PLA News Archive
Published: Wednesday 26th June 2024
Could Participatory Maternal and Newborn Health Groups improve wellbeing in the UK?
Participatory Learning and Action for Maternal and Newborn Health (PLA-MNH) improves maternal and newborn health and reduces mortality. It does this through empowering communities in low and middle income countries to identify health barriers and implement local, feasible solutions.
With the support of Costello Medical, we are exploring whether PLA-MNH could be adapted for the UK to mitigate inequalities in maternal and neonatal health (MNH).
A recent study, led by Professor Monica Lakhanpaul and supported by the NIHR Applied Research Collaboration (ARC) North Thames, trialled PLA in East London to improve infant feeding, care and dental hygiene amongst South Asian children under 2 years old. The study reported promising results, suggesting PLA-MNH could be transferable to high-income settings.
The inequalities in maternal and neonatal health are associated with intersectional factors including ethnicity, socioeconomic status and age, which affect access to and quality of care, as well as maternal and neonatal health outcomes.
Through conducting focus groups and interviews with experts in community interventions and MNH, we have compiled the key factors to consider if PLA-MNH is adapted to a UK setting to address MNH inequalities.
The key factors for adapting for the UK
The success of an MNH intervention relies on building trust within communities. Due to challenges individuals have faced whilst accessing healthcare, such as discrimination based on race, poverty, religion, and age, there can be a general distrust of government services among some people or communities.
To overcome this distrust, a trauma-informed approach should be taken, e.g. keeping women informed, respecting communication preferences, and ensuring tasks are completed as promised.
It is crucial to collaborate with community gatekeepers and local organisations to facilitate the building of trust. They are embedded and well-trusted within communities, and will be able to support the recruitment of participants and ensure interventions are inclusive and meet community needs.
When introducing an MNH intervention to a new community, the community gatekeepers and organisations contacted should represent the full range of cultures, religions and experiences in the community.
The role of the facilitator is also pivotal for the success of an MNH intervention. The same facilitator should be used throughout the MNH intervention so they can build trust with the participants over time.
The facilitator also needs to be able to meet the community’s unique needs, such as having translational and first language speaking abilities, and an awareness of cultural sensitivities (such as taboo topics that participants might be hesitant to discuss).
Whilst being an attentive listener, the facilitator should also be able to steer discussions towards evidence-based practice.
The organisers of an MNH intervention need to ensure facilitators receive suitable payment, as well as career progression opportunities and recognition for their work.
The MNH intervention needs to be easily accessible to participants. For example, offering multiple dates and formats for participation (e.g. home visits and focus groups) to accommodate participants’ preferences and time constraints.
Interpreters and materials in multiple languages should be provided, and digital access issues should be addressed by using tools like virtual forums and WhatsApp.
These findings emphasise the need for a community-led approach when considering interventions to improve MNH.
Acknowledgements
Thank you to the people who shared their thoughts and expertise during our focus groups and interviews:
Benash Nazmeen, Assistant Professor in Midwifery at University of Bradford
Hannah Rayment-Jones, Advanced Research Fellow and Midwife at Kings College London
Ima Miah, Asian Resource Centre Croydon, CEO
Jenny Gilmour, 0-19 Development Lead, previously Clinical Director at Integrated 0−19 Services Health Visiting & School Health and Wellbeing at Tower Hamlets GP Care Group
Julia Clark, Research Officer at Sands
Katherine Miller Brunton, Policy, Communications and Engagement Officer, Birth Companions
Laura Seebohm, Chief Executive of Maternal Mental Health Alliance
Mike Davies, Coordinator and Manager at Jigso Swansea
Rahima Ahad, Asian Resource Centre Croydon, Project Researcher
Rosie Murphy, Health Equalities Lead, Central London Community Healthcare NHS Trust
Published: Q1 2023
New publication: GiveWell Intervention Report on PLA-MNH
GiveWell, the world leading non-profit charity assessment organisation, is dedicated to finding outstanding giving opportunities and publishing the full details of their analyses to help donors decide where to give.
GiveWell has recently completed an intervention report on the PLA-MNH approach. They found it to be “a potentially promising and highly cost-effective intervention with a strong evidence base”.
