Community interventions to reduce child mortality in Dhanusha, Nepal: study protocol for a cluster randomized controlled trial

Background: Neonatal mortality remains high in rural Nepal. Previous work suggests that local women's groups can effect significant improvement through community mobilisation. The possibility of identification and management of newborn infections by community-based workers has also arisen.Methods/Design: The objective of this trial is to evaluate the effects on newborn health of two community-based interventions involving Female Community Health Volunteers.MIRA Dhanusha community groups: a participatory intervention with women's groups. MIRA Dhanusha sepsis management: training of community volunteers in the recognition and management of neonatal sepsis. The study design is a cluster randomized controlled trial involving 60 village development committee clusters allocated 1:1 to two interventions in a factorial design.MIRA Dhanusha community groups: Female Community Health Volunteers (FCHVs) are supported in convening monthly women's groups. Nine groups per cluster (270 in total) work through two action research cycles in which they (i) identify local issues around maternity, newborn health and nutrition, (ii) prioritise key problems, (iii) develop strategies to address them, (iv) implement the strategies, and (v) evaluate their success. Cycle 1 focuses on maternal and newborn health and cycle 2 on nutrition in pregnancy and infancy and associated postpartum care practices. MIRA Dhanusha sepsis management: FCHVs are trained to care for vulnerable newborn infants. They (i) identify local births, (ii) identify low birth weight infants, (iii) identify possible newborn infection, (iv) manage the process of treatment with oral antibiotics and referral to a health facility to receive parenteral gentamicin, and (v) follow up infants and support families.Primary outcome: neonatal mortality rates. Secondary outcomes: MIRA Dhanusha community group: stillbirth, infant and under-two mortality rates, care practices and health care seeking behaviour, maternal diet, breastfeeding and complementary feeding practices, maternal and under-2 anthropometric status. MIRA Dhanusha sepsis management: identification and treatment of neonatal sepsis by community health volunteers, infection-specific neonatal mortality

Do Participatory Learning and Action Women’s Groups Alone or Combined with Cash or Food Transfers Expand Women’s Agency in Rural Nepal?

Participatory learning and action women’s groups (PLA) have proven effective in reducing neonatal mortality in rural, high-mortality settings, but their impacts on women’s agency in the household remain unknown. Cash transfer programmes have also long targeted female beneficiaries in the belief that this empowers women. Drawing on data from 1309 pregnant women in a four-arm cluster-randomised controlled trial in Nepal, we found little evidence for an impact of PLA alone or combined with unconditional food or cash transfers on women’s agency in the household. Caution is advised before assuming PLA women’s groups alone or with resource transfers necessarily empower women

Enhancement of tunneling from a correlated 2D electron system by a many-electron Mossbauer-type recoil in a magnetic field

We consider the effect of electron correlations on tunneling from a 2D electron layer in a magnetic field parallel to the layer. A tunneling electron can exchange its momentum with other electrons, which leads to an exponential increase of the tunneling rate compared to the single-electron approximation. Explicit results are obtained for a Wigner crystal. They provide a qualitative and quantitative explanation of the data on electrons on helium. We also discuss tunneling in semiconductor heterostructures.Comment: published version, 4 pages, 2 figures, RevTeX 3.

[Accepted Manuscript] Formative qualitative research to develop community-based interventions addressing low birth weight in the plains of Nepal.

To explore the factors affecting intra-household food allocation practices to inform the development of interventions to prevent low birth weight in rural plains of Nepal. Qualitative methodology using purposive sampling to explore the barriers and facilitating factors to improved maternal nutrition. Rural Dhanusha District, Nepal. We purposively sampled twenty-five young daughters-in-law from marginalised groups living in extended families and conducted semi-structured interviews with them. We also conducted one focus group discussion with men and one with female community health volunteers who were mothers-in-law. Gender and age hierarchies were important in household decision making. The mother-in-law was responsible for ensuring that a meal was provided to productive household members. The youngest daughter-in-law usually cooked last and ate less than other family members, and showed respect for other family members by cooking only when permitted and deferring to others' choice of food. There were limited opportunities for these women to snack between main meals. Daughters-in-law' movement outside the household was restricted and therefore family members perceived that their nutritional need was less. Poverty affected food choice and families considered cost before nutritional value. It is important to work with the whole household, particularly mothers-in-law, to improve maternal nutrition. We present five barriers to behaviour change: poverty; lack of knowledge about cheap nutritional food, the value of snacking, and cheap nutritional food that does not require cooking; sharing food; lack of self-confidence; and deference to household guardians. We discuss how we have targeted our interventions to develop knowledge, discuss strategies to overcome barriers, engage mothers-in-law, and build the confidence and social support networks of pregnant women

Change in cost and affordability of a typical and nutritionally adequate diet among socio-economic groups in rural Nepal after the 2008 food price crisis

