Association of BCC Module Roll-Out in SHG meetings with changes in complementary feeding and dietary diversity among children (6-23 months)? Evidence from JEEViKA in Rural Bihar, India.

OBJECTIVES: Child dietary diversity is very low across rural communities in Bihar. Based on the experience of behavior change communication (BCC) module roll out in self-help group (SHG) sessions in rural Bihar, this study aims to assess the impact of the intervention on child dietary diversity levels in the beneficiary groups. METHODS: The study is based on a pre-post study design whereby child dietary diversity is examined for a sample of 300 children (6-23 months old from 60 village organizations) during both pre-intervention as well as post-intervention phase. The latter consists of two types of group viz. a) children whose mothers were directly exposed to BCC module in SHGs sessions and b) those who were non-participants but may have indirect exposure through spillovers of BCC activities. Econometric analysis including logistic regression as well as propensity score matching techniques are applied for estimating the changes in dietary diversity in the post-intervention phase. RESULTS: During the pre-intervention phase, 19% of the children (6-23 months) had adequate dietary diversity (eating from at least 4 out of 7 different food groups) and this increased to 49% among the exposed group and to 28% among the non-exposed group in the post-intervention phase. The exposed group have an odds ratio of 3.81 (95% CI: 2.03, 7.15) for consuming diverse diet when compared to the pre-intervention group. The propensity score matching analysis finds a 33% average treatment effect on the treated (ATT) for the group participating in BCC sessions at SHG events. CONCLUSION: BCC roll out among SHG members is an effective mode to increase dietary diversity among infants and young children. The impact on child dietary diversity was significantly higher among mothers directly exposed to BCC modules. The BCC module also improved knowledge and awareness levels on complementary feeding and child dietary diversity.

Key learnings from an outcome and embedded process evaluation of a direct to beneficiary mobile health intervention among marginalised women in rural Bihar, India.

INTRODUCTION: Mobile Vaani was implemented as a pilot programme across six blocks of Nalanda district in Bihar state, India to increase knowledge of rural women who were members of self-help groups on proper nutrition for pregnant or lactating mothers and infants, family planning and diarrhoea management. Conveners of self-help group meetings, community mobilisers, introduced women to the intervention by giving them access to interactive voice response informational and motivational content. A mixed methods outcome and embedded process evaluation was commissioned to assess the reach and impact of Mobile Vaani. METHODS: The outcome evaluation, conducted from January 2017 to November 2018, used a quasi-experimental pre-post design with a sample of 4800 married women aged 15-49 from self-help group households, who had a live birth in the past 24 months. Surveys with community mobilisers followed by meeting observations (n=116), in-depth interviews (n=180) with self-help group members and secondary analyses of system generated data were conducted to assess exposure and perceptions of the intervention. RESULTS: From the outcome evaluation, 23% of women interviewed had heard about Mobile Vaani. Women in the intervention arm had significantly higher knowledge than women in the comparison arm for two of seven focus outcomes: knowledge of how to make child's food nutrient and energy dense (treatment-on-treated: 18.8% (95% CI 0.4% to 37.2%, p<0.045)) and awareness of at least two modern spacing family planning methods (treatment-on-treated: 17.6% (95% CI 4.7% to 30.5%, p<0.008)). Women with any awareness of Mobile Vaani were happy with the programme and appreciated the ability to call in and listen to the content. CONCLUSION: Low population awareness and programme exposure are underpinned by broader population level barriers to mobile phone access and use among women and missed opportunities by the programme to improve targeting and programme promotion. Further research is needed to assess programmatic linkages with changes in health practices.

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.

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.

Impact of IRS: Four-years of entomological surveillance of the Indian Visceral Leishmaniases elimination programme.

