Maternal Health Literacy, Pilot Project, Kerala- Final Report

Maternal Health Literacy
Pilot Project, Kerala
Final Report

Maternal Health Literacy Pilot Project, Kerala
Final Report
Ver: Final

Principal author: Birth for Change (BfC)
Contributing authors: Network for Information & Digital Access
(NIDA)
Graphics: Carol Usher BfC/NIDA

This work is licensed under a Attribution-NoDerivs 3.0 Unported

Maternal Health Literacy Pilot Project, Kerala - Final Report

Contents

1. Introduction .......................................................................................................................... 3
2. First investigations – situation report .................................................................................... 3
3. Method ................................................................................................................................. 4
4. The Health Literacy intervention ........................................................................................... 5
4.1 Clinic ...................................................................................................................................... 5
4.2 Classes ................................................................................................................................... 6
5. Findings of impact evaluation ............................................................................................... 7
5.1 Class participants ................................................................................................................... 7
5.2 Clinic participants .................................................................................................................. 8
5.3 Control Group ........................................................................................................................ 8
6. Statistical testing for significant differences ........................................................................ 11
7. Methodological issues and limitations ................................................................................ 12
8. Conclusions ......................................................................................................................... 13
References ................................................................................................................................ 13
Appendix 1: Pre and Post impact questions ............................................................................... 14
Appendix 2: Class Outline .......................................................................................................... 16

Maternal Health Literacy Pilot Project, Kerala - Final Report 3
1. Introduction
The aim of this project was to assess and evaluate the impact of a series of health education classes and
clinic interventions in Udaya, a slum community in Cochin, Kerala, South India, to gather information
regarding the health literacy of the women in the community and how this could be improved. The starting
point was a maternal health survey carried out within the slum colony in April 2017 by the Birth for Change
foundation (BfC), who planned to postulate an information encounter approach to address the problem
and to increase ‘health literacy’. In addition, they planned to develop some training resources, run health
education classes and health clinic encounters as well as design and carry out an evaluation of the impact
and recommend what should happen next.
2. First investigations – situation report
A meeting between a sister from the 'Sisters of the Destitute' convent and Birth for Change took place in
late January 2017. The sister had worked with the slum colonies since 1993 when she first moved to the
convent. In that time, she had provided some tuition for children and ran a girl’s music band. In her view,
the women wouldn’t need an incentive to come or take part. She reported that they were keen to access
health care but there was not much available to them.
The sister informed the BfC team that:
• Udaya colony had 124 families living in it, but close by are 3 other colonies- one of 300, one of 64
and one of 15 families (the last one she described as ‘unlivable’ because of the bad conditions
leading to the families having alcohol problems. There is a major problem with overflowing from
the stagnant, highly polluted canals so their homes are often flooded, which in turn leads to
disease.
• The younger generations are becoming more literate but women over 25 are not able to read or
write for the most part (an estimated 80% of mothers between the ages of 30 and 50 are not
literate but can count money). The women go to work in the government waste collection scheme
from 3am to 11am and then often have other jobs after that. From this sought-after work, they will
earn around 15000 INR (175 GBP) a month. The team focused mainly on women and children in
their questioning, but the sister reported that boys do not do much work until they get to around
17 when they get try to get sales jobs or drive auto rickshaws.
• Women often start living with a man when they are around 18/20 years old. Surprisingly they are
often not married, which is not the norm in India, and start having children soon afterwards.
Families are of mixed religions, which is not common in India. Other than the tuition offered by the
nuns, there were no other free education options available to the children as far as they knew.
• Overall health is poor, she reported there is a lot of alcoholism for men and women: and that
around 40% of women had alcohol problems which affects their ability to care for themselves and
their families. Children have a high incidence of asthma and allergies, likely to be caused by the
canals and pollution. She reported that there used to be a government health clinic on the colony
but it ‘got moved and the people of the slum won’t go far’. Every second Saturday there was a
government health clinic available for women and children to get vaccinations, she believed around
25-30 people attended. There was a homeopathy doctor who also offered a service.
• Birth is in hospital; the sister said no babies are born in the slums anymore: women attend the
government hospitals or there is one private one that is used by the slum community: the sister
believed that the latter does nott provide proper treatment there because the women are
uneducated and aren’t in a position to contest what they receive.

