Maternal mental health and economic autonomy in lowland rural Nepal: Do parents-in-law provide constraint or support?

Background and objectives: In patrilocal societies, married women typically co-reside with their parents-in-law, who may act in their son's reproductive interests. These relationships may shape maternal mental health and autonomy. Few studies have examined these dynamics from an evolutionary perspective. Theoretically, marital kin may increase their fitness by increasing maternal investment or by reducing paternity uncertainty. We explored how co-residence with parents-in-law and husband is associated with maternal outcomes to evaluate whether marital kin provide support or constraint. Methodology: We analysed data from 444 households in rural lowland Nepal. Maternal mental health was assessed by General Health Questionnaire. Logistic regression models investigated whether, relative to mothers living with both husband and parents-in-law, those co-resident with other combinations of relatives had poorer mental health and lower household economic autonomy (decision-making, bargaining power), adjusting for socio-economic confounders. Results: Co-residence with husband only, or neither husband nor parents-in-law, was associated with higher odds of mothers reporting feeling worthless and losing sleep but also earning income and making household expenditure decisions. Husband co-residence was associated with overall maternal distress but also with less unpaid care work and greater decision-making responsibility. There were no differences in maternal outcomes for mothers living with parents-in-law only, relative to those living with both husbands and parents-in-law. Conclusions and implications: Co-residence of parents-in-law and husbands was associated with contrasting patterns of maternal mental health and economic autonomy. We suggest that different marital kin place different economic demands on mothers, while restricting their autonomy in different ways as forms of 'mate-guarding'.

Confronting the consequences of racism, xenophobia, and discrimination on health and health-care systems.

Racism, xenophobia, and discrimination are key determinants of health and equity and must be addressed for improved health outcomes. We conclude that far broader, deeper, transformative action is needed compared with current measures to tackle adverse effects of racism on health. To challenge the structural drivers of racism and xenophobia, anti-racist action and other wider measures that target determinants should implement an intersectional approach to effectively address the causes and consequences of racism within a population. Structurally, legal instruments and human rights law provide a robust framework to challenge the pervasive drivers of disadvantage linked to caste, ethnicity, Indigeneity, migratory status, race, religion, and skin colour. Actions need to consider the historical, economic, and political contexts in which the effects of racism, xenophobia, and discrimination affect health. We propose several specific actions: a commission that explores how we action the approaches laid out in this paper; building a conversation and a series of events with international multilateral agency stakeholders to raise the issue and profile of racism, xenophobia, and discrimination within health; and using our multiple platforms to build coalitions, expand knowledge, highlight inequities, and advocate for change across the world.

Mechanisms for community prevention of violence against women in low- and middle-income countries: A realist approach to a comparative analysis of qualitative data.

Growing evidence suggests that community-based interventions in low- and middle-income countries (LMICs) can effectively address harmful social norms that promote or sustain gender inequality and drive violence against women (VAW). However, understanding what actions communities are already taking to address harmful social norms and prevent VAW is an essential first step for intervention development. Towards this goal, drawing on collective action theory, we conducted a realist analysis of secondary qualitative data collected with communities in India, Afghanistan, Peru and Rwanda. We coded interview and focus-group data from 232 participants to identify the contexts, mechanisms and outcomes (CMO) relevant for community action. We synthesized CMO configurations from each dataset into a conceptual framework composed of three middle-range theories of mechanisms driving community action to prevent VAW in LMICs. Our results highlight the importance of dedicated spaces for discussing VAW, VAW leaders as positive role models, and community perceptions of VAW as a problem worthy of intervention. In Rwanda and Peru, there was strong evidence to support the operation of these mechanisms. Contextual factors, including national and local policy and programmes targeting VAW, activated mechanisms that led to community action. In India and Afghanistan, evidence for the presence of these mechanisms was weaker, with social norms about women's position and violence being a private family matter preventing communities from addressing violence. Despite contextual differences, our data demonstrated communities in all four settings were somewhere along a pathway of change towards VAW prevention. This supports the need to build future prevention interventions on pre-existing mechanisms that trigger community action, rather than implementing existing interventions without local adaptation. Our conceptual framework serves as a tool for assessing these mechanisms of community action as part of intervention development research, centring community knowledge and fostering local ownership for more relevant and sustainable VAW prevention interventions.

