Theme Six of this blog is about better health and nutrition practices and greater use of vital health products and services. The emphasis is on knowledge and practices, not health and nutrition outcomes, because at that point in The Evidence Project, I was examining intermediate outcomes rather than ultimate impacts. Now it is time to shift to ultimate outcomes in the arena of health and nutrition. In addition to demonstrating impacts on knowledge and practice, post # 68, in particular, showed that a great variety of health outcomes can be achieved through health interventions delivered by or with microfinance providers to clients and their families:
- reproductive health
- prevention and primary care for children
- child nutrition and breastfeeding
- child diarrhea
- HIV prevention
- domestic abuse/gender-based violence
- sexually transmitted infections
However, within the health field, the historic, hunger-related focus of Freedom from Hunger has been on the nutritional status of the family, and in particular, on the nutritional status of the most vulnerable family members, the youngest children—those in the first five years of life.
The past couple of decades have produced more and more evidence that the period of nine months in the mother’s womb and the first 24 months after birth is the critical window during which proper nutrition is absolutely vital for body and brain development, which literally determine the child’s prospects for life. The accumulating evidence reaffirms the crucial importance of Credit with Education’s original emphasis on “child survival” training for mothers, which emphasized child nutrition and the deadly challenges from traditional breastfeeding and feeding practices, diarrhea-related practices, ignorance of the value of immunization against common childhood diseases, and multiple assaults on the health and nutrition of mothers, pregnant women and, more generally, young women of child-bearing age and even younger. Add to that the crucial importance in some regions of Freedom from Hunger’s more recent emphasis on malaria prevention and treatment in both Credit with Education and Saving for Change.
Given the historical centrality of child nutrition to the Freedom from Hunger mission, we need to explore the evidence that interventions delivered to credit groups and savings groups are actually leading to improvements in child nutrition. This also gets us into maternal nutrition and related health outcomes.
Evidence from Credit with Education in Ghana and Bolivia
Post # 66 described results from Barbara MkNelly’s field research in Ghana and Bolivia, but solely the results regarding impacts on knowledge and practices. She went beyond these to study impacts on actual mother and child nutrition status. I excerpt here from the Credit with Education Impact Review No. 3: Children’s Nutritional Status by Barbara MkNelly and April Watson.
Impact of Credit with Education on children’s nutritional status was determined by measuring the heights and weights of one-year-old children in the baseline and follow-up periods. These measurements were converted into height-for-age (HAZ) and weight-for-age (WAZ) z-scores, which control for the variation in heights and weights at different ages and by gender. Z-scores represent the standard deviation from the National Center for Health Statistics (NCHS) median for children of that age and sex. For example, a z-score of 0 would indicate a height-for-age measurement equal to the NCHS median, while z-score values of 1 or -1 represent one standard deviation above or below the median. The World Health Organization and others classify measurements falling between -1 and -2 standard deviations as “mildly malnourished,” between -2 and -3 standard deviations as “moderately malnourished,” and below -3 standard deviations as “severely malnourished.”
The results of the study in Ghana are clear. In both height-for-age and weight-for-age, participants’ one-year-old children showed improved nutritional status compared to the children of residents of control communities. The mean HAZ for participants’ one-year-olds was 0.3 better in the follow-up period, whereas the mean HAZ for children in control communities was 0.2 worse, and for nonparticipants in the Credit with Education communities, it was 0.15 worse.
It is also important to consider these results in light of the fact that when nutritional status was measured at baseline, the children in communities assigned randomly to the control group had significantly better nutritional status compared to the children in communities assigned to receive the program.
Weight-for-age measures are often referred to as measures of short-term or acute malnutrition, because a child’s weight can fluctuate more dramatically than his/her height in a relatively short period. For the same reason, height-for-age measures are said to better capture longer-term or chronic malnutrition. The study results in Ghana indicated that Credit with Education had positive and significant impact on both the chronic and acute malnutrition of participants’ one-year-old children. Both height and weight for age improved for participants’ children between 1993 and 1996, while the two nonparticipant groups showed deterioration in both scores.
A similar, although statistically insignificant, effect was found in the prevalence of chronic and acute malnutrition. Fewer of the participants’ children (15%) were malnourished upon follow-up in 1996 relative to the children of nonparticipants in program communities (20%) or residents in control communities (23%).
The parallel study in Bolivia yielded mixed results. No evidence was found for improved nutritional status of participants’ children until results were disaggregated by the quality of the education received by participants. Some significant results were then found in nutritional status and percentage of malnourished of children of mothers receiving good-quality nutrition education. The variable quality of education seemed to be due to lapses of supervision in some program areas of Bolivia, which allowed some individual field agents to do the education part of their jobs poorly or not at all.
MkNelly and Watson concluded that microfinance has good potential to impact children’s nutritional status, but implementers must be intentional and deliberate in doing so.
The study design in Ghana and Bolivia did not have sufficient statistical power to give us full confidence in the results. It would be hard to dismiss the results as due to chance, given the differences are all in the directions predicted by our hypothesis. Still, I have looked for corroboration in parallel studies in other, similar programs. Post # 68 offers some examples, but a very recently reported study really clinches it for me.
