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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 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. Self-report of discussions within SHGs on specific topics was associated with increased related maternal behaviours.

Further work is needed to understand the specific impacts of health layering upon SHGs.

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Working through SHGs is a promising vehicle for improving primary health care. Addressing poverty, hunger, health, and gender equality are key Sustainable Development Goals but few interventions have strong evidence for improving outcomes across financial, social and health sectors simultaneously [ 1 ]. Self-help groups SHGs have an expanding evidence base of influence on income, asset ownership, savings, and household ability to withstand economic shocks [ 2 ].

Evidence is growing for non-financial outcomes as well, including political empowerment, social cohesion, collective action and personal agency, and health [ 3 ]. In the West, these groups are known primarily for providing mental health peer support, often led by a facilitator, as in the case of Alcoholics Anonymous [ 4 ]. In the global health context and that of India, these groups primarily address the financial and social needs of poor and maginalised populations. Although they were founded as a vehicle to increase economic empowerment using microcredit, they have grown to address non-financial social issues primarily for rural women and increasingly through collective action strategies [ 5 ].

They are also an important mechanism used by the Indian Government to engage poor women in central systems, including health and poverty reduction schemes [ 5 ]. Under these frameworks, the most frequently studied outcomes of SHGs are financial, ranging from increased savings, access to credit and microenterprise, income for small enterprises, and ownership of assets [ 38 ]. Similarly, Seward et al showed roughly a 2-fold increase in health-promoting behaviours during and after home deliveries among SHG members engaged in health education and participatory learning and action activities [ 11 ].

In India, SHGs started over 30 years ago with a direct tie to microfinance. SHGs are scaling at a rapid pace throughout India and include an estimated million members in 8. We examine the health impact of SHGs at scale, but do not differentiate the type of SHG; this is the subject of a subsequent manuscript [ 15 ]. The current study extends prior findings to examine indicators across the RMNCHN continuum of care at scale, including characteristics associated with SHG performance [ 16 ].

Though there were several nuances in SHG funding sources, formation and types, we do not address these in the current manuscript. Woman seeking men Borkum the Woman seeking men Borkum of this study, fromSHGs in Bihar were scaled-up statewide to all 38 districts [ 24 ]. For the current analysis, we used respondent-identification of SHG membership.

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SHGs are variable in their structure and function but generally are organised around three main themes. Savings groups are typically formed by women but can be promoted by either NGOs or the government; these usually have members [ 8 Agriculture-related groups typically are comprised of both women and men typically members and aim to increase connections to markets as well as create risk-pooling [ 8 ].

In qualitative studies, women belonging to these groups report that group membership is positive and decreases poverty [ 26 ]. In Bihar, groups generally were organised around access to microfinance and some, but not all, had specific embedded health objectives or health layering [ 16 ]. The methodology of survey administration and calculation of survey weights has been described ly [ 21 ]. In brief, sampling was conducted in all 38 districts, including each block within each district. For each block, the sample size was proportionate to the known population of the block, subject to a minimum of 19 households.

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AWCs were randomly selected. Survey enumerators visited the fifth household from the index household, using a right-hand rule, to assess eligibility. Enumerators visited the next fifth household until one mother of in each of five age-groups,and months was surveyed. Stratification by age-group,and months was used to limit recall bias and enable assessment of key domains that were the focus of program implementation across the continuum of care for health, nutrition and sanitation.

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We also identified survey questions in CHS about characteristics of women associated with SHG membership including age and parity. We focused initially on 66 indicators which broadly reflected the continuum of care from conception through infancy Table S1 in the Online Supplementary Document. We restricted our analytical cohort to women with children aged months for antenatal, delivery and postnatal care and postpartum family planning indicators; months for immunisation, nutrition and family planning indicators, and months for sanitation and family planning indicators.

These indicators were selected because they were most relevant to the health modules layered on SHGs while still representing a broad array of indicators in the continuum of care.

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Prior to analysis, indicators were grouped into the following domains according to the continuum of care: antenatal care ANC and birth preparedness, delivery childbirth carepostnatal care, nutrition, immunisation, family planning, and sanitation Table S1 in the Online Supplementary Document.

The P -values in all models were adjusted for multiple comparisons using the False Discovery Rate-controlling method of Benjamini-Hochberg [ 28 ] and were additionally adjusted for maternal age and focal child gender.

Models incorporated study de using sampling weights. As most of these variables were highly collinear with the primary predictor, SHG membership, we present data based on adjustment for maternal age and focal child gender for our primary analyses. We examined the prevalence of discussions of various topics in SHGs and whether the discussions were associated with relevant indicators, comparing women in SHGs who had the topic discussed compared to women in SHGs who did not.

