Individual Interventions, Collective Lessons: Developing Mid-range Theory on Women's Groups to Improve Health

"Our theory posits that engagement of sufficient intensity with women's groups that build group or community capabilities can improve health outcomes relevant to the group through individual or collective action."

Public health policy in India promotes community engagement as an important strategy. Two major policy initiatives in India engage women's groups in health interventions: the National Health Mission engages health workers to facilitate participatory learning and action cycles with women in some states, and the National Rural Livelihoods Mission engages women's self-help groups in interventions such as information dissemination on nutrition, maternal health, and linkages with non-communicable disease programmes. This study developed a mid-range theory to predict how interventions with women's groups can improve women and children's health in multiple settings. Mid-range theories sit between working hypotheses about why events unfold in a certain way in a given context and broader theory.

The researchers applied realist principles to develop and refine a mid-range theory on the effectiveness of women's groups interventions. The process followed three phases, through which the researchers:
 

1. Developed preliminary mid-range theories based on three empirical sources: (i) a mixed-methods systematic review published in 2020 that included 44 quantitative impact evaluations and 55 non-experimental studies that examined effects, enablers and barriers related to women's groups interventions in India (see Related Summaries, below); (ii) an analysis of social and behaviour change (SBC) theories relevant to women's groups, which we previously used to develop a published typology of approaches; and (iii) and a mapping of SBC change techniques to interventions, using a taxonomy to categorise 14 types of techniques. During this phase, they also consulted over 30 implementers and stakeholders, including through a roundtable in 2019 and visits to six programmes across different states in India and meetings with experts in women's groups between 2020-2022.
2. Developed in-depth case studies in each domain to contextualise the initial mid-range theories using programme-specific details. Table 1 in the paper describes the programmes used as case studies. For two intervention sites where earlier or ongoing process data were not available, they conducted additional interviews with 14 key informants.
3. Refined the overarching and domain-specific mid-range theories through mapping each intervention onto the mid-range theories, identified consistency and departures to add or remove contextual considerations and mechanisms, and reflected on the process.

This process led to the development of mid-range theories across three areas: maternal and newborn health, nutrition, and violence against women, as well as an overarching mid-range theory on how women's groups can improve health. The latter theory posits that interventions focused on building the capabilities of groups and communities through activities such as joint problem identification or group-based collective action operate differently than interventions that use the group as a platform for individual-level information transfer. Intervention intensity - which includes the proportion of relevant women engaged, duration, length and coverage of meetings and interactions - is an important marker to understand potential effectiveness.

The overarching mid-range theory suggests that effective interventions should: build group or community capabilities; focus on health outcomes relevant to group members; and approach health issues modifiable through women's individual or collective actions.

Finally, the researchers identified four key lessons from the mid-range theories:
 

• Facilitators for women's groups need to be appropriately trained and incentivised.
• Intensity of exposure matters, as does success in reaching the right community members. [For example, in an intervention to address violence against women, implementers often only engaged members of SHGs' federated village organisations rather than mobilising members of the village at large. Identifying survivors of violence is challenging, and survivors generally preferred turning to women they trust. Implementers noted that comparatively few women had approached them for help with gender-based violence compared to the number of women approaching them for help with access to government entitlements, a much less sensitive issue.]
• Not all health outcomes can be improved without significant supply-side strengthening.
• Scaling up requires adapting intervention delivery while maintaining fidelity to intervention theory.

In conclusion, this experience "demonstrated the feasibility of developing mid-range theory from a combination of evidence and insights from practice. It also underscored the importance of community engagement and ongoing research to 'thicken' mid-range theories to design effective and scalable women's groups interventions in India and similar settings."