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Health-related outcomes among female informal workers in debt: Retrospective quasi-experimental study on the impact of microfinance health interventions in Pakistan ForJournal: peerBMJ Open review only Manuscript ID bmjopen-2020-043544
Article Type: Original research
Date Submitted by the 09-Aug-2020 Author:
Complete List of Authors: Jafree, Sara; Forman Christian College Zakar, Rubeena; The University of Lahore Ahsan, Humna; Forman Christian College Mustafa, Mudasir; Utah State University Fischer, Florian; Charité Universitätsmedizin Berlin, Institute of Public Health; University of Applied Sciences Ravensburg-Weingarten, Doggenriedstraße
Health policy < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Keywords: PUBLIC HEALTH, EPIDEMIOLOGY
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1 2 3 Health-related outcomes among female informal workers in debt: 4 5 6 Retrospective quasi-experimental study on the impact of microfinance health 7 8 interventions in Pakistan 9 10 11 Sara Rizvi Jafree, Rubeena Zakar, Humna Ahsan, Mudasir Mustafa, Florian Fischer 12 13 14 15 Dr. Sara Rizvi Jafree 16 Department of Sociology,For Forman peer Christian review College University, only Lahore, Pakistan; 17 18 [email protected] 19 20 Prof. Dr. Rubeena Zakar 21 22 Institute of Social and Cultural Studies, University of the Punjab, Lahore, Pakistan; 23 [email protected] 24 25 26 Dr. Humna Ahsan 27 Department of Economics, Forman Christian College University, Lahore, Pakistan; 28 [email protected] 29 30 31 Mudasir Mustafa 32
Department of Sociology, Social Work, and Anthropology, Utah State University, Logan, United http://bmjopen.bmj.com/ 33 34 States of America; [email protected] 35 36 Dr. Florian Fischer 37 38 1) Institute of Public Health, Charité – Universitätsmedizin Berlin, Germany; 39 [email protected] 40
2) Institute of Gerontological Health Services and Nursing Research, Ravensburg-Weingarten on September 30, 2021 by guest. Protected copyright. 41 42 University of Applied Sciences, Germany; [email protected] 43 44 Corresponding author: 45 Dr. Florian Fischer 46 47 Charité – Universitätsmedizin Berlin 48 Institute of Public Health 49 Charitéplatz 1 50 51 10117 Berlin 52 E-Mail: [email protected] 53 54 55 Word count: 4,259 56 57 58 - 1 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 1 Abstract 4 5 6 2 In countries where dependable public health service structure and universal financial protection 7 8 3 for health coverage is missing, particularly impoverished families are at risk. In the past years, 9 10 4 different kinds of microfinance health interventions were established to promote health among 11 12 disadvantaged population groups. The purpose of this study is to assess the impact of microfinance 13 5 14 15 6 health interventions (health insurance and health awareness programs) on health-related outcomes 16 For peer review only 17 7 of female informal workers in Pakistan. We conducted a retrospective quasi-experimental study 18 19 8 among a total of 447 female borrowers from seven microfinance providers (MFPs) in 2018. A 20 21 22 9 standardized tool was used for data collection. Probit regression has been used to identify the 23 24 10 probability of female borrowers gaining improvement in health outcomes based on their socio- 25 26 11 demographic characteristics. Propensity score matching (PSM) has been used to assess the overall 27 28 29 12 impact of health interventions. Results show that women receiving health insurance and health 30 31 13 awareness programs had greater probability of better health outcomes when they were from 32 http://bmjopen.bmj.com/ 33 14 Punjab, borrow in groups, and attend monthly meetings at MFPs. The results of the PSM show 34 35 significant improvements in overall perceived health status when women received health insurance 36 15 37 38 16 and improvement in the purchase of prescribed medicine when women received a health awareness 39 40 17 program. Health and social policies are vital to secure health and wellbeing of poor women 41 on September 30, 2021 by guest. Protected copyright. 42 18 working in the informal sector of the economy. Targeting improved equity across female 43 44 45 19 population groups for health intervention will in the long run improve women’s health, capacity 46 47 20 expansion and income-earning abilities. 48 49 21 50 51 52 22 Keywords: borrow, informal sector, health insurance, health awareness, microfinance 53 54 23 55 56 57 58 - 2 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 24 Strengths and limitations of the study 4 5 6 25 This study is part of a larger mixed-methods study on the well-being of female 7 8 26 microfinance borrowers. 9 10 27 Potentially the first study which focuses on female microfinance borrowers in Pakistan to 11 12 13 28 assess the impact of health interventions on health-related outcomes of poor women. 14 15 29 Although a quasi-experimental analysis framework has been used, the two-group cross- 16 For peer review only 17 30 sectional designs suffers from the limitations related to a single measurement for all 18 19 20 31 subjects. 21 22 32 Future studies need to consider additional burdens of loan repayment and small business 23 24 33 investment. 25 26 27 34 28 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 30, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 - 3 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 5 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 35 Introduction 4 5 6 36 More than half (57%) of the female population in Pakistan is illiterate. Less than a quarter (23%) 7 8 37 of women is employed, with a majority working in the informal sector [1]. There are several 9 10 38 problems to consider with regard to the health of female informal workers in Pakistan, including 11 12 high rates of poverty and low health literacy, as well as inadequate access to public health services 13 39 14 15 40 [2], reinforced by low government health budget allocation for this population group [3]. In 16 For peer review only 17 41 addition to the overall absence of universal health coverage, there are limited coverage for public 18 19 42 health emergencies like pandemics [4] and greater risks for acquiring infectious diseases in female 20 21 22 43 informal workers due to mostly unsanitary living conditions in disadvantaged communities [5]. 23 24 44 Pakistan has one of the largest out-of-pocket healthcare expenditures globally, with an 25 26 45 overwhelming proportion of 90% [6]. Although health insurance can become an important support 27 28 29 46 system for buffering the poor in out-of-pocket payments, it covers only 1% of health expenditure 30 31 47 in the country yet [2]. This is because health insurances are mainly used by richer and urban 32 http://bmjopen.bmj.com/ 33 48 populations. 34 35 The efficacy and limitations of private providers for health interventions in Pakistan are not clear. 36 49 37 38 50 One of the few private providers offering health interventions to women employed in the informal 39 40 51 sector are microfinance providers (including banks, institutes and non-governmental organizations 41 on September 30, 2021 by guest. Protected copyright. 42 52 [NGOs]) [7]. Microfinance providers (MFPs) are mainly operational in under-developed 43 44 45 53 communities providing loans to the poorest women for small business development [8]. There are 46 47 54 50 MFPs operating in Pakistan, with nearly 40 reporting some form of health intervention for 48 49 55 clients, including health insurance and health awareness programs [9]. The MFPs are regulated 50 51 52 56 either by the State Bank of Pakistan or the Securities Exchange Commission Pakistan. An inherent 53 54 57 function of the original model of microfinance was to catalyze wider social development for 55 56 57 58 - 4 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 6 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 58 women, including improved health behavior and, therefore, better health-related outcomes [10]. It 4 5 6 59 is in the interest of MFPs to couple health interventions with loan services as healthy clients are 7 8 60 more likely to return loans and run successful businesses [11]. 9 10 61 The role of microfinance health interventions is even more critical for countries like Pakistan, 11 12 where poverty is high and out-of-pocket payments are not possible for impoverished families. 