User:Kpotharaju/sandbox

PE Org
My PE org is SNEHA (Society for Nutrition, Education, and Health Action), which is located in Mumbai, India. SNEHA is a non-profit organization of around 500 people founded in 1999 that seeks to improve the health of women and children in urban slums. Their core principles are evidence-based intervention, partnerships with local health centers to scale their model, and self-sustainable programs. For my PE, I anticipate being involved with research into the methods and effects of their interventions, which will likely include reviewing/compiling data from recent studies for publication, preparing evidence summary documents, and conducting impact assessments. I may also be involved with field work collecting data about the women and children served by these programs.

= Wikipedia Article Selection = These are some ideas for my Wikipedia articles.

Chosen article: Women's health in India
I think this article is the most relevant one with regard to the work that SNEHA does to improve health outcomes for women and children. SNEHA works with a variety of issues such as malnutrition, reproductive health, and domestic violence, which are all discussed in this article. I plan to add information about maternal health outcomes to this article.

Family planning in India
This would give a similar background as the article above, but with more focus to family planning and reproductive health that I am probably going to be working with.

Violence against women in India
Part of the mission of my (likely) PE org is to protect women and children from cycles of abuse.

Public health system in India
I have chosen this article because it discusses various drawbacks of the public health system in India. Since SNEHA is a public heath organization that partners with numerous public health facilities Mumbai to scale their intervention models, this article felt relevant to the sector of my PE org's work. I plan to add to the "barriers of access" portion of this article, since a large part of SNEHA's work is improving access to healthcare for women and children.

Primary Health Centre (India)
My PE will potentially involve learning about how access to primary or diagnostic health care can improve long term health outcomes, so this could be a good background for the topic.

Urban Health Resource Centre
This is would be a good way to examine the various methods of providing access to healthcare for people living in urban settlements (such as Mumbai's slums).

Healthcare in India
Mumbai has one of the most robust public health infrastructures in India, so this would allow me to learn about the public services offered to Indian citizens and how that can be improved.

Wikipedia Article Evaluation
I am evaluating the article titled "Primary Health Centre (India)".

Content
The article discusses some of the basic details surrounding Primary Health Centres in India, which are primarily directed towards providing resources to rural communities (so this article may not be entirely relevant to my PE, since I will be working in urban areas in Mumbai). The article indicates that PHCs are one sub-unit of the larger public health system in India. Several of the special operations of the PHCs are highlighted as well, but only one sentence descriptions of each are given. Also, the links provided are somewhat random and haphazard; for example, the article for antivenoms is hyperlinked, but not something like Water supply and sanitation in India. The public health goals of the Alma-Ata declaration are listed to identify the underlying purpose of an initiative like the PHC, but it seems like that section is more of a summary of the declaration than a true explanation of what the functions of the PHC are. Additionally, there is insufficient information provided regarding the locations of the PHCs; while it is mentioned that they are located in rural areas and that there are 28,863 PHCs, there is no explanation of exactly what rural areas have PHCs, how the distribution of these centers is determined, who staffs them, or how many are located in each state. Also, the number of PHCs is sourced from a 2012 government document and could be outdated by now. This article's content could also be improved by adding images of typical PHCs to demonstrate the state of these facilities. Another idea for improving the content of this article could be by discussing the "brain drain" that is causing a lack of qualified primary care staff to serve in these PHCs. Overall, while this article does a good job of providing a basic idea of what a PHC is, there is insufficient information regarding the role that the PHCs play in the Indian public health system or how they function.

Tone
The tone of this article is straightforward and simple. There does not seem to be any particular bias in the viewpoints represented.

Talk Page
This article is part of two WikiProjects: WikiProject India and WikiProject Hospitals. It is rated as Start-Class for both projects, but of low-importance for WikiProject India. There are no other conversations surrounding this topic on the talk page, likely because it is not an article of high importance for the two WikiProjects. Additionally, this article has not been evaluated by WikiProject India since March 2012, which explains why some of the sources are so outdated.

Area
1) Agarwal P, Singh M M, Garg S. Maternal health-care utilization among women in an urban slum in Delhi. Indian J Community Med 2007; 32:203-5.

http://www.ijcm.org.in/article.asp?issn=0970-0218;year=2007;volume=32;issue=3;spage=203;epage=205;aulast=Agarwal

This article examines interviews with around a hundred women from Mumbai's Balmiki Basti slum. Findings included that illiterate women were significantly less likely to receive antenatal or postnatal care. The information presented could be a good starting point for identifying the major obstacles to healthcare access in slum areas.

