Hamad et al. report that microfinance clients randomized to receive education to promote Integrated Management of Childhood Illnesses (IMCI) showed greater knowledge about child health but no subsequent changes in anthropometric measures or health status of the children of mothers exposed to education for a period of eight months. The authors reasonably conclude that child health education delivered through one microfinance institution (MFI) in Peru was insufficient to improve child health status. However, they go well beyond the scope of the research design and the evidence presented to assert that MFIs may not be an appropriate setting for child health interventions.
In the interest of full disclosure, we point out that we work for Freedom from Hunger, the institution that developed the IMCI education module and trained the MFI (PRISMA) that delivered the education evaluated by this research. Moreover, Freedom from Hunger has trained many MFIs around the world to use this and other health education modules. Freedom from Hunger is a U.S.-based organization that works with MFIs and other organizations to offer both financial and non-financial services (including health education and health protection services) to very poor women. We conduct or support rigorous evaluations of our work to continually improve our products. We work with our implementing partners to address problems of quality of education delivery which have been revealed by our own research as well as that of external researchers such as Hamad et al. However, placing this interest aside and from the perspective of researchers in our own right, we feel it is important to express our concerns about the conclusions reached in this study, given three limitations of the research design.
First, the education delivered by PRISMA focused on helping caregivers recognize the danger signs of common ailments that indicate a child under the age of five years or a child two months old or younger should be taken immediately to a professional health care provider. As the authors mention, many IMCI interventions include several components that include community education, health provider training and health service monitoring and they also might focus on breastfeeding as well as disease prevention and treatment that would be expected to have a direct impact on anthropometric measures, but this particular module does not.
Second, only eleven months elapsed between the baseline data collection (January 2007) and the endline (January–February 2008). Since the education intervention took eight months to complete, this allowed exactly two months over which to assess the impact of the education on the child health status measures. During that two-month period, we would not expect enough severe illness events to occur in the sample population to detect behavior change (see below), much less to have changed health outcomes.
Third, this study did not report health behaviors, which would have been better short-term indicators of impact of this intervention. Without looking at whether children with diarrhea received appropriate home treatment or were taken to the doctor when advised, it is not possible to conclude that this intervention “may have been insufficient to change behavior.” Future research looking at health interventions during short time periods should focus on assessing client outcomes that are possible to influence in the given evaluation time period.
Given these three limitations and the evidence of intended knowledge gain due to the education, we cannot share the authors’ conclusion that MFIs are not a promising platform for delivering health education, especially in light of extensive evidence of success of education and other health interventions by MFIs reported by Leatherman, Metcalfe, Geissler and Dunford (Health Policy and Planning 2011: 1-17).
Bobbi Gray and Megan Gash, Research & Evaluation Specialists, Freedom from Hunger, Davis, CA, USA
Competing interests
The authors of this commentary work for Freedom from Hunger, the organization that developed the IMCI education module and trained the MFI (PRISMA) that delivered the education evaluated by this research.
Research Conclusion Needs Further Review
15 June 2011
Hamad et al. report that microfinance clients randomized to receive education to promote Integrated Management of Childhood Illnesses (IMCI) showed greater knowledge about child health but no subsequent changes in anthropometric measures or health status of the children of mothers exposed to education for a period of eight months. The authors reasonably conclude that child health education delivered through one microfinance institution (MFI) in Peru was insufficient to improve child health status. However, they go well beyond the scope of the research design and the evidence presented to assert that MFIs may not be an appropriate setting for child health interventions.
In the interest of full disclosure, we point out that we work for Freedom from Hunger, the institution that developed the IMCI education module and trained the MFI (PRISMA) that delivered the education evaluated by this research. Moreover, Freedom from Hunger has trained many MFIs around the world to use this and other health education modules. Freedom from Hunger is a U.S.-based organization that works with MFIs and other organizations to offer both financial and non-financial services (including health education and health protection services) to very poor women. We conduct or support rigorous evaluations of our work to continually improve our products. We work with our implementing partners to address problems of quality of education delivery which have been revealed by our own research as well as that of external researchers such as Hamad et al. However, placing this interest aside and from the perspective of researchers in our own right, we feel it is important to express our concerns about the conclusions reached in this study, given three limitations of the research design.
First, the education delivered by PRISMA focused on helping caregivers recognize the danger signs of common ailments that indicate a child under the age of five years or a child two months old or younger should be taken immediately to a professional health care provider. As the authors mention, many IMCI interventions include several components that include community education, health provider training and health service monitoring and they also might focus on breastfeeding as well as disease prevention and treatment that would be expected to have a direct impact on anthropometric measures, but this particular module does not.
Second, only eleven months elapsed between the baseline data collection (January 2007) and the endline (January–February 2008). Since the education intervention took eight months to complete, this allowed exactly two months over which to assess the impact of the education on the child health status measures. During that two-month period, we would not expect enough severe illness events to occur in the sample population to detect behavior change (see below), much less to have changed health outcomes.
Third, this study did not report health behaviors, which would have been better short-term indicators of impact of this intervention. Without looking at whether children with diarrhea received appropriate home treatment or were taken to the doctor when advised, it is not possible to conclude that this intervention “may have been insufficient to change behavior.” Future research looking at health interventions during short time periods should focus on assessing client outcomes that are possible to influence in the given evaluation time period.
Given these three limitations and the evidence of intended knowledge gain due to the education, we cannot share the authors’ conclusion that MFIs are not a promising platform for delivering health education, especially in light of extensive evidence of success of education and other health interventions by MFIs reported by Leatherman, Metcalfe, Geissler and Dunford (Health Policy and Planning 2011: 1-17).
Bobbi Gray and Megan Gash, Research & Evaluation Specialists, Freedom from Hunger, Davis, CA, USA
Competing interests
The authors of this commentary work for Freedom from Hunger, the organization that developed the IMCI education module and trained the MFI (PRISMA) that delivered the education evaluated by this research.