13 62 14 15 63 Additionally, the public sector did not have a dependable service structure for complete or quality 16 For peer review only 17 64 healthcare and universal financial protection for health coverage is absent [4]. More than 2 million 18 19 65 poor women are loan-takers of microfinance in the country [12]. As poor populations do not have 20 21 22 66 the money to take traditional health insurance, microfinancing for health insurance becomes the 23 24 67 only option for them. However, small health insurance schemes have been severely criticized for 25 26 68 their minimal impact on clients lives due to minimal coverage and large burden of disease faced 27 28 29 69 by poor populations [13]. Evidence also suggests that poor populations receiving minimal health 30 31 70 insurance, in the event of sustaining large health costs, may resort to damaging practices such as 32 http://bmjopen.bmj.com/ 33 71 reducing household nutrition, removing children from school, and taking more loans [14]. In the 34 35 most recent times of the corona pandemic, debt-ridden poor women attempting to repay loans are 36 72 37 38 73 facing even more challenges in generating income from small businesses due to social isolation 39 40 74 and lockdown [15]. Therefore, health security is a major concern in women borrowers and there 41 on September 30, 2021 by guest. Protected copyright. 42 75 is a need to improve research and policy to financially protect poor women and also improve their 43 44 45 76 health literacy [16]. 46 47 77 To the best of our knowledge, there are no studies which have used female microfinance borrowers 48 49 78 as a sample to assess the impact of health interventions on health-related outcomes of poor women 50 51 52 79 [17]. Using a sample of female microfinance borrowers who are availing health insurance from a 53 54 80 private provider will help to identify suited policies for disease prevention and health promotion 55 56 57 58 - 5 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 7 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 81 in Pakistan. The following research questions are addressed in this study include: 1) Do female 4 5 6 82 borrowers of microfinance who are provided with health interventions show improved health- 7 8 83 related outcomes?, and 2) What are the socio-demographic, household, and loan portfolio 9 10 84 characteristics of female borrowers of microfinance that are associated with improved health- 11 12 related outcomes? 13 85 14 15 86 16 For peer review only 17 87 Methods 18 19 88 This study is part of a larger mixed-methods study on the wellbeing of female microfinance 20 21 22 89 borrowers. The qualitative part has already been published [18]. The results presented here are 23 24 90 based on a cross-sectional survey, in which females who have been borrowers of microfinance for 25 26 91 more than one year were interviewed with a structured quantitative questionnaire. We used the 27 28 29 92 framework of a quasi-experimental study to estimate the impact of microfinance health 30 31 93 interventions. 32 http://bmjopen.bmj.com/ 33 94 34 35 Sampling 36 95 37 38 96 First, seven MFPs were sampled randomly through a list available on Pakistan Microfinance 39 40 97 Network. All MFPs were asked for permission to interview their clients. Afterwards, 500 women 41 on September 30, 2021 by guest. Protected copyright. 42 98 borrowing money from these MFPs were contacted to participate in the study. The sampling took 43 44 45 99 place in all four provinces of Pakistan (Punjab, Sindh, Balochistan, and Khyber Pakhtunkhwa 46 47 100 [KPK]), not considering the two autonomous territories and the federal territory of Islamabad. The 48 49 101 sampling frame at the level of individual women took the population weightage of the provinces 50 51 52 102 into account. A total of 442 women were willing to participate in the study and provided informed 53 54 103 written consent, which is a response rate of 88.4%. These women were sampled from seven cities 55 56 57 58 - 6 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 8 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 104 within the four provinces (Punjab: n=252 [cities: Gujranwala, Lahore, Khanewal, Sheikhapura]; 4 5 6 105 Sindh: n=100 [city: Matiari]; Balochistan: n=50 [city: Lasbela]; KPK: n=40 [city: Abbottabad]. 7 8 106 Study participants received financial support from the following types of MFPs: four microfinance 9 10 107 banks (n=340), one microfinance institute (n=41), one government microfinance scheme (n=50), 11 12 and one Islamic microfinance organization (n=11), 13 108 14 15 109 16 For peer review only 17 110 Data collection 18 19 111 Data collection took place between February and November 2018. Each city had one research team 20 21 22 112 leader and two assistants in the data collection team, comprising a total of 21 persons for data 23 24 113 collection. The assistants were all MPhil graduates who had experience in field research and were 25 26 114 hired through the assistance of universities in each city. Training of the data collection team took 27 28 29 115 place over a two-week period and was done either in person or through video calls. The structured 30 31 116 surveys were completed on behalf of the female respondents with the assistance of the trained 32 http://bmjopen.bmj.com/ 33 117 research team, as most of the women were illiterate or semi-literate. Data collection took place in 34 35 face-to-face-interviews in a private space at the MFP premises, in order to preserve the privacy of 36 118 37 38 119 women in lieu of the personal questions. 39 40 120 41 on September 30, 2021 by guest. Protected copyright. 42 121 Measures 43 44 45 122 A structured interview schedule was used for data collection (see Supplementary Appendix). 46 47 123 Questions in this tool were taken from instruments used in various studies, such as Women’s 48 49 124 Healthcare Experiences Survey [19], Baseline Nutrition and Food Security Survey by UNICEF 50 51 52 125 [20], WHO Multi-country Study on Women’s Health and Domestic Violence against Women [21], 53 54 126 and WHO Survey on Workplace Violence [22]. 55 56 57 58 - 7 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 9 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 127 This study assesses the association of health interventions offered by MFPs on four dependent 4 5 6 128 health-related variables: 1) women perceive health to be good overall, 2) women visit a general 7 8 129 practitioner in the last year, 3) women have the ability to purchase prescribed medicine in the last 9 10 130 year, and 4) women’s intake of multivitamins has improved in the last year. The four dependent 11 12 variables have been categorized as binominal and coded as either “Yes” (1) or “No” (0). 13 131 14 15 132 Several socio-demographic variables such as age (0=less than 30 years; 1=30 years and older), 16 For peer review only 17 133 religion (0=Muslim; 1=Other than Muslim), literacy of the female borrower (0=Illiterate; 18 19 134 1=Literate), literacy of the spouse (0=Illiterate; 1=Literate), house ownership (0=Yes; 1=No), and 20 21 22 135 number of depending children living in the house (0=None; 1=One or more) have been assessed 23 24 136 as confounding variables. It is necessary to control for these variables as they have an impact on 25 26 137 each of the dependent variables mentioned above. Province is also controlled as the region is a 27 28 29 138 proxy for socio-cultural norms which would impact how women perceive their health and whether 30 31 139 they are able to visit a general practitioner or to purchase medicine (0=Other than Punjab [Sindh, 32 http://bmjopen.bmj.com/ 33 140 Balochistan, or KPK]; 1=Punjab). 34 35 The other set of variables related to microfinance provider services such as loan amount 36 141 37 38 142 (0=10,000–20,000 PKR; 1=21,000 PKR and more), monthly meetings (0=No; 1=Yes), interest 39 40 143 rate, which is the amount charged on top of the principal by a lender to a borrower (0=2.5–10%; 41 on September 30, 2021 by guest. Protected copyright. 42 144 1=11% and more), group loan, meaning that a group of customers are willing to guarantee each 43 44 45 145 other for the repayment of loan (0=No; 1=Yes), and debt age (0=1–2 years; 1=3 or more years) 46 47 146 have been included as they assess the impact of the provision of non-financial services on each of 48 49 147 the dependent variables. 50 51 52 148 53 54 55 56 57 58 - 8 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 10 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 149 Intervention 4 5 6 150 Using a quasi-experimental framework, the study estimates the impact of getting access to health 7 8 151 interventions against the counterfactual of those women who are receiving the loan for small 9 10 152 business mobilization in the absence of health interventions. The control group (푇 = 0) consists 11 12 13 153 of women who have been provided the loan but lack the provision of health intervention and the 14 15 154 treatment group (푇 = 1) includes women who will have provision of both, the loan as well as 16 For peer review only 17 155 health intervention. 