Evidence from the Ekjut Trial in Eastern India
The study is called the “ekjut trial,” named for the Indian NGO, ekjut, that implemented the program and led the study, which is reported in the highly esteemed medical journal Lancet: “Effect of a participatory intervention with women’s groups on birth outcomes and maternal depression in Jharkhand and Orissa, India: a cluster-randomised controlled trial.” It assessed whether a “participatory learning and action” approach (quite similar in design and delivery to the “dialogue-based education” used in Credit with Education, Saving for Change and Microfinance and Health Protection programs of Freedom from Hunger partners) with women’s groups (“self-help groups” similar to Saving for Change groups) might improve birth outcomes in poor rural communities. Like nutrition outcomes, improving birth outcomes presents a complex challenge that involves changing deeply seated traditional practices. My reason for valuing the comparison is this: if a very similar intervention design with very similar women’s groups in a largely tribal and rural population in three districts in eastern India (the poorest part of the country) could generate major change in birth outcomes, the same could be done for nutrition outcomes. The following are excerpts from the “ekjut trial” report.
From 36 population clusters in Jharkhand and Orissa, with an estimated population of 228,186, the study assigned 18 clusters to intervention or control using stratified randomization. Women were eligible to participate if they were ages 15–49 years, residing in the project area, and had given birth during the study. The intervention was conducted with 244 self-help groups (SHGs), with one SHG per 468 population. In Year One, 546 (18%) of 3,119 newly pregnant women attended the groups, rising to 1,718 (55%) of 3,126 in Year Three. The primary outcomes were reductions in neonatal mortality rate (NMR) and maternal depression scores, measured with an “intent to treat” design (data are from whole population clusters, not just from the SHGs in those clusters).
In the 18 intervention clusters, from mid-2005 to mid-2008, facilitators convened SHGs to support “participatory action and learning” by women to develop and implement strategies to address maternal and newborn health problems. Every group met monthly for a total of 20 meetings, and a local woman, selected on the basis of criteria identified by the community (including speaking the local language and having the ability to travel to meetings), facilitated the meetings. After a seven-day residential training course to review the intervention’s contents and to practice participatory communication techniques, facilitators were given support through biweekly meetings with district coordinators. Facilitators coordinated an average of 13 meetings every month with as many groups. Community members who were not regular SHG members were also encouraged to participate in discussions.
Information about clean delivery practices and care-seeking behavior was shared through stories and games, rather than presented as key messages. By discussion of case studies imparted through contextually appropriate stories, group members identified and prioritized maternal and newborn health problems in the community, collectively selected relevant strategies to address these problems, implemented the strategies and assessed the results. Although some strategies were common, each group was free to implement its own combination of strategies. The intervention team adapted facilitation materials from an earlier, similar pilot program in Makwanpur, Nepal, to guide the meetings. Groups used methods such as picture-card games, role-play and story-telling to help move discussions about the causes and effects of typical problems in mothers and infants, and they devised strategies for prevention, home-care support and consultations.
Over the three years, 9,770 women gave birth in intervention clusters and 9,260 in control clusters. The researchers recorded a 32% reduction in NMR during the three-year trial (data were adjusted for clustering, stratification and baseline differences). Reflecting the increasing participation of pregnant women over the three years, NMR was reduced by 45% in intervention clusters compared with control clusters during the last two years. To put it mildly, these reductions were highly “significant.” I think “astounding” is the more apt adjective!
No significant differences were noted in healthcare- seeking behavior between control and intervention clusters. However, home-care practices showed substantial improvements—in intervention clusters, birth attendants were more likely to wash their hands, use a safe-delivery kit and a plastic sheet, and boil the thread used to tie the cord than were those in the control clusters. The proportion of infants exclusively breastfed at six weeks was higher in intervention areas for Years Two and Three. These were truly changes in traditional practices within the communities themselves.
While the intervention did not significantly decrease the incidence of severe maternal depression, it did cause a large reduction in moderate maternal depression during Year Three. The researchers hypothesize this reduction could have occurred through improvements in social support and problem-solving skills of the groups. They point out that prior studies have shown how adequate social support reduces the risk of depression during pregnancy and is an important social determinant of mental health. In the SHG meetings, information was shared about the difficulties encountered by mothers in the community, and practical ways to collectively address them were established. Group meetings also strengthened problem-solving skills, a component of psycho-therapeutic interventions that has been shown to affect depression in other settings. If so, this would be powerful evidence of women’s groups, properly facilitated, actually empowering members and thereby yielding an important mental health outcome. Such empowerment was also no doubt a major factor in reducing neonatal mortality.
The researchers conclude that participatory groups have the advantage of helping the poorest, being scalable at low cost, and producing potentially wide-ranging and long-lasting effects. By addressing critical consciousness, groups have the potential to create improved capability in communities to deal with the health and development difficulties arising from poverty and social inequalities. The intervention requires a training and support structure to manage facilitators in charge of 12–14 groups per month, with every group responsible for a population of about 500 and for recruiting up to half of newly pregnant women. Costs are lower than for most other primary healthcare interventions, and these interventions can complement other impacts generated by existing SHGs in the community.
In summary, I conclude that women’s groups, whether supported by microfinance institutions or community mobilization NGOs, in India, Ghana, Bolivia or elsewhere, can produce and have produced important child health and nutrition impacts when integrated with well-designed and implemented, low-cost education and facilitation of group decision-making.
You just have to want to do it!