BACKGROUND: In 2005, Bangladesh, India and Nepal agreed to eliminate visceral leishmaniasis (VL) as a public health problem. The approach to this was through improved case detection and treatment, and controlling transmission by the sand fly vector Phlebotomus argentipes, with indoor residual spraying (IRS) of insecticide. Initially, India applied DDT with stirrup pumps for IRS, however, this did not reduce transmission. After 2015 onwards, the pyrethroid alpha-cypermethrin was applied with compression pumps, and entomological surveillance was initiated in 2016. METHODS: Eight sentinel sites were established in the Indian states of Bihar, Jharkhand and West Bengal. IRS coverage was monitored by household survey, quality of insecticide application was measured by HPLC, presence and abundance of the VL vector was monitored by CDC light traps, insecticide resistance was measured with WHO diagnostic assays and case incidence was determined from the VL case register KAMIS. RESULTS: Complete treatment of houses with IRS increased across all sites from 57% in 2016 to 70% of houses in 2019, rising to >80% if partial house IRS coverage is included (except West Bengal). The quality of insecticide application has improved compared to previous studies, average doses of insecticide on filters papers ranged from 1.52 times the target dose of 25mg/m2 alpha-cypermethrin in 2019 to 1.67 times in 2018. Resistance to DDT has continued to increase, but the vector was not resistant to carbamates, organophosphates or pyrethroids. The annual and seasonal abundance of P. argentipes declined between 2016 to 2019 with an overall infection rate of 0.03%. This was associated with a decline in VL incidence for the blocks represented by the sentinel sites from 1.16 per 10,000 population in 2016 to 0.51 per 10,000 in 2019. CONCLUSION: Through effective case detection and management reducing the infection reservoirs for P. argentipes in the human population combined with IRS keeping P. argentipes abundance and infectivity low has reduced VL transmission. This combination of effective case management and vector control has now brought India within reach of the VL elimination targets.

Development and Evaluation of Active Case Detection Methods to Support Visceral Leishmaniasis Elimination in India.

As India moves toward the elimination of visceral leishmaniasis (VL) as a public health problem, comprehensive timely case detection has become increasingly important, in order to reduce the period of infectivity and control outbreaks. During the 2000s, localized research studies suggested that a large percentage of VL cases were never reported in government data. However, assessments conducted from 2013 to 2015 indicated that 85% or more of confirmed cases were eventually captured and reported in surveillance data, albeit with significant delays before diagnosis. Based on methods developed during these assessments, the CARE India team evolved new strategies for active case detection (ACD), applicable at large scale while being sufficiently effective in reducing time to diagnosis. Active case searches are triggered by the report of a confirmed VL case, and comprise two major search mechanisms: 1) case identification based on the index case's knowledge of other known VL cases and searches in nearby houses (snowballing); and 2) sustained contact over time with a range of private providers, both formal and informal. Simultaneously, house-to-house searches were conducted in 142 villages of 47 blocks during this period. We analyzed data from 5030 VL patients reported in Bihar from January 2018 through July 2019. Of these 3033 were detected passively and 1997 via ACD (15 (0.8%) via house-to-house and 1982 (99.2%) by light touch ACD methods). We constructed multinomial logistic regression models comparing time intervals to diagnosis (30-59, 60-89 and ≥90 days with <30 days as the referent). ACD and younger age were associated with shorter time to diagnosis, while male sex and HIV infection were associated with longer illness durations. The advantage of ACD over PCD was more marked for longer illness durations: the adjusted odds ratios for having illness durations of 30-59, 60-89 and >=90 days compared to the referent of <30 days for ACD vs PCD were 0.88, 0.56 and 0.42 respectively. These ACD strategies not only reduce time to diagnosis, and thus risk of transmission, but also ensure that there is a double check on the proportion of cases actually getting captured. Such a process can supplement passive case detection efforts that must go on, possibly perpetually, even after elimination as a public health problem is achieved.

Home Fortification of Complementary Foods Reduces Anemia and Diarrhea among Children Aged 6-18 Months in Bihar, India: A Large-Scale Effectiveness Trial.

BACKGROUND: Home fortification of complementary foods with multiple micronutrient powders (MNPs) is recommended to reduce child anemia in resource-poor settings. However, evidence of program effectiveness in India to guide policies and programs is lacking. OBJECTIVES: We implemented a large-scale intervention of MNPs in Bihar, India. The primary outcome was MNP consumption and change in hemoglobin concentration among children aged 6-18 mo between baseline and endline (12 mo). Secondary outcomes were change in child weight and length and infant and young child feeding (IYCF) practices (initiation, diversity, and feeding frequency). Ad hoc analyses included changes in anemia; stunting; underweight; wasting; and reported diarrhea, fever, and hospitalization. METHODS: We conducted a cluster-randomized, effectiveness trial in >4000 children within the context of ongoing health and nutrition programs implemented by CARE, India. Seventy health subcenters were randomly assigned to receive either MNPs with IYCF counseling (intervention) or IYCF counseling only (control). We used an adjusted difference-in-difference approach using repeat cross-sectional surveys at baseline and endline to evaluate impact. RESULTS: At baseline, 75% of intervention and 69% of control children were anemic and 33% were stunted. By endline, 70% of intervention households reported their child had ever consumed MNPs, and of those, 64% had consumed MNPs in the past month. Relative to control, hemoglobin concentration increased (0.22 g/dL; 95% CI: 0.00, 0.44 g/dL) and anemia declined by 7.1 percentage points (pp) (95% CI: -13.5, -0.7 pp). There was no impact on anthropometry nor IYCF practices. However, there was a decline of 8.0 pp (95% CI: -14.9, -1.1 pp) in stunting among children aged 12-18 mo. Diarrhea prevalence in the past 2 wk was reduced by 4.0 pp (95% CI: -7.6, -0.4 pp). CONCLUSIONS: Home fortification of complementary foods within a government-run program in Bihar had moderate compliance and caused modest improvements in hemoglobin and reductions in anemia and diarrhea prevalence.

