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Lessons in inequity from a global health study

A public health program in India improved maternal and child health initially, but was at risk of leaving behind disadvantaged participants when it expanded.

A large public health program in rural India improved maternal and child health in its pilot phase, but was at risk of leaving behind the most-disadvantaged participants when the program expanded, according to a Stanford-led study. The research has lessons for other thorny problems in health equity, including how to handle COVID-19 in the United States, according to the authors.

The study, published recently in the Journal of Global Health, uncovered disparities in who benefited from a multi-year public health intervention for pregnant women, babies and young children.

The program, called Ananya ("limitless" or "unique" in Hindi), focused on people living in Bihar, a state in Northeastern India that borders Nepal. The program included many interventions, such as encouraging women to give birth in health care facilities instead of at home; giving nutrition advice; and promoting postpartum contraception and childhood vaccinations.

At first, in a two-year pilot phase for a region of 28 million people, Ananya succeeded in bringing health information to poor, rural women and their children, thereby improving many of the 50+ markers of maternal and child health that were studied.

"There was quite a bit of progress in a short period of time," said Gary Darmstadt, MD, associate dean for maternal and child health at the School of Medicine, professor of pediatrics and senior author of the new study. But when Ananya was expanded to the entire state of Bihar, "it really became challenging," he said.

As the responsibility for Ananya was shifted from NGOs to the government of Bihar, there was less attention paid to health interventions at the village level, and more emphasis on improving health care facilities, which changed who could benefit.

Also, while the program empowered lower caste, poor, marginalized women through self-help groups -- improving health-related knowledge and behaviors of women who participated -- the groups did not reach all of Bihar's villages.

"What we found at a population level was that, over time, those that were the best off were impacted, but the most marginalized groups didn't have much change," said Victoria Ward, MD, clinical assistant professor of pediatrics and the lead author on equity analysis, which is one of 17 research papers that describe outcomes of Ananya.

"Part of what emerged, and was so interesting about the equity analysis, is that if you put too much focus on facilities versus the community, that has implications for who you're going to reach," said Darmstadt.

Getting health advice to remote villages

In 2010, global health experts from the Bill and Melinda Gates Foundation -- including Darmstadt, then the director of family health at the foundation -- began working with Bihar's leaders to rebuild health care for their population of 104 million after a challenging period of political upheaval.

"The state was very poor ... but at a hopeful stage with new leadership," said Darmstadt, who went to Bihar at the time. "Some of the villages we visited were absolutely heartbreaking, with among the hardest levels of poverty I had ever seen. You might meet a 9-month-old who hadn't been fed anything other than breast milk" because the family had so little food. Babies should start eating solid foods by 6 months of age.

Gates Foundation leaders knew that addressing the region's widespread public health problems would be a huge challenge.

"It was super courageous, " said Darmstadt. "They said, 'We're going to work at the epicenter of public health,' from the standpoint of, 'If we could do it here, we could do it anywhere.'"

The pilot phase of Ananya launched in 2012 in eight of Bihar's 38 districts. It focused on mobilizing front-line health care workers, who received planning and communication tools as well as training that enabled them to share basic health advice.

For instance, the workers told women that birth attendants should wash their hands; advised mothers to hold their babies skin-to-skin and begin breastfeeding immediately after birth; and promoted birth control, good nutrition, and childhood vaccines.

The workers facilitated women's self-empowerment groups, helped run monthly village health fairs, and shared demonstration cards and audio recordings -- played on phones -- of a fictional "Dr. Anita" giving health information. Over the next two years, these interventions worked quite well.

Program expansion left some behind

But the expansion to include all 38 districts of Bihar -- the entire population of 104 million -- was less successful. At the end of the four-year expansion, most markers of maternal and child health had fallen back to where they started from at the beginning of the project.

In analyzing what happened, the scientists decided to explore whether participants' wealth and caste influenced their ability to benefit from the Ananya program.

Even the most disadvantaged women acted on health advice when they were able to do so, researchers found. Impoverished, low-caste women in Bihar registered their pregnancies, the first step in getting prenatal care, and breastfed their infants immediately, for example. Both actions could be completed for free at monthly village health fairs or at home.

But these women lagged behind wealthier, higher-caste counterparts in seeking care for pregnancy complications and giving birth at health care facilities. In general, if following a health recommendation required resources, such as transportation to a health care facility, the women who were worst-off often could not participate.

"These findings demonstrate the importance of focusing on how programs are reaching the most marginalized communities, particularly for interventions intended to benefit the most disadvantaged," said Ward.

Lessons for COVID-19

The results hold important lessons for planning future global-health initiatives, and for thinking about how to address health inequality in the United States, too, said Darmstadt, adding, "It's really interesting that we have learning from one of the poorest places in the world that is highly relevant for us right now."

Surges in COVID-19 have been concentrated among marginalized U.S. populations, such as people with front-line jobs and crowded housing conditions, who don't have the resources to follow social-distancing guidelines. People with better resources, especially those with jobs that could be done successfully from home, have had lower infection rates.

"COVID has really revealed that there are universal principles here that, even in a society like our own, are playing out in the same way," Darmstadt said.

"We have to measure and hold ourselves accountable to reaching everyone, particularly those who are most left behind. If we're not thoughtful and intentional about that, we may widen disparities," he concluded. "Just having the aspiration to help isn't enough."

Image by Ashish_wassup6730

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