Matching Intent With Intensity: Implementation Research on the Intensity of Health and Nutrition Programs With Women's Self-Help Groups in India.

INTRODUCTION: In India, a large network of self-help groups (SHGs) implements interventions to improve women's and children's health and nutrition. There is growing evidence on the effectiveness of women's group interventions to improve health but limited information on implementation intensity, including how often groups meet, for how long, and with whom, despite this often being cited as a key factor for success. We aimed to assess the implementation intensity of large SHG-based health and nutrition interventions with rural, low-income women, to inform program design, delivery, and measurement. METHODS: We synthesized process data from surveys, meeting observations, and process evaluations across 8 maternal and child health and nutrition interventions in India. We examined the implementation intensity of 3 common intervention delivery channels: group meetings, home visits, and community-level activities. RESULTS: SHG members spent approximately 30 minutes in monthly meetings discussing health or nutrition. SHG dissolution or limited participation in meetings was a common challenge. Beyond group meetings, home visits reached approximately 1 in 3 households with an SHG member. Pregnant and breastfeeding women's participation in community events varied across interventions. DISCUSSION: Interventions that aim to capitalize on existing networks of financial women's groups not specifically formed for health and nutrition objectives, such as SHGs, will need to have an implementation intensity that matches the ambition of their health objectives: substantial changes in behavioral or mortality outcomes are unlikely to be achieved with relatively light intensity. Interventions that require sustained interactions with members to achieve health outcomes need to ensure adequate community and individual outreach to supplement group meetings, as well as improved participation through more intensive community mobilization approaches. Evaluations of group-based interventions should report on implementation intensity to support the interpretation of evaluation evidence and to inform further scale-up.

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

INTRODUCTION: India is home to over 6 million women's groups, including self-help groups. There has been no evidence synthesis on whether and how such groups improve women's and children's health. METHODS: We did a mixed-methods systematic review of quantitative and qualitative studies on women's groups in India to examine effects on women and children's health and to identify enablers and barriers to achieving outcomes. We searched 10 databases and included studies published in English from 2000 to 2019 measuring health knowledge, behaviours or outcomes. Our study population included adult women and children under 5 years. We appraised studies using standard risk of bias assessments. We compared intervention effects by level of community participation, scope of capability strengthening (individual, group or community), type of women's group and social and behaviour change techniques employed. We synthesised quantitative and qualitative studies to identify barriers and enablers related to context, intervention design and implementation, and outcome characteristics. FINDINGS: We screened 21 380 studies and included 99: 19 randomised controlled trial reports, 25 quasi-experimental study reports and 55 non-experimental studies (27 quantitative and 28 qualitative). Experimental studies provided moderate-quality evidence that health interventions with women's groups can improve perinatal practices, neonatal survival, immunisation rates and women's and children's dietary diversity, and help control vector-borne diseases. Evidence of positive effects was strongest for community mobilisation interventions that built communities' capabilities and went beyond sharing information. Key enablers were inclusion of vulnerable community members, outcomes that could be reasonably expected to change through community interventions and intensity proportionate to ambition. Barriers included limited time or focus on health, outcomes not relevant to group members and health system constraints. CONCLUSION: Interventions with women's groups can improve women's and children's health in India. The most effective interventions go beyond using groups to disseminate health information and seek to build communities' capabilities. TRIAL REGISTRATION NUMBER: The review was registered with PROSPERO: CRD42019130633.