• The average number of children in a family is 3, children are born in quick succession, the nuns said
that women don’t have control over this because of lack of information, alcoholism and a lack of
intermarital sexual consent. Women are not aware of health issues related to pregnancies in close
succession. Nutrition is also an issue: the sister reported that people who live in the community eat
a lot of junk food and have very poor nutrition. A packet of crisps costs 5INR(5p), so is more
affordable than fruits and vegetables.
• The sister did not have information about whether women understood the link between
menstruation and fertility and/or what, if anything, mothers tell their daughters about
menstruation. She reported that when a girl starts her menstrual, there is a celebration, but she
was not sure if the girl would have any understanding of the meaning behind it. The sister did not
know of any other customs or traditions related to menstruation. She reported that girls are not
sent out of the house anymore, neither is menstruation seen as very unclean.
• There is no sex education in schools in India in general, so it is unlikely that the women in the slums
would have education about this to pass on to their daughters.
With the information provided, BfC concluded that there was a clear opening for a project such as the one
under consideration.
3. Method
Initially, the team considered conducting a Randomized Control Trial (RCT) to assess a specific aspect of the
objective expressed in the project concept. It was considered that the sample size available would not be
adequate to produce evidence which would be accepted as valid for wider adoption and that other
methodological barriers may have inhibited the usefulness of such an approach.
BfC therefore proposed to test effectiveness through an impact assessment process following the results of
a programme of health education and information interventions in a clinic setting, by means of a group of
specific questions, put initially to the whole sample of participants in the community. The BfC nurse and
midwives went from door to door in the colony to collect data from women. Women were included if they
were between the ages of 18 and 60 years old. The pre-impact questions were asked once consent had
been gained (see appendix for questions). Confidentiality of the women was maintained using anonymised
participant numbers. Following the completion of health classes and the clinic, the nurses and midwives
revisited the women at their homes to follow up with the impact post-test questions.
The questions were answered both before and after the programme of interventions to measure changes
in the knowledge, attitudes or behaviour of the respondents. All questions were also put to a ‘control’
group of women who did not attend either the class or the clinic but who lived within the slum colony.
Health literacy has been recognised as an important public health issue, yet there are currently few valid
widely-used health literacy screening tools, suitable for this study. Three different methods of
measurement were therefore used in the approach to impact assessment.
1) A fact-based question, in which we were testing the participants’ knowledge and recollection of the
subject. This method was used for the assessment of Menstruation and Alcohol and Smoking.
2) The Rapid Estimate for Adult Literacy in Medicine (REALM), which uses word recognition and has
been shown to correlate highly with measures of health literacy (Ibrahim et al, 2008). The scoring
system uses a short form of 7 words, the higher the number of words recognised the higher the
level of health literacy. This method was used for the topics of Diet and Pregnancy.