Economic abuse and its associations with symptoms of common mental disorders among women in a cross-sectional survey in informal settlements in Mumbai, India.

BACKGROUND: Domestic violence takes a range of interconnected forms, of which economic abuse is common, but less studied than others. We examine the prevalence of economic abuse, its determinants, and its association with symptoms of depression, anxiety, and suicidal ideation. METHODS: Our cross-sectional survey in informal settlement areas in Mumbai, India, asked women aged 18-49 years 15 questions about acquisition, use, and maintenance of economic resources, demographic and socioeconomic factors, and physical, sexual, and emotional violence. We administered the Patient Health Questionnaire 9 (PHQ-9) and Generalised Anxiety Disorder 7 (GAD-7) scales and asked about suicidal thinking. Determinants of economic abuse and its associations with positive screens for depression and anxiety were explored in univariable and multivariable logistic regression models. RESULTS: Of 4906 ever-married women respondents, 23% reported at least one form of economic abuse by either an intimate partner or another family member. The commonest were denial of property rights (10%), not being trusted with money (8%), and coercive appropriation of belongings (7%). Economic abuse was more commonly reported by widowed, separated, or divorced women than by married women (aOR 12.4; 95% CI 6.4, 24.1), and when their partners used alcohol or drugs (aOR 1.4; 95% CI 1.2-1.7). Women had greater odds of reporting economic abuse if they had suffered emotional (aOR 6.3; 95% CI 5.0-7.9), physical (aOR 1.9; 95% CI 1.4-2.6), or sexual violence (aOR 5.4; 95% CI 3.6-8.1) in the preceding 12 months. Economic abuse was independently associated with positive screens for moderate-severe depression (aOR 2.6; 95% CI 2.0-3.4), anxiety (aOR 2.7; 95% CI 1.9-3.8), and suicidal ideation (aOR 2.2; 95% CI 1.5-3.1). The odds of anxiety and depression increased with each additional form of economic abuse. DISCUSSION: To our knowledge, this is the first community-based study in India of the prevalence of economic abuse and its associations with symptoms of common mental disorders. It provides empirical support for the idea that economic abuse is at least as harmful to women's mental health as physical violence. Surveys should include questions on economic abuse and prevention and intervention strategies need to help survivors to understand its forms.

Costs and cost-effectiveness of management of possible serious bacterial infections in young infants in outpatient settings when referral to a hospital was not possible: Results from randomized trials in Africa.