2) Badge, Vijay Loknath et al. “A cross-sectional study of migrant women with reference to their antenatal care services utilization and delivery practices in an urban slum of Mumbai” Journal of family medicine and primary care vol. 5,4 (2016): 759-764.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5353809/

This article also discusses other reasons for a lack of utilization for antenatal care services. The population studied was a cross-sectional population of migrant women in Mumbai's slums, since many slum residents are from neighboring states and are therefore unfamiliar with the resources available. This could again be useful to familiarize myself with access to antenatal care.

3) Bhate-Deosthali, Padma, et al. “Poor Standards of Care in Small, Private Hospitals in Maharashtra, India: Implications for Public-Private Partnerships for Maternity Care.” Reproductive Health Matters, vol. 19, no. 37, May 2011, pp. 32–41.

https://www.tandfonline.com/doi/full/10.1016/S0968-8080%2811%2937560-X

This study focuses on maternal healthcare provision in the context of issues in the provision of quality care. Maternal health outcomes are significantly impacted by poor record-keeping, limited and outdated equipment, and inadequate patient counseling.

4) Matthews, Zoe, et al. "Village in the city: autonomy and maternal health-seeking among slum populations of Mumbai." A focus on gender: collected papers on gender using DHS data (2005).

 https://www.dhsprogram.com/pubs/pdf/OD32/OD32.pdf#page=75 

This article explores the way varying levels of autonomy (a women's ability to make her own decisions) correlate to utilization of maternal health services. Various factors affect a woman's ability to decide these services, such as her access to transportation to overcome geographical barriers or her influence on her family to make her maternal needs clear and justified. Also, it is shown that overall, residents of urban areas (including slums) utilize healthcare far more than their rural counterparts.

5) Das, Sushmita, et al. "Prospective study of determinants and costs of home births in Mumbai slums." BMC Pregnancy and Childbirth (2010) 10:38.

https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/1471-2393-10-38

This article identifies several of the reasons for preferring home births over institutional deliveries (one of the most common area where maternal health care is under-utilized). These reasons include custom, fear of institutions, and not having company to the hospital or permission to go to a hospital during delivery.

6) Thaddeus, Sereen, and Deborah Maine. “Too Far to Walk: Maternal Mortality in Context.” Social Science & Medicine, Pergamon, 4 July 2002.https://www.sciencedirect.com/science/article/pii/0277953694902267?via%3Dihub

This article was cited by several others as it creates a framework for the main reasons of maternal healthcare under-utilization: 1) delaying the decision to seek care, 2) delaying going to the institution of care, and 3) delaying of the actual care provided.

7) Hussein J, Newlands D, D’Ambruoso L, Thaver I, Talukder R, Besana G. Identifying practices and ideas to improve the implementation of maternal mortality reduction programmes: findings from five South Asian countries. BJOG 2010;117:304–313.

Delegating maternal care duties to midwives (known as dais in India) allows the delivery of crucial services even when trained doctors are not present. Additionally, community health workers are sometimes given monetary incentives to encourage maternal care utilization in the communities they work in. The government may partner with/outsource to private or nonprofit groups to improve the quality of the services it delivers. Lastly, encouraging women to bring a companion during childbirth increases the likelihood of maternal health care utilization.

8) Stephens, Carolyn. "Training Urban Traditional Birth Attendants: Balancing International Policy and Local Reality." Social Science Medicine (1992) 35: 811-817.

Trained traditional birth attendants (dais) can be a valuable resource in urban settings as they are in rural areas, where health infrastructure is unable to meet the needs of pregnant women. Factors that can affect a woman's choice to use a dai include the social status of the dai (such as caste), but not necessarily the dai 's level of training. Ultimately, these birth assistants are necessary to supplement allopathic health providers, though women may choose these providers over a dai.

