title: Bundling Health Insurance and Microfinance in India: There Cannot be Adverse Selection if There is No Demand. A combined microfinance and training intervention can reduce HIV risk behaviour in young female participants Integrating prevention of acute respiratory infections with micro-credit programme: experience of BRAC, Bangladesh. Assessing the incremental effects of combining economic and health interventions: the IMAGE study in South Africa. Formative Research in School and Community-Based Health Programs and Studies: “State of the Art” and the TAAG Approach Integrating group counseling, cell phone messaging, and participant-generated songs and dramas into a microcredit program increases Nigerian women's adherence to international breastfeeding recommendations. Micro-Loans, Insecticide-Treated Bednets and Malaria: Evidence from a Randomized Controlled Trial in Orissa (India) Effect of women's groups and volunteer peer counselling on rates of mortality, morbidity, and health behaviours in mothers and children in rural Malawi (MaiMwana): a factorial, cluster-randomised controlled trial Effect of a participatory intervention with women's groups on birth outcomes in Nepal: cluster-randomised controlled trial Mobilizing community-based health insurance to enhance awareness & prevention of airborne, vector-borne & waterborne diseases in rural India Health education for microcredit clients in Peru: a randomized controlled trial Can health-insurance help prevent child labor? An impact evaluation from Pakistan. Pitfalls of and controversies in cluster randomization trials. Changes in health indicators related to health promotion and microcredit programs in the Dominican Republic. The equity impact of participatory women’s groups to reduce neonatal mortality in India: secondary analysis of a cluster-randomised trial The effect of increased coverage of participatory women's groups on neonatal mortality in Bangladesh: A cluster randomized trial. Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: a cluster randomised trial Effect of a participatory intervention with women's groups on birth outcomes and maternal depression in Jharkhand and Orissa, India: a cluster-randomised controlled trial Empowering sex workers in India to reduce vulnerability to HIV and sexually transmitted diseases. Evidence-based public health: moving beyond randomized trials. Microfinance against malaria: impact of Freedom from Hunger's malaria education when delivered by rural banks in Ghana. Microcredit, Family Planning Programs, and Contraceptive Behavior: Evidence From a Field Experiment in Ethiopia Understanding the impact of a microfinance-based intervention on women's empowerment and the reduction of intimate partner violence in South Africa. Can social capital be intentionally generated? a randomized trial from rural South Africa. The impact of a comprehensive microfinance intervention on depression levels of AIDS-orphaned children in Uganda. Leveraging microfinance to impact HIV and financial behaviors among adolescents and their mothers in West Bengal: a cluster randomized trial Efficacy of a savings-led microfinance intervention to reduce sexual risk for HIV among women engaged in sex work: a randomized clinical trial.
abstract: Microfinance institutions have started to bundle their basic loans with other financial services , such as health insurance . Using a r and omized control trial in Karnataka , India , we evaluate the impact on loan renewal from m and ating the purchase of actuarially-fair health insurance covering hospitalization and maternity expenses . Bundling loans with insurance led to a 16 percentage points ( 23 percent ) increase in drop-out from microfinance  , as many clients preferred to give up microfinance than pay higher interest rates and receive insurance . In a Pyrrhic victory , the total absence of dem and for health insurance led to there being no adverse selection in insurance enrollment Objective : To assess effects of a combined microfinance and training intervention on HIV risk behavior  among young female participants in rural South Africa . Design : Secondary analysis of quantitative and qualitative data from a cluster r and omized trial , the Intervention with Microfinance for AIDS and Gender Equity study . Methods : Eight villages were pair-matched and r and omly allocated to receive the intervention . At baseline and after 2 years , HIV risk behavior was assessed among female participants aged 14–35 years . Their responses were compared with women of the same age and poverty group from control villages . Intervention effects were calculated using adjusted risk ratios employing village level summaries . Qualitative data collected during the study explored participants ' responses to the intervention including HIV risk behavior . Results : After 2 years of follow-up , when compared with controls , young participants had higher levels of HIV-related communication ( adjusted risk ratio 1.46 , 95 % confidence interval 1.01–2.12 ) , were more likely to have accessed voluntary counseling and testing ( adjusted risk ratio 1.64 , 95 % confidence interval 1.06–2.56 ) , and less likely to have had unprotected sex at last intercourse with a nonspousal partner ( adjusted risk ratio 0.76 , 95 % confidence interval 0.60–0.96 ) . Qualitative data suggest a greater acceptance of intrahousehold communication about HIV and sexuality . Although women noted challenges associated with acceptance of condoms by men , increased confidence and skills associated with participation in the intervention supported their introduction in sexual relationships . Conclusions : In addition to impacts on economic well being , women 's empowerment and intimate partner violence , interventions addressing the economic and social vulnerability of women may contribute to reductions in HIV risk behavior The contribution of acute respiratory infection control project within the framework of micro-credit-based development intervention in promoting maternal knowledge of ARIs in children was assessed . Data came from a cross-sectional survey of 2814 mothers of under 