Facilitating behavioral change: A comparative assessment of ASHA efficacy in rural Bihar.

Community health worker (CHW) programs are essential for expanding health services to many areas of the world and improving uptake of recommended behaviors. One of these programs, called Accredited Social Health Activists (ASHA), was initiated by the government of India in 2005 and now has a workforce of about 1 million. ASHAs primarily focus on improving maternal and child health but also support other health initiatives. Evaluations of ASHA efficacy have found a range of results, from negative, to mixed, to positive. Clarity in forming a general impression of ASHA efficacy is hindered by the use of a wide range of evaluation criteria across studies, a lack of comparison to other sources of behavioral influence, and a focus on a small number of behaviors per study. We analyze survey data for 1,166 mothers from Bihar, India, to assess the influence of ASHAs and eight other health influencers on the uptake of 12 perinatal health behaviors. We find that ASHAs are highly effective at increasing the probability that women self-report having practiced biomedically-recommended behaviors. The ASHA's overall positive effect is larger than any of the nine health influencer categories in our study (covering public, private, and community sources), but their reach needs to be more widely extended to mothers who lack sufficient contact with ASHAs. We conclude that interactions between ASHAs and mothers positively impact the uptake of recommended perinatal health behaviors. ASHA training and program evaluation need to distinguish between individual-level and program-level factors in seeking ways to remove barriers that affect the reach of ASHA services.

Layering of a health, nutrition and sanitation programme onto microfinance-oriented self-help groups in rural India: results from a process evaluation.

BACKGROUND: The state of Bihar has been lagging behind Indian national averages on indicators related to maternal and child health, primarily due to lack of knowledge among mothers of young children on lifesaving practices and on where to seek services when healthcare is needed. Hence, the JEEViKA Technical Support Programme was established in 101 blocks to support the state rural livelihood entity, JEEViKA, in order to increase demand for and link rural families to existing health, nutrition and sanitation services. Programme activities were geared to those engaged in JEEViKA's microfinance-oriented self-help groups. These groups were facilitated by a village-based community mobilizer who was trained on health, nutrition and sanitation-related topics which she later shared in self-help group meetings monthly and during ad hoc home visits. Further, a block-level health, nutrition and sanitation integrator was introduced within JEEViKA to support community mobilizers. Also, indicators were added into the existing monitoring system to routinely capture the layering of health, nutrition and sanitation activities. METHODS: A process evaluation was conducted from August-November 2017 which comprised of conducting 594 quantitative surveys with community mobilizers, from program and non-programme intervention blocks. Linear and logistic regressions were done to capture the association of at least one training that the community mobilizers received on knowledge of the topics learned and related activities they carried out. RESULTS: Community mobilizers who had received at least one training were more likely to have higher levels of knowledge on the topics they learned and were also more likely to carry out related activities, such as interacting with block-level integrators for guidance and support, routinely collect data on health, nutrition and sanitation indicators and spend time weekly on related activities. CONCLUSIONS: Successful integration of health, nutrition and sanitation programming within a non-health programme such as JEEViKA is possible through trainings provided to dedicated staff in decentralized positions, such as community mobilizers. The findings of this evaluation hold great promise for engaging existing non-health, nutrition and sanitation systems that are serving vulnerable communities to become partners in working towards ensuring stronger health, nutrition and sanitation outcomes for all.

Tradition, taste and taboo: the gastroecology of maternal perinatal diet.

