborn, and child health (MNCH) behaviors and CBNC. We explored the extent to which attitudes and behaviors during the prenatal and perinatal periods varied by the implementation strength of the Demand Creation Strategy for MNCH-CBNC. METHODS: Using an embedded, multiple case study design, we purposively selected four kebeles (villages) from two districts with different levels of implementation strength of demand creation activities. We collected information from a total of 150 key stakeholders across kebeles using multiple qualitative methods including in-depth interviews, focus group discussions, and illness narratives; sessions were transcribed into English and coded using NVivo 10.0. We developed case reports for each kebele and a final cross-case report to compare results from high and low implementation strength kebeles. RESULTS: We found that five MNCH attitudes and behaviors varied by implementation strength. In high implementation strength kebeles women felt more comfortable disclosing their pregnancy early, women sought antenatal care (ANC) in the first trimester, families did not have fatalistic ideas about newborn survival, mothers sought care for sick newborns in a timely manner, and newborns received care at the health facility in less than an hour. We also found changes across all kebeles that did not vary by implementation strength, including male engagement during pregnancy and a preference for giving birth at a health facility. CONCLUSIONS: Findings suggest that a demand creation approach-combining participatory approaches with community empowering strategies-can promote shifts in behaviors and attitudes to support the health of mothers and newborns, including use of MNCH services. Future studies need to consider the most efficient level of intervention intensity to make the greatest impact on MNCH attitudes and behaviors.

The role of integrated community case management projects in strengthening health systems: case study analysis in Ethiopia, Malawi and Mozambique.

Integrated community case management (iCCM) has now been implemented at scale globally. Literature to-date has focused primarily on the effectiveness of iCCM and the systems conditions required to sustain iCCM. In this study, we sought to explore opportunities taken and lost for strengthening health systems through successive iCCM programmes. We employed a systematic, embedded, multiple case study design for three countries-Ethiopia, Malawi and Mozambique-where Save the Children implemented iCCM programmes between 2009 and 2017. We used textual analysis to code 62 project documents on nine categories of functions of health systems using NVivo 11.0. The document review was supplemented by four key informant interviews. This study makes important contributions to the theoretical understanding of the role of projects in health systems strengthening by not only documenting evidence of systems strengthening in multi-year iCCM projects, but also emphasizing important deficiencies in systems strengthening efforts. Projects operated on a spectrum, ranging from gap-filling interventions, to support, to actual strengthening. While there were natural limits to the influence of a project on the health system, all successive projects found constructive opportunities to try to strengthen systems. Alignment with the Ministry of Health was not always static and simple, and ministries themselves have shown pluralism in their perspectives and orientations. We conclude that systems strengthening remains 'everybody's business' and places demands for realism and transparency on government and the development architecture. While mid-size projects have limited decision space, there is value in better defining where systems strengthening contributions can actually be made. Furthermore, systems strengthening is not solely about macro-level changes, as operational and efficiency gains at meso and micro levels can have value to the system. Claims of 'systems strengthening' are, however, bounded within the quality of evaluation and learning investments.

Health systems effects of successive emergency health and nutrition projects: an embedded retrospective case study analysis in Sudan and Pakistan.

Despite increasing attention to the concept of a humanitarian-development nexus in recent years, limited research is available to improve health systems strengthening practice within humanitarian programmes. We used an exploratory, systematic, embedded, multiple case study design to discern systems effects of successive Save the Children chronic emergency health and nutrition projects implemented in Sudan and Pakistan between 2011 and 2018. We used textual analysis to code 63 documents focused on eight themes using NVivo 11.0. This was supplemented by six key informant interviews. Findings offer a complex and mixed picture, with contributions to systems strengthening in community systems, their linkages to health management structures, and human resources for health. Projects with primary mandates for urgent service delivery progressively found systems strengthening opportunities, through a combination of tacit choices and explicit objectives. In both countries, some 'parallel systems' were set in place initially, with immediate gains (e.g. quality of services) only occasionally accompanied by enhanced systems capacity to sustain them. Cycles of implementation, however, achieved financial transition of 'macro-costs' to the government (e.g. facilities in Sudan, staff in Pakistan) through indirect pathways and the influence of pluralistic governmental structures themselves. Opportunities were taken, or missed, based on dynamic relationships within the government-development partners eco-system. Transition steps also came with unintended effects and drops in intensity. Both project contributions to systems strengthening and our own study were limited by substantial gaps in evaluation and documentation processes. We provide cautious recommendations based on the literature and our two case studies. Even mid-size chronic emergency projects can and should make meaningful and explicit contributions to systems strengthening. This contribution will, however, depend on the development eco-system context, and development of better collective intelligence (coordination, evaluation and learning, benchmarking, accountability) to improve individual projects' adaptive management efforts to improve fit with evolving national systems.

