Audrey Prost

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.

BACKGROUND Community mobilisation through participatory womens groups might improve birth outcomes in poor rural communities. We therefore assessed this approach in a largely tribal and rural population in three districts in eastern India. METHODS From 36 clusters in Jharkhand and Orissa, with an estimated population of 228 186, we assigned 18 clusters to intervention or control using stratified randomisation. Women were eligible to participate if they were aged 15-49 years, residing in the project area, and had given birth during the study. In intervention clusters, a facilitator convened 13 groups every month to support participatory action and learning for women, and facilitated the development and implementation of strategies to address maternal and newborn health problems. The primary outcomes were reductions in neonatal mortality rate (NMR) and maternal depression scores. Analysis was by intention to treat. This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN21817853. FINDINGS After baseline surveillance of 4692 births, we monitored outcomes for 19 030 births during 3 years (2005-08). NMRs per 1000 were 55.6, 37.1, and 36.3 during the first, second, and third years, respectively, in intervention clusters, and 53.4, 59.6, and 64.3, respectively, in control clusters. NMR was 32% lower in intervention clusters adjusted for clustering, stratification, and baseline differences (odds ratio 0.68, 95% CI 0.59-0.78) during the 3 years, and 45% lower in years 2 and 3 (0.55, 0.46-0.66). Although we did not note a significant effect on maternal depression overall, reduction in moderate depression was 57% in year 3 (0.43, 0.23-0.80). INTERPRETATION This intervention could be used with or as a potential alternative to health-worker-led interventions, and presents new opportunities for policy makers to improve maternal and newborn health outcomes in poor populations. FUNDING Health Foundation, UK Department for International Development, Wellcome Trust, and the Big Lottery Fund (UK).

Women's groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis

BACKGROUND Maternal and neonatal mortality rates remain high in many low-income and middle-income countries. Different approaches for the improvement of birth outcomes have been used in community-based interventions, with heterogeneous effects on survival. We assessed the effects of womens groups practising participatory learning and action, compared with usual care, on birth outcomes in low-resource settings. METHODS We did a systematic review and meta-analysis of randomised controlled trials undertaken in Bangladesh, India, Malawi, and Nepal in which the effects of womens groups practising participatory learning and action were assessed to identify population-level predictors of effect on maternal mortality, neonatal mortality, and stillbirths. We also reviewed the cost-effectiveness of the womens group intervention and estimated its potential effect at scale in Countdown countries. FINDINGS Seven trials (119,428 births) met the inclusion criteria. Meta-analyses of all trials showed that exposure to womens groups was associated with a 37% reduction in maternal mortality (odds ratio 0.63, 95% CI 0.32-0.94), a 23% reduction in neonatal mortality (0.77, 0.65-0.90), and a 9% non-significant reduction in stillbirths (0.91, 0.79-1.03), with high heterogeneity for maternal (I(2)=58.8%, p=0.024) and neonatal results (I(2)=64.7%, p=0.009). In the meta-regression analyses, the proportion of pregnant women in groups was linearly associated with reduction in both maternal and neonatal mortality (p=0.026 and p=0.011, respectively). A subgroup analysis of the four studies in which at least 30% of pregnant women participated in groups showed a 55% reduction in maternal mortality (0.45, 0.17-0.73) and a 33% reduction in neonatal mortality (0.67, 0.59-0.74). The intervention was cost effective by WHO standards and could save an estimated 283,000 newborn infants and 41,100 mothers per year if implemented in rural areas of 74 Countdown countries. INTERPRETATION With the participation of at least a third of pregnant women and adequate population coverage, womens groups practising participatory learning and action are a cost-effective strategy to improve maternal and neonatal survival in low-resource settings. FUNDING Wellcome Trust, Ammalife, and National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Birmingham and the Black Country programme.