18 19 156 The three independent variables for microfinance health intervention are: 1) receiving health 20 21 22 157 insurance, 2) attended at least one health workshop, and 3) received health-related talks by loan 23 24 158 officers. The last two independent variables of health workshop and health-related talks by loan 25 26 159 officers were compounded to make one variable indicating whether the women received a health 27 28 29 160 awareness program (0=No; 1=Yes). 30 31 161 32 http://bmjopen.bmj.com/ 33 162 Data analysis 34 35 36 163 Data were analyzed using SPSS and STATA. The impact of health insurance and health awareness 37 38 164 programs provided by the MFP on the four dependent health-related variables will first be 39 40 estimated using a Probit estimation for the following linear regression equation: 165 on September 30, 2021 by guest. Protected copyright. 41 42 166 푌 = 훽 + 훽 푇 + 훽 푋 + 훽 푍 + 훽 퐿 + 휀 43 푖 0 1 2 푖 3 푖 4 푖 푖 44 45 167 where 푌푖 is the dependent variable measuring the four health-related outcomes. T is the treatment 46 47 variable (1 if “yes”, and 0 otherwise) measuring the three microfinance health interventions. is 48 168 푋푖 49 50 169 a set of socio-demographic characteristics including age, religion, province, and literacy; 푍푖 is a 51 52 170 set of household characteristic including house ownership and number of dependent children living 53 54 55 56 57 58 - 9 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 11 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 171 in the house; 퐿푖 is a set of loan portfolio characteristics including debt age, group loan, loan amount, 4 5 6 172 interest rate, and monthly meetings; and 휀푖 is the error term. 7 8 173 Following Rosenbaum and Rubin, we used Propensity Score Matching (PSM) to estimate the 9 10 174 unobserved counterfactuals and make an impact analysis of health interventions. PSM is a non- 11 12 13 175 parametric statistical method which matches the treated (those receiving health intervention) and 14 15 176 the controlled on the basis of conditional probability of participation, given observable 16 For peer review only 17 177 characteristics [23]. As we only have cross-sectional data, we can compare the dependent variables 18 19 20 178 related to women’s health and wellbeing in terms of those who have access to non-financial health- 21 22 179 related services provided by the microfinance provider (in this study called “health awareness 23 24 180 program”) and those who do not, as long as these services are randomly distributed and there is no 25 26 27 181 selection bias. The estimation of instrumental variables is one technique that is frequently used 28 29 182 within PSM. However, these results are only robust if a valid instrument is being used. As it not 30 31 183 easy to find a valid instrument in our study, we used statistical matching which has been widely 32 33 http://bmjopen.bmj.com/ 184 used before as well [24-26]. 34 35 36 185 Our study satisfies the main conditions of PSM, which are 1) using a rich set of control variables, 37 38 186 which are observable characteristics, 2) using the same survey for treated and control groups, and 39 40 187 3) having the same community belonging to treated and control group [27]. The PSM model on September 30, 2021 by guest. Protected copyright. 41 42 43 188 constructs a statistical comparison group based on the probability of participating in the treatment 44 45 189 T, conditional on observed characteristics, X or the propensity score, 46 47 190 푝(푋) = 푃푟(푇 = 1│푋). 48 49 50 191 where T = {0, 1} is the indicator of exposure to treatment and X is the multidimensional vector of 51 52 192 pre-treatment characteristics. Following the estimation for the propensity score, the region for 53 54 193 common support is defined where distributions of the propensity score for the treatment and 55 56 57 58 - 10 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 12 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 194 comparison group overlap. Observations within the control and treatment group that lie outside 4 5 6 195 the common support are eliminated [28]. As PSM is intended to help in identifying the impact of 7 8 196 the health intervention, we used the computation of ‘average treatment effect on the treated’ 9 10 197 (ATT). We used two matching criteria (Nearest Neighbor Matching [NNM] and Kernel Matching 11 12 [KM]), to assess statistical significance from different perspectives and to test the robustness of 13 198 14 15 199 the results [24]. NNM is used to evaluate absolute differences between propensity scores and KM 16 For peer review only 17 200 is used to compare each treated unit to a weighted average of the outcomes of all untreated units. 18 19 201 20 21 22 202 Patient and Public Involvement 23 24 203 This research was conducted without involvement of public or patients. However, the view of 25 26 204 females was already included in the qualitative part of this mixed-methods approach, which has 27 28 29 205 already been published elsewhere [18]. 30 31 206 32 http://bmjopen.bmj.com/ 33 207 Results 34 35 Sample characteristics 36 208 37 38 209 All women in our sample earned less than $4.82 per day and belonged to the poorest strata of 39 40 210 society. They were taking loans for small business mobilization to improve their life opportunities. 41 on September 30, 2021 by guest. Protected copyright. 42 211 The majority of women were Muslim, from Punjab, and illiterate. About three quarters had been 43 44 45 212 borrowers for more than 3 years, were attending monthly meetings with loan officers, and were 46 47 213 paying interest rates less than 10%. Out of the 442 women borrowers in the sample, 64.2% (n=284) 48 49 214 were taking health insurance and 71.0% (n=314) have participated in a health awareness program 50 51 52 215 by attending a health workshop or receiving health talks by loan officers (Table 1). 53 54 216 55 56 217 57 58 - 11 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 13 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 218 Table 1: Descriptive statistics of women borrowers receiving health interventions (n=442) 4 5 Receiving health Receiving health 6 insurance Chi-square awareness program Chi-square Variable 1 1 7 n (%) test n (%) test (N=284) (N=314) 8 Age 9 <29 years 165 (58.1%) 0.557 177 (56.4%) 0.077 10 ≥30 years 119 (41.9%) 137 (43.6%) 11 Religion 12 Muslim 254 (89.4%) 0.740 276 (87.9%) 0.337 13 Other 30 (10.6%) 38 (12.1%) 14 Province 15 Punjab 197 (69.4%) 37.977*** 203 (64.6%) 16.372*** 16 Other For peer review87 (30.6%) only 111 (35.4%) 17 Literacy 18 Illiterate 195 (68.7%) 3.770* 219 (69.7%) 9.109** 19 Literate 89 (31.3%) 95 (30.3%) 20 Spouse literacy 21 Illiterate 191 (67.3%) 7.135** 199 (63.4%) 0.231 22 Literate 93 (32.7%) 115 (36.6%) 23 House ownership 24 Other 225 (79.2%) 9.583** 233 (74.2%) 0.030 25 Owned 59 (20.8%) 81 (25.8%) 26 Children 27 None 116 (40.8%) 1.907 121 (38.5%) 0.002 28 One or more 168 (59.2%) 193 (61.5%) 29 Debt age 30 1–2 years 75 (26.4%) 15.755*** 83 (26.4%) 21.342*** 31 ≥3 years 209 (73.6%) 231 (73.6%) Group loan 32 No 168 (59.2%) 0.102 173 (55.1%) 5.480** http://bmjopen.bmj.com/ 33 Yes 116 (40.8%) 141 (44.9%) 34 Loan amount (in PKR) 35 10,000–20,000 123 (43.3%) 25.096*** 121 (38.5%) 6.515** 36 ≥21,000 161 (56.7%) 193 (61.5%) 37 Interest rate 38 2.5–10% 202 (71.7%) 1.044 237 (75.5%) 18.527*** 39 ≥11% 82 (28.9%) 77 (24.5%) 40 Monthly meeting on September 30, 2021 by guest. Protected copyright. 41 No 70 (24.6%) 0.091 73 (23.2%) 2.005 42 Yes 214 (75.4%) 241 (76.8%) 43 Overall perceived good health 44 No 185 (65.1%) 5.545** 216 (68.8%) 0.023 45 Yes 99 (34.9%) 98 (31.2%) 46 Improved ability to visit general practitioner 47 No 124 (43.7%) 0.065 127 (40.4%) 3.383* 48 Yes 160 (56.3%) 187 (59.6%) 49 Improved ability to purchase prescribed 50 medicine 51 No 152 (53.5%) 19.127*** 175 (55.7%) 13.073*** 52 Yes 132 (46.5%) 139 (44.3%) 53 Improved intake of multivitamins 54 No 182 (64.1%) 6.6040** 214 (68.2%) 0.015 Yes 102 (35.9%) 100 (31.8%) 55 1 *** Significant at 1% level, ** Significant at 5% level, * Significant at 10% level 56 219 57 58 - 12 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 14 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 220 4 5 221 Women taking loans from the Government Scheme or Islamic Finance Provider were not receiving 6 7 222 health insurance interventions. However, both the Government Scheme and Islamic Finance 8 9 10 223 Provider were giving health awareness interventions. The Government Providers offered the 11 12 224 women a separate government health insurance scheme, called Sehat Sahulat Program, but none 13 14 225 of the study participants was availing this scheme. The Islamic Finance provider was supporting 15 16 For peer review only 17 226 Lahore-based women clients with a free medical camp for diabetes and heart disease (Table 2). 18 19 227 20 21 228 Table 2: Health insurance schemes of microfinance providers sampled in this study 22 Microfinance Government 23 Microfinance Bank Islamic Finance Institute Scheme 24 (n=340) (n=11) (n=41) (n=50) 25 Coverage Female borrower + Female borrower + - - 26 any family member spouse 27 Term One year One year - - 28 Premium PKR 490–990 per PKR 1,200 (if - - 29 family member unmarried); 30 PKR 1,850 (married) 31 Insurance Only hospitalization Only hospitalization - - 32