A number of PLA implementing partners are now in discussions with GiveWell regarding funding to implement PLA-MNH at scale and conduct further research, particularly to test the impact of PLA-MNH on post-neonatal mortality.
GiveWell is interested in exploring further implementation proposals from PLA implementing partners, and research to clarify any final uncertainties around external validity.
New resource: PLA-MNH Value Messages
In 2022 Women and Children First was fortunate to receive extensive pro-bono support from Costello Medical across a number of global health projects.
One of these projects focussed on collating evidence and experience on PLA-MNH and developing a value message pack, to support advocacy in efforts to take the approach to scale..
Published: Q3 2022
Upcoming research papers on PLA effectiveness, including an economic evaluation in India
Our partners continue to produce and publish world class research on PLA.
Dr. Andy Seal et al have recently submitted a paper on the effectiveness of PLA in increasing knowledge and uptake of child vaccination in an internally displaced peoples camp in Somalia.
The paper, to be published soon, is titled: “Use of an adapted participatory learning and action cycle approach to increase knowledge and uptake of child vaccination in internally displaced persons camps (IVACS): A cluster-randomised controlled trial”.
Dr. Hassan Haghparast-Bidgoli et al have also recently submitted the economic evaluation of PLA at scale in India. “Economic evaluation of participatory women’s groups scaled up by the public health system to improve birth outcomes in Jharkhand, eastern India”.
This paper supplements the previous publication by Dr. Nirmala Nair et al on the incredible results of their pragmatic cluster non-randomised controlled trial on the effectiveness of PLA at scale in Jharkhand, eastern India.
The trial showed that PLA reduced neonatal mortality by 24%. Published in BMJ Global Health, the trial was the largest ever of a health intervention scaled up by government frontline health workers embedded in the public health system. You can read the full paper for free here.
PLA in Uganda: Reducing maternal, perinatal and neonatal mortality in Oyam District, Uganda
Women and Children First has been working with Doctors with Africa CUAMM in Oyam District, Uganda since 2017.
Together we have established 200 groups with funding from Comic Relief, the Big Lottery Fund, the Vitol Foundation and our supporters.
We have also trained 200 teenagers to become sexual health ‘adolescent champions’. They are sharing knowledge with peers, teens and friends, making them aware of available health services and their right to quality sexual and reproductive health care.
The project recently closed and we have collated our learning here, including a 22% increase in women attending 4 or more antenatal care visits.
Published: Q1 2022
BMJ Global Health Paper: The Impact of PLA Groups at Scale in Jharkhand, Eastern India
Nirmala Nair et al have just published the incredible results of their pragmatic cluster non-randomised controlled trial on the effectiveness of PLA at scale in Jharkhand, eastern India.
The trial shows that PLA reduced neonatal mortality by 24% at a cost of 41 international dollars per life saved, warranting scale-up in other high-mortality, rural settings.
Published in BMJ Global Health, the trial is the largest ever of a health intervention scaled up by government frontline health workers embedded in the public health system.
It also found that:
Effects on mortality were most likely driven by changes in thermal care practices, such as skin-to-skin contact, exclusive breastfeeding, and increased synergy with existing frontline worker activities, such as postnatal visits
Government buy-in, innovating health systems through on-the-job training systems, and giving enhanced roles to frontline worker supervisors, are key systems enablers for scale-up
London Community-Led Infant Nutrition Programme Wins Prestigious Award
The Nurture Early for Optimal Nutrition (NEON) programme has been awarded the Royal Society for Public Health (RSPH) Health and Wellbeing Award 2021, in the ‘Health at Every Age’ category.
The NEON programme aims to improve the nutrition, growth and cognitive development of children of South Asian origin under 2 in East London.
NEON was developed by UCL in partnership with South Asian communities in East London and a wide range of academic, health, local government and charity partners.
Women and Children First has been involved in advising on the adaptation of PLA approach to improve child nutrition and growth, alongside other interventions such as a cultural recipe book, a list of local support services and lists of low-cost fruit and vegetable shops and play areas.
NEON has led to improvements in nutrition and feeding practices, maternal and neonatal survival rates. The research has influenced Tower Hamlets and Newham Local Authorities in their early years programmes.