Effect of scaling up women's groups on birth outcomes in three rural districts in Bangladesh: a cluster-randomised controlled trial

BACKGROUND Two recent trials have shown that womens groups can reduce neonatal mortality in poor communities. We assessed the effectiveness of a scaled-up development programme with womens groups to address maternal and neonatal care in three rural districts of Bangladesh. METHODS 18 clusters (with a mean population of 27 953 [SD 5953]) in three districts were randomly assigned to either intervention or control (nine clusters each) by use of stratified randomisation. For each district, cluster names were written on pieces of paper, which were folded and placed in a bottle. The first three cluster names drawn from the bottle were allocated to the intervention group and the remaining three to control. All clusters received health services strengthening and basic training of traditional birth attendants. In intervention clusters, a facilitator convened 18 groups every month to support participatory action and learning for women, and to develop and implement strategies to address maternal and neonatal health problems. Women were eligible to participate if they were aged 15-49 years, residing in the project area, and had given birth during the study period (Feb 1, 2005, to Dec 31, 2007). Neither study investigators nor participants were masked to treatment assignment. In a population of 229 195 people (intervention clusters only), 162 womens groups provided coverage of one group per 1414 population. The primary outcome was neonatal mortality rate (NMR). Analysis was by intention to treat. This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN54792066. FINDINGS We monitored outcomes for 36 113 births (intervention clusters, n=17 514; control clusters, n=18 599) in a population of 503 163 over 3 years. From 2005 to 2007, there were 570 neonatal deaths in the intervention clusters and 656 in the control clusters. Cluster-level mean NMR (adjusted for stratification and clustering) was 33.9 deaths per 1000 livebirths in the intervention clusters compared with 36.5 per 1000 in the control clusters (risk ratio 0.93, 95% CI 0.80-1.09). INTERPRETATION For participatory womens groups to have a significant effect on neonatal mortality in rural Bangladesh, detailed attention to programme design and contextual factors, enhanced population coverage, and increased enrolment of newly pregnant women might be needed. FUNDING Women and Children First, the UK Big Lottery Fund, Saving Newborn Lives, and the UK Department for International Development.

The effect of increased coverage of participatory women's groups on neonatal mortality in Bangladesh : A cluster randomized trial

IMPORTANCE Community-based interventions can reduce neonatal mortality when health systems are weak. Population coverage of target groups may be an important determinant of their effect on behavior and mortality. A womens group trial at coverage of 1 group per 1414 population in rural Bangladesh showed no effect on neonatal mortality, despite a similar intervention having a significant effect on neonatal and maternal death in comparable settings. OBJECTIVE To assess the effect of a participatory womens group intervention with higher population coverage on neonatal mortality in Bangladesh. DESIGN A cluster randomized controlled trial in 9 intervention and 9 control clusters. SETTING Rural Bangladesh. PARTICIPANTS Women permanently residing in 18 unions in 3 districts and accounting for 19 301 births during the final 24 months of the intervention. INTERVENTIONS Womens groups at a coverage of 1 per 309 population that proceed through a participatory learning and action cycle in which they prioritize issues that affected maternal and neonatal health and design and implement strategies to address these issues. MAIN OUTCOMES AND MEASURES Neonatal mortality rate. RESULTS Analysis included 19 301 births during the final 24 months of the intervention. More than one-third of newly pregnant women joined the groups. The neonatal mortality rate was significantly lower in the intervention arm (21.3 neonatal deaths per 1000 live births vs 30.1 per 1000 in control areas), a reduction in neonatal mortality of 38% (risk ratio, 0.62 [95% CI, 0.43-0.89]) when adjusted for socioeconomic factors. The cost-effectiveness was US

Social, Behavioural, and Intervention Research among People of Sub-Saharan African Origin Living with HIV in the UK and Europe: Literature Review and Recommendations for Intervention

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Feasibility and acceptability of offering rapid HIV tests to patients registering with primary care in London (UK): a pilot study.

393 per year of life lost averted. Cause-specific mortality rates suggest reduced deaths due to infections and those associated with prematurity/low birth weight. Improvements were seen in hygienic home delivery practices, newborn thermal care, and breastfeeding practices. CONCLUSIONS AND RELEVANCE Womens group community mobilization, delivered at adequate population coverage, is a highly cost-effective approach to improve newborn survival and health behavior indicators in rural Bangladesh. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN01805825.