BACKGROUND: Maternal malnutrition is a major source of regional health inequity and contributes to maternal and infant morbidity and mortality. Bihar, a state in eastern India adjacent to Jharkhand and West Bengal, has relatively high neonatal mortality rates because a large portion of infants are born to young mothers. Bihar has the second-highest proportion of underweight children under 3 in India, with infant mortality rates of 48 per 1000 live births. Maternal malnutrition remains a major threat to perinatal health in Bihar, where 58.3% of pregnant women are anaemic. METHODS: We examined dietary beliefs and practices among mothers, mothers-in-law and community members, including Accredited Social Health Activists (ASHAs), using focus group discussions (n=40 groups, 213 participants), key informant interviews (n=50 participants) and quantitative surveys (n=1200 recent mothers and 400 community health workers). We report foods that are added/avoided during the perinatal period, along with stated reasons underlying food choice. We summarise the content of the diet based on responses to the quantitative survey and identify influencers of food choice and stated explanations for adding and avoiding foods. KEY FINDINGS: Analyses for all methodologies included gathering frequency counts and running descriptive statistics by food item, recommendation to eat or avoid, pregnancy or post partum, food group and health promoting or risk avoiding. During pregnancy, commonly added foods were generally nutritious (milk, pulses) with explanations for consuming these foods related to promoting health. Commonly avoided foods during pregnancy were also nutritious (wood apples, eggplant) with explanations for avoiding these foods related to miscarriage, newborn appearance and issues with digestion. Post partum, commonly added foods included sweets because they ease digestion whereas commonly avoided foods included eggplants and oily or spicy foods. Family, friends, relatives or neighbours influenced food choice for both mothers and ASHAs more than ASHAs and other health workers.Perinatal dietary beliefs and behaviours are shaped by local gastroecologies or systems of knowledge and practice that surround and inform dietary choices, as well as how those choices are explained and influenced. Our data provide novel insight into how health influencers operating within traditional and biomedical health systems shape the perinatal dietary beliefs of both mothers and community health workers.

Perinatal risk and the cultural ecology of health in Bihar, India.

The objective of the current study is to examine the cultural ecology of health associated with mitigating perinatal risk in Bihar, India. We describe the occurrences, objectives and explanations of health-related beliefs and behaviours during pregnancy and postpartum using focus group discussions with younger and older mothers. First, we document perceived physical and supernatural threats and the constellation of traditional and biomedical practises including taboos, superstitions and rituals used to mitigate them. Second, we describe the extent to which these practises are explained as risk-preventing versus health-promoting behaviour. Third, we discuss the extent to which these practises are consistent, inconsistent or unrelated to biomedical health practises and describe the extent to which traditional and biomedical health practises compete, conflict and coexist. Finally, we conclude with a discussion of the relationships between traditional and biomedical practises in the context of the cultural ecology of health and reflect on how a comprehensive understanding of perinatal health practises can improve the efficacy of health interventions and improve outcomes. This article is part of the theme issue 'Ritual renaissance: new insights into the most human of behaviours'.

Health impact of self-help groups scaled-up statewide in Bihar, India.

BACKGROUND: The objective of this study was to assess the impact of self-help groups (SHGs) and subsequent scale-up on reproductive, maternal, newborn, child health, and nutrition (RMNCHN) and sanitation outcomes among marginalised women in Bihar, India from 2014-2017. METHODS: We examined RMNCHN and sanitation behaviors in women who were members of any SHGs compared to non-members, without differentiating between types of SHGs. We analysed annual surveys across 38 districts of Bihar covering 62 690 women who had a live birth in the past 12 months. All analyses utilised data from Community-based Household Surveys (CHS) rounds 6-9 collected in 2014-2017 by CARE India as part of the Bihar Technical Support Program funded by the Bill & Melinda Gates Foundation. We examined 66 RMNCHN and sanitation indicators using survey logistic regression; the comparison group in all cases was age-comparable women from the geographic contexts of the SHG members but who did not belong to SHGs. We also examined links between discussion topics in SHGs and changes in relevant behaviours, and stratification of effects by parity and mother's age. RESULTS: SHG members had higher odds compared to non-SHG members for 60% of antenatal care indicators, 22% of delivery indicators, 70% of postnatal care indicators, 50% of nutrition indicators, 100% of family planning and sanitation indicators and no immunisation indicators measured. According to delivery platform, most FLW performance indicators (80%) had increased odds, followed by maternal behaviours (57%) and facility care and outreach service delivery (22%) compared to non-SHG members. Self-report of discussions within SHGs on specific topics was associated with increased related maternal behaviours. Younger SHG members (<25 years) had attenuated health indicators compared to older group members (≥25 years), and women with more children had more positive indicators compared to women with fewer children. CONCLUSIONS: SHG membership was associated with improved RMNCHN and sanitation indicators at scale in Bihar, India. Further work is needed to understand the specific impacts of health layering upon SHGs. Working through SHGs is a promising vehicle for improving primary health care. STUDY REGISTRATION: ClinicalTrials.gov number NCT02726230.

