Equity and empowerment effects: Multiple styles of 'voluntarism' in community-based health projects.

Community health workers (CHW) are individuals with no formal health training who perform various roles to address health disparities. There are long-sustained debates over how different forms of incentives shape CHW programs, which are often staffed with volunteer or minimally remunerated women. These debates are complicated by the diversity of CHW roles and contexts in which they work. Evidence is particularly scant around "change-agent" style CHWs, who shape health knowledge and norms within their community. This paper addresses this gap through an analysis of a change agent-staffed program that provided nutrition participatory education through women's groups in three eastern Indian sites. We examine how contextual factors across sites shaped change-agent management, and analyze the implications of each approach for efficacy, empowerment, and equity. Analyzing 68 interviews and 10 focus groups this study advances a typology of 'varieties' of voluntarism that we name laissez faire, active-cultivation, and honorarium-accountability, and uses comparative analysis to examine the equity and empowerment effects within selection, management, and payment. First, we find tensions in the community-based selection of volunteers because rather than selecting highly motivated women, groups selected women in the most favorable socioeconomic position to volunteer. Second, there is a tension around responsibility and expectations in that greater training and responsibility leads women to see more psychosocial empowerment (e.g., knowledge, confidence), but also may create more 'costs' to participation and leads to wider economic inequities in change-agent ranks. Third, we observe a misplaced focus on payments as central to change-agent motivation. While the two volunteer-only sites see payment as 'the answer' to motivation problems, the honorarium site sees payments as 'the problem' because they attract less intrinsically motivated individuals. We conclude that while payments may not make an unmotivated volunteer into a motivated one, this analysis suggests payments would potentially allow more marginalized women to participate, which may be key to making more equitable and efficacious impacts.

The Women Farmer Stress Inventory: Examining women farmer stress in the United States Corn Belt.

PURPOSE: While women identifying as primary farmers have increased in the United States, there has not been research focused on the antecedents of stress and quality of life among women farmers in particular. This study set out to construct a Women Farmer Stress Inventory (WFSI) , test its dimensionality, and assess its criterion-related validity by looking at its relationship with subjective wellbeing as measured by the Satisfaction with Life Scale (SWLS). We then examined sociodemographic and farm-level correlates to assess their relationship with stress. METHODS: We utilized responses from a random sample of 592 Iowan women farmers who responded to a mailout survey that included the WFSI. We conducted exploratory factor analysis to identify the factorial structure of the WFSI, and used linear regression to evaluate how sociodemographic and farm-level characteristics were related to each factor. RESULTS: The analysis revealed 5 unique factors that reflected different aspects of women farmer stress: time pressures and workload, environmental concern, external stressors from governments and market, interpersonal relationships, and rural amenities. All factors except rural amenities had high levels of internal consistency (Cronbach's alpha >0.80) and were validated using the external criteria of SWLS measures. Young age, being married, and engagement in off-farm work, and smaller farm size were associated with greater levels of stress across most domains. CONCLUSION: The WFSI is a promising tool that shows high internal consistency and is validated with life satisfaction. Our study also finds certain sociodemographic and farm characteristics associated with different stress domains, which could inform both future research and community-based interventions.

The "Corona Warriors"? Community health workers in the governance of India's COVID-19 response.

India's nearly 1-million strong band of quasi-volunteer accredited social health activists (ASHAs) have been key actors in government efforts to control COVID-19. Utilizing a nationalist rhetoric of war, ASHAs were swiftly mobilized by the government in March 2020 as 'COVID warriors' engaged in tracking illness, disseminating information, and caring for quarantined individuals. The speed at which ASHAs were mobilized into mentally and physically grueling labor was all the more stunning given these minimally paid community health workers have long been seen to have low morale given their precarious, informalized work arrangements. Building on work examining the spatialities of global health governance alongside literature on geographic contingency, this paper explores the ways that nationalist COVID-19 war rhetoric promulgated from Delhi worked as a technology of health governance to propel ASHAs into certain forms of action, yet also opened up spaces of potentiality for them to reimagine their relationship to both the state and the communities they serve. In particular, in our analysis of in-depth telephone interviews with ASHA workers in the state of Himachal Pradesh, we find that their hailing as COVID warriors inspired patriotic calls to duty and legitimized their (long over-looked) roles as critical governance actors, yet also was subject to resistance and reworking due to a combination of institutional histories, local politics, as well as happenstantial everyday encounters of ASHA work. The precarious employment of ASHAs - in terms of basic remuneration as well as the great on-the-job risks that they have faced - underscores both the fragile nature of India's health governance system as well as possible political movements for its renewal. We conclude by calling for geographers to give greater attention to community health care workers as a key window into understanding the uneven ways in which health systems are made manifest on the ground, and their ability to respond to citizens' healthcare needs - both in the COVID-19 pandemic and beyond.