3) A further method aimed to gather information about the perception of the woman regarding her
knowledge of the subject, whether she felt that she understood the subject and therefore her
confidence applying it to her daily life. When analysing the answers, the midwives also compared
the woman’s perception of her knowledge with an assessment of actual understanding of the
subject, in order to help decipher whether the knowledge that the woman described correlated
with accurate and appropriate information. This method was used regarding the topics of ‘Taking
care of children (first aid)’ and ‘Healthy Birth Practices’.
Participant information was discussed with the women and informed consent gained. Women took part
voluntarily. Initially the Birth for Change team felt that taking technological equipment into the colony may
alienate women, so it was felt that it would be more appropriate to use paper and pen to record their
answers. However, after the first day of interviews it became apparent that this would not be time efficient
or effective in gathering all the information provided. Therefore, the answers to pre- and post- test
questions in methods 1) and 3) above were recorded during the meetings and transcribed verbatim later to
ensure all information given by the women was captured. The answers were then categorised by 2
midwives independently according to the categories: ‘Understands’’, ‘Partly Understands’, ‘Inaccurately
Understands’ and ‘No understanding’.
The questions regarding the women’s views of their own understanding (method 3) were divided into two,
with the above categorisation applied first, followed by a categorisation by the midwives, assessing
whether the woman’s feelings about her understanding represented correct facts. Questions were asked
before the initiation of the services in April 2017 and again post-service delivery in August 2017. During
collection of data, the nurses and midwives often found that the women used the opportunity to offload
their feelings around the subjects in the questions to their attentive listener, so that the length of
interviews varied greatly. Recorded Interviews were anonymised with participant numbers and deleted
once transcribed.
It was expected that the project from the outset (project design) to completion (final report with impact
evaluation) would take between 9 to 12 months.
4. The Health Literacy intervention
The Sisters provided details of a space that the BfC team could use to conduct weekly clinics for women and
children in which information could also be given to the women about a chosen health topic. The Sisters
suggested an inaugural function to spread awareness of the clinic and education sessions for bright posters
were prepared and tea and snacks arranged. 40 women attended the inauguration and it was felt that
there was a good general interest in the clinic and classes. A monthly education session over a period of 6
months, which began in April 2017 was suggested. See Appendix 2 for the proposed outline programme for
these sessions.
4.1 Clinic
A clinic space was found within the slum colony to provide easy access for the women and children of the
slum. A doctor from a local hospital volunteered his time for 2 hours every Friday afternoon, and with the
support of a midwife and nurse saw the attending women and children. During the clinic time women
would have an appointment with the doctor regarding their concern(s) and then move into another room
with the nurse and midwife who would aim to provide them with some information about their health,
including provision of leaflets about nutrition, smoking, alcohol and fertility cycle beads, which are a
handheld tool used to identify fertile and non-fertile days in a woman’s menstrual cycle for effective family
planning.

The first 3 months of the clinic were well attended, on average between 15-25 women and children
attended in the 2-hour time frame. Care was provided for minor ailments, blood pressure, blood sugar and
thyroid consultations, fertility, pregnancy and growth assessments of children.
By August 2017, the clinic was becoming less well attended. The BfC team began to seek further
information from the women of the community. At this point women were more forthcoming with
information as they had become familiar with the team. They were told that a government health clinic was
also running at the same time on a Friday afternoon within the slum colony. This clinic supplied free
medications but not free blood tests, therefore women were using the project clinic for blood tests and the
government clinic for free medications. BfC arranged a meeting with the doctor at the government clinic to
find out what service they were providing and how we could move forward. The elderly doctor in this
meeting explained that the clinic had been set up 33 years ago by a Christian charity, when all they
attended to was ‘running nose and scabies’, but due to funds was not reliably running every week. She now
ran the clinic voluntarily. She told the team that her clinic used to be very well attended but that the needs
of the women had changed, the living conditions have improved, and now younger women prefer to save
for private care and attend a hospital for their medical needs. She also felt that it was difficult to encourage
community involvement in this colony. In addition, for women living in an urban area, access to services
was not difficult should they seek it. There are a number of hospitals within a 3-mile radius of the slum
colonies. By the end of August, the project clinic was poorly attended, and it was therefore agreed that it
would be closed with a view to utilise staff time in a more effective way in a possible community outreach
programme to schools.
4.2 Classes
Classes were to be held free of charge in the hall attached to the convent of the ‘Sisters of the destitute’ on
a Saturday afternoon at 4pm, since this was felt to be an appropriate day and time for working women. The
hall was felt to have the space and seating needed for the classes and was situated in the slum colony for
easy access. Prior to classes each month, the BfC team would go from door to door in the slum colony
handing out flyers with the dates and times of the classes. A large information banner was also attached to
the wall of the convent hall.
6 women attended the first class in which a PowerPoint including videos of animations and explanations in
Malayalam (the Keralan local language) was given and cycle beads and information leaflets were provided.
Women sat on benches facing the teacher. Snacks were not provided at this class as it was initially felt that
women would attend without incentive. The women in attendance showed a great deal of interest and
asked questions about the topic. However, following the class it was felt that we would need to make the
class more interactive and informal to involve and engage the women in their learning process. It was
hoped that as word spread about the classes, more women would attend week by week.
For the second class, a blanket was placed on the floor and participants sat around in a circle in the hope
that this would make the class feel more informal and interactive. 13 women attended and the BfC nurse
involved the women in games and questions surrounding their diet and nutrition. Healthy snacks and juice
were supplied. This class felt more like a community event, with women laughing and chatting around the
subject area. However, the following class about alcohol and smoking had a small attendance of only 3
women. Of the 3 attendees, 2 were illiterate. Time was spent explaining and including them in a quiz with
information provided. The after-impact questions were asked to the women who attended, however
women often left the class at the end before the question could be asked, and in these cases the team
were not able to complete this task.