PKR 2,000–4,000 PKR 30,000 http://bmjopen.bmj.com/ 33 daily 34 Limit Between 10–30 days One-off payment - - 35 Life insurance PKR 25,000–50,000 - - - 36 in event of death 37 Other Option to take Health clinic in 38 government Sehat Lahore only; 39 Sahulat Program. treating patients 40 with diabetes and 41 heart disease on September 30, 2021 by guest. Protected copyright. 42 229 Information in this table is based on data from microfinance provider loan officers 43 44 230 45 46 231 Women borrowing from the banks can take insurance for themselves and any family member. 47 48 232 They have to pay a premium ranging from PKR 490–990 per person and are insured only in the 49 50 233 event of hospital admission. However, the insurance does not cover hospital costs and instead pays 51 52 53 234 the client the amount of daily wages lost, ranging from PKR 2,000–4,000 daily. The scheme also 54 55 235 covers a one-off payment in the event of death ranging from PKR 25,000–50,000. Female 56 57 58 - 13 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 15 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 236 borrowers from the microfinance institute are only covered for themselves and spouse. They have 4 5 6 237 to pay a premium of PKR 1,200 if unmarried or PKR 1,850 if married. Clients are provided with 7 8 238 a one-off payment of PKR 30,000 in the event of hospitalization. 9 10 239 11 12 Determinants of health-related outcomes after health insurance intervention 13 240 14 15 241 Table 3 presents the determinants of health-related outcomes for recipients of a health insurance. 16 For peer review only 17 242 Overall perceived good health was significantly associated with group borrowers, small loan 18 19 243 amount, and smaller interest rate. Improved ability to visit a general practitioner shows a positive 20 21 22 244 correlation with women borrowers from Punjab province, attending monthly meetings, group loan, 23 24 245 and smaller loan amount. Women had a significantly improved ability to purchase prescribed 25 26 246 medicine when they were from Punjab, took smaller loans, owned a house. The uptake of 27 28 29 247 multivitamins was increased in women with smaller loans, owning a house, being borrowers since 30 31 248 no longer than two years, and attending monthly meetings. Therefore, only a small loan amount 32 http://bmjopen.bmj.com/ 33 249 was a significant determinant in all four health-related outcomes among recipients of a health 34 35 insurance. 36 250 37 38 39 40 41 on September 30, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 - 14 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 16 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 251 Table 3: Probit analysis on determinants of health-related outcomes among recipients of health insurance 4 5 Overall perceived Improved ability to Improved ability to Improved 6 good health visit general purchase prescribed multivitamin 7 practitioner medicine uptake Z- Z- Z- Z- 8 Coeff. Coeff. Coeff. Coeff. Score Score Score Score 9 Age -0.2588 -1.43 0.2754 1.39 -0.2915 -1.51 0.0703 0.36 10 Religion 0.4079 1.37 -0.2711 -0.97 0.4165 1.46 -0.0102 -0.03 11 Province -0.2676 -1.04 0.9990*** 4.05 1.043*** 4.21 0.0315 0.12 12 Literacy -0.0999 -0.49 0.2018 0.96 0.0828 0.42 0.1994 0.98 13 Spouse literacy 0.2410 1.18 0.1779 0.85 0.2424 1.20 0.1323 0.64 14 House ownership 0.1550 0.69 -0.3397 -1.45 -0.6825** -2.65 -0.5699** -2.17 15 Children 0.2094 1.15 0.2213 1.20 0.1530 0.85 0.2829 1.54 16 Debt age For-0.4130 peer-0.16 review0.1650 0.63 only0.3807 1.50 -0.6088** -2.41 17 Group loan 0.8582*** 3.76 0.4813** 2.25 0.1567 0.73 -0.3705* -1.69 18 Loan amount -0.7765*** -3.27 -0.8863** -3.50 -1.2028*** -5.05 -1.9933*** -4.13 19 Interest rate 0.7250** 2.94 0.2777 1.12 -0.0691 -0.28 0.2345 0.98 20 Monthly meetings 0.1370 0.61 0.7753*** 3.58 0.0166 0.08 -0.4233* -1.84 21 No. of observations 284 284 284 284 22 Wald Chi2 42.74 76.93 64.57 53.15 23 Prob> Chi2 0.0001 0.0000 0.0000 0.0000 24 Log likelihood -158.6116 -146.0385 -157.5241 -153.7125 25 252 *** Significant at 1% level, ** Significant at 5% level, * Significant at 10% level 26 253 27 28 254 Determinants of health-related outcomes after health awareness intervention 29 30 255 In Table 4, the determinants for all four health-related outcomes among recipients of a health 31 32 33 256 awareness program are presented. Women with the following characteristics have a greater http://bmjopen.bmj.com/ 34 35 257 probability of overall perceived good health: group borrowers, smaller loans, smaller interest rates, 36 37 258 younger women, and those with literate spouses. The ability of visiting the general practitioner for 38 39 40 259 regular checkups in the last year was higher in women from Punjab province, with smaller loans, 41 on September 30, 2021 by guest. Protected copyright. 42 260 attending monthly meetings, above 29 years of age, and non-Muslim women. Similarly, women 43 44 261 from Punjab province, having smaller loans, owning their house, and younger women had a higher 45 46 47 262 probability of improved ability to purchase prescribed medicine. The probability of increased 48 49 263 uptake of multivitamins was greater in women who took smaller loans, had not been in debt for 50 51 264 more than 2 years, were group borrowers, and who attended monthly meetings. As for health 52 53 265 insurance, the only variable significantly associated with all health-related outcomes among 54 55 56 266 recipients of a health awareness program was the small loan amount. 57 58 - 15 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 17 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 267 4 5 268 Table 4: Probit analysis on determinants of health-related outcomes among recipients of health awareness 6 269 programs 7 8 Overall perceived Improved ability to Improved ability to Improved 9 good health visit general purchase prescribed multivitamin 10 practitioner medicine uptake Z- Z- Z- Z- 11 Coeff. Coeff. Coeff. Coeff. 12 Score Score Score Score 13 Age -0.3747* -1.70 0.3781* 1.70 -0.4329* -2.02 0.1058 0.48 14 Religion 0.5185 1.59 -0.5503* -1.76 0.3880 1.24 0.1904 0.56 15 Province -0.3898 -1.24 1.3048*** 4.39 1.029*** 3.83 0.1983 0.65 16 Literacy For-0.1537 peer-0.65 0.2229review0.91 only0.1405 0.61 0.3411 1.43 17 Spouse literacy 0.4163* 1.80 0.2546 1.09 0.0860 0.38 0.2310 1.00 House ownership 0.3495 1.42 -0.2453 -0.96 -0.6360** -2.48 -0.4271 -1.54 18 Children 0.3209 1.55 0.2765 1.33 0.2424 1.21 0.2833 1.36 19 Debt age -0.0066 -0.02 0.4529 1.49 0.3817 1.36 -0.7164** -2.51 20 Group loan 0.8817*** 3.33 0.3640 1.51 0.1030 0.43 -0.6352** -2.55 21 Loan amount -0.7199** -2.65 -0.6511** -2.28 -1.9361*** -3.52 -0.9170*** -3.35 22 Interest rate 0.6739** 2.23 0.3860 1.28 0.2428 0.83 0.3726 1.26 23 Monthly meetings 0.2357 0.88 0.7689** 3.08 -0.0556 -0.22 -0.5816** -2.10 24 No. of observations 314 314 314 314 25 Wald Chi2 35.68 64.57 53.25 48.79 26 Prob> Chi2 0.0004 0.0000 0.0000 0.0000 27 Log likelihood -126.4054 -116.6811 -128.2105 -121.2616 28 270 *** Significant at 1% level, ** Significant at 5% level, * Significant at 10% level 29 30 271 31 32 272 Impact of interventions on health-related outcomes 33 http://bmjopen.bmj.com/ 34 273 The results from the PSM model (Table 5) show that women receiving health insurance had a 35 36 37 274 significantly greater chance of overall perceived good health. According to NNM, 17.4% of 38 39 275 women with health insurance had greater likelihood for overall perceived good health; the results 40 on September 30, 2021 by guest. Protected copyright. 