Association between Clean Delivery Kit Use, Clean Delivery Practices, and Neonatal Survival: Pooled Analysis of Data from Three Sites in South Asia

Africans are the second largest group affected by HIV in Western Europe after men who have sex with men (MSM). This review describes and summarises the literature on social, behavioural, and intervention research among African communities affected by HIV in the UK and other European countries in order to make recommendations for future interventions. We conducted a keyword search using Embase, Medline and PsychInfo, existing reviews, ‘grey literature’, as well as expert working group reports. A total of 138 studies met our inclusion criteria; 31 were published in peer-reviewed journals, 107 in the grey literature. All peer-reviewed studies were observational or “descriptive,” and none of them described HIV interventions with African communities. However, details of 36 interventions were obtained from the grey literature. The review explores six prominent themes in the descriptive literature: (1) HIV testing; (2) sexual lifestyles and attitudes; (3) gender; (4) use of HIV services; (5) stigma and disclosure (6) immigration status, unemployment and poverty. Although some UK and European interventions are addressing the needs of African communities affected by HIV, more resources need to be mobilised to ensure current and future interventions are targeted, sustainable, and rigorously evaluated.

Stepped wedge randomised controlled trials: systematic review of studies published between 2010 and 2014

Objective: To assess the acceptability and feasibility of offering rapid HIV tests to patients registering with primary care in London, UK. Methods: All Anglophone and Francophone patients aged between 18 and 55 years attending a large inner city general practice in London for a new patient health check were recruited. All eligible patients were offered a rapid HIV test on oral fluid and asked to participate in a qualitative interview. The uptake of rapid HIV testing among participants was measured and semistructured interviews were carried out focusing on the advantages and disadvantages of testing for HIV in primary care. Results: 111 people attended the health check, of whom 85 were eligible, 47 took part in the study and 20 completed qualitative interviews. Nearly half of eligible participants (38/85, 45%) accepted a rapid HIV test. The main reason for accepting a test was because it was offered as “part of a check up”. As a combined group, black African and black Caribbean patients were more likely to test in the study compared with patients from other ethnic backgrounds (p = 0.014). Participants in the qualitative interviews felt that having rapid HIV tests available in general practice was acceptable but expressed concerns about support for the newly diagnosed. Conclusions: Offering patients a rapid HIV test in primary care is feasible and could be an effective means to increase testing rates in this setting. A larger descriptive study or pragmatic trial is needed to determine whether this strategy could increase timely diagnosis and reduce the proportion of undiagnosed HIV infections in the UK.

The equity impact of participatory women’s groups to reduce neonatal mortality in India: secondary analysis of a cluster-randomised trial

A pooled analysis of data from three studies in South Asia demonstrates an association between use of clean delivery kits during home births and reduced risk of neonatal mortality.

Intracluster correlation coefficients and coefficients of variation for perinatal outcomes from five cluster-randomised controlled trials in low and middle-income countries: results and methodological implications

BackgroundIn a stepped wedge, cluster randomised trial, clusters receive the intervention at different time points, and the order in which they received it is randomised. Previous systematic reviews of stepped wedge trials have documented a steady rise in their use between 1987 and 2010, which was attributed to the design’s perceived logistical and analytical advantages. However, the interventions included in these systematic reviews were often poorly reported and did not adequately describe the analysis and/or methodology used. Since 2010, a number of additional stepped wedge trials have been published. This article aims to update previous systematic reviews, and consider what interventions were tested and the rationale given for using a stepped wedge design.MethodsWe searched PubMed, PsychINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Web of Science, the Cochrane Library and the Current Controlled Trials Register for articles published between January 2010 and May 2014. We considered stepped wedge randomised controlled trials in all fields of research. We independently extracted data from retrieved articles and reviewed them. Interventions were then coded using the functions specified by the Behaviour Change Wheel, and for behaviour change techniques using a validated taxonomy.ResultsOur review identified 37 stepped wedge trials, reported in 10 articles presenting trial results, one conference abstract, 21 protocol or study design articles and five trial registrations. These were mostly conducted in developed countries (n = 30), and within healthcare organisations (n = 28). A total of 33 of the interventions were educationally based, with the most commonly used behaviour change techniques being ‘instruction on how to perform a behaviour’ (n = 32) and ‘persuasive source’ (n = 25). Authors gave a wide range of reasons for the use of the stepped wedge trial design, including ethical considerations, logistical, financial and methodological. The adequacy of reporting varied across studies: many did not provide sufficient detail regarding the methodology or calculation of the required sample size.ConclusionsThe popularity of stepped wedge trials has increased since 2010, predominantly in high-income countries. However, there is a need for further guidance on their reporting and analysis.