Health layering of self-help groups: impacts on reproductive, maternal, newborn and child health and nutrition in Bihar, India.

BACKGROUND: Self-help group (SHG) interventions have been widely studied in low and middle income countries. However, there is little data on specific impacts of health layering, or adding health education modules upon existing SHGs which were formed primarily for economic empowerment. We examined three SHG interventions from 2012-2017 in Bihar, India to test the hypothesis that health-layering of SHGs would lead to improved health-related behaviours of women in SHGs. METHODS: A model for health layering of SHGs - Parivartan - was developed by the non-governmental organisation (NGO), Project Concern International, in 64 blocks of eight districts. Layering included health modules, community events and review mechanisms. The health layering model was adapted for use with government-led SHGs, called JEEViKA+HL, in 37 other blocks of Bihar. Scale-up of government-led SHGs without health layering (JEEViKA) occurred contemporaneously in 433 other blocks, providing a natural comparison group. Using Community-based Household Surveys (CHS, rounds 6-9) by CARE India, 62 reproductive, maternal, newborn and child health and nutrition (RMNCHN) and sanitation indicators were examined for SHGs with health layering (Pavivartan SHGs and JEEViKA+HL SHGs) compared to those without. We calculated mean, standard deviation and odds ratios of indicators using surveymeans and survey logistic regression. RESULTS: In 2014, 64% of indicators were significantly higher in Parivartan members compared to non-members residing in the same blocks. During scale up, from 2015-17, half (50%) of indicators had significantly higher odds in health layered SHG members (Parivartan or JEEViKA+HL) in 101 blocks compared to SHG members without health layering (JEEViKA) in 433 blocks. CONCLUSIONS: Health layering of SHGs was demonstrated by an NGO-led model (Parivartan), adapted and scaled up by a government model (JEEViKA+HL), and associated with significant improvements in health compared to non-health-layered SHGs (JEEViKA). These results strengthen the evidence base for further layering of health onto the SHG platform for scale-level health change. STUDY REGISTRATION: ClinicalTrials.gov number NCT02726230.

Improving primary health care delivery in Bihar, India: Learning from piloting and statewide scale-up of Ananya.

In 2010, the Bill and Melinda Gates Foundation (BMGF) partnered with the Government of Bihar (GoB), India to launch the Ananya program to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) outcomes. The program sought to address supply- and demand-side barriers to the adoption, coverage, quality, equity and health impact of select RMNCHN interventions. Approaches included strengthening frontline worker service delivery; social and behavior change communications; layering of health, nutrition and sanitation into women's self-help groups (SHGs); and quality improvement in maternal and newborn care at primary health care facilities. Ananya program interventions were piloted in approximately 28 million population in eight innovation districts from 2011-2013, and then beginning in 2014, were scaled up by the GoB across the rest of the state's population of 104 million. A Bihar Technical Support Program provided techno-managerial support to governmental Health as well as Integrated Child Development Services, and the JEEViKA Technical Support Program supported health layering and scale-up of the GoB's SHG program. The level of support at the block level during statewide scale-up in 2014 onwards was approximately one-fourth that provided in the pilot phase of Ananya in 2011-2013. This paper - the first manuscript in an 11-manuscript and 2-viewpoint collection on Learning from Ananya: Lessons for primary health care performance improvement - seeks to provide a broad description of Ananya and subsequent statewide adaptation and scale-up, and capture the background and context, key objectives, interventions, delivery approaches and evaluation methods of this expansive program. Subsequent papers in this collection focus on specific intervention delivery platforms. For the analyses in this series, Stanford University held key informant interviews and worked with the technical support and evaluation grantees of the Ananya program, as well as leadership from the India Country Office of the BMGF, to analyse and synthesise data from multiple sources. Capturing lessons from the Ananya pilot program and statewide scale-up will assist program managers and policymakers to more effectively design and implement RMNCHN programs at scale through technical assistance to governments.