5-y-old children residing in 200 r and omly selected villages in five districts in Bangladesh . Findings revealed that the ARI control project had significant positive effects in raising knowledge of clinical signs and preventive measures . When ARI control project activities were integrated with the credit-based development initiative , maternal knowledge improved even further . The study concludes that the micro-credit programme can be a catalytic agent in raising health knowledge among poor women in developing countries OBJECTIVE To explore whether adding a gender and HIV training programme to microfinance initiatives can lead to health and social benefits beyond those achieved by microfinance alone . METHODS Cross-sectional data were derived from three r and omly selected matched clusters in rural South Africa : ( i ) four villages with 2-year exposure to the Intervention with Microfinance for AIDS and Gender Equity ( IMAGE ) , a combined microfinance-health training intervention ; ( ii ) four villages with 2-year exposure to microfinance services alone ; and ( iii ) four control villages not targeted by any intervention .  Adjusted risk ratios ( aRRs ) employing village-level summaries compared associations between groups in relation to indicators of economic well-being , empowerment , intimate partner violence ( IPV ) and HIV risk behaviour . The magnitude and consistency of aRRs allowed for an estimate of incremental effects . FINDINGS A total of 1409 participants were enrolled , all female , with a median age of 45 . After 2 years , both the microfinance-only group and the IMAGE group showed economic improvements relative to the control group . However , only the IMAGE group demonstrated consistent associations across all domains with regard to women 's empowerment , intimate partner violence and HIV risk behaviour . CONCLUSION The addition of a training component to group-based microfinance programmes may be critical for achieving broader health benefits . Donor agencies should encourage intersectoral partnerships that can foster synergy and broaden the health and social effects of economic interventions such as microfinance Formative research uses qualitative and quantitative methods to provide information for research ers to plan intervention programs . Gaps in the formative research literature include how to define goals , implementation plans , and research questions ; select methods ; analyze data ; and develop interventions . The National Heart , Lung , and Blood Institute funded the Trial of Activity for Adolescent Girls ( TAAG ) , a r and omized , multicenter field trial , to reduce the decline in physical activity in adolescent girls . The goals of the TAAG formative research are to ( a ) describe study communities and schools , ( b ) help design the trial ’s interventions , ( c ) develop effective recruitment and retention strategies , and ( d ) design evaluation instruments . To meet these goals , a variety of methods , including telephone interviews , surveys and checklists , semistructured interviews , and focus group discussion s , are employed . The purpose , method of development , and analyses are explained for each method In northern Nigeria , interventions are urgently needed to narrow the large gap between international breastfeeding recommendations and actual breastfeeding practice s. Studies of integrated microcredit and community health interventions documented success in modifying health behaviors but typically had uncontrolled design s. We conducted a cluster-r and omized controlled trial in Bauchi State , Nigeria , with the aim of increasing early breastfeeding initiation and exclusive breastfeeding among female microcredit clients . The intervention had 3 components . Trained credit officers led monthly breastfeeding learning sessions during regularly scheduled microcredit meetings for 10 mo . Text and voice messages were sent out weekly to a cell phone provided to small groups of microcredit clients ( 5 - 7 women ) . The small groups prepared songs or dramas about the messages and presented them at the monthly microcredit meetings . The control arm continued with the regular microcredit program . R and omization occurred at the level of the monthly meeting groups . Pregnant clients were recruited at baseline and interviewed again when their infants were aged ≥6 mo . Logistic regression models accounting for clustering were used to estimate the odds of performing recommended behaviors . Among the clients who completed the final survey ( n = 390 ) , the odds of exclusive breastfeeding to 6 mo ( OR : 2.4 ; 95 % CI : 1.4 , 4.0 ) and timely breastfeeding initiation ( OR : 2.6 ; 95 % CI : 1.6 , 4.1 ) were increased in the intervention vs. control arm . Delayed introduction of water explained most of the increase in exclusive breastfeeding among clients receiving the intervention . In conclusion , a breastfeeding promotion intervention integrated into microcredit increased the likelihood that women adopted recommended breastfeeding practice s. This intervention could be scaled up in Nigeria , where local organizations provide microcredit to > 500,000 clients . Furthermore , the intervention could be adopted more widely given that > 150 million women , many of childbearing age , are involved in microfinance globally Many severe health risks in developing countries could be substantially reduced with access to appropriate preventive measures . However , the associated costs are often high enough to restrict access among poor households , and free provision through public health campaigns is often not financially feasible . We describe findings from the first large-scale cluster r and omized controlled trial in a developing country context that evaluates the uptake of a health-protecting technology , insecticide-treated bednets ( ITNs ) , through micro-consumer loans , as compared to free distribution and control conditions . Numerous studies have shown that widespread , regular use of ITNs is one the most effective preventive measures against malaria . However , ownership rates remain very low in most malarious