Published: July 2021
Key Findings From Adapting PLA Beyond MNH Webinar
Three of the most interesting points raised included:
1. The flexible nature of PLA
Joanna mentioned how feasible it is to apply PLA to different topics because of its flexible nature.
“It is flexible to the context and the issue” and the power of PLA seems to be its ability to improve 100 things by 1%, rather than improving one thing by 100%.
However, Joanna set out a few important questions to answer when considering an adaptation of PLA beyond maternal and newborn health.
These include whether there is support for participatory approaches, and highlighted the importance of formative research, including with key stakeholders.
2. Understanding the nature of the issue being addressed
Annemijn presented WCF’s experience of adapting PLA to improve family planning uptake in Ethiopia.
Discussion of family planning in the project setting is not common, which meant that key adaptations were needed.
As a result, the groups were framed with a broader wellbeing focus to maximise the opportunity for unmarried women and adolescent girls to attend.
The cycle was also adapted to ensure that group members could learn about and take action on family planning issues earlier, shortening the lead-in time for uptake of contraception.
3. Understanding how people can participate
Kishwar highlighted that one of the key considerations they had to take into account when adapting PLA to prevent Type-2 diabetes in rural Bangladesh, was to understand how people wished to participate.
The team had to take gender norms and convenient meeting times into consideration to enable the participation of both men and women.
As a result, they adapted the intervention by initiating separate men’s and women’s groups.
The Evidence Consortium on Women’s Groups (ECWG)
Our colleagues at the ECWG are dedicated to producing and compiling robust evidence to guide key stakeholders in implementing and strengthening programming and policies on women’s groups, with a particular focus on India, Nigeria and Uganda.
There is much we can learn from the ECWG and apply to our practice of PLA. Their website contains evidence reviews, including new research on women’s savings groups and financial inclusion and livelihoods programmes.
There is also a comprehensive series of blogs and events.
To read more, visit womensgroupevidence.org
Published: May 2021
Improving Maternal, Perinatal, Newborn Health in Goro, Ethiopia
Women and Children First, with Doctors with Africa CUAMM, has recently completed a project in the Goro Woreda, Ethiopia.
Together, they have supported 100 communities, saved a projected 54 lives and benefited 18,276 women, children and adolescents.
The project summary explains the problems, processes, results and lessons learned from using PLA, alongside health systems strengthening, advocacy and Covid-19 response. It is available in the Library section and is in bold.
The three-year project resulted in sizeable improvements in care-seeking, and an increase in use of contraception, from 29% to 54%.
This has shown once again that “PLA groups are a relevant and effective way to stimulate community action on maternal and newborn health.”
Published: April 2021
Key Findings from Scaling PLA Webinar
In March Rajkumar Gope from Ekjut and Joanna Drazdzewska from Women and Children First led a fascinating session around the potential routes to scale for the PLA approach.
Three of the most interesting points included:
1. There is no substitute for governments and markets.
Rajkumar illustrated how under the right conditions health systems are powerful platforms for scale-up. Jo showed how social markets may also have a role to play, when government systems are now well placed, but that these systems raise additional questions regarding fidelity and ownership.
2. Prioritise intermediation.
To deliver PLA at scale, there is need for intermediary organisations specialised in building the capacity of partners in a position to scale up the approach.
These intermediary organisations need to develop a range of tools and approaches to build capacity that maximise fidelity and minimise cost.
Rajkumar presented Ekjut’s ‘odd-even’ training system and Jo outlined Women and Children First’s multi-modal technical assistance package.
3. Plan backwards.
Both Rajkumar and Jo explained how they had imagined PLA at scale and worked backwards to identify how to get there.
For Women and Children First this included finding the right partner and a donor willing to fund the ‘institutionalisation approach’.
For Ekjut this included developing partnerships at all levels – global, national, state, regional, district and block – and including representatives in planning and implementation from the very start.
To gain further insights, including how PLA can reduce rather than increase the workload of community health workers, and how tracking simple metrics can help to manage scale-up programmes, watch the webinar in full.
New Article: Effect of Nutrition-Sensitive Agriculture Interventions
This month The Lancet Planetary Health published a new article on the effects of three nutrition sensitive agriculture interventions on maternal and child nutrition in India – participatory videos delivered through women’s groups, nutrition specific videos and PLA.