A Quasi-Experimental Evaluation of a Nutrition Behavior Change Intervention Delivered Through Women's Self-Help Groups in Rural India: Impacts on Maternal and Young Child Diets, Anthropometry, and Intermediate Outcomes.

Background: Women's self-help groups (SHGs) have become one of the largest institutional platforms serving the poor. Nutrition behavior change communication (BCC) interventions delivered through SHGs can improve maternal and child nutrition outcomes. Objectives: The objective was to understand the effects of a nutrition BCC intervention delivered through SHGs in rural India on intermediate outcomes and nutrition outcomes. Methods: We compared 16 matched blocks where communities were supported to form SHGs and improve livelihoods; 8 blocks received a 3-y nutrition intensive (NI) intervention with nutrition BCC, and agriculture- and rights-based information, facilitated by a trained female volunteer; another 8 blocks received standard activities (STD) to support savings/livelihoods. Repeated cross-sectional surveys of mother-child pairs were conducted in 2017-2018 (n = 1609 pairs) and 2019-2020 (n = 1841 pairs). We matched treatment groups over time and applied difference-in-difference regression models to estimate impacts on intermediate outcomes (knowledge, income, agriculture/livelihoods, rights, empowerment) and nutrition outcomes (child feeding, woman's diet, woman and child anthropometry). Analyses were repeated on households with ≥1 SHG member. Results: Forty percent of women were SHG members and 50% were from households with ≥1 SHG member. Only 10% of women in NI blocks had heard of intervention content at endline. Knowledge improved in both NI and STD groups. There was a positive NI impact on knowledge of timely introduction of animal-sourced foods to children (P < 0.05) but not on other intermediate outcomes. No impacts were observed for anthropometry or diet indicators except child animal-source food consumption (P < 0.01). In households with ≥1 SHG member, there was a positive NI impact on child unhealthy food consumption (P < 0.05). Conclusions: Limited impacts could be due to limited exposure or skills of volunteers, and a concurrent national nutrition campaign. Our findings add to a growing literature on SHG-based BCC interventions and the conditions necessary for their success.

Forging just dietary futures: bringing mainstream and critical nutrition into conversation.

Despite decades of action to reduce global malnutrition, rates of undernutrition remain stubbornly high and rates of overweight, obesity and chronic disease are simultaneously on the rise. Moreover, while volumes of robust research on causes and solutions to malnutrition have been published, and calls for interdisciplinarity are on the rise, researchers taking different epistemological and methodological choices have largely remained disciplinarily siloed. This paper works to open a scholarly conversation between "mainstream" public health nutrition and "critical" nutrition studies. While critical nutrition scholars collectively question aspects of mainstream nutrition approaches, they also chart a different way to approach malnutrition research by focusing on politics, structural conditions, and the diverse ways people make sense of food and malnutrition. In this paper, we highlight the key research agendas and insights within both mainstream and critical nutrition in order to suggest spaces for their potential conversation. We ultimately argue that global public health nutrition interventions might achieve greater success in more equitable ways if they are informed by critical nutrition research. We aim for this intervention to facilitate more substantial crossing of disciplinary boundaries, critical to forging more socially and environmentally just dietary futures in the global South and beyond.

Self-help groups as platforms for development: The role of social capital.

