The effect of community health worker–led education on women’s health and treatment–seeking: A cluster randomised trial and nested process evaluation in Gujarat, India

Abstract

BackgroundA community–based health insurance scheme operated by the Self–Employed Women’s Association in Gujarat, India reported that the leading reasons for inpatient hospitalisation claims by its members were diarrhoea, fever and hysterectomy – the latter at the average age of 37. This claims pattern raised concern regarding potentially unnecessary hospitalisation amongst low–income women.MethodsA cluster randomised trial and mixed methods process evaluation were designed to evaluate whether and how a community health worker–led education intervention amongst insured and uninsured adult women could reduce insurance claims, as well as hospitalisation and morbidity, related to diarrhoea, fever and hysterectomy. The 18–month intervention consisted of health workers providing preventive care information to women in a group setting in 14 randomly selected clusters, while health workers continued with regular activities in 14 comparison clusters. Claims data were collected from an administrative database, and four household surveys were conducted amongst a cohort of 1934 randomly selected adult women.Results30% of insured women and 18% of uninsured women reported attending sessions. There was no evidence of an intervention effect on the primary outcome, insurance claims (risk ratio (RR) = 1.03; 95% confidence interval (CI) 0.81, 1.30) or secondary outcomes amongst insured and uninsured women, hospitalisation (RR = 1.05; 95% CI 0.58, 1.90) and morbidity (RR = 1.09; 95% CI 0.87, 1.38) related to the three conditions. The process evaluation suggested that participants retained knowledge from the sessions, but barriers to behaviour change were not overcome.ConclusionsWe detected no evidence of an effect of this health worker–led intervention to decrease claims, hospitalisation and morbidity related to diarrhoea, fever and hysterectomy. Strategies that capitalise on health workers’ role in the community and knowledge, as well as those that address the social determinants of diarrhoea, fever and the frequency of hysterectomy – such as water and sanitation infrastructure and access to primary gynaecological care – emerged as areas to strengthen future interventions.

Community interventions with women’s groups to improve women’s and children’s health in India: a mixed-methods systematic review of effects, enablers and barriers

“…We found less than three studies on: health expenditure, 62 63 water and sanitation 64 65 and mental health, 28 66 as well as two studies that addressed multiple health domains 67 68 (detailed findings reported in online supplemental text ).…”

“… 12 34 42 100 Inclusion of more outcomes to sustain interest among other members did not appear effective: interventions with more than two health domains had limited or no effects, plausibly due to lack of focus. 62 67 Effective interventions addressed outcomes with mechanisms that were in women’s control or addressed supply-side factors. For example, neonatal survival improved through supply-independent mechanisms such as wrapping newborn infants, while child wasting, stunting and underweight only improved with direct food provision.…”

Frequency and determinants of health care utilization for symptomatic reproductive tract infections in rural Indian women: A cross-sectional study

“…Further evidence suggests educational interventions led by community health workers that target women of reproductive age and are designed to increase awareness and prevention of RTI symptoms have some potential for changing female reproductive health care related behaviors in India [24–26]. When aiming to increase care seeking behavior for reproductive symptoms, though, it seems that community health programs targeting general education alone, without sex-specific reproductive biology education, may be insufficient for improvements [27].…”

Promoting women’s and children’s health through community groups in low-income and middle-income countries: a mixed-methods systematic review of mechanisms, enablers and barriers

“…We did not want to attempt the contentious task of defining the difference between community mobilisation and all its sister constructs and deciding which category individual interventions belonged to. We could not simply include all group-based interventions as this would fail to exclude classroom-style health education interventions that did not aim to empower in the spirit of community mobilisation 26. We, therefore, chose to include only community and social mobilisation as search terms, followed by manually screening articles for mention of community groups.…”