The team felt that the information regarding menstruation would be valuable to the women, so a repeat
class was arranged, however the day before the class was planned, the local police came to the colony and
arranged a mandatory meeting with the colony community at the same time as the class. Therefore, the
class was unattended. We later discovered a number of other reasons that women had found it difficult to
attend classes: a weekly woman’s meeting within the colony had started at the same time as the project
classes; and some women reported a feud between the Udaya and PNT colony which meant that the
women who lived at the PNT colony would not attend the classes or clinic in the Udaya colony.
It was becoming apparent that we were trying to provide a community service that was not being utilised.
As well as this, the next classes in the series were aimed at health in pregnancy and birth. As there were
only 4 pregnant women in the colonies at that time, who already had older children and had not been
attending previous classes, it was decided to complete the series of classes with the last class on the topic
of ‘Taking care of children and first aid’. 8 women attended.
5. Findings of impact evaluation
Women who attended 1 or more classes have been grouped together (CLASS participants), as have the
women who attended the clinic (CLINIC participants) and those who attended neither the classes or clinic
(the CONTROL group).
5.1 Class participants
Method 1): Of the women who attended the classes and completed the pre- and post-impact question
(See Appendix), there was an increase from 3 to 8 in the number who had a full understanding of
menstruation and its connection with pregnancy. The number of women with no understanding reduced
from 5 to 3.
Following the alcohol and smoking class, the number of women who had a good understanding of the topic
increased from 1 pre-class to 4. Those who had no understanding at all reduced from 2 to 1. 1 woman had
an inaccurate understanding before the classes which was improved to full understanding following the
classes.
Method 2): Overall, there were minor improvements in REALM word recognition numbers regarding diet. 1
woman scored 3 or less prior to the classes, her score increased following the class. 3 women had full
understanding before the classes which increased to 6 women with full understanding post classes. 1
women increased her score from 6 to 7. Limitations of the value of REALM scores for in a pre- and post-
test experiment are discussed below.
Method 3): 4 women felt they understood about taking care of children and first aid before-the class which
increased to 6 afterwards. Other markers stayed exactly the same. The number of women who felt they
understood increased to from 2 pre-class to 4 post-class but the midwives still felt that understanding was
partial only. From the discrepancies between the way that women felt about their own knowledge and the
midwives review of their understanding, it appears that the information the women felt they knew may
have been inaccurate at times and didn’t correlate with the professional view. This may be a result of a lack
of first hand education, or persistent misinformation passed to them through the generations.

