Testing theory of change assumptions of health behavior change interventions: A blended approach exploring local contexts.

This paper used a blended approach that involves multiple techniques to, first, test a set of assumptions around a health behavior change communication intervention theory of change (ToC) and, second, surface some unidentified assumptions involving the local context. The intervention was integrated with women's self-help groups (SHGs) in Uttar Pradesh, India. The key assumption tested in this paper was the linkage between SHG membership, program exposure, and maternal, newborn, and child health practices. Learnings were substantiated through empirical investigations, including structural equation modeling and mediation analysis, as well as 'co-learning' workshops within the community. The workshops aimed to capture and interpret the heterogeneity of local contexts through deep dialogs with the community and program implementers at various levels. Statistical analyses indicated a significant association between the amount of women's program exposure and their health practices. SHG membership was shown to affect maternal health practices; however, it did not have a direct effect on neonatal or child health practices. The 'co-learning' workshops revealed crucial aspects, such as prevailing socio-cultural norms, which prevented pregnant or recently delivered women from participating in SHG meetings. This paper encourages evaluators to work with the community to interpret and co-construct meaning in unpacking the contextual forces that seldom appear in the program ToC.

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.

Potential of organizing unmarried adolescent girls and young women into self-help groups for a better transition to adulthood: Findings from a cross-sectional study in India.

It is essential to equip adolescents with the right information and appropriate skills for a quality transition to their adulthood. This study examines the individual agency of unmarried adolescent girls and young women (AGYW) who were organized into self-help groups (SHG) as compared to those who were not in groups. The paper uses data from a cross-sectional survey conducted with 872 unmarried AGYW aged 15-21 years from 80 villages across two districts of Uttar Pradesh, India. The dependent variables were AGYW's financial independence, collective action, decisionmaking, mobility, self-expression, generalized perceived self-efficacy, gender norms attitudes, and attitudes toward violence. The primary independent variables were group membership and the duration of the membership. Bivariate and multiple logistic regression analyses were conducted to examine the relationship between group membership and various components of individual agency. More than half of the respondents, with an average age of 18 years were enrolled in school or college and one-third had 12 or more years of education. The group members, compared to non-members, were significantly more likely to be financially independent (odds ratio [OR] = 2.29, p<0.01), to take collective action for entitlements (OR = 3.80, p<0.01), and to have progressive attitudes toward gender roles and norms (OR = 1.43, p<0.05). A longer duration of group membership increases the likelihood of financial independence, collective action, and decisionmaking ability. The study highlights the need for further investment in adolescent girls' programming and highlights the potential of organizing AGYW into SHG and using the 'platform' to bring change in their lives and consequential individual agency.

Spousal Violence Against Women in India: A Social-Ecological Analysis Using Data From the National Family Health Survey 2015 to 2016.

Even after enactment of the Protection of Women From Domestic Violence Act 2005, over the last 10 years, the rate of decline of prevalence of spousal violence against women has remained low in India. This study attempts to explain the experience of spousal violence using a social-ecological framework. We analyzed the National Family Health Survey 2015 to 2016 (NFHS-4) data of 66,013 ever-married women aged 15 to 49 years. Participants in the domestic violence module of the NFHS-4 reported their experience of violence committed by their husband within the 12 months preceding the survey. Multilevel logistic regression analyses were done to determine the association between spousal violence and different explanatory variables of various levels of social ecology including variables on women's empowerment. About one fourth of ever-married women reported experiencing any form of violence during the last year. The experience of spousal violence was significantly associated with social ecology at multiple levels. At the individual level, the odds of experiencing physical violence were higher among younger women, who married at a younger age, had an age gap of 3 to 4 years with her husband, and had more children. Women in vulnerable groups, with poor economic status, and members of marginalized communities had higher odds of experiencing spousal violence. Women had high odds of experiencing spousal violence if living in a social ecology with unfavorable social norms, higher rates of domestic crimes, and a higher prevalence of underage marriage. The association of spousal violence with women's empowerment remained inconclusive. The results argue for manipulating contextual factors to empower women to challenge gender-related equations and investing in education for gender sensitization at the higher level social ecologies.

