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      Exploring the equity impact of a maternal and newborn health intervention: a qualitative study of participatory women’s groups in rural South Asia and Africa

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          Abstract

          Background

          A consensus is developing on interventions to improve newborn survival, but little is known about how to reduce socioeconomic inequalities in newborn mortality in low- and middle-income countries. Participatory learning and action (PLA) through women’s groups can improve newborn survival and home care practices equitably across socioeconomic strata, as shown in cluster randomised controlled trials. We conducted a qualitative study to understand the mechanisms that led to the equitable impact of the PLA approach across socioeconomic strata in four trial sites in India, Nepal, Bangladesh, and Malawi.

          Methods

          We conducted 42 focus group discussions (FGDs) with women who had attended groups and women who had not attended, in poor and better-off communities. We also interviewed six better-off women and nine poor women who had delivered babies during the trials and had demonstrated recommended behaviours. We conducted 12 key informant interviews and five FGDs with women’s group facilitators and fieldworkers.

          Results

          Women’s groups addressed a knowledge deficit in poor and better-off women. Women were engaged through visual learning and participatory tools, and learned from the facilitator and each other. Facilitators enabled inclusion of all socioeconomic strata, ensuring that strategies were low-cost and that discussions and advice were relevant. Groups provided a social support network that addressed some financial barriers to care and gave women the confidence to promote behaviour change. Information was disseminated through home visits and other strategies. The social process of learning and action, which led to increased knowledge, confidence to act, and acceptability of recommended practices, was key to ensuring behaviour change across social strata. These equitable effects were enabled by the accessibility, relevance, and engaging format of the intervention.

          Conclusions

          Participatory learning and action led to increased knowledge, confidence to act, and acceptability of recommended practices. The equitable behavioural effects were facilitated by the accessibility, relevance, and engaging format of the intervention across socioeconomic groups, and by reaching-out to parts of the population usually not accessed. A PLA approach improved health behaviours across socioeconomic strata in rural communities, around issues for which there was a knowledge deficit and where simple changes could be made at home.

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          Most cited references44

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          The theory of planned behavior

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          Organizational Behavior and Human Decision Processes, 50(2), 179-211
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            Qualitative data analysis for applied policy research

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              Every Newborn: progress, priorities, and potential beyond survival.

              In this Series paper, we review trends since the 2005 Lancet Series on Neonatal Survival to inform acceleration of progress for newborn health post-2015. On the basis of multicountry analyses and multi-stakeholder consultations, we propose national targets for 2035 of no more than 10 stillbirths per 1000 total births, and no more than 10 neonatal deaths per 1000 livebirths, compatible with the under-5 mortality targets of no more than 20 per 1000 livebirths. We also give targets for 2030. Reduction of neonatal mortality has been slower than that for maternal and child (1-59 months) mortality, slowest in the highest burden countries, especially in Africa, and reduction is even slower for stillbirth rates. Birth is the time of highest risk, when more than 40% of maternal deaths (total about 290,000) and stillbirths or neonatal deaths (5·5 million) occur every year. These deaths happen rapidly, needing a rapid response by health-care workers. The 2·9 million annual neonatal deaths worldwide are attributable to three main causes: infections (0·6 million), intrapartum conditions (0·7 million), and preterm birth complications (1·0 million). Boys have a higher biological risk of neonatal death, but girls often have a higher social risk. Small size at birth--due to preterm birth or small-for-gestational-age (SGA), or both--is the biggest risk factor for more than 80% of neonatal deaths and increases risk of post-neonatal mortality, growth failure, and adult-onset non-communicable diseases. South Asia has the highest SGA rates and sub-Saharan Africa has the highest preterm birth rates. Babies who are term SGA low birthweight (10·4 million in these regions) are at risk of stunting and adult-onset metabolic conditions. 15 million preterm births, especially of those younger than 32 weeks' gestation, are at the highest risk of neonatal death, with ongoing post-neonatal mortality risk, and important risk of long-term neurodevelopmental impairment, stunting, and non-communicable conditions. 4 million neonates annually have other life-threatening or disabling conditions including intrapartum-related brain injury, severe bacterial infections, or pathological jaundice. Half of the world's newborn babies do not get a birth certificate, and most neonatal deaths and almost all stillbirths have no death certificate. To count deaths is crucial to change them. Failure to improve birth outcomes by 2035 will result in an estimated 116 million deaths, 99 million survivors with disability or lost development potential, and millions of adults at increased risk of non-communicable diseases after low birthweight. In the post-2015 era, improvements in child survival, development, and human capital depend on ensuring a healthy start for every newborn baby--the citizens and workforce of the future. Copyright © 2014 Elsevier Ltd. All rights reserved.
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                Author and article information

                Contributors
                +44 207 905 2316 , Joanna.morrison@ucl.ac.uk
                +44 207 905 2316 , d.osrin@ucl.ac.uk
                +44 207 905 2316 , g.alcock@ucl.ac.uk
                +88 (0) 2 9661551-60 , kishwar.azad@gmail.com
                jyotimira2@gmail.com
                bbmagar3@gmail.com
                +88 (0) 2 9661551-60 , kudduspcp@dab-bd.org
                +8801816192278 , mahfuza.mala@gmail.com
                dsm@mira.org.np
                ankhata@gmail.com
                shrijanamira@gmail.com
                tambosiphiri@gmail.com
                shibanand.ekjut@gmail.com
                prasanta.ekjut@gmail.com
                +44 207 905 2316 , anthony.costello@ucl.ac.uk
                +31 10 408 2222 , a.j.houweling@erasmusmc.nl
                Journal
                Int J Equity Health
                Int J Equity Health
                International Journal for Equity in Health
                BioMed Central (London )
                1475-9276
                11 April 2019
                11 April 2019
                2019
                : 18
                : 55
                Affiliations
                [1 ]ISNI 0000000121901201, GRID grid.83440.3b, Institute for Global Health, , University College London, ; 30 Guilford Street, London, WC1N 1EH UK
                [2 ]BADAS, Room No-390, BIRDEM Building 122,Kazi Nazrul Islam Avenue,Shahbagh, Dhaka, 1000 Bangladesh
                [3 ]GRID grid.451043.7, MIRA, ; PO Box 921, Thapathali, Kathmandu, Nepal
                [4 ]ActionAid Bangladesh, R#136, H#08, Gulshan 1, Dhaka, 1212 Bangladesh
                [5 ]MaiMwana Project, Box 2, Mchinji, Malawi
                [6 ]Jharkhand, India
                [7 ]ISNI 0000000121901201, GRID grid.83440.3b, Institute for Global Health, , University College London, ; 30 Guilford Street, London, WC1N 1EH UK
                [8 ]Rotterdam, Netherlands
                Author information
                http://orcid.org/0000-0002-9241-8863
                Article
                957
                10.1186/s12939-019-0957-7
                6458781
                30971254
                6bc5bba4-b856-4197-bfea-65d4a27d4e26
                © The Author(s). 2019

                Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 12 November 2018
                : 2 April 2019
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100000269, Economic and Social Research Council;
                Award ID: ES/1033572/1
                Funded by: FundRef http://dx.doi.org/10.13039/100004440, Wellcome Trust;
                Award ID: 085417MA/Z/08/Z
                Award Recipient :
                Categories
                Research
                Custom metadata
                © The Author(s) 2019

                Health & Social care
                socio-economic,health inequalities,community participation,behavior change,community mobilization,maternal and child health,qualitative research

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