Abstract
BackgroundFew large and rigorous evaluations of participatory interventions systematically describe their context and implementation, or attempt to explain the mechanisms behind their impact. This study reports process evaluation data from the Ekjut cluster-randomised controlled trial of a participatory learning and action cycle with women's groups to improve maternal and newborn health outcomes in Jharkhand and Orissa, eastern India (2005-2008). The study demonstrated a 45% reduction in neonatal mortality in the last two years of the intervention, largely driven by improvements in safe practices for home deliveries.MethodsA participatory learning and action cycle with 244 women's groups was implemented in 18 intervention clusters covering an estimated population of 114 141. We describe the context, content, and implementation of this intervention, identify potential mechanisms behind its impact, and report challenges experienced in the field. Methods included a review of intervention documents, qualitative structured discussions with group members and non-group members, meeting observations, as well as descriptive statistical analysis of data on meeting attendance, activities, and characteristics of group attendees.ResultsSix broad, interrelated factors influenced the intervention's impact: (1) acceptability; (2) a participatory approach to the development of knowledge, skills and 'critical consciousness'; (3) community involvement beyond the groups; (4) a focus on marginalized communities; (5) the active recruitment of newly pregnant women into groups; (6) high population coverage. We hypothesize that these factors were responsible for the increase in safe delivery and care practices that led to the reduction in neonatal mortality demonstrated in the Ekjut trial.ConclusionsParticipatory interventions with community groups can influence maternal and child health outcomes if key intervention characteristics are preserved and tailored to local contexts. Scaling-up such interventions requires (1) a detailed understanding of the way in which context affects the acceptability and delivery of the intervention; (2) planned but flexible replication of key content and implementation features; (3) strong support for participatory methods from implementing agencies.
Highlights
Few large and rigorous evaluations of participatory interventions systematically describe their context and implementation, or attempt to explain the mechanisms behind their impact
Commitment to community participation in health is enduring. This is especially true in the field of maternal and child health, where programmes have recognized the importance of community involvement to improve both the supply and demand for appropriate health services [7]
Recent evaluations of participatory interventions have shown an impact on the intractable problem of high neonatal mortality in developing countries: two recent randomised controlled trials have demonstrated mortality reductions in rural, underserved communities of Nepal, and in eastern India [8,9]
Summary
Few large and rigorous evaluations of participatory interventions systematically describe their context and implementation, or attempt to explain the mechanisms behind their impact. More than thirty years after Alma Ata, multilateral development institutions, states and civil society organizations alike have embraced community participation in health, but meanings given to it vary widely between programs and measurable successes in improving health outcomes are scarce [4] This has resulted in increasing concerns about the legitimacy and effectiveness of participatory interventions, with critics contending that they are often ill-defined, co-opted by powerful development actors to disguise top down, ‘business as usual’ implementation of externally designed programs, or so context-specific that their replicability and scalability is doubtful [5,6]. Other evaluations of participatory interventions with women’s groups are underway or recently completed in Bangladesh, urban India and Malawi
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