Understanding female and male empowerment in Burkina Faso using the project-level Women's Empowerment in Agriculture Index (pro-WEAI): a longitudinal study.

BACKGROUND: Achieving gender equality and women's empowerment is a major global priority. The purpose of this study was to determine whether the Building the Resilience of Vulnerable Communities in Burkina Faso (BRB) project, an agricultural development program, improved women's empowerment, as measured by the project-level Women's Empowerment in Agriculture Index (pro-WEAI). METHODS: This study used a longitudinal, quasi-experimental study design. Participants included both treatment and comparison groups (total N = 751) comprising female members of savings groups and their husbands or main male household member in Burkina Faso. All participants completed the pro-WEAI questionnaire at both baseline and endline. The treatment group received a comprehensive intervention package consisting of agriculture loans and services, microenterprise loans, and education, nutrition education, and women's empowerment programs including gender-based discussions designed to facilitate personalized changes in gender relations. RESULTS: The proportion of the treatment group achieving empowerment did not change from baseline for women, but improved substantially for men. Women from the comparison group saw an increase in empowerment at endline while men saw a substantial decrease. Gender parity was high for women in both groups at baseline and increased slightly at endline. Women were more likely to have adequate empowerment in input in productive decisions, group membership, and membership in influential groups than men while men were more likely to have adequate empowerment in attitudes about domestic violence, control over use of income, and work balance than women. Participants from the treatment group reported an increase in the average number of empowerment indicators that they were adequate in while the comparison group saw a decrease in average adequacy over time (p = 0.002) after controlling for age, sex, and level of education. CONCLUSION: Despite starting at an empowerment disadvantage, the treatment group experienced gains in individual indicators of empowerment while the comparison group men and women experienced mixed results, with the women gaining, and the men losing empowerment. This research suggests that the BRB intervention may have provided some protection for the treatment group when they faced an economic down-turn prior to the endline, indicative of household resilience. Future research should consider and strengthen relationships between resilience and empowerment.

Mobile training and support (MOTS) service-using technology to increase Ebola preparedness of remotely-located community health workers (CHWs) in Sierra Leone.

BACKGROUND: The Ministry of Health in Sierra Leone has developed and operationalized the national Digital Health Strategy to guide integrated roll out of e-health/mobile health solutions. The goal is that "by 2023 an effective and efficient ICT enabled system supports delivery of quality, accessible, affordable, equitable, and timely healthcare services and moves Sierra Leone closer to achieving universal health coverage". Investing in digital platforms for the education of community health workers (CHWs) in Sierra Leone is a critical strategic approach to strengthening the country's readiness for future Ebola outbreaks. A new national curriculum for this target group is being implemented that is based upon classroom training approaches. In a country where many CHWs are remotely located, the use of technology can be an enabler to reach such individuals with key training content to repeat the most important messages. Here we describe the piloting of a mobile training and support (MOTS) service for CHWs using interactive voice response (IVR) technology in Bo district of Sierra Leone. This training platform delivers voice recorded training content in local languages on the topics of Vaccines and (Ebola) Disease Surveillance & Outbreak Response. METHODS: MOTS was developed in collaboration with the Sierra Leone Ministry of Health & Sanitation. Training content was customized in line with the national training curriculum and case reporting requirements. Local ethical approval was achieved and a test protocol involving recruitment of 125 consenting CHWs was implemented in Bo district of Sierra Leone. Two training modules-one covering vaccination and one covering outbreak response and disease surveillance were delivered to the mobile phones of participants as audio messages in the preferred local language. Knowledge change was assessed largely through pre- and post-quiz assessments also implemented through IVR. RESULTS: Knowledge acquisition was observed in the 123 CHWs completing this pilot assessment. The extent of knowledge acquired was higher with the Vaccine training module when compared to the (Ebola) Disease Surveillance & Outbreak Response module. The technology was readily accepted by this population and their engagement was such that they also provided important elements to be improved prior to further implementation. The order in which training modules are delivered as well as general fatigue of the IVR methodology for participating in the quiz assessments may be of importance and requires further investigation. CONCLUSIONS: Technology should be considered when planning delivery of training to CHWs and can be positioned as a vehicle by which repetitive aspects of important training content can be reinforced without the need for additional classroom presence of the CHW community. Sustainability of such solutions requires cost containment and subsequent software accessibility for authorities in resource limited settings. Transparent partnership and alignment with the Ministry of Health & Sanitation in Sierra Leone from the outset of this project is considered an important element to ensure successful implementation.