Women-led self-help groups (SHGs) are increasingly being utilized as platforms for delivering development activities by funding agencies and governmental bodies. However, there is currently little understanding as to whether SHGs are effective or equitable platforms for delivering health or livelihoods interventions. Social capital is hypothesized as a comparative advantage when utilizing SHGs as development platforms, however the specific mechanisms have yet to be explored. This paper investigates the efficacy and equity of SHGs as platforms for development programs through analyzing 64 interviews and 6 focus group discussions collected from an agriculture and behavior change intervention delivered through SHGs in eastern India. We find that while, theoretically, SHGs are a promising platform for health messaging this is largely dependent on SHG norms of attendance, which itself is closely tied to socioeconomic conditions and social capital. Social capital is important both within SHGs as well as between SHGs and the implementing organization. Sites with more mature SHGs had greater economic security allowing more active participation in the intervention than sites with more poverty and young SHGs. The former sites also had greater norms of trust and reciprocity (social capital) with the implementing organization that led them to accept additional interventions. In the latter sites, SHG members had competing demands on their time and less trust in the implementers, making it difficult to attend both SHG meetings and health sessions. We put forth a materialist understanding of social capital formation, where SHG members must have already received substantive benefit from membership for new activities to be successfully incorporated into their agenda. Further, using SHGs as a nutrition message delivery platform should not detract from individual engagement with more vulnerable members of the community.

Spaces for women: Rethinking behavior change communication in the context of women's groups and nutrition-sensitive agriculture.

Recently, nutrition-sensitive agriculture programs have taken aim at malnutrition's multi-sectoral roots through re-diversifying agricultural production while integrating women's empowerment and nutrition behavior-change communication components. For these integrated nutrition-sensitive agricultural programs, women-led self-help groups have emerged as promising platforms for program delivery. Yet, while well-designed nutrition behavior-change communication has been successfully used in self-help groups, and is central to nutrition-sensitive agriculture, it can take many forms. These vary widely in their theoretical and ethical underpinnings, communication strategies, and theory of change. As nutrition-sensitive agriculture continues to proliferate, it is critical to better understand how women interact with different behavior-change messages and how to engage individuals in ethical, effective ways. This paper analyzes qualitative data collected from a nutrition-sensitive agricultural project in India that used participatory storytelling to generate knowledge and awareness about malnutrition among women. Drawing from data across two sites, the paper analyzes why certain messages generated more discussion among women then others. We find self-help group women were drawn to topics of early marriage and diet diversity because they emotionally connected to them, and felt they were relevant to their lives with high perceived pay-off and actionability. While other topics on gender and health also provoked emotional, lively discussions, the stories were less effective due to their complexity, which were difficult for volunteer facilitators to communicate. We conclude that there is unmet demand among women in rural India for structured spaces to discuss gendered aspects of health and diet, and nutrition-sensitive agricultural programs could benefit from focusing attention here.

The wazan janch: The body-mass index and the socio-spatial politics of health promotion in rural India.

The body mass index (BMI), which measures body mass divided by height squared (kg/m²), has become a popular technology for quickly measuring and assessing individuals' health and disease risk. However, the BMI has also been widely criticized by health professionals who argue that it's a poor measure of health. Feminist scholars are also critical, arguing BMI is a technology of neoliberal health promotion that pathologizes body size, and produces responsibilized subjects invested in maintaining "proper" weights, while often ignoring the social and environmental conditions that result in differently sized bodies. In this paper, I look at a series of BMI "camps" held across rural North India in 2017 and put forth two central arguments. First, BMI is not an a priori technology of neoliberal governmentality, but can be also be a means to highlight social marginalization and create relations of care. I find the spaces of BMI deployment are tightly linked to the types of responsibility and care it produces. Second, while the intended goal of these BMI camps is to propel people, mostly women, to change their behavior to be more healthful, this behavior change was often stymied by the everyday business of surviving in India's current political economic climate. Despite that women were unable to implement much of the nutrition advice (and sometimes reported additional stress due to attendance at such camps), women continued to attend health-related camps. This paper draws on the notion of cruel optimism, which argues that the objects of our attachments, such as ideas of "the good life" can be self-detrimental, as a way to unpack the paradox of women who continue to show up for health camps despite not taking anyway many useful skill and sometimes causing them anxiety.

The discovery of potent nonstructural protein 5A (NS5A) inhibitors with a unique resistance profile-Part†1.

