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Trials of participation to improve maternal and newborn health
Correspondence
Susan Rifkin [email protected] Colorado School of Public Health, Denver, CO 80209, USA 1
I want to commend Audrey Prost and colleagues on their study of the contribution of participatory women’s groups to improve birth outcomes in poor communities in low-income and middle-income countries (May 18, p 1736).1 Their work is an important contribution to highlight the crucial importance of participation in health care improvement. I would be remiss, however, if I did not challenge the analytical framework in which these data are presented. To frame participation in women’s groups underpinned by Participation Learning and Action (PLA) as the intervention limits the understanding of participation. PLA, the most recent manifestation of Participatory Action Research, 2 is an approach that involves the intended beneficiaries in all aspects of the intervention design. It values the learning outcomes equal to the material outcomes. The value of PLA lies in the examination of outcomes that also lead to the empowerment, eventual ownership, and sustainability of that intervention. Participation, it has been argued, is better understood in both theory and practice as a process.3 To present participatory women groups as an intervention with a direct causal relationship to improved health outcomes is simplistic. The interpretation of data would be more robust if the process of participation was disaggregated, and issues around the transformation of attitudes and behaviours, power and control, and sustainability of health outcomes were addressed. Although such an investigation is complicated, the validity of these findings and the generalisability of what appears to be a panacea for a crucial global health problem are questionable. I declare that I have no conflicts of interest.
www.thelancet.com Vol 382 August 24, 2013
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Prost A, BolbournT, Seward N, et al. Women’s groups practicing participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis. Lancet 2013; 381: 1736–46. Tandon R. The historical roots and contemporary tendencies in participatory research: implications for health care. in: de Koning K, Martin M, eds. Participatory Research in Health: Issues and Experiences. London: Zed Books, 1996. Rifkin SB. Paradigms lost: toward a new understanding of community participation in health programs. Acta Tropica 1996; 61: 79–92.
Authors’ reply Susan Rifkin raises three important issues in relation to participatory women’s groups to improve maternal and newborn health.1 The first is that supporting participation in women’s groups does not in itself make an intervention participatory. Instead, being true to Participatory Learning and Action would require involvement of the intended beneficiaries in all aspects of the intervention, and valuing of the process of participation as much as its practical outcomes. On this matter we agree. The women’s group studies tread a fine line between valuing participation as a bottom-up, long-term, locally owned transformational process to redress inequities, and strategically engineering top-down health promotion approaches to improve health outcomes within the time constraints of trials.2 The tension of integrating bottom-up and top-down approaches is at the heart of many health interventions. The women’s group interventions examined in our meta-analysis, by necessity, sit within a range of participation, and do not claim to encompass all, or the purest forms, of participation.3 Rifkin’s second criticism is that presenting participatory women’s groups as an intervention with a direct causal relationship to improved health is simplistic. The meta-analysis does support a causal relationship between
participatory groups and reduced maternal and neonatal deaths. Several mechanisms, acting through both proximal (eg, improved behaviours) and distal (eg, women’s empowerment) outcomes, are likely to be implicated. Our meta-analysis has gone some way towards identifying changes in behaviours linked to reduced mortality. Opening the black box further involves generation and testing of hypotheses about more distal mechanisms, which was beyond the scope of the metaanalysis. Finally, Rifkin argues that the generalisability of our findings is questionable. Participatory women’s groups did reduce mortality in many settings. Further exploration of mechanisms can only help to increase the validity of the findings and transferability of the intervention to new settings. Cesar Victora commented that people who study empowerment are rarely those who do trials.4 Indeed, reviews have denounced the absence of studies measuring the effect of participatory approaches on health outcomes.5 We chose to measure this effect. Trials are vehicles to deploy a range of approaches to understanding change. In this sense, they are only reductionist if we allow them to be so. We invite Rifkin and others who promote participation not to shy away from trials, and to propose new methods for integrating process and impact assessments.
Corbis
Trials of participation to improve maternal and newborn health
We declare that we have no conflicts of interest.
*Audrey Prost, Mikey Rosato, Prasanta Tripathy, Anthony Costello [email protected] Institute for Global Health, University College London, London WC1N 1EH, UK (AP, MR, AC); and Ekjut, Chakradharpur, Jharkhand, India (PT) 1
2
Prost A, Colbourn T, Seward N, et al. Women’s groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis. Lancet 2013; 381: 1736–46. Labonte R, Laverack G. Capacity building in health promotion, Part 1: for whom? And for what purpose? Crit Public Health 2001; 11: 111–28.