Diet quality is an important determinant of nutrition and food security and access can be constrained by changes in food prices and affordability. Poverty, malnutrition, and food insecurity are high in Nepal and may have been aggravated by the 2008 food price crisis. To assess the potential impact of the food price crisis on the affordability of a nutritionally adequate diet in the rural plains of Nepal, data on consumption patterns and local food prices were used to construct typical food baskets, consumed by four different wealth groups in Dhanusha district in 2005 and 2008. A modelled diet designed to meet household requirements for energy and essential nutrients at minimum cost, was also constructed using the ‘Cost of Diet’ linear programming tool, developed by Save the Children. Between 2005 and 2008, the cost of the four typical food baskets increased by 19% – 26% and the cost of the nutritionally adequate modelled diet increased by 28%. Typical food baskets of all wealth groups were low in macro and micronutrients. Income data for the four wealth groups in 2005 and 2008 were used to assess diet affordability. The nutritionally adequate diet was not affordable for poorer households in both 2005 and 2008. Due to an increase in household income levels, the affordability scenario did not deteriorate further in 2008. Poverty constrained access to nutritionally adequate diets for rural households in Dhanusha, even before the 2008 food price crisis. Despite increased income in 2008, households remain financially unable to meet their nutritional requirements

Validating an Agency-based Tool for Measuring Women’s Empowerment in a Complex Public Health Trial in Rural Nepal

Despite the rising popularity of indicators of women’s empowerment in global development programmes, little work has been done on the validity of existing measures of such a complex concept. We present a mixed methods validation of the use of the Relative Autonomy Index for measuring Amartya Sen’s notion of agency freedom in rural Nepal. Analysis of think-aloud interviews (n = 7) indicated adequate respondent understanding of questionnaire items, but multiple problems of interpretation including difficulties with the four-point Likert scale, questionnaire item ambiguity and difficulties with translation. Exploratory Factor Analysis of a calibration sample (n = 519) suggested two positively correlated factors (r = 0.64) loading on internally and externally motivated behaviour. Both factors increased with decreasing education and decision-making power on large expenditures and food preparation. Confirmatory Factor Analysis on a validation sample (n = 509) revealed good fit (Root Mean Square Error of Approximation 0.05–0.08, Comparative Fit Index 0.91–0.99). In conclusion, we caution against uncritical use of agency-based quantification of women’s empowerment. While qualitative and quantitative analysis revealed overall satisfactory construct and content validity, the positive correlation between external and internal motivations suggests the existence of adaptive preferences. High scores on internally motivated behaviour may reflect internalized oppression rather than agency freedom

Does antenatal micronutrient supplementation improve children’s cognitive function? Evidence from the follow-up of a double-blind randomised controlled trial in Nepal

INTRODUCTION: Multiple Micronutrient (MMN) supplementation during pregnancy can decrease the proportion of infants born low birth weight and small for gestational age. Supplementation could also enhance children’s cognitive function by improving access to key nutrients during fetal brain development and increasing birth weight, especially in areas where undernutrition is common. We tested the hypothesis that children whose mothers received MMN supplementation during pregnancy would have higher intelligence in early adolescence compared with those receiving Iron and Folic Acid (IFA) only. METHODS: We followed up children in Nepal, whose mothers took part in a double-blind Randomised Controlled Trial (RCT) that compared the effects on birth weight and gestational duration of antenatal MMN versus IFA supplementation. We assessed children’s Full Scale Intelligence Quotient (FSIQ) using the Universal Non-verbal Intelligence Test (UNIT), and their executive function using the counting Stroop test. The parent trial was registered as ISRCTN88625934. RESULTS: We identified 813 (76%) of the 1069 children whose mothers took part in the parent trial. We found no differences in FSIQ at 12 years between MMN and IFA groups (absolute difference in means (diff): 1.25, 95% CI −0.57 to 3.06). Similarly, there were no differences in mean UNIT memory (diff: 1.41, 95% CI −0.48 to 3.30), reasoning (diff: 1.17, 95% CI −0.72 to 3.06), symbolic (diff: 0.97, 95% CI −0.67 to 2.60) or non-symbolic quotients (diff: 1.39, 95% CI −0.60 to 3.38). CONCLUSION: Our follow-up of a double-blind RCT in Nepal found no evidence of benefit from antenatal MMN compared with IFA for children’s overall intelligence and executive function at 12 years

Independent Ion Migration in Suspensions of Strongly Interacting Charged Colloidal Spheres

We report on sytematic measurements of the low frequency conductivity in aequous supensions of highly charged colloidal spheres. System preparation in a closed tubing system results in precisely controlled number densities between 1E16/m3 and 1E19/m^3 (packing fractions between 1E-7 and 1E-2) and electrolyte concentrations between 1E-7 and 1E-3 mol/l. Due to long ranged Coulomb repulsion some of the systems show a pronounced fluid or crystalline order. Under deionized conditions we find s to depend linearily on the packing fraction with no detectable influence of the phase transitions. Further at constant packing fraction s increases sublinearily with increasing number of dissociable surface groups N. As a function of c the conductivity shows pronounced differences depending on the kind of electrolyte used. We propose a simple yet powerful model based on independent migration of all species present and additivity of the respective conductivity contributions. It takes account of small ion macro-ion interactions in terms of an effectivly transported charge. The model successfully describes our qualitatively complex experimental observations. It further facilitates quantitative estimates of conductivity over a wide range of particle and experimental parameters.Comment: 32 pages, 17 figures, 2 tables, Accepted by Physical Review