Successful Use of Quality Improvement Methodology to Reduce Inpatient Length of Stay in Bronchiolitis Through Judicious Use of Intermittent Pulse Oximetry.

BACKGROUND AND OBJECTIVES: The American Academy of Pediatrics 2014 bronchiolitis guidelines recommend against the routine use of continuous pulse oximetry (CPO) because it has been implicated in prolonging the length of stay (LOS). At our institution, infants admitted with bronchiolitis were monitored by using CPO during the entire hospital stay and intermittent desaturations <90% appeared to delay discharge. This quality improvement initiative was designed to reduce the LOS by decreasing the use of CPO in stable infants with nonsevere bronchiolitis. METHODS: The quality improvement project was implemented on the inpatient units of 2 community hospitals during the 2016 and 2017 bronchiolitis seasons. In cycle 1 (January 2016 to April 2016), the bronchiolitis pathway from the associated quaternary children's hospital was used to (1) limit the use of CPO to patients with severe bronchiolitis and those at high risk for apnea or severe disease, (2) discontinue CPO as patients improved and stabilized, and (3) standardize discharge criteria. In cycle 2 (November 2016 to April 2017), the clinical pathway was adopted. The main outcome measure was LOS, measured from the time of the admission order to the time of the discharge order. Process measures included compliance with the interventions. RESULTS: The project included 373 patients, 180 preintervention and 193 postintervention. The average LOS decreased by 20 hours, from 53 hours at baseline to 33 hours in cycle 2. No adverse events were noted, and there was no significant change in the number of emergency department revisits and readmissions within 7 days. CONCLUSIONS: In our study, LOS was successfully reduced in bronchiolitis patients by using a clinical pathway that limited CPO to patients with severe bronchiolitis and those at risk for severe disease or apnea.

Credit with Health Education in Benin: A Cluster Randomized Trial Examining Impacts on Knowledge and Behavior.

We evaluate whether health education integrated into microcredit lending groups reduces health risks by improving health knowledge and self-reported behaviors among urban and rural borrowers in eastern Benin. In 2007, we randomly assigned 138 villages in the Plateau region of Benin to one of four variations of a group liability credit product, varying lending groups' gender composition and/or inclusion of health education using a 2 × 2 design. Women in villages receiving health education, regardless of gender composition of the groups, showed improved knowledge of malaria and of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), but not of childhood illness danger signs. No significant changes in health behavior were observed except an increase in HIV/AIDS prevention behavior, a result predominantly driven by an increase in respondents' self-reported ability to procure a condom, likely an indicator of increased perceived access rather than improved preventative behavior. Women in villages assigned to mixed-gender groups had significantly lower levels of social capital, compared with villages assigned to female-only groups. This suggests there may be an important trade-off to consider for interventions seeking improved health outcomes and social capital through provision of services to mixed-gender groups. Although bundling health education with microcredit can expand health education coverage and lower service-delivery costs, the approach may not be sufficient to improve health behaviors.

Determinants of better health: a cross-sectional assessment of positive deviants among women in West Bengal.

BACKGROUND: Rural women in West Bengal have been found to have low rates of formal education, poor health knowledge, high rates of malnutrition and anemia, and low levels of empowerment. Despite these difficult circumstances, some women have positive health outcomes compared to women with similarly disadvantaged backgrounds. The purpose of this study is to identify factors associated with positive health outcomes among women with primary education or less. METHODS: Multivariable regression models were built for outcomes of positive deviance to better characterize the factors in a woman's life that most impact her ability to deviate from the status quo. RESULTS: Positive deviants in this context are shown to be women who are able to earn an income, who have access to information through media sources, and who, despite little schooling, have marginally higher levels of formal education that lead to improved health outcomes. CONCLUSIONS: Study findings indicate that positive deviant women in disadvantaged circumstances can achieve positive outcomes amidst a host of contextual barriers that would predict poor health outcomes. Focusing on areas such as enhancing access to media sources, facilitating self-help groups for married women, and promoting prolonged education and delayed marriage for girls may improve health knowledge and behavior among married women with low levels of education.

Leveraging microfinance to impact HIV and financial behaviors among adolescents and their mothers in West Bengal: a cluster randomized trial.