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

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

Association of antenatal care and place of delivery with newborn care practices: evidence from a cross-sectional survey in rural Uttar Pradesh, India.

BACKGROUND: Appropriate immediate newborn care is vital for neonatal survival. Antenatal period is a crucial time to impart knowledge and awareness to mothers regarding newborn care, either during facility visits or during home visits by community health workers (CHWs) especially in the rural context. In this paper, we report newborn care practices in rural Uttar Pradesh (UP) and have explored association between newborn care practices with antenatal care, contact with community health workers during pregnancy and place of childbirth. METHODS: We use cross-sectional baseline data (which is part of a larger intervention project) collected from 129 gram panchayats (GPs) from 15 administrative blocks spread over five districts of UP in 2013. From currently married women (n = 2208) of 15-49 years, who delivered 15 months prior to the survey, we collected information on women's demographic and socio-economic characteristics, knowledge and practice of reproductive, maternal, newborn, child health and nutrition behaviours. Association of newborn practices with antenatal care, contacts by community health worker during pregnancy and place of childbirth were tested using random intercept logistic regression, adjusting for socio-economic and demographic factors and accounting for clustering at the GP and block levels. RESULTS: Eighty-three percent of 2208 mothers received ANC, but only half of the respondents received a minimum of three ANC visits. More than two thirds of respondents delivered at a health facility. Practice of newborn care was poor: merely one fourth of women practised clean cord care, one third of women followed good breastfeeding practices (initiation with an hour of birth, fed colostrum and did not give pre-lacteal feeds) and one third provided adequate thermal care (kept baby warm and delayed bathing). Only 5% followed all above practices with evidence of clustering of newborn care practices at the block and GP levels. While facility-based childbirth was strongly associated with appropriate newborn care practices, ANC visits and contacts with CHWs was not associated with all newborn care practices. CONCLUSION: The quality of ANC care provided needs to be improved to have an impact on newborn care practices. Our finding emphasizes the importance of facility-based birthing. There is a need for training CHWs to strengthen their counselling skills on newborn care. Variation of newborn care practices between communities should be taken into consideration while implementing any intervention to optimize benefits.

Gender-Based Violence in Rural Uttar Pradesh, India: Prevalence and Association With Reproductive Health Behaviors.

This study explores the prevalence of different forms of domestic violence and their impact on women's reproductive health behavior in rural Uttar Pradesh (UP), India. Data were collected as a part of a large household survey carried out in 2009-2010. A multistage stratified systematic sampling design was used. A total of 4,223 married women aged 15 to 49 years and 2,274 husbands of these women were interviewed. Data were analyzed using bivariate and multivariate analyses. More than one third of married women in rural UP had experienced one or more forms of violence, such as verbal abuse, physical manhandling, and sexual abuse by their spouse. Nearly 47% of the women had experienced some form of violence during their last pregnancy. Significant associations were found between violence and incorrect reproductive health behaviors, pregnancy complications, poor birth preparedness, poor likelihood of institutional delivery, limited postnatal care, and limited spousal communication for family planning. After controlling for socio-economic variables in multivariate analysis, only pregnancy complications (odds ratio [OR] = 1.62, 95% confidence interval [CI] = [1.40, 1.85]) and lack of delivery preparedness (OR = 0.79, 95% CI = [0.68, 0.93]) were found to be significantly associated with violence. Husband's attitude and reporting of violence by their wives in different situations were not significantly associated. This study provides evidence of the association of violence on the reproductive health behavior of married women in rural India. The results argue for frontline health workers to identify and counsel pregnant women experiencing violence during antenatal check-up to reduce maternal morbidity and mortality.