areas , including our study areas in rural Orissa ( India ) . Despite the un-subsidized price , 52 percent of sample households purchased at least one ITN  , leading to 16 percent of individuals using a treated net the previous night , relative to only 2 percent in control areas where nets were not offered for sale . However , the increase fell significantly short of the 47 percent previous-night usage rate achieved with free distribution . Most strikingly , we find that neither micro-loans nor free distribution led to improvements in malaria and anemia prevalence , measured using blood tests . We examine and rule out several plausible explanations for this latter finding . We conjecture that insufficient ITN coverage is the most likely explanation , and discuss implication s for public health policy BACKGROUND Women 's groups and health education by peer counsellors can improve the health of mothers and children . We assessed their effects on mortality and breastfeeding rates  in rural Malawi . METHODS We did a 2 × 2 factorial , cluster-r and omised trial in 185,888 people in Mchinji district . 48 equal-sized clusters were r and omly allocated to four groups with a computer-generated number sequence . 24 facilitators guided groups through a community action cycle to tackle maternal and child health problems . 72 trained volunteer peer counsellors  made home visits at five timepoints during pregnancy and after birth to support breastfeeding and infant care . Primary outcomes for the women 's group intervention were maternal , perinatal , neonatal , and infant mortality rates ( MMR , PMR , NMR , and IMR , respectively ) ; and for the peer counselling were IMR and exclusive breastfeeding ( EBF ) rates . Analysis was by intention to treat . The trial is registered as IS RCT N06477126 . FINDINGS We monitored outcomes of 26,262 births between 2005 and 2009 . In a factorial model adjusted only for clustering and the volunteer peer counselling intervention , in women 's group areas , for years 2 and 3 , we noted non-significant decreases in NMR ( odds ratio 0.93 , 0.64 - 1.35 ) and MMR ( 0.54 , 0.28 - 1.04 ) . After adjustment for parity , socioeconomic quintile , and baseline measures , effects were larger for NMR ( 0.85 , 0.59 - 1.22 ) and MMR ( 0.48 , 0.26 - 0.91 ) . Because of the interaction between the two interventions , a stratified analysis was done . For women 's groups , in adjusted analyses , MMR fell by 74 % ( 0.26 , 0.10 - 0.70 ) , and NMR by 41 % ( 0.59 , 0.40 - 0.86 ) in areas with no peer counsellors , but there was no effect in areas with counsellors ( 1.09 , 0.40 - 2.98 , and 1.38 , 0.75 - 2.54 ) . Factorial analysis for the peer counselling intervention for years 1 - 3 showed a fall in IMR of 18 % ( 0.82 , 0.67 - 1.00 ) and an improvement in EBF rates ( 2.42 , 1.48 - 3.96 ) . The results of the stratified , adjusted analysis showed a 36 % reduction in IMR ( 0.64 , 0.48 - 0.85 ) but no effect on EBF ( 1.18 , 0.63 - 2.25 ) in areas without women 's groups , and in areas with women 's groups there was no effect on IMR ( 1.05 , 0.82 - 1.36 ) and an increase in EBF ( 5.02 , 2.67 - 9.44 ) . The cost of women 's groups was US$ 114 per year of life lost ( YLL ) averted and that of peer counsellors was $ 33 per YLL averted , using stratified data from single intervention comparisons . INTERPRETATION Community mobilisation through women 's groups and volunteer peer counsellor health education are methods to improve maternal and child health outcomes in poor rural population s in Africa . FUNDING Saving Newborn Lives , UK Department for International Development , and Wellcome Trust BACKGROUND Neonatal deaths in developing countries make the largest contribution to global mortality in children younger than 5 years . 90 % of deliveries in the poorest quintile of households happen at home . We postulated that a community-based participatory intervention could significantly reduce neonatal mortality rates . METHODS We pair-matched 42 geopolitical clusters in Makwanpur district , Nepal , selected 12 pairs r and omly , and r and omly assigned one of each pair to intervention or control . In each intervention cluster ( average population 7000 ) , a female facilitator convened nine women 's group meetings every month . The facilitator supported groups through an action-learning cycle in which they identified local perinatal problems and formulated strategies to address them . We monitored birth outcomes in a cohort of 28?931 women , of whom 8 % joined the groups . The primary outcome was neonatal mortality rate . Other outcomes included stillbirths and maternal deaths , uptake of antenatal and delivery services , home care practice s , infant morbidity , and health-care seeking . Analysis was by intention to treat . The study is registered as an International St and ard R and omised Controlled Trial , number IS RCT N31137309 . FINDINGS From 2001 to 2003 , the neonatal mortality rate was 26.2 per 1000 ( 76 deaths per 2899 livebirths ) in intervention clusters compared with 36.9 per 1000 ( 119 deaths per 3226 livebirths ) in controls ( adjusted odds ratio 0.70 [ 95 % CI 0.53 - 0.94 ] ) . Stillbirth rates were similar in both groups . The maternal mortality ratio was 69 per 100000 ( two deaths per 2899 livebirths ) in intervention clusters compared with 341 per 100000 ( 11 deaths per 3226 livebirths ) in control clusters ( 0.22 [ 0.05 - 0.90 ] ) . Women in intervention clusters were more likely to have antenatal care , institutional delivery , trained birth attendance , and hygienic care than were controls . INTERPRETATION Birth outcomes in a poor rural population improved greatly through a low cost , potentially sustainable and scalable , participatory intervention with women 's groups Background & Objectives : Despite remarkable progress in airborne , vector-borne and waterborne diseases in India , the morbidity associated with these diseases is still high . Many of these diseases are controllable through awareness and preventive practice . This study was an attempt to evaluate the effectiveness of a preventive care awareness campaign in enhancing