Women's empowerment and child health: exploring the impact of Rojiroti Microfinance in poor communities in Bihar, Northern India

Every year, 2.2 million children die of malnutrition. Many more feel the effects of malnutrition on their health and intellect. Programmes to combat malnutrition include: distributing food directly; giving children micronutrients; giving nutritional advice; and protecting malnourished children through immunisation. Research by the World Health Organisation (WHO) has shown that these strategies can lead to better nourished children. However, these approaches may fail to reach those most in need (those living in extreme poverty). In very poor countries, where men are dominant, women are often prevented from making important family decisions and this may be linked to poor nutrition in their children.
We are a group of community workers, economists, social scientists and doctors. Our partners are the Centre for Promoting Sustainable Livelihood (CPSL) - which is a non-governmental organisation in India; a UK charity (Rojiroti UK); the School of Sociology & Social Policy; and the School of Medicine (both at the University of Nottingham). Our team have experience of helping very poor people in rural areas of India to fight poverty. Our community workers encourage people in poor hamlets or "tolas" in Northern India to form self help groups (SHGs). Most SHGs are formed by women. They are asked to save a little money regularly, initially Rs2.5 (3 pence) per week. If they save regularly, their savings entitle them to a loan. These loans start small - Rs50 (50 pence). Women in the group can receive external loans (from CPSL) of Rs500 (£5) after 3 months and Rs3,000 (£30) after 6 months (if credit is good). Loans may be used for emergencies (eg medical expenses); to allow women access existing government support schemes (eg money to travel to subsidised food shops); or to invest in livestock or agricultural equipment. Using these loans helps women avoid local money lenders (who charge much higher interest) and avoid emergency sales of their property (at knock down prices). We call this programme Rojiroti (which translates as "daily bread").

We have recently completed a trial which tested whether Rojiroti improves children's health. This was a "cluster randomised trial" where 28 tolas (small village communities) were chosen at random to receive Rojiroti immediately and 28 to get the programme only after 18 months (control group). At the end of the first 18 months (before the control group started) we weighed and measured all the children under 5 in both sets of tolas. We found that the nutritional measures were better in the Rojiroti group. The effect was big enough to be important in practice and was unlikely to have arisen by chance. Overall 1326 mothers and 2064 children took part.

We now want to understand how Rojiroti improved children's nutrition. We also want to know if the scheme helps empower women (improve their status in society and their freedom to make decisions). We have already collected economic data such as whether loans were emergency or general loans, the amount borrowed, the purpose of the loan, whether the loan was repaid. We will carefully check and collate these data. We will also conduct 20 in-depth interviews with women who took part in the Rojiroti trial and around 10 interviews with CPSL volunteers. These interviews will be conducted by an ethnographer (someone who studies different cultures) who will visit Bihar for one month. We will analyse these interviews carefully. The voices of the participants and volunteers, combined with the economic data will allow us to work out what are the essential features of Rojiroti which allow the scheme to benefit children. We will also see whether Rojiroti helps empower women. We hope this will allow others to use Rojiroti in other parts of the work where there is poverty and malnutrition and where women do not get to make important decisions about their lives.

Who will benefit from this research?
A. The global health research community
B. Women living in extreme poverty and their families
C. Users of our findings: Bihar State Government; Non-Governmental Organisations working to alleviate poverty and malnutrition in the region and throughout the world.
D. Rojiroti UK and the Centre for Promoting Sustainable Livelihood (CPSL)
E. Our group of collaborators and planned academic partners such as A N Sinha Institute of Social Sciences; Patna Medical Collage and UNICEF.

How will they benefit?
A. As described under "Academic Beneficiaries", the global health community have already benefitted from the novel approach to consent, described in our published protocol [Trials 2014; 15(1): 298]. It is challenging to obtain valid consent from women living in extreme poverty, many of whom will be illiterate. We hope that this approach will be useful to field investigators, evaluating complex interventions in poor communities.

At the conclusion of the planned qualitative study, we will publish the following papers:
Description of the mechanisms by which Rojiroti microfinance improves child nutrition
A paper exploring whether Rojiroti microfinance leads to the empowerment of SHG members
A paper recording women's narratives of their experience of the Rojiroti process
A mechanistic paper describing the process of partnership building

B. We have already shown that participants in Rojiroti self-help groups (SHGs) experience nutritional benefits for their children (as well as economic benefits for themselves). In our recent trial, we collected data from 1326 mothers and 2064 children, from 56 small village communities (tolas) at 18 month follow up. The women who participated have very limited decision making agency - only 5% of women could travel outside the tola without the permission of a male relative. However, participation in Rojiroti was associated with a better outcome in children's nutritional indices such as weight for height Z score (WHZ) - our primary outcome. Mean WHZ was significantly better in the intervention group (-1.02) vs. control (-1.37; regression coefficient adjusted for clustering beta=0.38, 95% CI 0.16 to 0.61, p=0.001). Significantly fewer children were wasted in the intervention group (122, 18.1%) vs. control (200, 28.5%; odds ratio=0.46, 95% CI 0.28 to 0.74, p=0.002).

Our planned qualitative study will give a voice to these female SHG participants, allowing us to understand whether Rojiroti has helped empower them. Our work will also elucidate the mechanism by which Rojiroti benefitted their children.

C. Our planned qualitative research will allow Rojiroti to be rolled out more widely in Bihar (by the Bihar State Government) and also elsewhere in Northern India. Our findings may be applicable outside Northern India and similar approaches to Rojiroti may be implemented in communities throughout the world, where there is extreme poverty.

D. Both the qualitative data and economic will be used by Rojiroti UK and the (CPSL) to understand better the communities where Rojiroti microfinance is offered.

E. Our findings will allow us to plan future collaborative work with the A N Sinha Institute of Social Sciences, Patna Medical Collage and UNICEF. We have already had preliminary discussions with each of these institutions. The planned workshop at the end of the study will give us a further opportunity to develop these collaborations.