Testing theory of change assumptions of health behavior change interventions: A blended approach exploring local contexts.

This paper used a blended approach that involves multiple techniques to, first, test a set of assumptions around a health behavior change communication intervention theory of change (ToC) and, second, surface some unidentified assumptions involving the local context. The intervention was integrated with women's self-help groups (SHGs) in Uttar Pradesh, India. The key assumption tested in this paper was the linkage between SHG membership, program exposure, and maternal, newborn, and child health practices. Learnings were substantiated through empirical investigations, including structural equation modeling and mediation analysis, as well as 'co-learning' workshops within the community. The workshops aimed to capture and interpret the heterogeneity of local contexts through deep dialogs with the community and program implementers at various levels. Statistical analyses indicated a significant association between the amount of women's program exposure and their health practices. SHG membership was shown to affect maternal health practices; however, it did not have a direct effect on neonatal or child health practices. The 'co-learning' workshops revealed crucial aspects, such as prevailing socio-cultural norms, which prevented pregnant or recently delivered women from participating in SHG meetings. This paper encourages evaluators to work with the community to interpret and co-construct meaning in unpacking the contextual forces that seldom appear in the program ToC.

Effects of health behaviour change intervention through women's self-help groups on maternal and newborn health practices and related inequalities in rural india: A quasi-experimental study.

BACKGROUND: Despite the health system efforts, health disparities exist across sub-populations in India. We assessed the effects of health behaviour change interventions through women's self-help groups (SHGs) on maternal and newborn health (MNH) behaviours and socio-economic inequalities. METHODS: We did a quasi-experimental study of a large-scale SHG program in Uttar Pradesh, India, where 120 geographic blocks received, and 83 blocks did not receive health intervention. Data comes from two cross-sectional surveys with 4,615 recently delivered women in 2015, and 4,250 women in 2017. The intervention included MNH discussions in SHG meetings and community outreach activities. The outcomes included antenatal, natal and postnatal care, contraceptive use, cord care, skin-to-skin care, and breastfeeding practices. Effects were assessed using multilevel mixed-effects regression adjusted difference-in-differences (DID) analysis adjusting for geographic clustering and potential covariates, for all, most-marginalised and least-marginalised women. Concentration indices examined the socio-economic inequality in health practices over time. FINDINGS: The net improvements (5-11 percentage points [pp]) in correct MNH practices were significant in the intervention areas. The improvements over time were higher among the most-marginalised than least-marginalised for antenatal check-ups (DID: 20pp, p<0•001 versus DID: 6pp, p = 0•093), consumption of iron folic acid tablets for 100 days (DID: 7pp, p = 0•036 versus DID: -1pp, p = 0•671), current use of contraception (DID: 12pp, p = 0•046 versus DID: 10pp, p = 0•021), cord care (DID: 12pp, p = 0•051 versus DID: 7pp, p = 0•210), and timely initiation of breastfeeding (DID: 29pp, p = 0•001 versus DID: 1pp, p = 0•933). Lorenz curves and concentration indices indicated reduction in rich-poor gap in health practices over time in the intervention areas. INTERPRETATION: Disparities in MNH behaviours declined with the efforts by SHGs through behaviour change communication intervention.

Measuring coordination between women's self-help groups and local health systems in rural India: a social network analysis.

OBJECTIVES: To assess how the health coordination and emergency referral networks between women's self-help groups (SHGs) and local health systems have changed over the course of a 2-year learning phase of the Uttar Pradesh Community Mobilization Project, India. DESIGN: A pretest, post-test programme evaluation using social network survey to analyse changes in network structure and connectivity between key individuals and groups. SETTING: The study was conducted in 18 villages located in three districts in Uttar Pradesh, India. INTERVENTION: To improve linkages and coordination between SHGs and government health providers by building capacity in leadership, management and community mobilisation skills of the SHG federation. PARTICIPANTS: A purposeful sampling that met inclusion criteria. 316 respondents at baseline and 280 respondents at endline, including SHG members, village-level and block-level government health workers, and other key members of the community (traditional birth attendants, drug sellers, unqualified rural medical providers, pradhans or elected village heads, and religious leaders). MAIN OUTCOME MEASURES: Social network analysis measured degree centrality, density and centralisation to assess changes in health services coordination networks at the village and block levels. RESULTS: The health services coordination and emergency referral networks increased in density and the number of connections between respondents as measured by average degree centrality have increased, along with more diversity of interaction between groups. The network expanded relationships at the village and block levels, reflecting the rise of bridging social capital. The accredited social health activist, a village health worker, occupied the central position in the network, and her role expanded to sharing information and coordinating services with the SHG members. CONCLUSIONS: The creation of new partnerships between traditionally under-represented communities and local government can serve as vehicle for building social capital that can lead to a more accountable and accessible community health delivery system.