5.2 Clinic participants
Method 1): Of women who attended the clinic, no women understood the link between menstruation and
pregnancy in the pre-test, but this increased to 4 post-clinic attendance. 7 women had no understanding
which decreased to 3. The understanding of the harms of alcohol and smoking increased from 4 women
pre- to 8 post-. The markers for those who partially understood stayed the same pre and post. However,
those who had no understanding decreased from 4 to 0, suggesting that those who had no understanding
before the clinic gained full understanding post. Those who inaccurately understood reduced from 2 to 1.
Method 2): REALM scores showed an improvement between pre and post testing about diet. The scores
improved from 10 women with a score of 6 pre-clinic, to 5 women with a score of 6 and 5 with a full
recognition score of 7 post clinic. Recognition of all 7 words related to pregnancy increased from 6 pre-
clinic to 10 post-clinic. The increase of those who recognised all 7 words came from those who had
recognised 6 words pre-clinic.
Method 3): 12 women felt they understood fully about first aid and taking care of children, however the
midwives’ review assessed that only 5 women actually did understand pre-clinic. However, the number of
women fell to 11 women who felt they understood after the clinic, with a midwife view that 6 actually did.
The decrease in the number of women with a perception of full understanding might be explained by the
assessment of their understanding, in some instances women explained partially what they would do in the
event of an injury to their child with minimal information to describe their understanding so were therefore
assessed to have partial understanding rather than full understanding.
Although, women’s perceptions about their understanding on this topic reduced by 1, the midwives felt
that overall 1 woman had gained more full understanding. 4 women felt they understood birth processes
before their attendance at clinic which improved to 9 women after the clinic, however the midwives felt
that no full understanding had been gained but that partial understanding had. This could be due to
limitations of explanation of birth processes, women tended to describe their own birth experiences and
their understanding of them which could veer away from factual information at times.
5.3 Control Group
25 out of 80 women’s pre and post questions were reviewed and included, every 3rd woman that
participated that had not attended either the class or clinic but who lived within the slum community was
included.
Method 1): 19 of the 25 women included had no understanding about the link between menstruation and
pregnancy when asked the questions before any services had been provided in the community. This
reduced to 13 with no understanding post-. 2 had full understanding before which reduced to 1 following,
with 4 women with partial understood before increasing to 6 afterwards. Inaccurate understanding also
increased 1 to 4 women.
The number of women who had full understanding of alcohol and smoking pre- to post- services also
increased from 7 in the pre-testing in May 2017 to 16 in the post-testing in August 2017. Partial
understanding decreased from 8 to 7 and no understanding reduced from 10 women to 2. Suggesting that
some women had gained a better understanding of these topics.
Method 2): The REALM scores regarding diet increased from 9 women in the control group with a score of 7
pre and 11 post. 8 women had a score of 6 pre- and 10 a score of 6 post-. This increase comes from women
who had scores of 5 women who had scores of 4 or less before the services. This is an increase showing a
larger number of women did recognise a higher number of words.

The REALM test showed higher levels of recognition following the provision of services on the topic of
pregnancy. 15 women recognised all 7 of the REALM words prior to the clinic which increased to 23 post
clinic attendance. The move from a recognition score of 6 to 7 accounts for this. 23 of the 25 women
included felt they understood about taking care of children and first aid, this increased by 1 post services.
However, midwives felt that true understanding was only described in 14 women pre-, which increased to
19 women post. The number of women who felt they understood remained the same pre and post when
asked about healthy birth practices, but midwives felt that their understanding was not as accurate as the
women felt it was. 16 of the women who felt they either understood or partially understood were viewed
to have no understanding of the subject in the pre-test, 13 in the post-test. This improvement could be
explained by women hearing the words used in the REALM scoring system for the second time in the pre
and post questions.
Method 3): 23 women felt that they understood about taking care of children in the control group before
the provision of services, this increased by 1 woman following. 1 woman felt she had no understanding
before which stayed the same afterwards. Of the 23 women who felt they understood, the midwives
assessed that 14 of them did have full understanding, this number increased to 19 women following the
services. These numbers suggest that the team had a more critical view of women’s understanding. Fewer
women who felt they understood, actually did. But there was an improvement in understanding post
services in the midwives’ view.
These figures are summarised in the following tables:

Menstruation
Pre Post
Class Clinic Control Class Clinic Control
Understood 0 0 2 3 4 1
Partial understanding 1 5 4 2 6 6
Inaccurate understanding 0 3 1 0 1 4
No understanding 5 7 19 3 3 13
Total 6 15 26 8 14 24

Alcohol & Smoking
Pre Post
Total 6 15 25 8 14 25

Diet Pre Post
No. of words understood Class Clinic Control Class Clinic Control
1 0 0 0 0 0 0
2 0 0 0 0 0 0
3 1 2 1 0 0 0
4 0 0 2 2 1 0
5 2 1 5 1 3 4
6 3 10 8 4 5 10
7 0 2 9 1 5 11
Total 6 15 25 8 14 25

Pregnancy Pre Post
No. of words understood Class Clinic Control Class Clinic Control
1 0 0 0 0 0 0
2 0 0 0 0 0 0
3 0 0 1 0 0 0
4 1 1 0 0 0 1
5 1 1 0 0 1 0
6 2 7 9 4 3 1
7 2 6 15 4 10 23
Total 6 15 25 8 14 25

Taking care of children
Participants results
Pre Post
Felt understood 4 12 23 6 11 24
Felt partially understood 1 1 1 1 1 0
Didn’t understand 1 2 1 1 2 1
Total 6 15 25 8 14 25

Taking care of children
Midwives perceptions
Pre Post
Total 6 15 25 8 14 25


Healthy birth practices
Participants results
Pre Post
Felt understood 1 4 11 3 9 11
Felt partially understood 2 4 3 1 1 3
Didn’t understand 2 7 11 3 4 11
Total 5 15 25 7 14 25

Healthy birth practices
Midwives perceptions
Pre Post
Total 5 15 25 7 14 25

6. Statistical testing for significant differences
A two-tailed t-test on paired data for individual women for each of the six topics within each of the three
groups – CLASS, CLINIC and CONTROL was also carried out.
Within the CLASS group, the sample size (n= 8) was below the usual minimum strictly allowable in science
to draw a conclusion on whether the difference was significant, based on a reliable bell-curve. Even
ignoring this major caveat, potentially significant p-values (less than 0.05 (5%) i.e. 95% confidence of a
significant difference were not indicated for any of the topics.
Within the CLINIC group, where the sample size (n= 15) did meet the minimum criterion, p-values showing
a significant difference occurred in the following:
• Increase in the number of women who understood the issue represented by the question on
Menstruation (p= 0.03205)
• Decrease in the number of women who had no understanding of the issue represented by the
question on Alcohol and Smoking (p= 0.03205)
• Decrease in the number of women who felt they Partially Understood the issue represented by
the question on Healthy Birth Practices (p =0.03205). This can be correlated with a clear
increase in the number of women who felt they Fully Understood and simultaneously a
decrease in the number of women who felt they had No Understanding. However, the last two
data did not produce a p-value showing a significant difference.
The tests on the REALM word-recognition intervention for two topics: Diet and Pregnancy did not show any
significant difference in the number of words recognised. Over 90% of women understood either 6 or 7 of
the seven words in both the pre-and post-test.