Microfinance can be used to reach women and adolescent girls with HIV prevention education. We report findings from a cluster-randomized control trial among 55 villages in West Bengal to determine the impact of non-formal education on knowledge, attitudes and behaviors for HIV prevention and savings. Multilevel regression models were used to evaluate differences between groups for key outcomes while adjusting for cluster correlation and differences in baseline characteristics. Women and girls who received HIV education showed significant gains in HIV knowledge, awareness that condoms can prevent HIV, self-efficacy for HIV prevention, and confirmed use of clean needles, as compared to the control group. Condom use was rare and did not improve for women. While HIV testing was uncommon, knowledge of HIV-testing resources significantly increased among girls, and trended in the positive direction among women in intervention groups. Conversely, the savings education showed no impact on financial knowledge or behavior change.

Educating for the future: adolescent girls' health and education in West Bengal, India.

Adolescent girls in India carry a disproportionate burden of health and social risks; girls that do not finish secondary education are more likely to have an earlier age of sexual initiation, engage in risky sexual behavior, and consequentially be at greater risk of dying from pregnancy-related causes. This paper presents a comparison of girls in school and girls not in school from 665 participants in rural West Bengal, India. The social cognitive theory (SCT), a comprehensive theoretical model, was used as a framework to describe the personal, behavioral, and environmental factors affecting the lives of these adolescent girls. There were significant differences between girls in and out of school in all three categories of the SCT; girls in school were more likely to have heard of sexually transmitted diseases or infections than girls not in school (p<0.0001). Girls in school were also more likely than girls not in school to boil water before drinking (p=0.0078), and girls in school lived in dwellings with 2.3 rooms on average, whereas girls not in school lived in dwellings with only 1.7 rooms (p<0.0001). Indian adolescent girls who are not in school are disadvantaged both economically and by their lack of health knowledge and proper health behaviors when compared with girls who are still in school. In addition, to programs to keep girls in school, efforts should also be made to provide informal education to girls not in school to improve their health knowledge and behaviors.

Microfinance against malaria: impact of Freedom from Hunger's malaria education when delivered by rural banks in Ghana.

A community randomized pre-test/post-test design was used to compare the knowledge and behaviors of microfinance clients receiving malaria education (n=213) to those receiving diarrhea education (n=223) and to non-client controls (n=268). Comparisons assessed differences at follow-up as well as within-group changes over time. At follow-up, malaria clients had significantly better malaria knowledge than comparison groups: 48.4% of malaria clients were able to identify groups most vulnerable to malaria compared with 39.2% of diarrhea clients (P=0.044) and 37.7% of non-clients (P=0.024). Malaria clients were more likely than diarrhea clients (P=0.024) (P<0.001) and non-clients (P=0.028) (P=0.004) to report that insecticide-treated nets (ITNs) provide the best protection against malaria, and to agree that pregnant women should use ITNs, respectively. Between baseline and follow-up, malaria clients were most likely to: improve in knowledge of malaria complications during pregnancy; to own at least one bed net; and to report at least one child or woman of reproductive age sleeping under a bed net. Malaria clients also experienced the greatest increases in ITN ownership/use (9% vs. 2.9% and 6.7% among diarrhea clients and non-clients). Results indicate that, although significant barriers to malaria control remain, a malaria education program provided by microfinance institutions can effectively contribute to community and national malaria initiatives.

Who sleeps under bednets in Ghana? A doer/non-doer analysis of malaria prevention behaviours.

BACKGROUND: Malaria prevention programmes should be based in part on knowledge of why some individuals use bednets while others do not. This paper identifies factors and characteristics of women that affect bednet use among their children less than five years of age in Ghana. METHODS: Data come from the baseline component of an evaluation of Freedom from Hunger's malaria curriculum. A quasi-experimental design was used to select clients (n = 516) of Credit with Education (an integrated package of microfinance and health education) and non-clients (n = 535). Chi-squares, Fisher's Exact tests and logistic regression were used to compare the characteristics of mothers whose children use bednets (doers) with those whose children do not (non-doers) and to identify factors associated with bednet use among children less than five years of age. RESULTS: The following factors were most closely associated with bednet use: region of residence; greater food security; and caregivers' beliefs about symptoms, causation and groups most vulnerable to malaria. Most respondents knew mosquitoes caused malaria; however, 20.6% of doers and 12.3% of non-doers (p = .0228) thought overworking oneself caused malaria. Ninety percent of doers and 77.0% of non-doers felt that sleeping under a net was protective against malaria (p = .0040). In addition, 16.5% of doers and 7.5% of non-doers (p = .0025) identified adult males as most vulnerable to malaria. CONCLUSION: Greater knowledge about malaria does not always translate into improved bednet use. Though culturally-based ideas about malaria may vary between communities, integrating them into traditional health education messages may enhance the effectiveness of public health efforts.