knowledge related with airborne , vector-borne and waterborne diseases , carried out in 2011 in three rural communities in India ( Pratapgarh and Kanpur-Dehat in Uttar Pradesh and Vaishali in Bihar ) . Methods : Data for this analysis were collected from two surveys , one done before the campaign and the other after it , each of 300 r and omly selected households drawn from a larger sample of Self-Help Groups ( SHGs ) members invited to join community-based health insurance ( CBHI ) schemes . Results : The results showed a significant increase both in awareness ( 34 % , p<0.001 ) and in preventive practice s ( 48 % , P=0.001 ) , suggesting that the awareness campaign was effective . However , average practice scores ( 0.31 ) were substantially lower than average awareness scores ( 0.47 ) , even in post campaign . Awareness and preventive practice s were less prevalent in vector-borne diseases than in airborne and waterborne diseases . Education was positively associated with both awareness and practice scores . The awareness scores were positive and significant determinants of the practice scores , both in the pre- and in the post-campaign results . Affiliation to CBHI had significant positive influence on awareness and on practice scores in the post-campaign period . Interpretation & Conclusions : The results suggest that well-crafted health educational campaigns can be effective in raising awareness and promoting health-enhancing practice s in re source -poor setting s. It also confirms that CBHI can serve as a platform to enhance awareness to risks of exposure to airborne , vector-borne and waterborne diseases , and encourage preventive practice Background Poverty , lack of female empowerment , and lack of education are major risk factors for childhood illness worldwide . Microcredit programs , by offering small loans to poor individuals , attempt to address the first two of these risk factors , poverty and gender disparity . They provide clients , usually women , with a means to invest in their businesses and support their families . This study investigates the health effects of also addressing the remaining risk factor , lack of knowledge about important health issues , through r and omization of members of a microcredit organization to receive a health education module based on the World Health Organization 's Integrated Management of Childhood Illness ( IMCI ) community intervention . Methods Baseline data were collected in February 2007 from clients of a microcredit organization in Pucallpa , Peru ( n = 1,855 ) and their children ( n = 598 ) . Loan groups , consisting of 15 to 20 clients , were then r and omly assigned to receive a health education intervention involving eight monthly 30-minute sessions given by the organization 's loan officers at monthly loan group meetings . In February 2008 , follow-up data were collected , and included assessment s of sociodemographic information , knowledge of child health issues , and child health status ( including child height , weight , and blood hemoglobin levels ) . To explore the effects of treatment ( i.e. , participation in the health education sessions ) on the key outcome variables , multivariate regressions were implemented using ordinary least squares . Results Individuals in the IMCI treatment arm demonstrated more knowledge about a variety of issues related to child health , but there were no changes in anthropometric measures or reported child health status . Conclusions Microcredit clients r and omized to an IMCI educational intervention showed greater knowledge about child health , but no differences in child health outcomes compared to controls . These results imply that the intervention did not have sufficient intensity to change behavior , or that microcredit organizations may not be an appropriate setting for the administration of child health educational interventions of this type . Trial Registration This study is registered with Clinical Trials.gov , NCT01047033 Child labor is a common consequence of economic shocks in developing countries . We show that reducing vulnerability can affect child labor outcomes . We exploit the extension of a health and accident insurance scheme by a Pakistani microfinance institution  that was set up as a r and omized controlled trial and accompanied by household panel surveys . Together with increased coverage the microfinance institution offered assistance with cl aim procedures in treatment branches . We find lower incidence of child labor , hazardous occupations and child labor earnings caused by the innovation . Boys are more often engaged in child labor in our sample , but also seem to profit more from the insurance innovation It is now well known that st and ard statistical procedures become invali date d when applied to cluster r and omized trials in which the unit of inference is the individual . A result ing consequence is that research ers conducting such trials are faced with a multitude of design choices , including selection of the primary unit of inference , the degree to which clusters should be matched or stratified by prognostic factors at baseline , and decisions related to cluster subsampling . Moreover , application of ethical principles developed for individually r and omized trials may also require modification . We discuss several topics related to these issues , with emphasis on the choices that must be made in the planning stages of a trial and on some potential pitfalls to be avoided OBJECTIVE To assess the impact of health promotion programs and microcredit programs on three communities in the Dominican Republic . One community had only the health promotion program , one community had only the microcredit program , and one community had both a health promotion program and a microcredit program .  