Sector
1) Rath, Suchitra, et al. “Explaining the Impact of a Women's Group Led Community Mobilisation Intervention on Maternal and Newborn Health Outcomes: the Ekjut Trial Process Evaluation.” BMC International Health and Human Rights, vol. 10, no. 25, 22 Oct. 2010.

https://bmcinthealthhumrights.biomedcentral.com/articles/10.1186/1472-698X-10-25

This article examines the effectiveness of a participatory women’s group in a population of around 115,000 in eastern India (the border districts between Jharkhand and Orissa). Using local facilitators, relevant and appropriate discussion materials, and flexible meeting times, women’s groups were able to increase community mobilization and produce a tangible impact on health outcomes for mothers and newborns.

2) Davis, Lwende Moonzwe, et al. “Women's Empowerment and Its Differential Impact on Health in Low-Income Communities in Mumbai, India.” Global Public Health, vol. 9, 2014, pp. 481–494.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4624628/

This article looks specifically at how increased levels of empowerment, defined in this case as one’s ability to achieve desired outcomes or quality of life, serve to decrease pregnancy-related health problems because they have better control over their own bodies and more mobility. However, empowerment efforts must focus on changing community and cultural norms, not empowerment at the individual level since the latter is likely to fuel conflict with family members.

3) Alcock, Glyn A., et al. “Community-Based Health Programmes: Role Perceptions and Experiences of Female Peer Facilitators in Mumbai's Urban Slums.” Health Education Research, vol. 24, no. 6, 1 Dec. 2009, pp. 957–966.

https://academic.oup.com/her/article/24/6/957/630693

This article discusses the use of peer facilitators to provide emotional support and advice to encourage community members to use available health resources. These workers, called sakhis, serve to seek out information and share it with the community, rather than being a source of knowledge themselves.

4) Sharma, Aradhana, "Crossbreeding Institutions, Breeding Struggle: Women's Employment, Neoliberal Governmentality, and State (Re)Formation in India" (2006). Division II Faculty Publications. 40. https://wesscholar.wesleyan.edu/div2facpubs/40 

This article discusses government involvement in grassroots empowerment movements through partnerships with NGOs, as well as government-organized NGOs (GONGOs). Sharma discusses the hybridization of public-private interventions through the way that the government is working with various other organizations to address empowerment practices.

5) Leslie, Charlie. "India's Community Health Worker Scheme: A Sociological Analysis" (1989). Ancient Science of Life 9:2.

The government of India started the CHW scheme in 1977 as a means of creating a cadre of volunteers who would mediate between the professional government healthcare system and underserved populations. However, CHWs are often improperly trained in promoting public health measures and alternative forms of medicine (though they understood traditional allopathic medicine). Initially, very few volunteers in the program were women, despite women and children comprising the majority of the population served. Because of this, CHWs are ill-equipped to cater to the needs of the populations they serve and are therefore under-utilized.

6) Singh, Nirvikar. "Decentralization And Public Delivery Of Health Care Services In India." Health Affairs 27, no. 4 (2008): 991–1001.

Public service delivery programs such as the CHW initiative are hampered by a lack of monitoring/accountability for volunteers and program operators, a failure to address infrastructural issues generating health issues, and high levels of government corruption.

7) Arima Mishra (2014) ‘Trust and teamwork matter’: Community health workers' experiences in integrated service delivery in India, Global Public Health, 9:8, 960-974, DOI: 10.1080/17441692.2014.934877

A successful CHW program does not solely depend on resources and infrastructure. It is essential that CHWs build trust with the members of the community, as well as work with each other in order to establish a "continuum of care" to ensure that all needs are met. A top-down, bureaucratic approach is not the most effective way of ensuring these sociological factors that greatly impact the success of CHW programs; an example of this is that the bureaucratic focus on very limited measures of health improvement (such as infant mortality) greatly limit the work that CHWs seek to do and also encourage volunteers to cut corners/falsify data.

8) Sulakshana Nandi, Helen Schneider, Addressing the social determinants of health: a case study from the Mitanin (community health worker) programme in India, Health Policy and Planning, Volume 29, Issue suppl_2, September 2014, Pages ii71–ii81, https://doi.org/10.1093/heapol/czu074 

https://academic.oup.com/heapol/article/29/suppl_2/ii71/587209

The Mitanin program is a community health worker program founded in the state of Chhattisgarh in 2002. Most community health worker programs and their evaluation have been with regard to improving health outcomes. However, the female volunteer CHWs in the Mitanin program are an example of workers addressing social determinants of health by working as agents of change in their community and building community empowerment.