INTRODUCTION: Serious bacterial neonatal infections are a major cause of global neonatal mortality. While hospitalized treatment is recommended, families cannot access inpatient treatment in low resource settings. Two parallel randomized control trials were conducted at five sites in three countries (Democratic Republic of Congo, Kenya, and Nigeria) to compare the effectiveness of treatment with experimental regimens requiring fewer injections with a reference regimen A (injection gentamicin plus injection procaine penicillin both once daily for 7 days) on the outpatient basis provided to young infants (0-59 days) with signs of possible serious bacterial infection (PSBI) when the referral was not feasible. Costs were estimated to quantify the financial implications of scaleup, and cost-effectiveness of these regimens. METHODS: Direct economic costs (including personnel, drugs and consumable costs) were estimated for identification, prenatal and postnatal visits, assessment, classification, treatment and follow-up. Data on time spent by providers on each activity was collected from 83% of providers. Indirect marginal financial costs were estimated for non-consumables/capital, training, transport, communication, administration and supervision by considering only a share of the total research and health system costs considered important for the program. Total economic costs (direct plus indirect) per young infant treated were estimated based on 39% of young infants enrolled in the trial during 2012 and the number of days each treated during one year. The incremental cost-effectiveness ratio was calculated using treatment failure after one week as the outcome indicator. Experimental regimens were compared to the reference regimen and pairwise comparisons were also made. RESULTS: The average costs of treating a young infant with clinical severe infection (a sub-category of PSBI) in 2012 was lowest with regimen D (injection gentamicin once daily for 2 days plus oral amoxicillin twice daily for 7 days) at US$ 20.9 (95% CI US$ 16.4-25.3) or US$ 32.5 (2018 prices). While all experimental regimens B (injection gentamicin once daily plus oral amoxicillin twice daily, both for 7 days), regimen C (once daily of injection gentamicin injection plus injection procaine penicillin for 2 days, thereafter oral amoxicillin twice daily for 5 days) and regimen D were found to be more cost-effective as compared with the reference regimen A; pairwise comparison showed regimen D was more cost-effective than B or C. For fast breathing, the average cost of treatment with regimen E (oral amoxicillin twice daily for 7 days) at US$ 18.3 (95% CI US$ 13.4-23.3) or US$ 29.0 (2018 prices) was more cost-effective than regimen A. Indirect costs were 32% of the total treatment costs. CONCLUSION: Scaling up of outpatient treatment for PSBI when the referral is not feasible with fewer injections and oral antibiotics is cost-effective for young infants and can lead to increased access to treatment resulting in potential reductions in neonatal mortality. CLINICAL TRIAL REGISTRATION: The trial was registered with Australian New Zealand Clinical Trials Registry under ID ACTRN 12610000286044.

Health management committee strengthening and community mobilisation through women's groups to improve trained health worker attendance at birth in rural Nepal: a cluster randomised controlled trial.

BACKGROUND: Engaging citizens and communities to make services accountable is vital to achieving health development goals. Community participation in health management committees can increase public accountability of health services. We conducted a cluster randomised controlled trial to test the impact of strengthened health management committees (HMCs) and community mobilisation through women's groups on institutional deliveries and deliveries by trained health workers in rural Nepal. METHODS: The study was conducted in all Village Development Committee clusters in the hills district of Makwanpur (population of 420,500). In 21 intervention clusters, we conducted three-day workshops with HMCs to improve their capacity for planning and action and supported female community health volunteers to run women's groups. These groups met once a month and mobilised communities to address barriers to institutional delivery through participatory learning and action cycles. We compared this intervention with 22 control clusters. Prospective surveillance from October 2010 to the end of September 2012 captured complete data on 13,721 deliveries in intervention and control areas. Analysis was by intention to treat. RESULTS: The women's group intervention was implemented as intended, but we were unable to support HMCs as planned because many did not meet regularly. The activities of community based organisations were systematically targeted at control clusters, which meant that there were no true 'control' clusters. 39% (5403) of deliveries were in health institutions and trained health workers attended most of them. There were no differences between trial arms in institutional delivery uptake (1.45, 0.76-2.78) or attendance by trained health workers (OR 1.43, 95% CI 0.74-2.74). CONCLUSIONS: The absence of a true counterfactual and inadequate coverage of the HMC strengthening intervention impedes our ability to draw conclusions. Further research is needed to test the effectiveness of strengthening public accountability mechanisms on increased utilisation of services at delivery. TRIAL REGISTRATION: Current Controlled Trials ISRCTN99834806. Date of registration:28/09/10.

Community interventions to prevent violence against women and girls in informal settlements in Mumbai: the SNEHA-TARA pragmatic cluster randomised controlled trial.