Implementing Community-Based Participatory Research with Communities Affected by Humanitarian Crises: The Potential to Recalibrate Equity and Power in Vulnerable Contexts.

Worldwide, over 70.8 million people are forcibly displaced from their homes as a result of persecution, conflict, violence, or human rights violation. In humanitarian crises, protection and the provision of basic needs are often prioritized. Research may be seen as opportunistic. However, without documenting and researching humanitarian responses, knowledge is not shared and does not accumulate, limiting the application of evidence-based interventions where they are most needed. Research in humanitarian crises is complex, both ethically and methodologically. Community-engaged research, and specifically community-based participatory research (CBPR), can address some of the challenges of research in these settings. Using case studies of research we have conducted with communities affected by humanitarian crises, we highlight challenges and opportunities of the application of the ten core principles of CBPR in humanitarian settings. Despite some challenges and barriers, CBPR is a highly effective approach to use when engaging these populations in research. We argue that the application of CBPR in these settings has the potential to recalibrate the scales of equity and power among vulnerable populations.

Community-based savings groups, women's agency, and maternal health service utilisation: Evidence from Mozambique.

This study, using data collected as part of an ongoing programme evaluation, investigates whether participation in Saving Groups (SGs)-a community-owned microfinance intervention focused on poor households - is associated with maternal health service utilisation, and whether this association is mediated by women's agency - as measured by self-efficacy and decision-making autonomy. We compared maternal health service utilisation among SG members (n=105) and non-members (n=100) in rural Mozambique. We estimated prevalence ratios for SG membership and women's agency using Poisson regression while controlling for confounding factors. We also estimated mediation effects for women's agency. The results showed that SG membership is associated with four or more antenatal care (ANC) visits, skilled birth attendant (SBA) use, and postnatal care within 48 h of delivery. Self-efficacy mediated the relationship between SG membership and ANC vists and SBAuse, but not postnatal care; whereas women's decision-making autonomy mediated the relationship with SBA use and postnatal care, but not ANC visits. This study suggests that the impact of SG membership on use of maternal health services goes beyond improvements in household income and may operate through women's agency by giving women the ability to realize their preference for quality health care.

Social capital and disaster preparedness in Oromia, Ethiopia: An evaluation of the "Women Empowered" approach.

Ethiopia is faced with challenges posed by natural disasters, especially drought. Integrated approaches to disaster risk reduction are necessary to improve the lives and livelihoods of those most vulnerable to disaster. The Women Empowered (WE) approach provides economic and social opportunities for women to build resilience to respond to disasters. This study examines the association between WE group membership and disaster preparedness and whether this relationship is mediated by social capital. We used a multi-stage random cluster sampling strategy to select and interview 589 female respondents from Lage Hidha district (298 from the intervention area and 291 in the comparison area). Using Stata 14.0, we employed Poisson regression analysis to study the mechanisms through which WE groups are associated with disaster preparedness. After controlling for clustering and confounding factors, we found that different components of social capital mediate the relationship between WE group membership and disaster preparedness. Specifically, taking action to prepare for a disaster is primarily mediated by emotional support from the group and perceived preparedness for a disaster is mediated by social network support, emotional support from the group, collective action, and trust. This study suggests that the association between WE groups and disaster preparedness operates through social capital in drought-prone areas of Ethiopia. Future research is needed to determine which forms of social capital have the greatest potential to help families prepare for and respond to a variety of humanitarian crises.

Comparing the association between social capital and self-rated health in poor and affluent nations.