Nonstructural protein 5A (NS5A) represents a novel target for the treatment of hepatitis C virus (HCV). Daclatasvir, recently reported by Bristol-Myers-Squibb, is a potent NS5A inhibitor currently under investigation in phase 3 clinical trials. While the performance of daclatasvir has been impressive, the emergence of resistance could prove problematic and as such, improved analogues are being sought. By varying the biphenyl-imidazole unit of daclatasvir, novel inhibitors of HCV NS5A were identified with an improved resistance profile against mutant strains of the virus while retaining the picomolar potency of daclatasvir. One compound in particular, methyl ((S)-1-((S)-2-(4-(4-(6-(2-((S)-1-((methoxycarbonyl)-L-valyl)pyrrolidin-2-yl)-1H-imidazol-5-yl)quinoxalin-2-yl)phenyl)-1H-imidazol-2-yl)pyrrolidin-1-yl)-3-methyl-1-oxobutan-2-yl)carbamate (17), exhibited very promising activity and showed good absorption and a long predicted human pharmacokinetic half-life. This compound represents a promising lead that warrants further evaluation.

The discovery of potent nonstructural protein 5A (NS5A) inhibitors with a unique resistance profile-Part†2.

In ongoing studies towards novel hepatitis C virus (HCV) therapeutics, inhibitors of nonstructural protein 5A (NS5A) were evaluated. Specifically, starting from previously reported lead compounds, peripheral substitution patterns of a series of biaryl-linked pyrrolidine NS5A replication complex inhibitors were probed and structure-activity relationships were elucidated. Using molecular modelling and a supercritical fluid chromatographic (SFC) technique, intramolecular H-bonding and peripheral functional group topology were evaluated as key determinants of activity and membrane permeability. The novel compounds exhibited retained potency as compared with the lead compounds, and also showed promising results against a panel of resistance viruses. Together, the results of the study take us a step closer towards understanding the potency of daclatasvir, a clinical candidate upon which the compounds were based, and to designing improved analogues as second-generation antiviral agents targeting NS5A.

Pyrimido[4,5-d]azepines as potent and selective 5-HT2C receptor agonists: design, synthesis, and evaluation of PF-3246799 as a treatment for urinary incontinence.

New pyrimido[4,5-d]azepines 7 are disclosed as potent 5-HT(2C) receptor agonists. A preferred example, 7b had minimal activation at either the 5-HT(2A) or 5-HT(2B) receptors combined with robust efficacy in a preclinical canine model of stress urinary incontinence (SUI) and attractive pharmacokinetic and safety properties. Based on this profile, 7b (PF-3246799) was identified as a candidate for clinical development for the treatment of SUI. In addition, it proved to be critical to build an understanding of the translation between recombinant cell-based systems, native tissue preparations and in vivo preclinical models. This was a significant undertaking and proved to be crucial in compound selection.

Design and synthesis of piperazinylpyrimidinones as novel selective 5-HT(2C) agonists.

This Letter reports the design and synthesis of several novel series of piperazinyl pyrimidinones as 5-HT(2C) agonists. Several of the compounds presented exhibit good in vitro potency and selectivity over the closely related 5-HT(2A) and 5-HT(2B) receptors. Compound 11 was active in in vivo models of stress urinary incontinence.

Design and synthesis of a functionally selective D3 agonist and its in vivo delivery via the intranasal route.

This paper reports the synthesis and biological activity of a novel series of aryl-morpholine dopamine receptor agonists. Several compounds show high levels of functional selectivity for the D3 over the D2 dopamine receptor. Compound 26 has >1000-fold functional selectivity and has been successfully progressed in vivo using an intranasal delivery route.

Highly potent and selective zwitterionic agonists of the delta-opioid receptor. Part 1.

A series of zwitterionic delta-opioid agonists, with targeted physicochemistry, as a strategy to limit potential for CNS exposure, were prepared. These agents were found to possess exquisite potency and selectivity over mu and kappa-opiate activity. Furthermore, analogue 3a was found to display restricted CNS exposure, as evidenced by its inactivity in a rodent hyperlocomotion assay of central opiate activity. Dog pharmacokinetic studies on 3a indicated encouraging oral bioavailability.