BACKGROUND: In a cluster randomised controlled trial in Mumbai slums, we will test the effects on the prevalence of violence against women and girls of community mobilisation through groups and individual volunteers. One in three women in India has survived physical or sexual violence, making it a major public health burden. Reviews recommend community mobilisation to address violence, but trial evidence is limited. METHODS: Guided by a theory of change, we will compare 24 areas receiving support services, community group, and volunteer activities with 24 areas receiving support services only. These community mobilisation activities will be evaluated through a follow-up survey after 3 years. Primary outcomes will be prevalence in the preceding year of physical or sexual domestic violence, and prevalence of emotional or economic domestic violence, control, or neglect against women 15-49 years old. Secondary outcomes will describe disclosure of violence to support services, community tolerance of violence against women and girls, prevalence of non-partner sexual violence, and mental health and wellbeing. Intermediate theory-based outcomes will include bystander intervention, identification of and support for survivors of violence, changes described in programme participants, and changes in communities. DISCUSSION: Systematic reviews of interventions to prevent violence against women and girls suggest that community mobilisation is a promising population-based intervention. Already implemented in other areas, our intervention has been developed over 16 years of programmatic experience and 2 years of formative research. Backed by public engagement and advocacy, our vision is of a replicable community-led intervention to address the public health burden of violence against women and girls. TRIAL REGISTRATION: Controlled Trials Registry of India, CTRI/2018/02/012047. Registered on 21 February 2018. ISRCTN, ISRCTN84502355. Registered on 22 February 2018.

Impact of adversity on early childhood growth & development in rural India: Findings from the early life stress sub-study of the SPRING cluster randomised controlled trial (SPRING-ELS).

INTRODUCTION: Early childhood development is key to achieving the Sustainable Development Goals and can be negatively influenced by many different adversities including violence in the home, neglect, abuse and parental ill-health. We set out to quantify the extent to which multiple adversities are associated with impaired early childhood growth & development. METHODS: This was a substudy of the SPRING cluster randomised controlled trial covering the whole population of 120 villages of rural India. We assessed all children born from 18 June 2015 for adversities in the first year of life and summed these to make a total cumulative adversity score, and four subscale scores. We assessed the association of each of these with weight-for-age z-score, length-for-age z-score, and the motor, cognitive and language developmental scales of the Bayley Scales of Infant Development III assessed at 18 months. RESULTS: We enrolled 1726 children soon after birth and assessed 1273 of these at both 12 and 18 months of age. There were consistent and strongly negative relationships between all measures of childhood adversity and all five child growth & development outcome measures at 18 months of age. For the Bayley motor scale, each additional adversity was associated with a 1.1 point decrease (95%CI -1.3, -0.9); for the cognitive scales this was 0.8 points (95%CI -1.0, -0.6); and for language this was 1.4 points (95%CI -1.9, -1.1). Similarly for growth, each additional adversity was associated with a -0.09 change in weight-for-age z-score (-0.11, -0.06) and -0.12 change in height-for-age z-score (-0.14, -0.09). DISCUSSION: Our results are the first from a large population-based study in a low/middle-income country to show that each increase in adversity in multiple domains increases risk to child growth and development at a very early age. There is an urgent need to act to improve these outcomes for young children in LMICs and these findings suggest that Early Childhood programmes should prioritise early childhood adversity because of its impact on developmental inequities from the very start.

'There is no point giving cash to women who don't spend it the way they are told to spend it' - Exploring women's agency over cash in a combined participatory women's groups and cash transfer programme to improve low birthweight in rural Nepal.

Cash transfer programmes form an integral part of nutrition, health, and social protection policies worldwide, but the mechanisms through which they achieve their health and nutritional impacts are incompletely understood. We present results from a process evaluation of a combined participatory women's groups and cash transfer programme to improve low birth weight in rural Nepal. We explored the ways in which context, implementation, and mechanism of the intervention affected beneficiary women's agency over cash transfers. Informed by a grounded theory framework, we conducted and analysed semi-structured interviews with 22 beneficiary women, 15 of their mothers-in-law, 3 of their elder sisters-in-law and 20 husbands, as well as a focus group discussion with 7 supervisors of the women's group intervention. Our study reveals how women's group facilitators, their supervisors and community members developed a shared dynamic around persuading and compelling recipients of unconditional cash transfers into spending them according to criteria developed by the group. We found these dynamics effectively constituted 'soft conditions' on beneficiary spending which restricted women's ability to make decisions over their cash transfers, but also increased their likelihood of spending them on their own pregnancy. Our findings demonstrate the importance of understanding how programmes are implemented and responded to in order to understand their implications for beneficiary agency and empowerment.