9) Ved et al. "How are gender inequalities facing India’s one million ASHAs being addressed? Policy origins and adaptations for the world’s largest all-female community health worker programme." Human Resources for Health (2019) 17:3.

https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-018-0338-0

This article discusses a variety of factors that affect women who volunteer as community health workers, such as the fear of gender-based violence, the perpetuation of existing caste boundaries, and economic insecurity.

[OTHER CONSIDERED ARTICLES]
4) More, Neena Shah et al. "Cluster-randomised controlled trial of community mobilisation in Mumbai slums to improve care during pregnancy, delivery, postpartum and for the newborn." Trials (2008) 9:7. -> Follow up article: More NS, Bapat U, Das S, Alcock G, Patil S, et al. (2012) Community Mobilization in Mumbai Slums to Improve Perinatal Care and Outcomes: A Cluster Randomized Controlled Trial. PLOS Medicine 9(7): e1001257. https://doi.org/10.1371/journal.pmed.1001257 

https://trialsjournal.biomedcentral.com/articles/10.1186/1745-6215-9-7

https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001257

This article relates to my PE org's work because it looks at how groups of women can improve community health, which is similar to what SNEHA's work with the Mahila Arogya Samiti is (empowering groups of women to advocate for their own health). This article was actually based on SNEHA's work and provides evidence for the benefits of these groups.

'''Chandrana S, Zinner D. "Maternal Compliance of Educational Intervention in Urban Slums in India." Journal of Student Research Vol. 6 (2017): 21-30.'''

http://jofsr.com/index.php/path/article/view/376/166

This article is based on SNEHA's work and details various educational intervention methods for improving maternal health literacy, especially in slum populations. The findings encourage community organizers to work more closely with expectant mothers to facilitate healthcare access.

'''Madula et al. "Healthcare provider-patient communication: a qualitative study of women’s perceptions during childbirth." Reproductive Health (2018) 15:135'''

https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-018-0580-x

This article details the impact of healthcare-provider-patient communication on improved maternal healthcare access. Although the study deals with a population in Malawi, the perceptions and barriers to open communication is applicable to low-literacy populations in Mumbai also.

'''Adhikari S, Brendenkamp C. "Monitoring for Nutrition Results in ICDS: Translating Vision into Action." IDS Bulletin (2009) 40:7-77.'''

This article details the implementation of the ICDS (Integrated Child Development Services) and the role that the environment plays with regard to supporting nutrition monitoring in India. Since one of SNEHA's goals is to improve the capacity of anganwadi sevikas to support ICDS services, this could be a valuable insight into the way that this system operates.

'''Das, Sushmita et al. "Intimate partner violence against women during and after pregnancy: a cross-sectional study in Mumbai slums." BMC Public Health (2013) 13:817'''

This article relates to SNEHA's work in preventing violence against women in order to improve their health outcomes and provides insight into various methods of violence prevention in these populations. This could be useful in determining how impactful SNEHA's prevention methods are compared to other means.

Area
Literacy and a lack of familiarity with available resources are two of the biggest reasons that impede women in urban slums from accessing the healthcare that they need, particularly antenatal care. Additionally, there may be cultural influences that lead women to avoid using these resources. For example, some women consider it unnecessary to go to a hospital to deliver their child because their family does not want to go through the effort or they do not know other women who do so. Overall, autonomy -- which is an intersectional concept -- is an important factor in a woman's ability to seek care.

Sector
There are several different issues that affect maternal health outcomes: education, nutrition, domestic violence, and the quality of care itself. Community participatory groups are a key public health intervention method that has been proven to create changes in health behavior, although large population-wide effects have not yet been observed. Many of these groups are created through partnerships between the government and other institutions like NGOs.

Women's health in India (Area) -> Maternal Health
"The lack of maternal health contributes to future economic disparities for mothers and their children. Poor maternal health often affects a child's health in adverse ways and also decreases a woman's ability to participate in economic activities.[26] Therefore, national health programmes such as the National Rural Health Mission (NRHM) and the Family Welfare Programme have been created to address the maternal health care needs of women across India.[26]

Although India has witnessed dramatic growth over the last two decades, maternal mortality remains stubbornly high in comparison to many developing nations [26] As a nation, India contributed nearly 20 percent of all maternal deaths worldwide between 1992 and 2006.[26] The primary reasons for the high levels of maternal mortality are directly related to socioeconomic conditions and cultural constraints limiting access to care.[26]*

However, maternal mortality is not identical across all of India or even a particular state; urban areas often have lower overall maternal mortality due to the availability of adequate medical resources.[26]** For example, states with higher literacy and growth rates tend to have greater maternal health and also lower infant mortality.[26]"- Women's health in India

[This is what is already written in the Wiki article. It is listed under the section titled "Reproductive health" although it mainly discussed maternal health. Perhaps it would be wise to rename the section to something like "Reproductive and maternal health" or simply "Maternal health" since other reproductive issues are not discussed.