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'.

Effect of sharing health messages on antenatal care behavior among women involved in microfinance-based self-help groups in Bihar India.

Background: Bihar state in India has one of the highest rates of maternal and infant mortality in South Asia. Microfinance-based self-help groups (SHGs), involving rural women, are being utilized to improve maternal and child health practice and reduce mortality. SHG members receive information on key maternal and child health practices as well as encouragement for their practice. This study measures the association of health messaging to SHG members with their antenatal care (ANC) behaviors. Methods: The study was conducted in eight districts of Bihar in 2016. A three-stage cluster sampling design (with a random selection of blocks, villages, and SHGs) selected the sample of 1204 SHG members who had an infant child; of these, 597 women were members of SHGs that received dedicated sessions on health messages, while 607 women belonged to SHGs that did not. To examine the impact of the health intervention on ANC practice, radius caliper method of propensity score matching controlled for various socio-demographic characteristics between the two groups. Results: Most of the interviewed women (91.5%) belonged to a scheduled caste or tribe. Nearly 44% of SHG members exposed to the health intervention were engaged in some occupation, compared to 35% of those not exposed to the intervention. After matching unexposed SHG women with exposed SHG women, no significant differences were found in their socio-demographic characteristics. Findings suggest that exposure to a health intervention is associated with increased likelihood of at least four ANC visits by SHG women (ATE = 7.2, 95% CI: 0.76-13.7, p < 0.05), consumption of iron-folic acid for at least 100 days (ATE = 8.7, 95% CI: 5.0-12.5, p < 0.001) and complete ANC (ATE = 3.6, 95% CI: 2.3-4.9, p < 0.001), when compared to women not exposed to the health intervention. Conclusions: The study shows that sharing health messages in microfinance-based SHGs is associated with significant increase in ANC practice. While the results suggest the potential of microfinance-based SHGs for improved maternal health services, the approach's sustainability needs to be further examined.

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.

Use of mobile technology by frontline health workers to promote reproductive, maternal, newborn and child health and nutrition: a cluster randomized controlled Trial in Bihar, India.

BACKGROUND: mHealth technology holds promise for improving the effectiveness of frontline health workers (FLWs), who provide most health-related primary care services, especially reproductive, maternal, newborn, child health and nutrition services (RMNCHN), in low-resource - especially hard-to-reach - settings. Data are lacking, however, from rigorous evaluations of mHealth interventions on delivery of health services or on health-related behaviors and outcomes. METHODS: The Information Communication Technology-Continuum of Care Service (ICT-CCS) tool was designed for use by community-based FLWs to increase the coverage, quality and coordination of services they provide in Bihar, India. It consisted of numerous mobile phone-based job aids aimed to improve key RMNCHN-related behaviors and outcomes. ICT-CCS was implemented in Saharsa district, with cluster randomization at the health sub-center level. In total, evaluation surveys were conducted with approximately 1100 FLWs and 3000 beneficiaries who had delivered an infant in the previous year in the catchment areas of intervention and control health sub-centers, about half before implementation (mid-2012) and half two years afterward (mid-2014). Analyses included bivariate and difference-in-difference analyses across study groups. RESULTS: The ICT-CCS intervention was associated with more frequent coordination of AWWs with ASHAs on home visits and greater job confidence among ASHAs. The intervention resulted in an 11 percentage point increase in FLW antenatal home visits during the third trimester (P = 0.04). In the post-implementation period, postnatal home visits during the first week were increased in the intervention (72%) vs the control (60%) group (P < 0.01). The intervention also resulted in 13, 12, and 21 percentage point increases in skin-to-skin care (P < 0.01), breastfeeding immediately after delivery (P < 0.01), and age-appropriate complementary feeding (P < 0.01). FLW supervision and other RMNCHN behaviors were not significantly impacted. CONCLUSIONS: Important improvements in FLW home visits and RMNCHN behaviors were achieved. The ICT-CCS tool shows promise for facilitating FLW effectiveness in improving RMNCHN behaviors.