41 276 for KM showed a greater likelihood in 11.8%. Female borrowers receiving a health awareness 42 43 277 program from the MFP in the form of health workshop or health talk by loan officer show 44 45 46 278 significant improvement in their ability to purchase prescribed medicine (NNM=10.1%; KM 47 48 279 =11.7%). For the two other outcomes, neither of the interventions showed a significant effect. 49 50 280 51 52 53 54 55 56 57 58 - 16 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 18 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 281 Table 5: Impact of interventions on health-related outcomes based on propensity score matching 4 5 Overall Improved ability to Improved ability to Improved 6 perceived visit general purchase prescribed multivitamin 7 good health practitioner medicine uptake Z- Z- Z- Z- 8 Coeff. Coeff. Coeff. Coeff. Score Score Score Score 9 Nearest Neighbor Matching 10 11 Health insurance 0.1740*** 3.45 0.0038 0.04 0.1271 1.46 0.0343 0.38 12 Health awareness program 0.0599 0.97 0.0141 0.23 0.1016* 1.70 0.0291 0.42 13 14 Kernel Matching 15 Health insurance 0.1175* 1.67 -0.0256 -0.32 0.1062 1.21 0.0775 1.09 16 Health awareness programFor 0.0240peer0.42 review0.0292 0.41 only0.1167** 2.08 0.0703 1.15 17 282 *** Significant at 1% level, ** Significant at 5% level, * Significant at 10% level 18 19 283 20 21 284 Discussion 22 23 285 In the absence of universal health coverage and compulsory educational enrollment, poor and 24 25 26 286 predominantly illiterate female informal workers and borrowers of microfinance are dependent on 27 28 287 MFP for receiving health coverage and promoting health. This study has measured four health- 29 30 288 related outcomes in female borrowers. The results show that there is inequity in uptake of health 31 32 33 289 insurance and health-related outcomes. http://bmjopen.bmj.com/ 34 35 290 Women from Punjab have better health-related outcomes compared to women from Sindh, 36 37 291 Balochistan and KPK. National health surveys of Pakistan also report that Punjab has better health- 38 39 40 292 related outcomes compared to other provinces, as the provincial government of Punjab has greater 41 on September 30, 2021 by guest. Protected copyright. 42 293 budget allocation for running health awareness campaigns [29]. The fact that our results show that 43 44 294 older women and non-Muslim women have higher likelihood of improved ability to visit general 45 46 295 practitioner after receiving health awareness intervention indicates that younger Muslim women 47 48 49 296 face barriers to health access due to regressive norms [30]. Muslim families are known to prevent 50 51 297 fertile women from accessing healthcare in an attempt to control their reproductive choices and 52 53 298 health options. Our results align with other research which suggests that Muslims suffer from 54 55 56 299 health disparities due to religious fallacies [31]. 57 58 - 17 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 19 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 300 Conversely, younger women show better overall perceived health and ability to purchase 4 5 6 301 prescribed medicine This may be because at a younger age less health issues occur and also 7 8 302 because of greater state and NGO efforts for maternal healthcare [32]. Our results confirm that 9 10 303 women under the age of 29 years receive privileged support in a patriarchal society during prime 11 12 childbearing years to consume maternal health related medication [33]. Women with literate 13 304 14 15 305 spouses are also showing improvement in overall general health after receiving health insurance. 16 For peer review only 17 306 This may be because spouse literacy has a direct effect on women’s improved health behavior and 18 19 307 mental health [34]. 20 21 22 308 Women who borrow the loan in groups show better health-related outcomes compared to women 23 24 309 who are single borrowers. Our results suggest that women in groups share their health knowledge 25 26 310 and encourage each other toward improved health behavior [35]. Similarly, women who attend 27 28 29 311 monthly meetings with loan officers have better health-related outcomes. The results suggest that 30 31 312 caring loan officers are fulfilling an important responsibility in supporting women borrowers in 32 http://bmjopen.bmj.com/ 33 313 improved health behavior and health-related outcomes. Given the conservative culture of Pakistan 34 35 and the disadvantaged background of the female borrowers, loan-taking women might not be able 36 314 37 38 315 to utilize health services due to issues of permission or ignorance. 39 40 316 Women who receive smaller microfinance loans and do not have a long debt age show improved 41 on September 30, 2021 by guest. Protected copyright. 42 317 health-related outcomes. This finding suggests that women with debt burden over a longer period 43 44 45 318 of time may be suffering from debt fatigue converting to declined health-related outcomes [36]. 46 47 319 Women and their families who live in owned houses also have better health-related outcomes, 48 49 320 specifically related to the ability to visit general practitioners and improved uptake of 50 51 52 321 multivitamins. The results imply that provision of health insurance and not having to pay 53 54 322 household rents on a monthly basis translates to better health-related outcomes. Impoverished 55 56 57 58 - 18 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 20 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 323 families that have to pay high rents for accommodation are usually employed in multiple jobs and 4 5 6 324 have little time for health and wellbeing [37]. 7 8 325 The impact of microfinance is only visible on two health-related variables. Although there are no 9 10 326 effects on general practitioner visitation and uptake of multivitamins, we found that a microfinance 11 12 health insurance has an impact on an improved perception of general health. This shows that being 13 327 14 15 328 insured is an emotional support and wellbeing facilitator for poor women. The emotional buttress 16 For peer review only 17 329 provided by health insurance can go a long way in improving perceived wellbeing, which can 18 19 330 translate to greater commitment to self, family, and business development in poor women from 20 21 22 331 disadvantaged backgrounds [38]. In addition, microfinance health awareness interventions have 23 24 332 an impact on improved purchase of prescribed medicine. Many poor women in Pakistan do not 25 26 333 take prescribed medicine unless it is freely available due to the greater need to prioritize purchase 27 28 29 334 of basic necessities and household consumption [39]. The impact of microfinance interventions is 30 31 335 comparable to previous research. A review highlighted that most interventions combined 32 http://bmjopen.bmj.com/ 33 336 microfinance with health education. However, positive effects were mainly found for health 34 35 knowledge and behavior, but not health status [40]. A meta-analysis indicated the potential for 36 337 37 38 338 females, as microfinance may lead to changes in the use of contraceptives, strengthen female 39 40 339 empowerment and improve children’s nutrition [41]. 41 on September 30, 2021 by guest. Protected copyright. 42 340 However, for female borrowers of microfinance, there might be additional burdens of loan 43 44 45 341 repayment and small business investment. Our results suggest that illiterate and poor women of 46 47 342 the country are benefiting from health awareness in recognizing that if they do not consume 48 49 343 prescribed medicine for chronic ailments (heart disease, cholesterol, or diabetes) it can have 50 51 52 344 serious consequences for their own life and the future livelihood of their families. There needs to 53 54 345 be urgent recognition that a triadic health insurance safety net is necessary, instead of dependency 55 56 57 58 - 19 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 21 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 346 on private providers to protect informal working women in Pakistan. Employers and the 4 5 6 347 government must join forces to ensure universal health insurance and – particularly in times of the 7 8 348 corona pandemic – infectious disease outbreak insurances for health emergencies. State financing 9 10 349 of healthcare is essential through increased allocations of gross domestic product (GDP), 11 12 government-run business profits, and increasing income and corporate tax base from the elite. 