681
Susan Rifkin [email protected] Colorado School of Public Health, Denver, CO 80209, USA 1
I want to commend Audrey Prost and colleagues on their study of the contribution of participatory women’s groups to improve birth outcomes in poor communities in low-income and middle-income countries (May 18, p 1736).1 Their work is an important contribution to highlight the crucial importance of participation in health care improvement. I would be remiss, however, if I did not challenge the analytical framework in which these data are presented. To frame participation in women’s groups underpinned by Participation Learning and Action (PLA) as the intervention limits the understanding of participation. PLA, the most recent manifestation of Participatory Action Research, 2 is an approach that involves the intended beneficiaries in all aspects of the intervention design. It values the learning outcomes equal to the material outcomes. The value of PLA lies in the examination of outcomes that also lead to the empowerment, eventual ownership, and sustainability of that intervention. Participation, it has been argued, is better understood in both theory and practice as a process.3 To present participatory women groups as an intervention with a direct causal relationship to improved health outcomes is simplistic. The interpretation of data would be more robust if the process of participation was disaggregated, and issues around the transformation of attitudes and behaviours, power and control, and sustainability of health outcomes were addressed. Although such an investigation is complicated, the validity of these findings and the generalisability of what appears to be a panacea for a crucial global health problem are questionable. I declare that I have no conflicts of interest.
www.thelancet.com Vol 382 August 24, 2013
2
3
Prost A, BolbournT, Seward N, et al. Women’s groups practicing participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis. Lancet 2013; 381: 1736–46. Tandon R. The historical roots and contemporary tendencies in participatory research: implications for health care. in: de Koning K, Martin M, eds. Participatory Research in Health: Issues and Experiences. London: Zed Books, 1996. Rifkin SB. Paradigms lost: toward a new understanding of community participation in health programs. Acta Tropica 1996; 61: 79–92.
Authors’ reply Susan Rifkin raises three important issues in relation to participatory women’s groups to improve maternal and newborn health.1 The first is that supporting participation in women’s groups does not in itself make an intervention participatory. Instead, being true to Participatory Learning and Action would require involvement of the intended beneficiaries in all aspects of the intervention, and valuing of the process of participation as much as its practical outcomes. On this matter we agree. The women’s group studies tread a fine line between valuing participation as a bottom-up, long-term, locally owned transformational process to redress inequities, and strategically engineering top-down health promotion approaches to improve health outcomes within the time constraints of trials.2 The tension of integrating bottom-up and top-down approaches is at the heart of many health interventions. The women’s group interventions examined in our meta-analysis, by necessity, sit within a range of participation, and do not claim to encompass all, or the purest forms, of participation.3 Rifkin’s second criticism is that presenting participatory women’s groups as an intervention with a direct causal relationship to improved health is simplistic. The meta-analysis does support a causal relationship between
participatory groups and reduced maternal and neonatal deaths. Several mechanisms, acting through both proximal (eg, improved behaviours) and distal (eg, women’s empowerment) outcomes, are likely to be implicated. Our meta-analysis has gone some way towards identifying changes in behaviours linked to reduced mortality. Opening the black box further involves generation and testing of hypotheses about more distal mechanisms, which was beyond the scope of the metaanalysis. Finally, Rifkin argues that the generalisability of our findings is questionable. Participatory women’s groups did reduce mortality in many settings. Further exploration of mechanisms can only help to increase the validity of the findings and transferability of the intervention to new settings. Cesar Victora commented that people who study empowerment are rarely those who do trials.4 Indeed, reviews have denounced the absence of studies measuring the effect of participatory approaches on health outcomes.5 We chose to measure this effect. Trials are vehicles to deploy a range of approaches to understanding change. In this sense, they are only reductionist if we allow them to be so. We invite Rifkin and others who promote participation not to shy away from trials, and to propose new methods for integrating process and impact assessments.
Corbis
Trials of participation to improve maternal and newborn health
We declare that we have no conflicts of interest.
*Audrey Prost, Mikey Rosato, Prasanta Tripathy, Anthony Costello [email protected] Institute for Global Health, University College London, London WC1N 1EH, UK (AP, MR, AC); and Ekjut, Chakradharpur, Jharkhand, India (PT) 1
2
Prost A, Colbourn T, Seward N, et al. Women’s groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis. Lancet 2013; 381: 1736–46. Labonte R, Laverack G. Capacity building in health promotion, Part 1: for whom? And for what purpose? Crit Public Health 2001; 11: 111–28.
681