Effect of health intervention integration within women's self-help groups on collectivization and healthy practices around reproductive, maternal, neonatal and child health in rural India.

BACKGROUND: This study evaluates an eight-session behavior change health intervention with women's self-help groups (SHGs) aimed to promote healthy maternal and newborn practices among the more socially and economically marginalized groups. METHODS: Using a pre-post quasi-experimental design, a total of 545 SHGs were divided into two groups: a control group, which received the usual microcredit intervention; and an intervention group, which received additional participatory training around maternal, neonatal, and child health issues. Women members of SHGs who had a live birth in the 12 months preceding the survey were surveyed on demographics, practices around maternal, neonatal and child health (MNCH), and collectivization. Outcome effects were assessed using difference-in-difference (DID) methods. RESULTS: Women from the SHGs with health intervention, relative to controls over time (time 1 to time 2), were more likely to: use contraceptive methods (DID: 9 percentage points [pp], p<0.001), have institutional delivery (DID: 9pp, p<0.05), practice skin-to-skin care (DID: 17pp, p<0.05), delay bathing for 3 or more days (DID: 19pp, p<0.001), initiate timely breastfeeding (DID: 21pp, p<0.001), exclusively breastfeed the child (DID: 27pp, p<0.001), and provide age-appropriate immunization (DID: 9pp, p<0.001). Additionally, women from the SHGs with health intervention when compared to the control group over time were more likely to report: collective efficacy (DID: 17pp, p<0.001), support through accompanying SHG members for antenatal care (DID: 8pp, p<0.05), receive a visit from SHG member within 2 days post-delivery (DID: 32pp, p<0.001), and receive reproductive, maternal, neonatal and child health information from an SHG member (DID: 45pp, p<0.001). CONCLUSION: Findings demonstrate that structured participatory communication on MNCH with women's groups improve positive health practices. In addition, SHGs can reach a substantial proportion of women while providing an avenue for pregnant women and young mothers to be assisted by others in learning and practicing healthy behaviors, thus building social cohesion on health.

Sustainability of a Community-Based CHOICE Program to Improve the Health and Nutrition Status of Mothers and Infants in Indonesia.

Objectives Few studies have been undertaken to determine whether and how project results are sustained. University of Notre Dame (ND) and Project Concern International conducted a Post-Project Sustainability Study (PSS) of a USAID-funded program (CHOICE), implemented in Indonesia, Banten province, between 2003 and 2007, in order to determine lasting effects and improve PSS methodologies. Methods Sustainability was measured through a comparison of data collected on mother-infant pairs in 2014 with final evaluation data from 2007; and through a comparison of 2014 data collected from the CHOICE villages and comparison villages. Results The analysis showed positive differences in multiple indicators in CHOICE villages between 2007 and 2014, including births attended by skilled personnel (Mean Difference 48.56, 95% CI 38.68 to 58.43) and treatment of diarrhea (MD 16.42, 95% CI - 0.94 to 33.37). However, only one statistically significant difference between intervention and comparison groups in 2014 was observed, infants with diarrhea whose mothers sought advice or treatment (MD - 5.48, 95% CI - 9.55 to 1.39), showing more mothers in intervention group sought advice or treatment. Because contextual factors were not studied in detail and baseline data was not available for the comparison villages, it is difficult to determine the reasons for the results. Given that longitudinal data was not collected, it is also difficult to determine whether results fluctuated between 2007 and 2014. Conclusions for practice This PSS contributes to the limited body of knowledge in sustainability research. Lessons learned from this study will increase potential for sustainable impact of projects, as more rigorous measurement will lead to greater overall understanding of how sustainability actually "happens".

Assessing impact and sustainability of health, water, and sanitation interventions in Bolivia six years post-project.