13 350 14 15 351 With regard to women microfinance borrowers, we recommend microfinance regulatory bodies to 16 For peer review only 17 352 urgently legislate the following reforms: (i) coverage of children and other dependents, maternity 18 19 353 costs, and non-hospitalization costs, (ii) expand coverage for religious and ethnic minorities, (iii) 20 21 22 354 reduce interest rates for those paying high house rents and introduce house ownership loans, (iv) 23 24 355 introduce mandatory group borrowing and monthly meetings with loan officers, and (iv) alter 25 26 356 repayment timelines and interest rate packages for women taking bigger loans. 27 28 29 357 We recommend the following urgent social policy improvements, which would adjoin in helping 30 31 358 health policy efforts: (i) development of public primary healthcare services for women in the 32 http://bmjopen.bmj.com/ 33 359 communities with mandatory quarterly General Practitioner meeting, (ii) upgrading of poverty 34 35 alleviation programs for support of poor women, (iii) capping for housing rents and improvement 36 360 37 38 361 of neighborhood sanitation to curb infection, (iv) advancement of home-based business 39 40 362 opportunities for informal women workers for income maintenance, including digitalization and 41 on September 30, 2021 by guest. Protected copyright. 42 363 internet access in the homes, and (v) income supplementation and cash transfers for multivitamin 43 44 45 364 and food nutrition intake for immunity and health overall [42]. 46 47 365 48 49 366 Limitations 50 51 52 367 This study has some limitations, most important the cross-sectional design. Although we were able 53 54 368 to compare the effects of an intervention because of the quasi-experimental analysis framework, 55 56 57 58 - 20 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 22 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 369 two-group cross-sectional designs are suffering from the limitations related to a single 4 5 6 370 measurement for all subjects. Therefore, within-person changes over time are not observable. 7 8 371 Without repeated measures in a two-group design, causality cannot be identified, because temporal 9 10 372 sequencing on the intervention and outcomes cannot be established. For that reason, we 11 12 recommend longitudinal data collection in future studies. Furthermore, the results need to be 13 373 14 15 374 interpreted with caution, because the four health-related outcomes are non-homogenous and 16 For peer review only 17 375 dependent on socio-environmental factors specific to the region and community where the 18 19 376 interventions are taking place. Despite the limitations, we feel this study is significant for the 20 21 22 377 development of microfinance health services in Pakistan and the role of state and interest-free 23 24 378 microfinance health interventions. 25 26 379 27 28 29 380 Conclusion 30 31 381 It is critical to assess the health needs of women employed in the informal sector. As primary 32 http://bmjopen.bmj.com/ 33 382 caregivers at home as well as primary contributors for household income, the health of women 34 35 383 assumes a salience that would place both structures of the family and the economy at risk. Health 36 37 38 384 policy must consider several social policies for protecting disadvantaged women, who are poverty- 39 40 385 ridden, illiterate or semi-literate, and loan takers. Health insurance schemes and health promotion 41 on September 30, 2021 by guest. Protected copyright. 42 386 at the workplace must be made mandatory by employers, microfinance providers, and the 43 44 45 387 government, given the cultural barriers of uptake for women. Targeting improved equity across 46 47 388 female population groups for health intervention will in the long run improve women’s health, 48 49 389 capacity expansion and income-earning abilities. 50 51 52 390 Designing and implementing a health and social policy protection net for female informal workers 53 54 391 requires empirical evidence regarding health interventions and socio-demographic characteristics 55 56 392 impacting on health outcomes. Since public sector health sector shortages and inefficiencies are a 57 58 - 21 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 23 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 393 concern in Pakistan, the ‘health card’ must be accepted in both the private and public sector, 4 5 6 394 whichever is able to serve the poor first. As Pakistan is struggling with low GDP and tax collection 7 8 395 base, we recommend more research into options for social franchising, and partnership with 9 10 396 independent health insurance companies to serve disadvantaged women. 11 12 13 397 14 15 398 Acknowledgements 16 For peer review only 17 399 We thank the female borrowers who consented and gave their time to participate in the study. We 18 400 are grateful to our research team members in charge of logistical planning and coordination for 19 20 401 data collection across Pakistan including Rizwan Haider and Amir Naseem. Individual data 21 22 402 collection heads for each city are thanked for their efforts, especially for resolving gate keeping 23 403 issues, including Nida Abbas (Lahore), Zainab Asif (Abbotabad), Hina Bukhari (Gujranwala), 24 25 404 Sadia BiBi (Khanewal), Ansari Abbass (Sheikhapura), Azra Shakeel and Shumaila Sadique 26 27 405 (Matari), and Javaria Imran (Lasbela). The research assistant Bilal Asghar is also thanked for 28 29 406 entering all data. 30 407 We acknowledge support from the German Research Foundation (DFG) and the Open Access 31 32 408 Publication Fund of Charité – Universitätsmedizin Berlin. 33 http://bmjopen.bmj.com/ 34 409 35 Competing interests 36 410 37 411 The authors declare that no competing interests exist. 38 39 412 40 41 413 Funding on September 30, 2021 by guest. Protected copyright. 42 414 This study received funding by the Office of Research, Innovation and Commercialization at 43 44 415 Forman Christian College. 45 46 416 47 48 417 Data sharing 49 418 Data is available upon reasonable request from the corresponding author. 50 51 419 52 53 54 55 56 57 58 - 22 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 24 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
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1 2 3 480 21. World Health Organization. WHO multi-country study on women's health and domestic 4 5 481 violence against women: summary report of initial results on prevalence, health outcomes 6 7 482 and women's responses. Geneva: World Health Organization; 2005. 8 22. Di Martino V. Relationship between work stress and workplace violence in the health 9 483 10 484 sector. Geneva: World Health Organization; 2003. 11 12 485 23. Rosenbaum PR, Rubin DB. The central role of the propensity score in observational studies 13 14 486 for causal effects. Biometrika 1983;70(1):41–55. 15 487 24. Becker SO, Ichino A. Estimation of average treatment effects based on propensity scores. 16 For peer review only 17 488 The Stata Journal 2002;2(4):358–77. 18 19 489 25. Dehejia R. Practical propensity score matching: a reply to Smith and Todd. Journal of 20 21 490 Econometrics 2005;125(1-2):355–64. 22 491 26. Dehejia RH, Wahba S. Propensity score-matching methods for nonexperimental causal 23 24 492 studies. Review of Economics and Statistics 2002;84(1):151–61. 25 26 493 27. Abadie A, Imbens GW. Matching on the estimated propensity score. Econometrica 27 494 2016;84(2):781–807. 28 29 495 28. Caliendo M, Kopeinig S. Some practical guidance for the implementation of propensity 30 31 496 score matching. Journal of Economic Surveys 2008;22(1):31–72. 32 33 497 29. Akram M, Khan FJ. Health care services and government spending in Pakistan. PIDE- http://bmjopen.bmj.com/ 34 498 Working Papers 32. Pakistan Institute of Development Economics. 35 36 499 30. Mumtaz Z, Salway S. ‘I never go anywhere’: extricating the links between women's 37 38 500 mobility and uptake of reproductive health services in Pakistan. Soc Sci Med 39 40 501 2005;60(8):1751–65. on September 30, 2021 by guest. Protected copyright. 41 502 31. Padela AI, Zaidi D. The Islamic tradition and health inequities: A preliminary conceptual 42 43 503 model based on a systematic literature review of Muslim health-care disparities. Avicenna 44 45 504 J Med 2018;8(1):1–13. 46 505 32. Bhutta ZA, Hafeez A, Rizvi A, et al. Reproductive, maternal, newborn, and child health in 47 48 506 Pakistan: challenges and opportunities. Lancet 2013;381(9884):2207–18. 