Country context has been shown to influence the association between social capital and health; however, few studies have examined how the level of societal affluence affects the relationship between social capital and health. Drawing on the study of individual-level socioeconomic variation in the returns to social capital by Uphoff and colleagues (2013), we examine two possible explanations about the differential impact of social capital on health based on country-level socioeconomic variation. The buffer hypothesis posits that social capital will have a greater benefit for poorer (versus more affluent) nations, whereas the dependency hypothesis suggests that social capital will be more beneficial in more affluent (versus poorer) nations. Using Waves 5 and 6 of the World Values Survey, we employed multilevel ordered logistic regression to examine whether national wealth moderates the association between social capital-as measured by particularized and generalized trust-and self-rated health across 72 countries. We also assessed five potential explanations for the moderating role of economic context based on the buffer and dependency hypotheses: institutional effectiveness, economic inequality, coverage of health services, human capital, and access to clean water and sanitation services. In support of the dependency hypothesis, we found that both particularized and generalized trust were associated with self-rated health to a greater extent in more affluent countries than in poorer countries; however, none of the potential explanations that we tested accounted for this pattern. Further, we found that particularized trust was more strongly associated with self-rated health compared to generalized trust across all countries. Future research should focus on the mechanisms by which economic context modifies the relationship between social capital and self-rated health.

Exploration of Factor Structure and Measurement Invariance by Gender for a Modified Shortened Adapted Social Capital Assessment Tool in India.

Social capital is defined as the nature of the social relationship between individuals or groups and the embedded resources available through their social network. It is considered as a critical determinant of health and well-being. Thus, it is essential to assess the performance of any tool when meaningfully comparing social capital between specific groups. Using measurement invariance (MI) analysis, this paper explored the factor structure of the social capital of men and women measured by a modified Shortened Adapted Social Capital Assessment Tool (SASCAT-I) in rural Uttar Pradesh (UP), India. The study sample comprised 5,287 men (18-101 years) and 7,186 women (15-45 years) from 6,218 randomly selected households who responded to SASCAT-I during a community-level cross-sectional survey. Social capital factor structure was examined by both exploratory and confirmatory factor analysis (CFA), and MI across genders was investigated using multigroup CFA. While disregarding gender, four unique factors (Organizational Participation, Social Support, Trust, and Social Cohesion) represented the structure of social capital. The MI analysis presented a partial metric-invariance indicating factor loadings for Organizational Participation and Social Support were the same across genders. The gender-stratified analysis demonstrated that a four-factor solution was best fitted for both men and women. Men and women of rural UP interpreted social capital differently as the perception of Trust and Social Cohesion varied across genders. For any future applications of SASCAT-I, we recommend gender-stratified factor analysis to quantify social capital's measure, acknowledging its multidimensionality.

Impact of social capital, harassment of women and girls, and water and sanitation access on premature birth and low infant birth weight in India.

BACKGROUND: Globally, preterm birth (PTB) and low infant birth weight (LBW) are leading causes of maternal and child morbidity and mortality. Inadequate water and sanitation access (WASH) are risk factors for PTB and LBW in low-income countries. Physical stress from carrying water and psychosocial stress from addressing sanitation needs in the open may be mechanisms underlying these associations. If so, then living in a community with strong social capital should be able to buffer the adverse effects of WASH on birth outcomes. The objective of this study is to assess the relationships between WASH access and social conditions (including harassment and social capital) on PTB and LBW outcomes among Indian women, and to test whether social conditions modified the association between WASH and birth outcomes. METHODS AND FINDINGS: This cohort study examined the effect of pre-birth WASH and social conditions on self-reported PTB status and LBW status for 7,926 women who gave birth between 2004/2005 and 2011/2012 Waves of the India Human Development Survey. PTB and LBW occurred in 14.9% and 15.5% of women, respectively. After adjusting for maternal biological and socioeconomic conditions, PTB was associated with sharing a building/compound latrine (Odds Ratio (OR) = 1.55; 95% Confidence Interval (CI) = 1.01, 2.38) versus private latrine access, but suggested an effect in the opposite direction for sharing a community/public latrine (OR = 0.67; CI = 0.45, 1.01). Open defecation, type of drinking water source, minutes per day spent fetching water, and one-way time to a drinking water source were not associated with PTB. LBW was associated with spending more than two hours per day fetching water compared to less than two hours (OR = 1.33; CI = 1.05, 1.70) and suggested an association with open defecation (OR = 1.22; CI = 1.00, 1.48), but was not associated with other types of sanitation, type of drinking water source, or time to a drinking water source. Harassment of women and girls in the community was associated with both PTB (OR = 1.33; CI = 1.09, 1.62) and LBW (OR = 1.26; CI = 1.03, 1.54). The data also showed a possible association of local crime with LBW (OR = 1.30; CI = 1.00, 1.68). Statistically significant (p<0.05) evidence of effect modification was only found for collective efficacy on the association between type of sanitation access and PTB. In addition, stratified analyses identified differences in effect size for walking time to the primary drinking water source and PTB by crime, sanitation access and PTB by harassment, and total hours per day fetching water and LBW by collective efficacy. Limitations of this observational study include risk of bias, inability to confirm causality, reliance on self-reported outcomes, and limited sub-group sample sizes for testing effect modification. CONCLUSIONS: The relationship between adverse birth outcomes and sanitation access, domestic water fetching, crime, and gender-based harassment suggests physical and psychosocial stress are possible mechanisms by which WASH access affects PTB and LBW among Indian women. Interventions that reduce domestic responsibilities related to water and sanitation and change social norms related to gender-based harassment may reduce rates of PTB and LBW in India.

