The Invisible Fishers
Condition: Anemia
MeSH terms: Anemia
Study type: Interventional

Summary: 
      This pilot study aims to introduce three interventions directed toward mitigating anemia
      among women in Ghana, including: 1) multi-sectoral behavior change, 2) strengthening market
      engagement of fish processors, 3) improving fish smoking technology and practices. These
      interventions will be implemented among female fish processors, a population that represents
      a promising focal area for intervention within fisheries value chains, which have been
      identified as a uniquely promising sector for intervention to mitigate anemia among women.
      The investigators expect that the findings from this study will inform understanding of how
      best to design, implement, and evaluate interventions into fisheries and other animal-source
      food value chains in Ghana and across sub-Saharan Africa to address anemia and other
      nutritional and health concerns.
    

Detailed description: 
      Anemia among women of reproductive age remains an intractable public health problem in many
      low- and middle-income countries, especially in sub-Saharan Africa (SSA) where more than
      one-third of women of reproductive age are anemic. The complex etiology of anemia suggests
      the importance of designing interventions that address both nutritional deficiencies and
      environmental drivers of anemia risk. This proposed research builds on new knowledge
      generated from ongoing formative research by our investigator team aimed at understanding the
      potential for interventions into animal-source food (ASF) value chains to influence anemia
      among adolescent girls and women in Ghana. The investigators have identified fisheries value
      chains in Ghana as a uniquely promising sector for intervention to mitigate anemia among
      women. Specifically, our research indicates that fish processing is the most promising focal
      area for intervention within fisheries value chains to address anemia among women. Therefore,
      the overall research objective of this proposed research is to develop, adapt, and pilot test
      a set of interventions into fisheries value chains in Ghana aimed at mitigating anemia among
      women. Specifically, the investigators aim to: 1) define the scope, feasibility, and
      scalability of priority intervention strategies that have been identified through our ongoing
      formative research, 2) adapt the interventions to the proposed study contexts, and 3) design
      and pilot test specific implementation strategies, as well as a monitoring and evaluation
      (M&E) framework for assessing intervention delivery, uptake, impacts, and mechanisms of
      impact at multiple loci along hypothesized program impact pathways.

      Our ongoing formative research and an extended consultation process with stakeholders and
      community participants have identified priority strategies for intervention within fisheries
      value chains in Ghana that are feasible, scalable, likely to reduce anemia through multiple
      mechanisms, and for which there is clear potential for sustainability of impact. The
      investigators expect that the pilot testing of these interventions and the associated M&E
      framework will directly inform the design, implementation and evaluation of a full randomized
      controlled trial (RCT) that will evaluate the effectiveness of these interventions on anemia
      mitigation among women in Ghana. As such, the design of this pilot research will mimic that
      of a RCT with three distinct treatments delivered to women in separate study arms, each arm
      reflecting the priority intervention strategies identified through our ongoing formative
      research:

        -  Treatment Arm 1 (TA1): a multi-sectoral anemia behavior change intervention focused on
           promoting a diversity of anemia-mitigating behaviors including consumption of
           micronutrient-rich ASFs, malaria and soil-transmitted helminth control practices, and
           water, sanitation and hygiene best practices (TA1 is also a component of Treatment Arms
           2 and 3);

        -  Treatment Arm 2 (TA2): an intervention aimed at strengthening women fish processors'
           engagement with markets through a group-based microcredit scheme, providing
           entrepreneurship training, and facilitating enhanced access to market price information;

        -  Treatment Arm 3 (TA3): an intervention introducing improved fish smoking technology and
           practices to women processors aimed both at improving earnings and reducing harmful
           occupational exposures associated with fish smoking.