This pilot project examined the hypothesis that the largest changes in 11 health indicators that were studied would be in the community with both a health promotion program and a microcredit program , that there would be intermediate changes in the community with only a health promotion program , and that the smallest changes would be in the community with only a microcredit program . METHODS The health promotion programs used  community volunteers  to address two major concerns : ( 1 ) the prevalent causes of mortality among children under 5 years of age and ( 2 ) women 's health ( specifically breast and cervical cancer screening ) . The microcredit program made small loans to individuals to start or exp and small businesses . Outcome measures were based on comparisons for 11 health indicators from baseline community surveys ( 27 households surveyed in each of the three communities , done in December 2000 and January 2001 ) and from follow-up surveys ( also 27 households surveyed in each of the three communities , in June and July 2002 , after the health promotion program had been operating for about 13 months ) . Households were r and omly chosen during both the baseline and follow-up surveys , without regard to their involvement in the microcredit or health promotion programs . RESULTS The health indicators improved in all three communities . However , the degree of change was different among the communities ( P < 0.001 ) . The community with parallel microcredit and health promotion programs had the largest changes for 10 of the 11 health indicators . CONCLUSIONS Multisector development is known to be important on a macroeconomic scale . The results of this pilot project support the view that multisector development is also important on a microeconomic level , given that the parallel microcredit and health promotion programs result ed in greater change in the measured health indicators than either program alone . As far as we authors know , this is the first published study to quantify changes in health indicators related to parallel health promotion and microcredit programs as compared to control communities with only a health promotion program or a microcredit program Progress towards the Millennium Development Goals ( MDGs ) has been uneven . Inequalities in child health are large and effective interventions rarely reach the most in need . Little is known about how to reduce these inequalities . We describe and explain the equity impact of a  women ’s group intervention in India that strongly reduced the neonatal mortality rate ( NMR )  in a cluster-r and omised trial . We conducted secondary analyses of the trial data , obtained through prospect i ve surveillance of a population of 228 186 . The intervention effects were estimated separately , through r and om effects logistic regression , for the most and less socio-economically marginalised groups . Among the most marginalised , the NMR was 59 % lower in intervention than in control clusters in years 2 and 3 ( 70 % , year 3 ) ; among the less marginalised , the NMR was 36 % lower ( 35 % , year 3 ) . The intervention effect was stronger among the most than among the less marginalised ( P-value for difference = 0.028 , years 2 - 3 ; P-value for difference = 0.009 , year 3 ) . The stronger effect was concentrated in winter , particularly for early NMR . There was no effect on the use of health-care services in either group , and improvements in home care were comparable . Participatory community interventions can substantially reduce socio-economic inequalities in neonatal mortality and contribute to an equitable achievement of the unfinished MDG agenda IMPORTANCE Community-based interventions can reduce  neonatal mortality  when health systems are weak . Population coverage of target groups may be an important determinant of their effect on behavior and mortality . A women 's group trial at coverage of 1 group per 1414 population in rural Bangladesh showed no effect on neonatal mortality , despite a similar intervention having a significant effect on neonatal and maternal death in comparable setting s. OBJECTIVE To assess the effect of a participatory women 's group intervention with higher population coverage on  neonatal mortality  in Bangladesh . DESIGN A cluster r and omized controlled trial in 9 intervention and 9 control clusters . SETTING Rural Bangladesh . PARTICIPANTS Women permanently residing in 18 unions in 3 districts and accounting for 19 301 births during the final 24 months of the intervention .  INTERVENTIONS Women 's groups at a coverage of 1 per 309 population that proceed through a participatory learning and action cycle in which they prioritize issues that affected maternal and neonatal health and design and implement strategies to address these issues . MAIN OUTCOMES AND MEASURES Neonatal mortality rate . RESULTS Analysis included 19 301 births during the final 24 months of the intervention . More than one-third of newly pregnant women joined the groups . The neonatal mortality rate was significantly lower in the intervention arm ( 21.3 neonatal deaths per 1000 live births vs 30.1 per 1000 in control areas ) , a reduction in neonatal mortality of 38 % ( risk ratio , 0.62 [ 95 % CI , 0.43 - 0.89 ] ) when adjusted for socioeconomic factors . The cost-effectiveness was US $ 220 to $ 393 per year of life lost averted . Cause-specific mortality rates suggest reduced deaths due to infections and those associated with prematurity/low birth weight . Improvements were seen in hygienic home delivery practice s , newborn thermal care , and breastfeeding practice s. CONCLUSIONS AND RELEVANCE Women 's group community mobilization , delivered at adequate population coverage , is a highly cost-effective approach to improve newborn survival and health behavior indicators in rural Bangladesh . TRIAL REGISTRATION is rct n.org Identifier : IS RCT N01805825 BACKGROUND HIV infection and intimate-partner violence share a common risk environment in much of southern Africa . The aim of the Intervention with Microfinance for AIDS and Gender Equity ( IMAGE ) study was to assess a structural intervention that combined a microfinance programme with a gender and HIV training curriculum . METHODS Villages in the rural Limpopo province of South Africa were pair-matched and r and omly allocated to receive the intervention at study onset ( intervention group , n=4 ) or 3 years later ( comparison group , n=4 ) . Loans were provided to poor women who enrolled in the intervention group . A participatory learning and action curriculum was integrated into loan meetings , which took place every 2 weeks . Both arms of the trial were divided into three groups :  direct programme participants or matched controls ( cohort one ) , r and omly selected 14 - 35-year-old household co-residents ( cohort two ) , and r and omly selected community members ( cohort three ) . Primary outcomes were experience of intimate-partner violence -- either physical or sexual -- in the past 12 months by a spouse or other sexual intimate ( cohort one ) , unprotected sexual intercourse at last occurrence with a non-spousal partner in the past 12 months ( cohorts two and three ) , and HIV incidence ( cohort three ) . Analyses were done on a per- protocol basis . This trial is registered with Clinical Trials.gov , number NCT00242957 . FINDINGS In cohort one , experience of intimate-partner violence was reduced by 55 % ( adjusted risk ratio [ aRR ] 0.45 , 95 % CI 0.23 - 0.91 ; adjusted risk difference -7.3 % , -16.2 to 1.5 ) . The intervention did not affect the rate of unprotected sexual intercourse with a non-spousal partner in cohort two ( aRR 1.02 , 0.85 - 1.23 ) , and there was no effect on the rate of unprotected sexual intercourse at last occurrence with a non-spousal partner ( 0.89 , 0.66 - 1.19 ) or HIV incidence ( 1.06 , 0.66 - 1.69 ) in cohort three . INTERPRETATION A combined microfinance and training intervention can lead to reductions in levels of intimate-partner violence in programme participants . Social and economic development interventions have the potential to alter risk environments for HIV and intimate-partner violence in southern Africa BACKGROUND Community mobilisation through participatory women 's groups might improve birth outcomes in poor rural communities . We therefore assessed this approach in a largely tribal and rural population in three districts in eastern India . METHODS From 36 clusters in Jharkh and and Orissa , with an estimated population of 228 186 , we assigned 18 clusters to intervention or control using stratified r and omisation . Women were eligible to participate if they were aged 15 - 49 years , residing in the project area , and had given birth during the study . In intervention clusters , a facilitator convened 13 groups every month to support participatory action and learning for women , and facilitated the development and implementation of strategies to address maternal and newborn health problems . The primary outcomes were reductions in neonatal mortality rate ( NMR ) and maternal depression scores . Analysis was by intention to treat . This trial is registered as an International St and ard R and omised Controlled Trial , number IS RCT N21817853 . FINDINGS After baseline surveillance of 4692 births , we monitored outcomes for 19 030 births during 3 years ( 2005 - 08 ) . NMRs per 1000 were 55.6 , 37.1 , and 36.3 during the first , second , and third years , respectively , in intervention clusters , and 53.4 , 59.6 , and 64.3 , respectively , in control clusters . NMR was 32 % lower in intervention clusters adjusted for clustering , stratification , and baseline differences ( odds ratio 0.68 , 95 % CI 0.59 - 0.78 ) during the 3 years , and 45 % lower in years 2 and 3 ( 0.55 , 0.46 - 0.66 ) . Although we did not note a significant effect on maternal depression overall , reduction in moderate depression was 57 % in year 3 ( 0.43 , 0.23 - 0.80 ) . INTERPRETATION This intervention could be used with or as a potential alternative to health-worker-led interventions , and presents new opportunities for policy makers to improve maternal and newborn health outcomes in poor population s. FUNDING Health Foundation , UK Department for International Development , Wellcome Trust , and the Big Lottery Fund ( UK ) The Sonagachi Project was initiated in Kolkata , India in 1992 as a  STD/HIV intervention for sex workers . The project evolved to adopt strategies common to women 's empowerment programs globally ( i.e. , community mobilization , rights-based framing , advocacy , micro-finance ) to address common factors that support effective , evidence -based HIV/STD prevention . The Sonagachi model is now a broadly diffused evidence -based empowerment program . We previously demonstrated significant condom use increases among female sex workers in a 16 month replication trial of the Sonagachi empowerment intervention ( n=110 ) compared to a control community ( n=106 ) receiving st and ard care of STD clinic , condom promotion , and peer education in two r and omly assigned rural towns in West Bengal , India ( Basu et al. , 2004 ) . This article examines the intervention 's impacts on 21 measured variables reflecting five common factors of effective HIV/STD prevention programs to estimate the impact of empowerment strategies on HIV/STD prevention program goals . The intervention which was conducted in 2000 - 2001 significantly : 1 ) improved knowledge of STDs and condom protection from STD and HIV , and maintained STD/HIV risk perceptions despite treatment ; 2 ) provided a frame to motivate change based on reframing sex work as valid work , increasing disclosure of profession , and instilling a hopeful future orientation reflected in desire for more education or training ; 3 ) improved skills in sexual and workplace negotiations reflected in increased refusal , condom decision-making , and ability to change work contract , but not ability to take leave ; 4 ) built social support by increasing social interactions outside work , social function participation , and helping other sex workers ; and 5 ) addressed environmental barriers of economic vulnerabilities by increasing savings and alternative income , but not working in other locations , nor reduced loan taking , and did not increase voting to build social capital . This study 's results demonstrate that , compared to narrowcast clinical and prevention services alone , empowerment strategies can significantly impact a broader range of factors to reduce vulnerability to HIV/STDs R and