Effects of team-based goals and non-monetary incentives on front-line health worker performance and maternal health behaviours: a cluster randomised controlled trial in Bihar, India.

INTRODUCTION: We evaluated the impact of a 'Team-Based Goals and Incentives' (TBGI) intervention in Bihar, India, designed to improve front-line (community health) worker (FLW) performance and health-promoting behaviours related to reproductive, maternal, newborn and child health and nutrition. METHODS: This study used a cluster randomised controlled trial design and difference-in-difference analyses of improvements in maternal health-related behaviours related to the intervention's team-based goals (primary), and interactions of FLWs with each other and with maternal beneficiaries (secondary). Evaluation participants included approximately 1300 FLWs and 3600 mothers at baseline (May to June 2012) and after 2.5 years of implementation (November to December 2014) who had delivered an infant in the previous year. RESULTS: The TBGI intervention resulted in significant increases in the frequency of antenatal home visits (15 absolute percentage points (PP), p=0.03) and receipt of iron-folic acid (IFA) tablets (7 PP, p=0.02), but non-significant changes in other health behaviours related to the trial's goals. Improvements were seen in selected attitudes related to coordination and teamwork among FLWs, and in the provision of advice to beneficiaries (ranging from 8 to 14 PP) related to IFA, cord care, breast feeding, complementary feeding and family planning. CONCLUSION: Results suggest that combining an integrated set of team-based coverage goals and targets, small non-cash incentives for teams who meet targets and team building to motivate FLWs resulted in improvements in FLW coordination and teamwork, and in the quality and quantity of FLW-beneficiary interactions. These improvements represent programmatically meaningful steps towards improving health behaviours and outcomes. TRIAL REGISTRATION NUMBER: NCT03406221.

Prelacteal feeding practice and maintenance of exclusive breast feeding in Bihar, India - identifying key demographic sections for childhood nutrition interventions: a cross-sectional study.

Background:  Exclusive breastfeeding (EBF) during the first six months of life is considered a high impact, but low-cost, measure for improving nutritional status, and reducing morbidity and mortality among children. However, providing prelacteal feed to a newborn, a widely practiced custom in rural India, is a major barrier to the practice of EBF.  The present study evaluated the association between provision of prelacteal feeding and continuation of EBF among children up to 3 months age in Bihar, a resource-poor Indian state. Methods: Data from four rounds of a population-based multi-stage sampling survey, conducted in 8 districts of Bihar between 2012 and 2013, were used for the present analysis. Using simple and adjusted logistic regression modelling, we tested the association of providing prelacteal feeding with two outcome measures - 1) giving only breastmilk during the last 24 hours, and 2) exclusively breastfed (EBF) since birth (excluding the first 3 days of life). Results: Among 10,262 children for whom prelacteal feeding data was available, 26% received prelacteal feeding. About 55% mothers reported that their children were exclusively breastfed, whereas 82% mothers provided only breastmilk to their children during the previous 24 hours. Children who received prelacteal feeding had approximately 60% lesser odds of being breastfed exclusively during the previous 24 hours [AOR = 0.39(0.33-0.47)] and 80% lesser odds of receiving continued EBF since birth [AOR = 0.20(0.17-0.24)]. Conclusions: Frontline workers (FLW) provide nutritional counselling to mothers and children of rural India. In order to improve uptake of EBF, the families practicing prelacteal feeding should be identified early and educated on the harmful effects of prelacteal feeding for EBF and subsequently on infant health. Midwives/nurses at the public and private facilities as well as the home birth attendants should also be made aware about the negative effects of prelacteal feed.

Use of monitoring data to improve implementation of a home fortification program in Bihar, India.