** Here, I plan to add further information about the reasons for high levels of maternal mortality and other obstacles to maternal care, particularly in urban areas. This subsection can be titled "Factors affecting maternal care".**

General facts:

-ANC utilization is very low in the first trimester (Badge, Das).

-One of the most important aspects of ANC is institutional deliveries. Most women who do not use ANCs and seek home births use dais to help them at home (Agarwal). Dais are preferred because they are cheaper alternatives to institutional care, particularly for pregnancies with low complications (Stephens). However, healthcare workers such as dais or community health workers (LINK TO SECTOR?) provide an intermediate form of care when professional institutional care is unavailable in resource-poor settings (Hussein et al).

-Overall, urban populations (including slum areas) report higher rates of healthcare utilization than their rural counterparts (Matthews).

---

Factors

Many of the factors affecting the utilization of maternal healthcare, particularly antenatal care, are intersectional.

-Thaddeus & Maine identify the three levels of barriers to care as 1) delaying the decision to seek care, 2) delaying arrival at the institution, and 3) delaying of the care itself.

-Autonomy affects antenatal care-seeking because women who are able to participate actively in decision-making process can choose to go to an institution - the first barrier to care-seeking according to Thaddeus & Maine (Matthews).

-Cultural factors like customs can prevent women from seeking care (Das). Culturally, it may not be considered necessary to receive more than 1-2 ANC visits (especially by older women who are given more respect/autonomy ) (Badge, Matthews).

-> ANC utilization is lower for Muslim women (Badge).

-> ANC utilization is also lower for women in joint families (Badge), lower socioeconomic status, or low literacy rates (Das). Cost of care is an important barrier that leads to preferential use of alternative methods like dais; this could potentially be addressed by providing waivers and exemptions to incentivize utilization (Hussein). -> ENCYCLOPEDIC???

-Distance to a care facility is reported as a significant factor (Badge). This is also related to autonomy because autonomous women can advocate for transportation use to be allocated to them in order to remove geographical distance as an obstacle (Matthews). -> [Is this encyclopedic?] Distance can also result in an inability to reach the institution after the start of labor (Das)

-Poor quality of care also affects utilization (Badge).

-> Private hospitals are increasingly used despite an investment in the Reproductive and Child Health Program. Majority of private hospitals in Mumbai did not have a midwife employed, which is a basic requirement for maternity care institutions. Only half of Mumbai hospitals had qualified doctors to perform Caesarean sections. Other services like blood storage or ambulances were minimally available (Bhate-Deosthali). -> [Too Mumbai-specific?]

QUESTION: Can maternal care and antenatal care be used interchangeably?

Talk page: Encourage discussion of postpartum care.

DRAFT

*"...[Start new paragraph] DELETE: The primary reasons for the high levels of maternal mortality are directly related to socioeconomic conditions and cultural constraints limiting access to care"

Factors contributing to high maternal mortality rates are often associated with utilization of antenatal care (ANC) prior to and during childbirth. Barriers to seeking care include delays in the decision to seek care, arrival at a medical institution, and provision of quality care. Autonomy and empowerment are correlated with the decision to seek care; women who are more actively involved in their family's decision-making processes are able to choose to utilize maternal care resources. As a result, ANC utilization is lower for Muslim women and women in joint families. Custom may also dictate that maternal care is unnecessary, particularly during the first trimester which has the lowest rates of ANC utilization. The cost of institutional care may also cause women to seek alternative care, such as utilizing a dai (traditional birth attendant) during childbirth. Dais are particularly useful options for care in low-resource settings. Arrival at a medical institution is often largely complicated by distance. Women may not have access to transportation, or they may not be able to reach an institution for childbirth after labor has initiated. Even if a woman chooses to seek maternal care and is able to successfully access a medical facility, poor quality of care can deter care utilization. Resources such as midwives, qualified doctors, or ambulances are not readily available at all hospitals; rural areas are especially lacking in these resources, leading to significantly lower ANC utilization compared to urban areas.

