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Background Self-help group (SHG) interventions have been widely studied in low and middle income countries. However, there is little data on specific impacts of health layering, or adding health education modules upon existing SHGs which were formed primarily for economic empowerment. We examined three SHG interventions from 2012-2017 in Bihar, India to test the hypothesis that health-layering of SHGs would lead to improved health-related behaviours of women in SHGs. Methods A model for health layering of SHGs – Parivartan – was developed by the non-governmental organisation (NGO), Project Concern International, in 64 blocks of eight districts. Layering included health modules, community events and review mechanisms. The health layering model was adapted for use with government-led SHGs, called JEEViKA+HL, in 37 other blocks of Bihar. Scale-up of government-led SHGs without health layering (JEEViKA) occurred contemporaneously in 433 other blocks, providing a natural comparison group. Using Community-based Household Surveys (CHS, rounds 6-9) by CARE India, 62 reproductive, maternal, newborn and child health and nutrition (RMNCHN) and sanitation indicators were examined for SHGs with health layering (Pavivartan SHGs and JEEViKA+HL SHGs) compared to those without. We calculated mean, standard deviation and odds ratios of indicators using surveymeans and survey logistic regression. Results In 2014, 64% of indicators were significantly higher in Parivartan members compared to non-members residing in the same blocks. During scale up, from 2015-17, half (50%) of indicators had significantly higher odds in health layered SHG members (Parivartan or JEEViKA+HL) in 101 blocks compared to SHG members without health layering (JEEViKA) in 433 blocks. Conclusions Health layering of SHGs was demonstrated by an NGO-led model (Parivartan), adapted and scaled up by a government model (JEEViKA+HL), and associated with significant improvements in health compared to non-health-layered SHGs (JEEViKA). These results strengthen the evidence base for further layering of health onto the SHG platform for scale-level health change. Study registration ClinicalTrials.gov number NCT02726230

The objective of the current study is to examine the cultural ecology of health associated with mitigating perinatal risk in Bihar, India. We describe the occurrences, objectives and explanations of health-related beliefs and behaviours during pregnancy and postpartum using focus group discussions with younger and older mothers. First, we document perceived physical and supernatural threats and the constellation of traditional and biomedical practises including taboos, superstitions and rituals used to mitigate them. Second, we describe the extent to which these practises are explained as risk-preventing versus health-promoting behaviour. Third, we discuss the extent to which these practises are consistent, inconsistent or unrelated to biomedical health practises and describe the extent to which traditional and biomedical health practises compete, conflict and coexist. Finally, we conclude with a discussion of the relationships between traditional and biomedical practises in the context of the cultural ecology of health and reflect on how a comprehensive understanding of perinatal health practises can improve the efficacy of health interventions and improve outcomes. This article is part of the theme issue ‘Ritual renaissance: new insights into the most human of behaviours’.

Background: Bihar has been lagging behind Indian national averages in maternal, neonatal and child health development indicators, primarily due to lack of knowledge on healthy lifesaving practices and where to seek services. Hence, a successful pilot project was scaled up as the JEEViKA Technical Support Program (JTSP), to support the state rural livelihood mission, JEEViKA, to increase demand for and link rural families to existing health, nutrition and sanitation (HNS) services. Program activities were geared in reaching those engaged in JEEViKA’s microfinance-based self-help groups (SHGs). This paper presents the results of the output evaluation following 18 months of program implementation. Methods: A mixed-methods study was conducted from August-November 2017. Sixty-five in-depth interviews were conducted with program, state, district and block-level officials. Quantitative surveys (678) were carried out among lower level staff, including village-based community mobilizers (CMs) who convene SHG meetings and support SHG-related activities.Results: JEEViKA layered HNS onto its existing system. The block health, nutrition and sanitation integrator (BHNSI) was introduced within JEEViKA to support the layering of HNS work at the block level. CMs were being trained on HNS topics to be shared during SHG meetings. JEEViKA funded the trainings and paid additional remuneration to trained CMs. HNS indicators were routinely collected by CMs and data were analyzed and used across JEEViKA. JEEViKA was supporting new mechanisms for SHG families to procure food while linking them to existing health and nutrition schemes and services. CMs with HNS trainings were more likely to have higher levels of knowledge on HNS topics and were more likely to carry out HNS-related activities, such as interacting with BHNSI for guidance and support, collecting HNS data routinely and spending time weekly on HNS activities. Conclusions: There is greater awareness within JEEViKA on the importance of addressing HNS issues to assist families in reducing economic shocks from health emergencies, improve nutrition and raise families out of poverty. Stronger integration of HNS programming within JEEViKA will be possible through the presence of decentralized staff to solely support these activities and a closer examination of the CMs’ time to integrate HNS activities more coherently.

