A Cluster-Randomized Trial to Test Sharing Histories as a Training Method for Community Health Workers in Peru.

BACKGROUND: Community health workers (CHWs) are increasingly deployed to support mothers' adoption of healthy home practices in low- and middle-income countries. However, little is known regarding how best to train them for the capabilities and cultural competencies needed to support maternal health behavior change. We tested a CHW training method, Sharing Histories (SH), in which CHWs recount their own childbearing and childrearing experiences on which to build new learning. METHODS: We conducted an embedded cluster-randomized trial in rural Peru in 18 matched clusters. Each cluster was a primary health facility catchment area. Government health staff trained female CHWs using SH (experimental clusters) or standard training methods (control clusters). All other training and system-strengthening interventions were equal between study arms. All CHWs conducted home visits with pregnant women and children aged 0-23 months to teach, monitor health practices and danger signs, and refer. The primary outcome was height-for-age (HAZ)<-2 Z-scores (stunting) in children aged 0-23 months. Household surveys were conducted at baseline (606 cases) and 4-year follow-up (606 cases). RESULTS: Maternal and child characteristics were similar in both study arms at baseline and follow-up. Difference-in-differences analysis showed mean HAZ changes were not significantly different in experimental versus control clusters from baseline to endline (P=.469). However, in the subgroup of literate mothers, mean HAZ improved by 1.03 on the Z-score scale in experimental clusters compared to control clusters from baseline to endline (P=.059). Using generalized estimating equations, we demonstrated that stunting in children of mothers who were literate was significantly reduced (Beta=0.77; 95% confidence interval=0.23, 1.31; P<.01), adjusting for covariates. CONCLUSION: Compared with standard training methods, SH may have improved the effectiveness of CHWs as change agents among literate mothers to reduce child stunting. Stunting experienced by the children of illiterate mothers may have involved unaddressed determinants of stunting.

Sampling Weights for Analyses of Couple Data: Example of the Demographic and Health Surveys.

In some surveys, women and men are interviewed separately in selected households, allowing matching of partner information and analyses of couples. Although individual sampling weights exist for men and women, sampling weights specific for couples are rarely derived. We present a method of estimating appropriate weights for couples that extends methods currently used in the Demographic and Health Surveys (DHS) for individual weights. To see how results vary, we analyze 1912 estimates (means; proportions; linear regression; and simple and multinomial logistic regression coefficients, and their standard errors) with couple data in each of 11 DHS surveys in which the couple weight could be derived. We used two measures of bias: absolute percentage difference from the value estimated with the couple weight and ratio of the absolute difference to the standard error using the couple weight. The latter shows greater bias for means and proportions, whereas the former and a combination of both measures show greater bias for regression coefficients. Comparing results using couple weights with published results using women's weights for a logistic regression of couple contraceptive use in Turkey, we found that 6 of 27 coefficients had a bias above 5 %. On the other hand, a simulation of varying response rates (27 simulations) showed that median percentage bias in a logistic regression was less than 3 % for 17 of 18 coefficients. Two proxy couple weights that can be calculated in all DHS surveys perform considerably better than either male or female weights. We recommend that a couple weight be calculated and made available with couple data from such surveys.

Husbands' and wives' reports of women's decision-making power in Western Guatemala and their effects on preventive health behaviors.

Surveys have attempted to measure married women's decision-making power by asking women who has a say and/or final say in a number of household decisions. In several studies where the same questions were posed to husbands, considerable discrepancies in reports were found. This paper assesses husband and wife reports of decision-making on four matters (whether or not to buy household items; what to do if a child becomes ill; whether or not to buy medicine for a family member who is ill; what to do if a pregnant women becomes very ill) and the relationship of these reports to three recent health behaviors (having an emergency plan during pregnancy; delivering in a health facility; having a postpartum checkup within 4 weeks). A sample of 1000 women in 53 communities in three departments of western Guatemala was selected using a stratified random sampling approach. A standard household questionnaire was used to identify the respondents as well as to obtain data on household characteristics. Husbands of interviewed women were interviewed in every other household giving information on 546 couples for this analysis. Women and men's questionnaires were similar and were designed to obtain information on the respondent's knowledge, attitudes and behaviors regarding maternal health. Consistent with other research, results show that relative to their husbands' report, wives tend to under-report their household decision-making power. In couples with both partners educated and in couples in which women work for pay, both partners were significantly more likely to report that both of them participate in the final decisions than was the case in couples without education or in which the wife did not work for pay. Women's reports of their decision-making power was significantly related to the household having a plan for what to do in case of a maternal emergency, but was not associated with place of childbirth or with having a postpartum checkup, while husband's reports of the wife's decision-making power was negatively associated with the likelihood of having the last birth in a health facility.