Within the largest CONTROL group (n=25) who attended neither Class or Clinic:
• A significant increase (p=0.00997) was shown in the number of women who Understood the
issue represented by the question on Alcohol and Smoking. This was correlated to a significant
decrease in the number of women who had No Understanding (p= 0.00735). These data
suggest that women in this community were influenced by factors or information arising from
external sources and/or by contact with women who had attended the Clinic.
• The number of women understanding 7 words in the REALM test on the Pregnancy topic
showed a significant increase in the post-test (p=0.00735) identical with a decrease in the
number of women who understood 6 words in the pre-test (p=0.00400). However, the
usefulness of this finding is questionable in terms of the value of using a word recognition twice
with the same people in a pre- and post-test context (described earlier).
No other statistically significant differences were derived from the t-test.
7. Methodological issues and limitations
Women in the slum community participated voluntarily but have many personal responsibilities as a
woman; attending to their house work, families and work. This may be a reason why they do not prioritise
their health and therefore attendance at clinic or health classes. This meant that sample size of women
who attended classes was small.
This was the first time the Birth for Change team had carried out an impact evaluation of this kind and,
although considerable thought and testing went into it, there may have been small discrepancies. It is not
considered that they were of high significance.
The team recognise that use of REALM as part of an impact evaluation may not have been appropriate. It is
hard to distinguish whether the patterns of recognition of the words was because of repetition of the tool
and words used within it or whether women understood and recognised the words due to a greater
knowledge of the subject.
In South India, different religious communities live together in the same society. Therefore, when arranging
the classes in the Christian convent hall it was thought that this would not be a concern. However, for
future practice, it may be worth considering a common hall with no religious tendency so as not to alienate
any women who would want to attend but might not feel welcome or trust religions different from their
own.
When gathering initial information in a small Indian community there are few robust or reliable ways to
verify information. The team had to rely on the word of people in the community to inform and educate
them about the community and what their access to services they had, which meant that this information
only became available as the project was underway and the community started interacting with and
building confidence in the BfC team. Bias from different sources should also be considered. When entering
a new community, the politics between individuals and sections of the community can be hard to navigate.
Overall, the methodical process of the project and lessons learnt during and from it have been valuable.
There is a case for repeating this methodology in a more rural area where women have very limited access
to services and would have to travel long distances to access them and would be much less likely to have
any access to health information.

8. Conclusions
Of the 2 groups that attended the available services, overall the women who attended the clinic appear to
have gained more understanding of the chosen topics than those who attended the classes. This could
suggest that necessary attendance to a clinic for a health need, with provision of information at that time
may be more likely to improve women’s understanding, possibly as it becomes more relevant to their
current situation. There is also a marked improvement in the numbers of women who gained
understanding of topics pre and post the provision of services in their community, despite not having
attended either (the control group). The factors which have led to this improvement are unclear, however
the team speculated that women discuss and pass on information between them in communities and
therefore transmission of information had taken place between women who came to the clinic and classes
and those who did not.
Information gained from the impact assessment of this service suggests that women had more
understanding of chosen topics in comparison to before, following attendance at the clinic more than
health classes.
A major limitation of this study is the small sample size participating in the class and clinic groups, mainly
due to the attrition factors described above. A further limitation in this respect, arose from the division of
the six ‘class’ topics between the three selected methods in pairs of two. More meaningful results could
have been produced had time allowed all six topics to be compared across all three methods.
These findings about the impact of the services provided and interaction with women during health classes
allow us to move forward with a more focused view for the South Indian population of women.
Empowerment of these women through education in a range of settings, and therefore an increase in their
role in decision making about their own health is vital to positive changes in women’s health in India. It
seems there is a need for a strategic approach to address these issues especially for younger women, those
who access government health facilities and those in rural areas with poor access to services.
There appears from this data to be a possible case for conducting further field trials and pilots, on a larger
scale, to validate the impact of Clinic-style interventions on women in other communities. Likewise, this
could beneficially be associated with comparative studies involving other types of intervention where a
minimum sample is available, including Class-style interventions.
References
• Ibrahim S, Reid F, Shaw A, Rowlands G, Gomez GB, Chesnokov M, Ussher M (2008) Validation of
health literacy screening tool (REALM) in a UK population with coronary heart disease. Journal of
public health. Vol 30:1. Pp 449-455

Appendix 1: Pre and Post impact questions

Participant number:
ORIGINAL BEFORE AND AFTER- METHOD 1
Session 1. Menstruation
What is the link between menstruation and getting pregnant?

