The effect of health education on women's treatment-seeking behaviour: Findings from a cluster randomised trial and an in-depth investigation of hysterectomy in Gujarat, India

A community-based health insurance scheme operated by the Self-Employed Women’s Association (SEWA), an organisation of women workers in India, reported that the leading reasons for inpatient hospitalisation claims by adult women were diarrhoea, fever and hysterectomy – the latter at the average age of 37. In 2010, SEWA initiated a cluster randomised trial to evaluate whether community health worker-led education amongst insured and uninsured adult women could reduce morbidity, hospitalisation and insurance claims related to these three conditions. This thesis reports the findings of the intervention evaluation and of an in-depth examination of hysterectomy, the most common cause of hospitalisation. Literature reviews were conducted on the effect of community health worker-led group health education and on the frequency of hysterectomy in low and middle-income countries. Analysis of the cluster randomised trial utilised data from SEWA’s insurance database and four household surveys. Hysterectomy was explored through an in-depth qualitative study and quantitative analyses using the study cohort to estimate incidence and identify determinants of the procedure. Lastly, findings were synthesised with process data to examine the intervention process, with a focus on hysterectomy. Statistical analyses indicated no evidence of an intervention effect on insurance claims, hospitalisations or morbidity related to fever, diarrhoea and hysterectomy. There was no evidence of effect modification by insurance status. Hysterectomy amongst women in their mid-thirties appeared to be rooted in its normalisation as a prophylactic, permanent treatment for gynaecological ailments. Incidence of hysterectomy was associated with income, age and number of children. Evaluation of the intervention process suggested that improved knowledge was necessary, but not sufficient, to change women’s treatment-seeking behaviour regarding hysterectomy. Interventions to reduce hysterectomy must integrate approaches that address the structural determinants of the procedure, such as the lack of reproductive and sexual health services, providers’ behaviour towards low-income women and attitudes towards the utility of the uterus.