      The investigators will recruit a total of 120 total participants from 12 communites in two
      regions of Ghana that represent marine and fresh water small-scale fisheries systems.
      Participants will be recruited into a nine-month pilot intervention with data collection
      occurring at baseline prior to the start of the intervention, at the middle point of
      intervention implementation, and at endline immediately following completion of intervention
      implementation. The investigators will use survey-based instruments, direct observation,
      participant diaries, anthropometric and dietary assessment, occupational exposure assessment,
      as well as analysis of blood and stool specimens to evaluate changes in anemia, micronutrient
      status, inflammation and infection, as well as changes in participants' knowledge, attitudes,
      behaviors, and exposures that the investigators hypothesize are linked to intervention
      exposure. Such an analysis is critical for understanding the relative importance of different
      mechanisms of impact for each intervention. The investigators will further carry out
      qualitative, semi-structured interviews with study participants and project implementation
      staff to understand their perceptions of the interventions, factors that facilitated or
      prevented successful implementation and uptake of interventions, and their perceptions of
      positive and negative changes resulting from participation in the project. These insights
      will be important for addressing our proposed research questions related to defining the
      scope of the proposed interventions, and assessing the feasibility of intervention uptake and
      implementation. A final project assessment workshop will also be carried out to internally
      assess the strengths and limitations of the project's M&E framework.

      Smoked fish value chains in Ghana have clear potential to influence anemia risk among women
      fish smokers via multiple, potentially interconnected and contradictory mechanisms. More
      broadly, these value chains also have significant potential to affect the nutrition and
      health status of coastal and lake communities and of consumers across the country whose diets
      are profoundly shaped by these value chains. The investigators expect that the findings of
      this research will significantly contribute to understanding how best to design, implement,
      and evaluate interventions into fisheries and other ASF value chains in Ghana and across SSA
      to address anemia and related nutrition and health concerns.
    

Intervention name(s): Mobile phone audio messaging; Peer-to-peer learning; Conditional cash transfer; Entrepreneurship training; Market price information; Improved smoke ovens
Intervention type(s): Behavioral; Behavioral; Behavioral; Behavioral; Behavioral; Behavioral
Intervention description(s): Audio messages will be "pushed" to participants' mobile phones twice weekly on a set schedule in discrete modules that include basic information related to each of the four behavioral domains followed by an integration of the information across behaviors through relatable, character-driven narratives that enable message recipients to engage with the content through a real-world context.; Women participants in each community will meet twice monthly for peer-to-peer learning sessions to reinforce the content of audio messages. These sessions will further use women's empowerment approaches including critical examination of gender dynamics, and discussions of solutions for equitable decision-making and control of resources within households. These discussions will be facilitated with male household members and grandmothers in separate learning sessions that will be held three times throughout the intervention period.; Participants will receive a conditional cash transfer to support their fish smoking business. The payment will be conditional on their participation in entrepreneurship trainings and the use of the investment into their fish smoking business.; Entrepreneurship training will focus on commonly lacking business knowledge, with an emphasis on establishing fundamental entrepreneurial skills (i.e., customer care, accounting), sound business management and decision-making, building strong and sustainable business relationships, and encouraging the use of loans for their intended purposes. This training will be introduced during the credit and savings group (CSG) meetings that will occur twice per month.; Average market prices for fresh and processed fish at community, district, and regional markets will be disseminated via audio message calls (using Viamo's Infoline platform) to the mobile phones of women with the price information in their preferred language. These market prices will be collected twice weekly by Viamo field enumerators and sent to regional coordinators for validation. A second, independent validation will be carried out to ensure that there are no discrepancies.; Local private sector artisans will construct and serve as suppliers of the new ovens. The promotion, uptake and impact of these improved Ahotor ovens will be tested among study participants. Awareness-raising workshops held in each community will promote the Ahotor in concert with a public retrofitting of a Chorkor stove. Immediately following this event, one month later, and three months later, study participants will receive additional one-on-one counseling to provide further support on the proper use of the smoke oven, as well as on optimal handling and smoking practices to enhance product quality.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Two communities in each of two study regions will be assigned to one of the three treatments (i.e., six communities in total per region). Assigning two communities to the same treatment in each region will allow us to assess differential intervention design and implementation needs for communities in similar geographic areas. Ten women in each community will be purposefully selected for participation to ensure intra-community variation on participant age, socioeconomic status, years of experience with fish smoking, and the scale of fish smoking enterprises. Across both regions, 120 women will be recruited from a total of 12 communities. While the interventions will be delivered to individual women, treatment assignment will be carried out at the community-level given the risk of sharing information and inputs within communities that could contaminate intervention exposure and bias observed treatment effects.
Masking: None (Open Label)
Primary purpose: Prevention
Keywords: fisheries; Ghana; sub-Saharan Africa; value chain; fish processing; fish smoking