This paper describes the use of program-monitoring data to track program performance and inform activities. Monitoring data were collected as part of an effectiveness trial of multiple micronutrient powders (MNPs) for children 6-18 months in Bihar, India. Communities (n = 70; reaching over 10,000 children) were randomized to receive either counselling on infant and young child feeding or both counselling and MNPs. Government frontline health workers (FLWs) implemented and monitored program activities with support from CARE India and university partners. Monitoring data were collected over the duration of the entire program to assess program impact pathways using various checklists, which captured information about (a) attendance and training of FLWs at health subcentre meetings, (b) distribution of MNPs, (c) receipt and use of MNPs at the household level, and (d) midline mixed methods survey. At the beginning of the program, 72% of households reported receiving and 53% reported currently consuming MNPs. These numbers fell to 40% and 43% at midline, respectively. The main barrier to use by household was a lack of MNPs, due in part to infrequent FLW distribution. However, FLWs rarely reported MNP shortages at Anganwadi centres. Side effects also emerged as a barrier and were addressed through revised recommendations for MNP use. Qualitative data indicated high community acceptance of MNPs and a good understanding of the program by FLWs. The use of real-time program data allowed for recognition of key program issues and decision-making to enhance program implementation.

'We pledge to improve the health of our entire community': Improving health worker motivation and performance in Bihar, India through teamwork, recognition, and non-financial incentives.

BACKGROUND: Motivation is critical to health worker performance and work quality. In Bihar, India, frontline health workers provide essential health services for the state's poorest citizens. Yet, there is a shortfall of motivated and skilled providers and a lack of coordination between two cadres of frontline health workers and their supervisors. CARE India developed an approach aimed at improving health workers' performance by shifting work culture and strengthening teamwork and motivation. The intervention-"Team-Based Goals and Incentives"-supported health workers to work as teams towards collective goals and rewarded success with public recognition and non-financial incentives. METHODS: Thirty months after initiating the intervention, 885 health workers and 98 supervisors completed an interviewer-administered questionnaire in 38 intervention and 38 control health sub-centers in one district. The questionnaire included measures of social cohesion, teamwork attitudes, self-efficacy, job satisfaction, teamwork behaviors, equitable service delivery, taking initiative, and supervisory support. We conducted bivariate analyses to examine the impact of the intervention on these psychosocial and behavioral outcomes. RESULTS: Results show statistically significant differences across several measures between intervention and control frontline health workers, including improved teamwork (mean = 8.8 vs. 7.3), empowerment (8.5 vs. 7.4), job satisfaction (7.1 vs. 5.99) and equitable service delivery (6.7 vs. 4.99). While fewer significant differences were found for supervisors, they reported improved teamwork (8.4 vs. 5.3), and frontline health workers reported improved fulfillment of supervisory duties by their supervisors (8.9 vs. 7.6). Both frontline health workers and supervisors found public recognition and enhanced teamwork more motivating than the non-financial incentives. CONCLUSIONS: The Team-Based Goals and Incentives model reinforces intrinsic motivation and supports improvements in the teamwork, motivation, and performance of health workers. It offers an approach to practitioners and governments for improving the work environment in a resource-constrained setting and where there are multiple cadres of health workers.

Effectiveness of a home fortification programme with multiple micronutrients on infant and young child development: a cluster-randomised trial in rural Bihar, India.

Research demonstrates the importance of nutrition for early brain development. Few studies have examined the effectiveness of multiple micronutrient powders (MNP) on child development. This study examined the impacts of home fortification with MNP on motor and mental development, executive function and memory of children living in Bihar. This two-arm cluster-randomised effectiveness trial selected seventy health sub-centres to receive either MNP and nutrition counselling (intervention) or nutrition counselling alone (control) for 12 months. Front-line health workers delivered the intervention to all households in study communities with a child aged 6-18 months. Data were collected using cross-sectional surveys at baseline and endline by selecting households from intervention (baseline, n 2184; endline, n 2170) and control (baseline, n 2176; endline, n 2122) communities using a two-stage cluster-randomised sampling strategy. Children in the intervention group had a significantly larger improvement from baseline to endline compared with those in the control group on scores for motor and mental development (Cohen's d, motor=0·12; 95 % CI 0·03, 0·22; mental=0·15; 95 % CI 0·06, 0·25). Greater impacts of MNP on motor and mental development were observed in children from households with higher stimulation scores at baseline compared with those with lower stimulation (Cohen's d, motor=0·20 v. 0·09; mental=0·22 v. 0·14; P interaction<0·05). No significant treatment differences were seen for executive function or memory. Home fortification with MNP through the existing health infrastructure in Bihar was effective in improving motor and mental development and should be considered in combination with other child development interventions such as stimulation.