omized controlled trials ( RCTs ) are essential for evaluating the efficacy of clinical interventions , where the causal chain between the agent and the outcome is relatively short and simple and where results may be safely extrapolated to other setting s. However , causal chains in public health interventions are complex , making RCT results subject to effect modification in different population s. Both the internal and external validity of RCT findings can be greatly enhanced by observational studies using adequacy or plausibility design s. For evaluating large-scale interventions , studies with plausibility design s are often the only feasible option and may provide valid evidence of impact . There is an urgent need to develop evaluation st and ards and protocol s for use in circumstances where RCTs are not appropriate A community r and omized pre-test/post-test design was used to compare the knowledge and behaviors of  microfinance clients receiving malaria education ( n=213 ) to those receiving diarrhea education ( n=223 ) and to non-client controls ( n=268 ) . Comparisons assessed differences at follow-up as well as within-group changes over time . At follow-up , malaria clients had significantly better malaria knowledge than comparison groups : 48.4 % of malaria clients were able to identify groups most vulnerable to malaria compared with 39.2 % of diarrhea clients ( P=0.044 ) and 37.7 % of non-clients ( P=0.024 ) . Malaria clients were more likely than diarrhea clients ( P=0.024 ) ( P<0.001 ) and non-clients ( P=0.028 ) ( P=0.004 ) to report that insecticide-treated nets ( ITNs ) provide the best protection against malaria , and to agree that pregnant women should use ITNs , respectively . Between baseline and follow-up , malaria clients were most likely to : improve in knowledge of malaria complications during pregnancy ; to own at least one bed net ; and to report at least one child or woman of reproductive age sleeping under a bed net . Malaria clients also experienced the greatest increases in ITN ownership/use ( 9 % vs. 2.9 % and 6.7 % among diarrhea clients and non-clients ) . Results indicate that , although significant barriers to malaria control remain , a malaria education program provided by microfinance institutions can effectively contribute to community and national malaria initiatives The impact of community-based family planning programs and access to credit on contraceptive use , fertility , and family size preferences has not been established conclusively in the literature . We provide additional evidence on the possible effect of such programs by describing the results of a r and omized field experiment whose main purpose was to increase the use of contraceptive methods in rural areas of Ethiopia . In the experiment , administrative areas were r and omly allocated to one of three intervention groups or to a fourth control group . In the first intervention group , both credit and family planning services were provided and the credit officers also provided information on family planning . Only credit or family planning services , but not both , were provided in the other two intervention groups , while areas in the control group received neither type of service . Using pre- and post-intervention surveys , we find that neither type of program , combined or in isolation , led to an increase in contraceptive use that is significantly greater than that observed in the control group . We conjecture that the lack of impact has much to do with the mismatch between women ’s preferred contraceptive method ( injectibles ) and the contraceptives provided by community-based agents ( pills and condoms ) OBJECTIVES We sought to obtain evidence about the scope of women 's empowerment and the mechanisms underlying the significant reduction in  intimate partner violence  documented by the Intervention With Microfinance for AIDS and Gender Equity ( IMAGE ) cluster-r and omized trial in rural South Africa . METHODS The IMAGE intervention combined a microfinance program with participatory training on underst and ing HIV infection , gender norms , domestic violence , and sexuality . Outcome measures included past year 's experience of intimate partner violence and 9 indicators of women 's empowerment . Qualitative data about changes occurring within intimate relationships , loan groups , and the community were also collected . RESULTS After 2 years , the risk of past-year physical or sexual violence by an intimate partner was reduced by more than half ( adjusted risk ratio=0.45 ; 95 % confidence interval=0.23 , 0.91 ) . Improvements in all 9 indicators of empowerment were observed . Reductions in violence result ed from a range of responses enabling women to challenge the acceptability of violence , expect and receive better treatment from partners , leave abusive relationships , and raise public awareness about intimate partner violence . CONCLUSIONS Our findings , both qualitative and quantitative , indicate that economic and social empowerment of women can contribute to reductions in intimate partner violence While much descriptive research has documented positive associations between social capital and a range of economic , social and health outcomes , there have been few intervention studies to assess whether social capital can be intentionally generated . We conducted an intervention in rural South Africa that combined group-based microfinance with participatory gender and HIV training in an attempt to catalyze changes in solidarity , reciprocity and social group membership as a means to reduce women 's vulnerability to intimate partner violence and HIV . A cluster r and omized trial was used to assess intervention effects among eight study villages . In this paper , we examined effects on structural and cognitive social capital among 845 participants and age and wealth matched women from households in comparison villages . This was supported by a diverse portfolio of qualitative research . After two years , adjusted effect estimates indicated higher levels of structural and cognitive social capital in the intervention group than