49 50 507 33. Hafeez A, Mohamud BK, Shiekh MR, Shah SAI, Jooma R. Lady health workers 51 52 508 programme in Pakistan: challenges, achievements and the way forward. Journal of the 53 509 Pakistan Medical Association 2011;61(3):210. 54 55 56 57 58 - 25 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 27 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 510 34. Hamid SA, Roberts J, Mosley P. Evaluating the health effects of micro health insurance 4 5 511 placement: Evidence from Bangladesh. World Development 2011;39(3):399–411. 6 7 512 35. Prost A, Colbourn T, Seward N, et al. Women’s groups practising participatory learning 8 and action to improve maternal and newborn health in low-resource settings: a systematic 9 513 10 514 review and meta-analysis. Lancet 2013;381(9879):1736–46. 11 12 515 36. Jacoby MB. Does indebtedness influence health? A preliminary inquiry. The Journal of 13 14 516 Law, Medicine & Ethics 2002;30(4):560–71. 15 517 37. Taylor L. Housing and Health: An Overview Of The Literature. Health Affairs Health 16 For peer review only 17 518 Policy Brief. 7 June 2019. doi: 10.1377/hpb20180313.396577. 18 19 519 38. Bauhoff S, Hotchkiss DR, Smith O. The impact of medical insurance for the poor in 20 21 520 Georgia: a regression discontinuity approach. Health Economics 2011;20(11):1362–78. 22 521 39. Zaidi S, Bigdeli M, Aleem N, Rashidian A. Access to essential medicines in Pakistan: 23 24 522 policy and health systems research concerns. PloS One 2013;8(5):e63515. 25 26 523 40. Lorenzetti LMJ. Evaluating the effect of integrated microfinance and health interventions: 27 524 an updated review of the evidence. Health Policy Plan 2017;32(5):732–56. 28 29 525 41. Gichuru W, Ojha S, Smith S, Smyth AR, Szatkowski L. Is microfinance associated with 30 31 526 changes in women's well-being and children's nutrition? A systematic review and meta- 32 33 527 analysis. BMJ Open 2019;9(1):e023658. http://bmjopen.bmj.com/ 34 528 42. Saha S. Provision of health services for microfinance clients: Analysis of evidence from 35 36 529 India. International Journal of Medicine and Public Health 2011;1(1):1–5. 37 38 39 40 41 on September 30, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 - 26 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 28 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 4 Relationship between Microfinance, Social Development and 5 6 Women’s Health 7 8 9 10 Cover Letter for Participants 11 12 Questionnaire Information for Women Microfinance Borrowers 13 14 Researcher: Dr. Sara Rizvi Jafree, e-mail: [email protected]; 0300 400 5740 15 16 Thank you for yourFor valuable peertime! Your namereview is not required only and all research analysis will be 17 18 undertaken with confidentiality and complete anonymity. At any point during the interview you 19 may leave, if you wish to do so. 20 21 (Translation in Roman Urdu: Apka Bohat Shukirya apke eemtay waat ke liye! Apke Nam Ka Bharna Zaruri 22 Nahi Hai Aur Yeh Tehkeek Ko Khoofiya Rakha Jaye Ga. Interview ke doran ap kabhi bhi uth ke jaana chahey to apko puri ijazat hai.) 23 24 25 The questionnaire has been designed to collect information about your loan portfolio and your 26 self-rated health. Our aim is to understand your needs and challenges, and ultimately try to 27 improve your loan portfolio and health access and services. 28 29 ((Translation in Roman Urdu: Is questionnaire Ka Masad Hai ke apse chand sawal loan aur sehat ke bare mein 30 puchna. Humara masad ye hai ke apke arze ki sahuliyat aur sehat dono ko behtar kiya jaye.) 31 32
Your honest and reliable answers will be appreciated, so that we can recommend the best http://bmjopen.bmj.com/ 33 solutions with regard to optimal loan portfolios and health satisfaction. 34
35 ((Translation in Roman Urdu: Apke Sache Aur Ba Aitibar Jawab Ke Shukarguzar Honge, Thake loan aur sehat ke 36 hawale se hum apke mushkilay ya rukawaton ko Samajh Sake.) 37 38 39 In the event that you feel disturbed or upset after answering questions or recalling memories 40 related to health problems or experiences of violence/ harassment, you may call or text the 41 researcher for free consultation services from trained female psychologists. on September 30, 2021 by guest. Protected copyright. 42 43 ((Translation in Roman Urdu: Agar apko in sawal aur jawab ki wajeh se koi preshani ho ya koi aisa waiya yad a 44 jaye jo apki zehni pareshani mein izafa kare, tho ap upar diye gaye number par call ya text kar ke rabta kar le. Hum 45 apki muft mein madat zanana mahir-e-nafsiyat se karwayenge.) 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 29 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 4 5 6 7 Sign or Thumb Impression for Written Consent 8 9 Instrument 10 11 The questionnaire will be read out and completed by the researcher, on behalf of the participant. 12 13 14 Province/City: ______Microfinance 15 Provider:______16 Area/locality: For peer review only Participant Code: 17 18 SECTION A: Code 19 SOCIO-DEMOGRAPHIC Entry 20 CHARACHTERISTICS 21 Q1.Age 1.20-29 2.30-39 3.40-49 4.50+ 22 Umar? 23 Q2.Religion 1.Muslim 2.Christian 3.Hindu 4.Other 24 Mazhab 25 Q3.Province 1.Punjabi 2.Sindhi 3.Baluchi 4.KPK 26 Sooba? 1.Lahore 3.Karachi 1.Quetta 1.Peshawar 27 Q4.City Shehr? 28 2.Islamabad 4.Hyderabad 29 Q5.City-Area 30
31 Q6.Language spoken at home with family Madri zubaan? 32 Q7.Race (β) http://bmjopen.bmj.com/ 33 Zaat 34 Q8.Marital Status 1.Married 2.Single 3.Divorced 4.Seperated 35 Kya ap shadi shuda hain? 36 Q9.Literacy 1.None 2.Primary 3.Secondary 4.Graduate 37 Taleem-i-qabiliyat
38 Q10.Occupation Pesha 39 1.None 2.Primary 3.Secondary 4.Graduate 40 Q10.Spouse literacy
Aapkay khaawand ki taleemi qabiliyat kya hai? on September 30, 2021 by guest. Protected copyright. 41 Q12.Spouse Occupation 42 Apkay khawand ka pesha kya hai? 43 Q13.Your earning in last month 1.Less than 5k 2.>5k-10k 2.>10k-20k 4.Other 44 Pichlay mahinay aap ki kamai kitni thi? 45 Q14.Your earning in last year 1.Less than 50k 2.>50k-70k 2.>70k-90k 4.Other 46 Pichlay saal apki kitni kamai thi? 47 Q15.Combined household income in a month (on 1.Less than 10k 2.>10k-15k 2.>15k-20k 4.Other 48 average) 49 Tamaam ghar ki amdani kitni hai? 1.Owned 2.Rented 3.Living with 4.Other 50 Q16.House Ownership Ghar ka malik kaun hai? someone 51 Q17.Number of children 1. None 2. 1-2 3. 3-5 4. >6 52 Apkay kitnay bachay hain? 53 Q18.Age of last child 54 Akhri bachay ki umar? 55 Q19.Number of people living in house 1. 1-2 2. 3-5 3. 6-9 4. >10 56 Ghar mai kitnay afraad rehte hain? 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 30 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 Q20.Number of rooms in house 1. 1 2. 2-3 3. 4-5 4. >6 4 Ghar mai kitnay kamray hain? 5 Q21.Are you currently taking care of a disabled/ 1.No 2.Yes If Yes, who: 6 dependent family member 7 Kya apkay ghar mai koi mazoor/jiska ap par inhasaar ho, 8 shakhs hai? Q22.Source of drinking water 1.Plain Tap 2.Filtered 3.Local 4.Other 9 Pani penay ka kya zarya hai? Pump 10 Q23.Type of energy used for cooking in house 1.Gas 2.Wood 3.Electricity 4.Other 11 Ghar mai khana pakanay ke liye kis chiz ka istemaal kartay 12 hain? (gas, coal, electric etc.) 13 Q24.Do you have toilet facility in house 1.Yes 2.No If No, what do you use 14 Apkay ghar mai bait-ul-khala hai? 15 Q25.How many toilets in the house 1. None 2. 1-2 3. 3-5 4. >6 16 Ghar mai kitnay bait-ul-khala hain? For peer 1.Yesreview 2.No onlyIf No, what do you use 17 Q26.Does the toilet have a flush Bait-ul-khala mai flush hai? 18 Q27.Is the drainage and gutter system of your 1.Yes 2.No 19 house satisfactory 20 Ganday pani ke ikhraj ka nizaam darust hai? 21 Q28.How do you dispose of the garbage 1.Throw it on 2.Garbage 3.Set Fire 4.Other 22 Ghar ki gandagi kahan phenkhtay hain? street/ far away collectors from home come to house 23 Q29.Are you taking any health insurance (not 1.Yes 2.No If Yes, who 24 provided by the microfinance provider)? (If so, 25 from where, how much installment) 26 Sehat ke liye insurance le rae hain? 27 SECTION B: 28 MICROFINANCE LOAN 29 CHARACHTERISTICS 30 Q30.Why are you taking loan (describe your work 31 type, hours of work, working conditions in detail) 32 Aap karz kyun le rahe hain? (kis tarah ka kaam hai, kitnay ghantay kaam kartay hain, jahan kaam kartay hain uskay halaat) http://bmjopen.bmj.com/ 33 34 35 36 Q31.What type of loan are you currently taking/ duration 37 Kis tarah ka karz le rahay hain/kitnay arsay se? 38 Q32.How long have you been a microfinance 1. 1-2 years 2. 3-5 years 3. 6-9 years 4. >10 39 borrower for years 40 Kitne arsay se karz le rahay hain? on September 30, 2021 by guest. Protected copyright. 