OBJECTIVE: To assess the impact and sustainability of health, water, and sanitation interventions in Bolivia six years post-project. METHODS: A mixed-method (qualitative-quantitative) study was conducted in 14 rural intervention and control communities in Bolivia in November 2008, six years after the completion of interventions designed to improve knowledge and practices related to maternal and child health and nutrition, community water systems, and household water and sanitation facilities. The degree to which participants had sustained the community and household practices promoted by the interventions was a particular focus. Community site visits were made to evaluate the status (functional condition) and sustainability (state of maintenance and repair) of community and household water and sanitation infrastructure. Key informant interviews and focus group discussions were conducted to assess knowledge and practices, and perceptions about the value of the interventions to the community. RESULTS: Six years post-project, participants remained committed to sustaining the practices promoted in the interventions. The average rating for the functional condition of community water systems was 42% higher than the average rating in control communities. In addition, more than two-thirds of households continued to practice selected maternal and child health behaviors promoted by the interventions (compared to less than half of the households in the control communities). Communities that received integrated investments (development and health) seemed to sustain the practices promoted in the interventions better than communities that received assistance in only one of the two sectors. CONCLUSIONS: Infrastructure for community water systems and household water and sanitation facilities was better built and maintained, and selected maternal and child health behaviors practiced more frequently, in intervention communities versus control communities.

Assessing impact and sustainability of health, water, and sanitation interventions in Bolivia six years post-project / Evaluación de la repercusión y la sostenibilidad a seis años de las intervenciones relacionadas con salud, agua y saneamiento en Bolivia

OBJECTIVE: To assess the impact and sustainability of health, water, and sanitation interventions in Bolivia six years post-project. METHODS: A mixed-method (qualitative-quantitative) study was conducted in 14 rural intervention and control communities in Bolivia in November 2008, six years after the completion of interventions designed to improve knowledge and practices related to maternal and child health and nutrition, community water systems, and household water and sanitation facilities. The degree to which participants had sustained the community and household practices promoted by the interventions was a particular focus. Community site visits were made to evaluate the status (functional condition) and sustainability (state of maintenance and repair) of community and household water and sanitation infrastructure. Key informant interviews and focus group discussions were conducted to assess knowledge and practices, and perceptions about the value of the interventions to the community. RESULTS: Six years post-project, participants remained committed to sustaining the practices promoted in the interventions. The average rating for the functional condition of community water systems was 42% higher than the average rating in control communities. In addition, more than two-thirds of households continued to practice selected maternal and child health behaviors promoted by the interventions (compared to less than half of the households in the control communities). Communities that received integrated investments (development and health) seemed to sustain the practices promoted in the interventions better than communities that received assistance in only one of the two sectors. CONCLUSIONS: Infrastructure for community water systems and household water and sanitation facilities was better built and maintained, and selected maternal and child health behaviors practiced more frequently, in intervention communities versus control communities.

OBJETIVO: Evaluar la repercusión y la sostenibilidad de las intervenciones relacionadas con la salud, el abastecimiento de agua y el saneamiento en Bolivia seis años después de la realización del proyecto. MÉTODOS: Se llevó a cabo un estudio de metodología mixta (cualitativa y cuantitativa) en 12 comunidades rurales donde se efectuó la intervención y 2 de control en Bolivia en noviembre del 2008, seis años después de la finalización de las intervenciones enfocadas a mejorar el conocimiento y las prácticas relacionadas con la salud y la nutrición maternoinfantil, los sistemas de abastecimiento de agua comunitarios y las instalaciones de abastecimiento de agua y saneamiento domiciliarias. Se estudió, en particular, el grado en el cual los participantes continuaban realizando las prácticas domiciliarias y comunitarias promovidas por las intervenciones. Se efectuaron visitas a sitios de la comunidad para evaluar el estado (condición funcional) y la sostenibilidad (estado de mantenimiento y reparación) de la infraestructura de abastecimiento de agua y saneamiento domiciliaria y comunitaria. Se llevaron a cabo entrevistas a informantes clave y análisis basados en grupos de discusión para evaluar el conocimiento, las prácticas y las percepciones acerca del valor de las intervenciones comunitarias. RESULTADOS: Seis años después del proyecto, los participantes continuaban llevando a cabo las prácticas promovidas en las intervenciones. La calificación promedio para la condición funcional de los sistemas de abastecimiento de agua comunitarios fue 42% más alta que la calificación promedio en las comunidades de control. Además, en más de dos terceras partes de los hogares se seguían poniendo en práctica ciertos hábitos relacionados con la salud maternoinfantil promovidos en las intervenciones (en comparación con menos de la mitad de los hogares en las comunidades de control). Las comunidades que recibieron inversiones integradas (desarrollo y salud) parecían conservar las prácticas promovidas en las intervenciones en mayor medida que las comunidades que recibieron ayuda solo en uno de los dos sectores. CONCLUSIONES: La infraestructura de los sistemas de abastecimiento de agua comunitarios y las instalaciones domiciliarias de abastecimiento de agua y saneamiento estaban mejor construidas y mantenidas, y ciertos hábitos de salud maternoinfantil se ponían en práctica con mayor frecuencia, en las comunidades de la intervención en comparación con las comunidades de control.