Session 3. Alcohol and smoking
What effects, other than intoxication, does alcohol have on your body?

REALM- METHOD 2
Session 2. Diet and Nutrition
Suggested Introduction:
Do you recognise any of these words in English or Malayalam?
Starting at the top of the list. If you don’t you recognize a word, you can say ‘pass’ and move on to the next
word.”
Interviewer: If the participant takes more than 5 seconds on a word, say “pass” and point to the next word.
Hold this scoring sheet so that it is not visible to the participant
Iron_____
Vitamins _____
Deficiency _____
Supplements_____
Hydration _____
Anaemia _____
Folic acid(Folate) _____
TOTAL SCORE ______

Session 4. Pregnancy
Suggested Introduction:
Do you recognise any of these words in English or Malayalam?
Starting at the top of the list. If you don’t you recognize a word, you can say ‘pass’ and move on to the next
word.”

Interviewer: If the participant takes more than 5 seconds on a word, say “pass” and point to the next word.
Hold this scoring sheet so that it is not visible to the participant

Morning sickness_____
Uterus _____
Foetal movements _____
Estimated due date _____
Midwife _____
Ultrasound scan _____
Placenta_____

TOTAL SCORE ______

PERCEPTIONS OF CHANGES- METHOD 3
Session 5. Taking care of children
Do you feel you have an understanding of what to do to help if you or your child (if applicable) hurts
themselves e.g. cut or burn?
Session 6. Healthy birth practices
Do you feel you know enough about what happens during childbirth to make decisions about your own
birth or advise a friend or family member about theirs?

Appendix 2: Class Outline

1. Menstruation-
v Group work/ cycle bead leaflet handout/ animated film
• The menstrual cycle
• The uterus
• Ovulation
• Fertile/non- fertile window
• Cycle beads
• Dealing with periods- pain, sanitary wear

2. Diet-
v Activities:
♦ Food pyramid- foods into relevant layer according to how much of what we should eat (old
pizza boxes, veg tins etc.)- women put in area they believe to be true
♦ Possible food diary- woman writes account of what she’s eaten in last 3 days and we discuss
with her individually/smaller groups
• The bodies need for vitamins and minerals
• The effect poor diet has on the body
• Nutritious foods- balanced diet- how to get the vitamins and minerals needed
• The effect of poor nutrition on growth and development of fetus and children

3. Alcohol and Smoking-
v Informal teaching Session, video, ‘drink aware’ like poster
v Alcohol and smoking quiz
v Video about effects on body
• The effects on the body
• Effects on sleep, relationships, caring for children, working life
• Fetal alcohol syndrome
• Health risks

4. Taking care of children
v Informal teaching session, interactive group work, posters
v First aid
v Bandages and doll to practice on
• Benefits of breastfeeding on a child’s health
• Nutrition
• Activity and stimulation
• Role of parental relationship
• Common ailments and when to seek help

* 5. Pregnancy
v Images, doll and pelvis, pregnancy art-exploring feelings and understanding of pregnancy
• Finding out you are pregnant
• Feelings during pregnancy
• Normal pregnancy symptoms
• Importance of fetal movements
• Nutrition and supplements
• When to seek support/ advice
• Antenatal care- accessing the new clinic

** 6. Healthy birth practices
v ‘Grab bag’ teaching of comfort measures, labelled areas of room- ask women to go to which area
they believe to be right answer in regard to questions about infant care, signs of labour etc.
• Signs of labour
• What to look out for
• Comfort measures/ what can help/ optimal fetal positioning
• The postpartum months
• Keeping mother and baby together
• Infant feeding

* and ** Classes in red were not held following poor attendance of previous classes.

Maternal Health Literacy, Pilot Project, Kerala- Final Report

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Maternal Health Literacy, Pilot Project, Kerala- Final Report