** " However, maternal mortality is not identical across all of India or even a particular state; urban areas often have lower overall maternal mortality due to the availability of adequate medical resources" and higher rates of maternal care utilization compared to their rural counterparts.

===============================

Public health system in India (Sector)
** I plan to write about the use of community participatory groups as a public health intervention method. Currently, there is a subsection on government public health initiatives that I think this could fit under.**

-There has been a proven reduction in neonatal mortality in some areas of India through the use of community participatory groups (Rath). Six factors were identified (Rath ):

1) Acceptance of participating in these groups

2) Active participation during skill development

3) Involvement of the community beyond participation in these groups

4) Active inclusion of marginalized communities

5) Recruitment of newly pregnant women to participate

6) Coverage of a large portion of the population.

-While community health workers are often employed to spread public health practices related to disease prevention or health promotion, many communities in India have begun to utilize peer health workers (trained through partnerships with NGOs) that are able to provide advice and support based on their knowledge of the community. These women are called sakhis and are effective health facilitators due to their credibility and familiarity owed to their membership in the community, as well as the fact that groups meet regularly to discuss issues. Because sakhis are peers from the community, they are able to identify with other women and utilize concrete examples to improve health practices (Alcock). Community health workers build trust with the community through methods such as tailoring allopathic health recommendations to fit traditional health beliefs, being involved in the coordination of care for the community, and appropriately providing preventative and curative care. CHWs must also cooperate with each other and with other types of health workers such as dais to encourage healthcare utilization (Mishra).

-CHWs also often serve as leaders and changemakers in their community due to their work on social determinants of health, which can extend to empowering women and demand policy action to address health inequities (Nandi).

-Empowered women are less likely to face health problems because they are 1) more likely to be aware of problems with their health and 2) more likely to seek care to address these problems (Davis). The government has increasingly gotten involved in promoting empowerment through its partnerships with NGOs (particularly Government Organized NGOs, or GONGOs). For example, community participatory groups organized by public-private partnerships organized by the government are an example of government involvement in grass-roots organization and empowerment (Sharma). Recent decentralization has resulted in the relegation of power to local and state governments, which diminishes the reach and strength of programs designed to ensure accountability and monitoring of public health programs (Singh).

-India's community health worker programs originated in 1977 and depended on volunteers to encourage important preventative and curative health practices. An additional responsibility of the volunteers includes mediating between allopathic and traditional/indigenous forms of medicine (Leslie).

DRAFT

The Indian government first began to implement community health worker (CHW) programs in 1977. Community health workers provide advice and support to other women in their community. Sometimes referred to as sakhis, these women capitalize on their familiarity with the community to gain credibility and promote public health measures, usually by leading participatory groups. CHWs also function to mediate between modern allopathic medicine and traditional indigenous forms of healing, such as by tailoring allopathic health recommendations to include and legitimize traditional beliefs. CHWs closely cooperate with each other and with other types of health workers (such as auxiliary nurse midwives) to encourage care utilization and deliver health services. Currently, India's largest CHW program, started in 2005 and now subsumed in the National Health Mission, consists of nearly one million ASHAs (accredited social health activists) at a ratio of one ASHA for every 1000 people in rural villages and marginalized urban communities.

Community health workers and participatory groups have been proven to change health behaviors and impact health outcomes such as neonatal mortality. Factors for these positive changes include active inclusion and recruitment of a large portion of women in the community, engagement and participation during skill development, and involvement of the community beyond group participation. CHWs may also serve as community leaders and change-makers by empowering women and demanding policy action to address health inequities. Addressing these social determinants of health has a direct impact on healthcare utilization. For example, empowered women are less likely to face health problems because they are more likely to be aware of problems with their health and therefore more likely to seek care to address these problems.

This grassroots intervention strategy often involves partnerships with local hospitals or government-organized non-governmental organizations (GONGOs), who train female volunteers from the community and help organize participatory groups. Though proven to be effective, CHW programs can be hampered by a lack of monitoring and accountability as a result of governmental decentralization. CHWs are not government employees but rather volunteers that state governments are responsible for training and financially incentivizing. Health workers may also lack a sufficient understanding of the public health measure they are trying to promote due to inadequate training and resources.