Factors influencing health care-seeking behaviours among Mayan women in Guatemala.

OBJECTIVE: to identify and better understand factors that influence care-seeking behaviour for women's health among indigenous Mayan populations in the highlands of Guatemala. DESIGN: adaptation of qualitative anthropological methods involving observations, key informant interviews and focus group discussions (FGDs). SETTING: Project Concern International's Casa Materna, Huehuetenango, Guatemala. PARTICIPANTS: Interviews and FGDs were conducted among 21 clients (current or past) of the Casa Materna and traditional birth attendants; 17 female advocates/promoters of the Casa Materna and related services; and 12 male advocates, including spouses, non-government organisation staff and community health workers. FINDINGS: the following findings emerged from focus group data: Women's support groups (WSGs) provided an enabling environment in which women could form friendships, bond, discuss concerns about their reproductive health, and identify concrete ways of addressing them; Supportive friends, family members and advocates influenced women's decisions to seek health care at the Casa Materna; Women's decisions to seek care were often associated with their sense of self-worth and self-esteem, and women's self-esteem was enhanced by their participation in the WSGs; Women's decisions to seek care were influenced by the perception that women would be able to access culturally appropriate, safe and secure health care services at the Casa Materna; The learned behaviour of negotiation with key decision-makers and/or opinion leaders was an effective tool for convincing such individuals of the value of accessing facility-based care; The proven track record, high quality of services and cultural competence offered at the Casa Materna increased the confidence and level of trust of clients and their family members about the care that would be received; Couple-based education and health promotion were effective techniques for achieving behaviour and attitude change among both men and women. KEY CONCLUSIONS: the Casa Materna and its community outreach strategy serve an essential purpose in the provision of maternity care for the isolated and vulnerable families of the Guatemalan highlands, by bridging traditional and Western approaches to health care services. The Casa Materna service model plays a critical role in improving women's self-efficacy and ultimately strengthening the social fabric that characterises this high risk and vulnerable population. IMPLICATIONS FOR PRACTICE: the Casa Materna model provides a foundation upon which to bridge and strengthen the relationship between community advocates, traditional community-based health care providers, and the government-funded system of health care. The findings of this study should be incorporated into future research to determine the potential for bringing the model to scale.

Learning from the community to improve maternal-child health and nutrition: the Positive Deviance/Hearth approach.

The "traditional" use of the Positive Deviance approach to behavior change involves studying children who thrive despite adversity, identifying uncommon model behaviors among Positive Deviant families, and then designing and implementing an intervention to replicate these behaviors among mothers of malnourished children. This article presents the results of a literature review designed to gather information on the role of the Positive Deviance/Hearth methodology in social and behavior change. Examples of how the methodology has been applied beyond infant and child malnutrition to address other health areas, such as improving pregnancy outcomes, are explored. An analysis of Positive Deviance programming being carried out by Project Concern International in Guatemala and Indonesia is conducted. The role of cultural context in the design and implementation of Positive Deviance/Hearth, as well as the role of Positive Deviance in affecting social and behavior change, require further exploration. The issues related to cultural context and the challenges for monitoring and evaluation of program outcomes are presented.