Discussion topics were only queried in CHS survey rounds 7 and 8, not in rounds 6 or 9. Thus, for example, for rounds 7 and 8 we examined whether a discussion on contraception was associated with increased family planning behaviour for the respondent.

Health impact of self-help groups scaled-up statewide in bihar, india

Discussions encompassed: 1 birth preparedness, 2 newborn care, 3 breastfeeding and complementary feeding, and 4 credit and savings. We examined whether time spent in SHGs, measured in months, impacted whether a woman saved money for delivery or received advice about whether to do so. This study is part of the Ananya program which was registered with ClinicalTrials.

Socioeconomic and demographic characteristics of the CHS study population for rounds during are displayed in Table 1. Thus, consistent with the intent of SHGs to reach marginalised women, SHG member women were, in general, at greater social disadvantage than non-SHG members, predisposing them to worse health indicators.

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Among delivery indicators, about one fifth showed higher odds for SHG members compared to non-members. All models presented were adjusted for age of the mother and sex of the focal. No immunisation indicators increased. We also examined the role of time spent in a SHG. They had 0. With each additional FLW visit, health indicators rose up to 2-fold.

This study in Bihar, India demonstrates that self-reported SHG membership was associated with higher levels of a range of health, nutrition and sanitation-related indicators compared to non-members. The effect sizes were modest ificant ORs ranging from slightly above 1. The positive associations are impressive considering the more marginalised status of women in SHGs. According to delivery platform, positive associations were seen most consistently for indicators related to FLW performance, followed by maternal behaviour; only a minority of indicators related to facility care and outreach service delivery improved.

This may reflect increased self-efficacy related to SHG membership and enhanced interactions with FLWs but not with health facilities [ 2425 ]. Moreover, there was a dose-dependent increase in benefits with SHG exposure; also, women in SHGs with more children and potentially more time in SHGs had better indicators. Conversely younger women had attenuated effects, suggesting the need for focal and age-relevant messaging among younger mothers within SHGs.

Lastly, FLW touchpoints were associated with Woman seeking men Borkum levels of most indicators for both SHG members and non-members, but greater increases were seen in non-SHG members, perhaps reflective of the importance of FLW visits, especially in the absence of SHG-related support.

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Perhaps FLW visits and SHGs serve as supplements for one another, by providing similar types of information, with the potential for increased health benefit through interactions between these platforms. These largely corroborated earlier findings by Saggurti et al. We found similar increases as Saggurtii et al. Women who reported discussing particular topics had higher corresponding reported behaviours. When compared to smaller studies using participatory learning action cycles, our findings underscore the importance of discussions at scale [ 1029 ].

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The mechanisms for SHG effects should be explored further. It is not known, for example, whether more mature groups have more positive benefits upon health or whether specific types of groups like those with health-layering may be afforded greater benefit [ 30 ].

Future research could also potentially use methods of causal inference to untangle mechanisms related to SHGs. SHGs may be implemented in different ways to optimise their impact. In the current model, women were primarily older, already having had on average three children. The average age of first birth in rural Bihar is about 16, whereas women in the groups were on average Some group members who are older mothers or even grandmothers could have a positive influence on younger mothers and their health decisions.

Our were similar, although attenuated for younger SHG members, suggesting that this is an area for potential improvement in SHG effectiveness. Given that younger SHG members may be able to change Woman seeking men Borkum health behaviours, SHGs could be developed and targeted to younger women in their adolescence, catching women before they have their first.

Perhaps strengthening interventions for younger mothers, including the development of more tailored interventions, messaging and communication strategies, may amplify the impact of SHGs for younger women.

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In addition, our analysis does not cover several related key issues, such as diffusion through SHGs, influence of SHGs on service provision and providers at the last mile, optimal group composition and size, cost, proportion of marginalised communities covered, or ratio of group leader to group participants. Further attention to these processes could potentially further increase the effectiveness of the SHG platform, the of marginalised women served and the geographical area covered.

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This evaluation had several strengths. It 1 included a comparison group of non-SHG members for determination of the impact of SHG processes on health, nutrition and sanitation; 2 determined and compared associations between SHG membership and a variety of RMNCHN and sanitation indicators — across the continuum of care from pregnancy to early childhood and through several delivery platforms; and 3 examined the inner working of SHGs, including the impact of specific discussion topics, length of membership, age and parity of group members.

Moreover, through the SHG model, the effects of the FLW platform or other systematic primary health care inputs can potentially be magnified, as the knowledge and behaviour change transfer within SHGs is collective instead of only a one-to-one approach.

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Author : Donna King.


Abnormal diurnal blood pressure BP rhythms such as non-dipping may contribute to an increased risk of cardiovascular and cerebrovascular events in HIV infected individuals.


McCauley, Tobey C.


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