Increasing knowledge of home based maternal and newborn care using self-help groups: Evidence from rural Uttar Pradesh, India.

BACKGROUND: In India, pregnant women and recently delivered mothers of marginalized communities in Uttar Pradesh (UP) remain un-reached by frontline-health-workers. In these communities, self-help groups (SHGs) have the potential to reach these women with knowledge of home-based maternal and newborn care (HBMNC). OBJECTIVE: The study examines the feasibility of SHGs to improve knowledge of HBMNC. The study identifies the facilitating factors and barriers to knowledge change. METHODS: A panel study with a quasi-experimental design was conducted in Jhansi, UP. Peer educators, called Swasthya Sakhi, of the SHGs of the experimental area were trained on how to conduct discussions on HBMNC topics. Both at baseline and endline 233 women from the experimental area and 237 women from the comparison area were interviewed to measure their knowledge change in HBMNC topics. The net-effect of the intervention was examined using difference-in-difference (DID) analysis with propensity-score-matching (PSM) controlling for the effect of background characteristics of the participants from two study areas. Generalized-estimating-equation (GEE) was used to identify the facilitating factors and barriers to the knowledge change. RESULTS: The findings show significant net-increases in women's knowledge for most of the HBMNC topics including danger signs for a pregnant mother and a newborn child, even after controlling for the background characteristics of the participants. The most significant determinant of the increase of knowledge was the women's education. CONCLUSION: Findings from the study showed SHGs can increase HBMNC knowledge among women. However, studies with longer duration are required to examine the scalability and sustainability of the intervention.

Perceived Social Networks and Newborn Health: Evidence from Self-Help Group Communities in Northern India.

The limitations of individual level interventions in changing behaviors to improve global maternal, newborn and child health have generated more interest in the patterns of social influence and decision making embedded in families, friends and communities. The purpose of this study is to expand the understanding of village dynamics in India and how first degree social and advice networks and cognitive perceptions of 185 recently delivered women (RDW) in areas with and without women's Self-Help Groups (SHGs) affect immediate breastfeeding. Data was collected in 6 blocks and 36 villages in Uttar Pradesh, India. The expansion of RDW's social worlds and creation of social capital through the organization of Self-Help Groups in their villages allowed us to examine basic relationships and advice formation as well as perceptions of interconnectedness of known groups. RDW living in SHG villages and blocks had consistently higher numbers of relationship ties, health advice ties and higher density of health advice networks than RDW living in the non-SHG areas. RDW's perceived knowing ties were also significantly higher between family and health workers in the SHG areas with related higher immediate breastfeeding rates. These results suggest that SHGs can accelerate community social capital and promote more accountability in the health system to engage with families and support the change from traditional to more evidence-based health practices.

Care-seeking behaviors for maternal and newborn illnesses among self-help group households in Uttar Pradesh, India.

BACKGROUND: India has made large strides in reducing maternal mortality ratio and neonatal mortality rate, yet care-seeking behavior for appropriate care is still a challenge. We conducted a qualitative study to understand the process of recognition and care-seeking for maternal and newborn illnesses in rural India where a health intervention through women's self-help groups (SHG) to improve maternal and newborn health behaviors is implemented by a non-governmental organization, the Rajiv Gandhi Mahila Vikas Pariyojana. The study aimed to understand the process of recognition and care-seeking for maternal and newborn illnesses from SHG and non-SHG households in the intervention area. METHODS: Thirty-two illness narratives, 16 of maternal deaths and illness and 16 of newborn illnesses and deaths, were conducted. Women, their family members, and other caretakers who were present during the event of illness or death were included in the interviews. About 14 key informants, mainly frontline health workers (FLWs), were also interviewed. The interviews were conducted by two Population Council staff using a pre-tested guideline in Hindi. RESULTS: Our findings suggest that perceptions of causes of illness as "supernatural" or "medical" and the timing of onset of illness influence the pathway of care-seeking. Deep-rooted cultural beliefs and rituals guided care-seeking behavior and restricted new mothers and newborns' mobility for care-seeking. Though families described experience of postpartum hemorrhage as severe, they often considered it as "normal." When the onset of illness was during pregnancy, care was sought from health facilities. As the step of care for maternal illness, SHG households went to government facilities, and non-SHG households took home-based care. Home-based care was the first step of care for newborn illnesses for both SHG and non-SHG households; however, SHG households were prompt in seeking care outside of home, and non-SHG households delayed seeking care until symptoms were perceived to be severe. CONCLUSION: Our findings indicate that care-seeking behavior for maternal and newborn morbidities could be improved by interventions through social platforms such as SHGs.