the comparison group , although confidence intervals were wide . Qualitative research illustrated the ways in which economic and social gains enhanced participation in social groups , and the positive and negative dynamics that emerged within the program . There were numerous instances where individuals and village loan centres worked to address community concerns , both working through existing social networks , and through the establishment of new partnerships with local leadership structures , police , the health sector and NGOs . This is among the first experimental trials suggesting that social capital can be exogenously strengthened . The implication s for community interventions in public health are further explored PURPOSE By adversely affecting family functioning and stability , poverty constitutes an important risk factor for children 's poor mental health functioning . This study examines the impact of a comprehensive microfinance intervention , design ed to reduce the risk of poverty , on depression among AIDS-orphaned youth . METHODS Children from 15 comparable primary schools in Rakai District of Ug and a , one of those hardest hit by HIV/AIDS in the country , were r and omly assigned to control ( n = 148 ) or treatment ( n = 138 ) conditions . Children in the treatment condition received a comprehensive microfinance intervention comprising matched savings accounts , financial management workshops , and mentorship . This was in addition to traditional services provided for all school-going orphaned adolescents ( counseling and school supplies ) . Data were collected at wave 1 ( baseline ) , wave 2 ( 10 months after intervention ) , and wave 3 ( 20 months after intervention ) . We used multilevel growth models to examine the trajectory of depression in treatment and control conditions , measured using Children 's Depression Inventory ( Kovacs ) . RESULTS Children in the treatment group exhibited a significant decrease in depression , whereas their control group counterparts showed no change in depression . CONCLUSIONS The findings indicate that over and above traditional psychosocial approaches used to address mental health functioning among orphaned children in sub-Saharan Africa , incorporating poverty alleviation-focused approaches , such as this comprehensive microfinance intervention , has the potential to improve psychosocial functioning of these children Abstract Microfinance can be used to reach women and adolescent girls with HIV prevention education . We report findings from a cluster-r and omized control trial among 55 villages in West Bengal to determine the impact of non-formal education on knowledge , attitudes and behaviors for HIV prevention and savings . Multilevel regression models were used to evaluate differences between groups for key outcomes while adjusting for cluster correlation and differences in baseline characteristics . Women and girls who received HIV education  showed significant gains in HIV knowledge , awareness that condoms can prevent HIV , self-efficacy for HIV prevention , and confirmed use of clean needles , as compared to the control group . Condom use was rare and did not improve for women . While HIV testing was uncommon , knowledge of HIV-testing re sources significantly increased among girls , and trended in the positive direction among women in intervention groups . Conversely , the savings education showed no impact on financial knowledge or behavior change OBJECTIVES We tested whether a structural intervention combining savings-led microfinance and HIV prevention components would achieve enhanced reductions in sexual risk among women engaging in street-based sex work in Ulaanbaatar , Mongolia , compared with an HIV prevention intervention alone . METHODS Between November 2011 and August 2012 , we r and omized 107 eligible women who completed baseline assessment s to either a 4-session HIV sexual risk reduction intervention ( HIVSRR ) alone ( n=50 ) or a 34-session HIVSRR plus a savings-led microfinance intervention ( n=57 ) . At 3- and 6-month follow-up assessment s , participants reported unprotected acts of vaginal intercourse with paying partners and number of paying partners with whom they engaged in sexual intercourse in the previous 90 days . Using Poisson and zero-inflated Poisson model regressions , we examined the effects of assignment to treatment versus control condition on outcomes . RESULTS At 6-month follow-up , the HIVSRR plus microfinance participants reported significantly fewer paying sexual partners and were more likely to report zero unprotected vaginal sex acts with paying sexual partners . CONCLUSIONS Findings advance the HIV prevention repertoire for women , demonstrating that risk reduction may be achieved through a structural intervention that relies on asset building , including savings , and alternatives to income from sex work
target: Results Most interventions combined microfinance with health education , which demonstrated positive effects on health knowledge and behaviours , though not health status .
  Interventions combining multiple health components in a given study demonstrated positive effects , though it was unclear which component was driving the effect .
  Discussion Integrated microfinance and health education programs were effective , though longer intervention periods are necessary to measure more complex pathways to health status .
  The effect of microfinance combined with other health components was less clear .
background: Background Solutions delivered within firm sectoral boundaries are inadequate in achieving income security and better health for poor population s.  Integrated microfinance and health interventions leverage networks of women to promote financial inclusion , build livelihoods , and safeguard against high cost illnesses .
  Our underst and ing of the effect of integrated interventions has been limited by variability in intervention , outcome , design , and method ological rigour .
  This systematic review synthesis es the literature through 2015 to underst and the effect of  integrated microfinance and health programs .