Background The state of Bihar has been lagging behind Indian national averages on indicators related to maternal and child health, primarily due to lack of knowledge among mothers of young children on lifesaving practices and on where to seek services when healthcare is needed. Hence, the JEEViKA Technical Support Programme was established in 101 blocks to support the state rural livelihood entity, JEEViKA, in order to increase demand for and link rural families to existing health, nutrition and sanitation services. Programme activities were geared to those engaged in JEEViKA’s microfinance-oriented self-help groups. These groups were facilitated by a village-based community mobilizer who was trained on health, nutrition and sanitation-related topics which she later shared in self-help group meetings monthly and during ad hoc home visits. Further, a block-level health, nutrition and sanitation integrator was introduced within JEEViKA to support community mobilizers. Also, indicators were added into the existing monitoring system to routinely capture the layering of health, nutrition and sanitation activities. Methods A process evaluation was conducted from August–November 2017 which comprised of conducting 594 quantitative surveys with community mobilizers, from program and non-programme intervention blocks. Linear and logistic regressions were done to capture the association of at least one training that the community mobilizers received on knowledge of the topics learned and related activities they carried out. Results Community mobilizers who had received at least one training were more likely to have higher levels of knowledge on the topics they learned and were also more likely to carry out related activities, such as interacting with block-level integrators for guidance and support, routinely collect data on health, nutrition and sanitation indicators and spend time weekly on related activities. Conclusions Successful integration of health, nutrition and sanitation programming within a non-health programme such as JEEViKA is possible through trainings provided to dedicated staff in decentralized positions, such as community mobilizers. The findings of this evaluation hold great promise for engaging existing non-health, nutrition and sanitation systems that are serving vulnerable communities to become partners in working towards ensuring stronger health, nutrition and sanitation outcomes for all.

OBJECTIVE: To assess the impact and sustainability of health, water, and sanitation interventions in Bolivia six years post-project. METHODS: A mixed-method (qualitative-quantitative) study was conducted in 14 rural intervention and control communities in Bolivia in November 2008, six years after the completion of interventions designed to improve knowledge and practices related to maternal and child health and nutrition, community water systems, and household water and sanitation facilities. The degree to which participants had sustained the community and household practices promoted by the interventions was a particular focus. Community site visits were made to evaluate the status (functional condition) and sustainability (state of maintenance and repair) of community and household water and sanitation infrastructure. Key informant interviews and focus group discussions were conducted to assess knowledge and practices, and perceptions about the value of the interventions to the community. RESULTS: Six years post-project, participants remained committed to sustaining the practices promoted in the interventions. The average rating for the functional condition of community water systems was 42% higher than the average rating in control communities. In addition, more than two-thirds of households continued to practice selected maternal and child health behaviors promoted by the interventions (compared to less than half of the households in the control communities). Communities that received integrated investments (development and health) seemed to sustain the practices promoted in the interventions better than communities that received assistance in only one of the two sectors. CONCLUSIONS: Infrastructure for community water systems and household water and sanitation facilities was better built and maintained, and selected maternal and child health behaviors practiced more frequently, in intervention communities versus control communities.

OBJECTIVE: To assess the impact and sustainability of health, water, and sanitation interventions in Bolivia six years post-project. METHODS: A mixed-method (qualitative-quantitative) study was conducted in 14 rural intervention and control communities in Bolivia in November 2008, six years after the completion of interventions designed to improve knowledge and practices related to maternal and child health and nutrition, community water systems, and household water and sanitation facilities. The degree to which participants had sustained the community and household practices promoted by the interventions was a particular focus. Community site visits were made to evaluate the status (functional condition) and sustainability (state of maintenance and repair) of community and household water and sanitation infrastructure. Key informant interviews and focus group discussions were conducted to assess knowledge and practices, and perceptions about the value of the interventions to the community. RESULTS: Six years post-project, participants remained committed to sustaining the practices promoted in the interventions. The average rating for the functional condition of community water systems was 42% higher than the average rating in control communities. In addition, more than two-thirds of households continued to practice selected maternal and child health behaviors promoted by the interventions (compared to less than half of the households in the control communities). Communities that received integrated investments (development and health) seemed to sustain the practices promoted in the interventions better than communities that received assistance in only one of the two sectors. CONCLUSIONS: Infrastructure for community water systems and household water and sanitation facilities was better built and maintained, and selected maternal and child health behaviors practiced more frequently, in intervention communities versus control communities.OBJETIVO: Evaluar la repercusión y la sostenibilidad de las intervenciones relacionadas con la salud, el abastecimiento de agua y el saneamiento en Bolivia seis años después de la realización del proyecto. MÉTODOS: Se llevó a cabo un estudio de metodología mixta (cualitativa y cuantitativa) en 12 comunidades rurales donde se efectuó la intervención y 2 de control en Bolivia en noviembre del 2008, seis años después de la finalización de las intervenciones enfocadas a mejorar el conocimiento y las prácticas relacionadas con la salud y la nutrición maternoinfantil, los sistemas de abastecimiento de agua comunitarios y las instalaciones de abastecimiento de agua y saneamiento domiciliarias. Se estudió, en particular, el grado en el cual los participantes continuaban realizando las prácticas domiciliarias y comunitarias promovidas por las intervenciones. Se efectuaron visitas a sitios de la comunidad para evaluar el estado (condición funcional) y la sostenibilidad (estado de mantenimiento y reparación) de la infraestructura de abastecimiento de agua y saneamiento domiciliaria y comunitaria. Se llevaron a cabo entrevistas a informantes clave y análisis basados en grupos de discusión para evaluar el conocimiento, las prácticas y las percepciones acerca del valor de las intervenciones comunitarias. RESULTADOS: Seis años después del proyecto, los participantes continuaban llevando a cabo las prácticas promovidas en las intervenciones. La calificación promedio para la condición funcional de los sistemas de abastecimiento de agua comunitarios fue 42% más alta que la calificación promedio en las comunidades de control. Además, en más de dos terceras partes de los hogares se seguían poniendo en práctica ciertos hábitos relacionados con la salud maternoinfantil promovidos en las intervenciones (en comparación con menos de la mitad de los hogares en las comunidades de control). Las comunidades que recibieron inversiones integradas (desarrollo y salud) parecían conservar las prácticas promovidas en las intervenciones en mayor medida que las comunidades que recibieron ayuda solo en uno de los dos sectores. CONCLUSIONES: La infraestructura de los sistemas de abastecimiento de agua comunitarios y las instalaciones domiciliarias de abastecimiento de agua y saneamiento estaban mejor construidas y mantenidas, y ciertos hábitos de salud maternoinfantil se ponían en práctica con mayor frecuencia, en las comunidades de la intervención en comparación con las comunidades de control.