Social capital and self-rated health: Clarifying the role of trust.

While research on social capital and health typically focuses on generalized trust (trust in abstract others), questions about the conceptualization and measurement of generalized trust remain, including whether trust should even be considered a part of social capital. We present a new approach to studying trust in the context of health and argue that consideration of the mechanisms through which social capital influences health highlights the central theoretical role of particularized trust (trust in known others). Furthermore, we argue that the effects of trust and social networks on health are dependent on one another. Analyzing data from Waves 5 and 6 of the World Values Survey (WVS), we find that, net of control variables, particularized trust is more strongly associated with self-rated health than is generalized trust. In addition, we find that the predicted effects of particularized and generalized trust on self-rated health are conditioned by membership in voluntary associations and vice versa.

Beyond the building blocks: integrating community roles into health systems frameworks to achieve health for all.

Achieving ambitious health goals-from the Every Woman Every Child strategy to the health targets of the sustainable development goals to the renewed promise of Alma-Ata of 'health for all'-necessitates strong, functional and inclusive health systems. Improving and sustaining community health is integral to overall health systems strengthening efforts. However, while health systems and community health are conceptually and operationally related, the guidance informing health systems policymakers and financiers-particularly the well-known WHO 'building blocks' framework-only indirectly addresses the foundational elements necessary for effective community health. Although community-inclusive and community-led strategies may be more difficult, complex, and require more widespread resources than facility-based strategies, their exclusion from health systems frameworks leads to insufficient attention to elements that need ex-ante efforts and investments to set community health effectively within systems. This paper suggests an expansion of the WHO building blocks, starting with the recognition of the essential determinants of the production of health. It presents an expanded framework that articulates the need for dedicated human resources and quality services at the community level; it places strategies for organising and mobilising social resources in communities in the context of systems for health; it situates health information as one ingredient of a larger block dedicated to information, learning and accountability; and it recognises societal partnerships as critical links to the public health sector. This framework makes explicit the oft-neglected investment needs for community health and aims to inform efforts to situate community health within national health systems and global guidance to achieve health for all.

Institutionalizing community-focused maternal, newborn, and child health strategies to strengthen health systems: A new framework for the Sustainable Development Goal era.

BACKGROUND: Stronger health systems, with an emphasis on community-based primary health care, are required to help accelerate the pace of ending preventable maternal and child deaths as well as contribute to the achievement of the Sustainable Development Goals (SDGs). The success of the SDGs will require unprecedented coordination across sectors, including partnerships between public, private, and non-governmental organizations (NGOs). To date, little attention has been paid to the distinct ways in which NGOs (both international and local) can partner with existing national government health systems to institutionalize community health strategies. DISCUSSION: In this paper, we propose a new conceptual framework that depicts three primary pathways through which NGOs can contribute to the institutionalization of community-focused maternal, newborn, and child health (MNCH) strategies to strengthen health systems at the district, national or global level. To illustrate the practical application of these three pathways, we present six illustrative cases from multiple NGOs and discuss the primary drivers of institutional change. In the first pathway, "learning for leverage," NGOs demonstrate the effectiveness of new innovations that can stimulate changes in the health system through adaptation of research into policy and practice. In the second pathway, "thought leadership," NGOs disseminate lessons learned to public and private partners through training, information sharing and collaborative learning. In the third pathway, "joint venturing," NGOs work in partnership with the government health system to demonstrate the efficacy of a project and use their collective voice to help guide decision-makers. In addition to these pathways, we present six key drivers that are critical for successful institutionalization: strategic responsiveness to national health priorities, partnership with policymakers and other stakeholders, community ownership and involvement, monitoring and use of data, diversification of financial resources, and longevity of efforts. CONCLUSION: With additional research, we propose that this framework can contribute to program planning and policy making of donors, governments, and the NGO community in the institutionalization of community health strategies.