Socio-economic determinants and inequities in coverage and timeliness of early childhood immunisation in rural Ghana.

OBJECTIVES: To assess the extent of socio-economic inequity in coverage and timeliness of key childhood immunisations in Ghana. METHODS: Secondary analysis of vaccination card data collected from babies born between January 2008 and January 2010 who were registered in the surveillance system supporting the ObaapaVita and Newhints Trials was carried out. 20 251 babies had 6 weeks' follow-up, 16 652 had 26 weeks' follow-up, and 5568 had 1 year's follow-up. We performed a descriptive analysis of coverage and timeliness of vaccinations by indicators for urban/rural status, wealth and educational attainment. The association of coverage with socio-economic indicators was tested using a chi-square-test and the association with timeliness using Cox regression. RESULTS: Overall coverage at 1 year of age was high (>95%) for Bacillus Calmette-Guérin (BCG), all three pentavalent diphtheria-pertussis-tetanus-haemophilus influenzae B-hepatitis B (DPTHH) doses and all polio doses except polio at birth (63%). Coverage against measles and yellow fever was 85%. Median delay for BCG was 1.7 weeks. For polio at birth, the median delay was 5 days; all other vaccine doses had median delays of 2-4 weeks. We found substantial health inequity across all socio-economic indicators for all vaccines in terms of timeliness, but not coverage at 1 year. For example, for the last DPTHH dose, the proportion of children delayed more than 8 weeks were 27% for urban children and 31% for rural children (P < 0.001), 21% in the wealthiest quintile and 41% in the poorest quintile (P < 0.001), and 9% in the most educated group and 39% in the least educated group (P < 0.001). However, 1-year coverage of the same dose remained above 90% for all levels of all socio-economic indicators. CONCLUSIONS: Ghana has substantial health inequity across urban/rural, socio-economic and educational divides. While overall coverage was high, most vaccines suffered from poor timeliness. We suggest that countries achieving high coverage should include timeliness indicators in their surveillance systems.

Has the Rate of Reduction in Infant Mortality Increased in India Since the Launch of National Rural Health Mission? Analysis of Time Trends 2000-2009 with Projection to 2015.

OBJECTIVES: National Rural Health Mission (NRHM) - India was launched in 2005 to tackle urban-rural health inequalities, especially in maternal and child health. We examined national and state level trends in Infant Mortality Rates (IMR) from 2000 through 2009 to: 1) assess whether the NRHM had increased the average annual reduction rate (AARR) of IMR 2) evaluate state-wise progress towards Millennium Development Goals (MDG4) and estimate required AARRs for 'off track' states. METHODS: Log-linear regression models were applied to national and state IMR data collated from the Sample Registration System (SRS)-India to estimate average annual reduction rates and compare AAARs before and after introduction of NRHM. The log-linear trend of infant mortality rates was also projected forward to 2015. RESULTS: The infant mortality rate in rural India declined from 74 to 55/1000 live births between 2000 and 2009, with AARR of 3.0% (95% CI=2.6%-3.4%) and the urban-rural gap in infant mortality narrowed (p =0.036). However there was no evidence (p=0.49) that AARR in rural India increased post NRHM (3.4%, 95% CI 2.0-4.7%) compared to pre NRHM (2.8%, 95% CI 2.1%-3.5%). States varied widely in rates of infant mortality reduction. Projections of infant mortality rates suggested that only eight states might be on track to help India achieve MDG4 by 2015. CONCLUSIONS AND PUBLIC HEALTH IMPLICATIONS: Despite a narrowing urban-rural gap and high AARRs in some states, there was no evidence that the rate of reduction in infant mortality has increased in rural India post NRHM introduction. India appears unlikely to achieve child survival-related NRHM and millennium development goals. Government should revisit the child survival related NRHM strategies and ensure equitable access to health services. More robust monitoring and evaluation mechanisms must be inbuilt for following years.