Objective to identify and better understand factors that influence care-seeking behaviour for women's health among indigenous Mayan populations in the highlands of Guatemala. Design adaptation of qualitative anthropological methods involving observations, key informant interviews and focus group discussions (FGDs). Setting Project Concern International's Casa Materna, Huehuetenango, Guatemala. Participants Interviews and FGDs were conducted among 21 clients (current or past) of the Casa Materna and traditional birth attendants; 17 female advocates/promoters of the Casa Materna and related services; and 12 male advocates, including spouses, non-government organisation staff and community health workers. Findings the following findings emerged from focus group data: Women's support groups (WSGs) provided an enabling environment in which women could form friendships, bond, discuss concerns about their reproductive health, and identify concrete ways of addressing them; Supportive friends, family members and advocates influenced women's decisions to seek health care at the Casa Materna; Women's decisions to seek care were often associated with their sense of self-worth and self-esteem, and women's self-esteem was enhanced by their participation in the WSGs; Women's decisions to seek care were influenced by the perception that women would be able to access culturally appropriate, safe and secure health care services at the Casa Materna; The learned behaviour of negotiation with key decision-makers and/or opinion leaders was an effective tool for convincing such individuals of the value of accessing facility-based care; The proven track record, high quality of services and cultural competence offered at the Casa Materna increased the confidence and level of trust of clients and their family members about the care that would be received; Couple-based education and health promotion were effective techniques for achieving behaviour and attitude change among both men and women. Key conclusions the Casa Materna and its community outreach strategy serve an essential purpose in the provision of maternity care for the isolated and vulnerable families of the Guatemalan highlands, by bridging traditional and Western approaches to health care services. The Casa Materna service model plays a critical role in improving women's self-efficacy and ultimately strengthening the social fabric that characterises this high risk and vulnerable population. Implications for practice the Casa Materna model provides a foundation upon which to bridge and strengthen the relationship between community advocates, traditional community-based health care providers, and the government-funded system of health care. The findings of this study should be incorporated into future research to determine the potential for bringing the model to scale.

The "traditional" use of the Positive Deviance approach to behavior change involves studying children who thrive despite adversity, identifying uncommon model behaviors among Positive Deviant families, and then designing and implementing an intervention to replicate these behaviors among mothers of malnourished children. This article presents the results of a literature review designed to gather information on the role of the Positive Deviance/Hearth methodology in social and behavior change. Examples of how the methodology has been applied beyond infant and child malnutrition to address other health areas, such as improving pregnancy outcomes, are explored. An analysis of Positive Deviance programming being carried out by Project Concern International in Guatemala and Indonesia is conducted. The role of cultural context in the design and implementation of Positive Deviance/Hearth, as well as the role of Positive Deviance in affecting social and behavior change, require further exploration. The issues related to cultural context and the challenges for monitoring and evaluation of program outcomes are presented.

Many of the factors that have contributed to the decline in breastfeeding around the world can be overcome by education and support. Examples of successful approaches to education at different levels (mother, health professional, institution) that impact breastfeeding are discussed. For example, because breastfeeding is a learned behaviour for both mother and baby, providing the mother with information, skills, and support for the breastfeeding process is integral to her ability to breastfeed successfully. In addition, because the health professional plays a pivotal role in the success or failure of breastfeeding it is essential I that education and training of health professionals be adequately addressed. By using an approach to healthprofessional education that builds on a highly trained core and spreads to all levels through a built-in multiplier effect, improvement of breastfeeding practices can be assured. In order to sustain these results, however, health-professional school curricula must include adequate information on the science of lactation and the clinical management of breastfeeding The experience of Chile's National Breastfeeding Programme is used to illustrate the power of education at each of these levels in influencing the success of breastfeeding and the feasibility of using education of both mothers and health professionals as a way of preserving this incredible natural resource.