41 Q33.Is it a group loan 1.Yes 2.No If Yes, who 42 Kya ap ne kisi ke sath mil ke karz liya hai? 43 Q34.How much is the loan for 44 Kitna karz liya hai? 45 Q35.What is the installment rate per month 46 Karz ko ada karnay ki mahana kist kya hai? 47 Q36.Do you attend monthly meetings with loan 1.Yes 2.No 48 officers Karz denay walay officer se kya apki mahwar mulakaat hoti 49 hai? 50 Q37.Do you attend weekly meetings with loan 1.Yes 2.No 51 officers 52 Karz dene walay officer se kya apki haftawar mulkaat hoti hai? 53 Q38.Who helps you in loan repayment 1.No one 2.Husband 3.Parents 4.Other 54 Karz ada karnay mai kya koi apki madad karta hai? 55 Q39.What exactly has the loan been used for 1.Business 2.Household 3.Old 4.Health 4.Other Ap karz kis liye istemal karti hain? expenditure Loans Costs 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 31 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 Q40.How much of the loan taken has been 1.All 2.Half 3.Quarter 4.Other 4 invested in business 5 Karz ka kitna hissa karobar mai kharch kiya hai? 6 Q41.Are you satisfied with loan amount 1.Yes 2.No 7 Kya aap karz ki rakam se mutmaeen hai? 8 Q42.Are you satisfied with loan repayment rate 1.Yes 2.No 9 Kya ap karz ki adaigi ki kist se mutmaeen hai? Q43.Will you be renewing loan 1.Yes 2.No 10 Kya aap karz dobara lena chahain gae? 11 Q44.Have you received any skill development 1.Yes 2.No 12 training 13 Kya apki silahiyaton ko barhanay ki koi tarbiyat mili hai? 14 Q45.Have you participated in any health 1.Yes 2.No 15 workshop/awareness campaign/talk… 16 Kya sehat se mutalik ap kisi agahi mohim ka hissa banay hai? For peer 1.Yesreview 2.No only 17 Q46.Has your loan officer or center ever talked to 18 you about health awareness or access Kya karz denay walay officer ne ap se sehat ke mutalik koi 19 agahi di hai? 20 Q47.Have you been offered saving insurance by 1.Yes 2.No 21 your MFP 22 Kya idaray ne apko bachat insurance ki peshkash ki hai? 23 Q48.Are you taking saving insurance with your 1.Yes 2.No 24 MFP 25 Kya idara ap ko bachat insurance de raha hai? 26 Q49.Have you been offered health insurance by 1.Yes 2.No 27 your MFP Kya idara aap ko sehat insurance deta hai? 28 Q50.Are you taking health insurance with your 1.Yes 2.No 29 MFP 30 Kya ap idaray se sehat insurance le rahay hain? 31 Q51.Has the loan so far satisfied your business 1.Yes 2.No 32 needs 33 Kya karz ki rakam ne apki karobari zaroriyat ko pura kiya hai? http://bmjopen.bmj.com/ 34 Q52.Has your loan taking from MF enabled you to 1.Yes 2.No 35 visit a trained private general practitioner, if 36 needed in last 12 months 37 Karzay k baad pichlay 12 maheenay mein kya app private doctor ko dekhanay gaye hain? 38 Q53.Has your employment from MF loan enabled 1.Yes 2.No 39 you to visit a trained private specialist practitioner, 40
if needed in last 12 months on September 30, 2021 by guest. Protected copyright. 41 Karzay k baad pichlay 12 maheenay mein kya app baday doctor 42 ko dekhanay gaye hain? 43 Q54.How is your ability to purchase prescribed 1.Very Good 2.Good 3.Fair 4.Poor 44 medicines (in case recommended by doctor) since 45 loan-taking? Kya karz lene ke bad dawayan khareednay ki istata’at mai koi 46 tabdeeli ai hai? 47 SECTION C 48 WOMEN’S HEALTH CARE EXPERIENCES 49 SURVEY 50 Q55. How would you rate your health in general? 1.Very Good 2.Good 3.Fair 4.Poor 51 Apki sehat kis mayar ki hai? 52 Q56.Compared to other women your age, how 1.Very Good 2.Good 3.Fair 4.Poor 53 would you rate your health 54 Apni hum umar auraton ki nisbat aap apni sehat ka kya mayaar samjhtay hain? 55 Q57. Do you feel your health could be better than 1.Yes 2.No If yes, could you say why/ 56 how: 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 32 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 it is presently? 4 Kya apki sehat ke mayaar mai koi behtari lai ja sakti hai? 5 6 7 Q58.Does your husband/ male relative/in-laws 1.Yes 2. I decide If yes, can you specify decide/ give approval when you or your children myself which relatives: 8 independently 9 need consultation from a medical practitioner Kya apka khawand/susral apko doctor pe janay ki ijazat deta 10 hai? Kya ye faisla bhi apka susral/khawand krta hai? 11 12 Q59.Does your husband/ male relative/in-laws 1.Yes 2. I decide If yes, can you specify 13 decide/ give approval when you or your children myself which relatives: independently 14 need to visit a clinic/ hospital 15 Kya apka khawand/susral apko hospital janay ki ijazat deta hai 16 or kya ye faisla kaun leta hai? For peer review only 17 18 Please indicate if you have experienced any of 1.Yes 2.No 19 the following health issues in the last 12 20 months? 21 Q60.Minor illness like the flu or an infection 22 Pichlay 12 mahinay mai apko nazla ya infection hua hai?
23 Q61.Had to go for a checkup or routine physical 24 exam Jismani muaaenay ke liye gae hain? 25 Q62.Were you pregnant? 26 Kya app hamla theen? 27 Q63.Did you need family planning or 28 preconceptional services? 29 Kya apko munsoba bandi ki zaroorat thee? 30 Q64.Did you have an injury that you have not 31 already mentioned? 32 Kya apko koi chot lagi hai?
http://bmjopen.bmj.com/ 33 Q65.Did you need care for a chronic health problem, (that is one that goes on for a long time)? 34 Kya apko kisi taweel bemari ke liye hospital jana para hai? 35 Q66.Did you need surgery for a condition not If yes, what? 36 already mentioned?
37 Kya apko operation keranay ki zaroorat parhi?
38 Q67.Were you feeling depressed, anxious, or Could you pinpoint why? 39 highly stressed?
40 Kya iski waja se apko kisi kisam ka zehni dabao ya bechaini on September 30, 2021 by guest. Protected copyright. 41 mehsoos hui hai? 42 Have you had one of the following tests in the 1.Yes 2.No 43 last 12 months? 44 Q68.Colon cancer screening, such as a check for 45 blood in your stool, sigmoidoscopy, or 46 colonoscopy 47 Q69.Test for glaucoma or pressure in the eye 48 Q70.Blood cholesterol test 49 Q71.Check for high blood pressure 50 Q72.Test for diabetes 51 Q73.Breast exam by a doctor or nurse 52 Q74.Mammogram 53 Q75.Pap test 54 Q76.Bone density test (for osteoporosis) 55 Q77.Genetic screening test 56 Q78.Screening for HIV/AIDS 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 33 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 Q79.Screening for other sexually transmitted 4 diseases 5 Q80.Dental exam 6 Q81.Shot for flu or pneumonia 7 Q82.Pregnancy test 8 Q83.Family planning services or contraception 9 Q84.Tests for infertility 10 Q85.Abortion information or services 11 Q86.Alcohol or drug abuse counseling or 12 treatment 13 In the past 12 months, did any of your health 1.Yes 2.No If yes, can you specify 14 care providers or microfinance loan managers who gave you this 15 talk with you or give you information about? information: 16 (pichlay 12 mahino maiFor kya apkay peer review only 17 doctor/nurse ya apkay karz dene walay 18 19 officer ne aap se in chizon ke baray mai 20 maloomat di hain?) 21 Q87.Smoking, second-hand smoke, or quitting 22 smoking Tambako noshi, kisi aisay shaks k saath bethtna/rehna jo 23 tambako noshi mein mulawis ho, ya tambako noshi chorna 24 Q88.Nutrition or diet 25 (Khuraak) 26 Q89.Alcohol or drug use 27 Shraab ya adviyaat? 28 Q90.Physical fitness or exercise 29 Jismani sehat ya warzish? Q91.Menopause or hormone replacement therapy 30 San – e - yaas ya hormone tabdeeli therapy? 31 Q92.Violence in the home or workplace 32 Kya ghar ya kaam pe kisi tashadud ka shikar hue hain? http://bmjopen.bmj.com/ 33 Q93.Work or financial problems 34 Kaam ya muaashi mushkilaat ka samna hua hai? 35 Q94.Family or relationship problems 36 Ghar walon ya rishtadaron ke masa’il? 37 Q95.Importance of child health and nutrition Bachon ki sehat or khuraak ki ehmiyat? 38 Q96.Stress management 39 Zehani dabao ko kum karna 40 Q97.Preventing unintended pregnancies & birth on September 30, 2021 by guest. Protected copyright. 41 spacing 42 Bachon ke darmiya wakfa? 43 Q98.Using alternative therapies, such as herbs or 44 acupuncture 45 Q99.Preventing osteoporosis 46 Hadion ke dard se bachao 1.Yes 2.No 47 Are there any dietary supplements that you have used in the last 12 months? 48 49
50 Q100.Vitamin C
51 Q101.Vitamin D
52 Q102.Vitamin E
53 Q103.B Complex
54 Q104.Calcium
55 Q105.Pregnancy Vitamin
56 Q106.Lactation Vitamin 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 34 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 Q107.General Multi-vitamin 4 What is your personal preference for health 1.Yes 2.No 3.Indfferent 5 services? 6 Tibbi saholiyat se mutalik apki zaati tarjihaat kya hain? 7 Q108.Family (e.g. mother/ mother-in-law/ aunt) If Yes, 8 Ghar walay? describe who: 9 10 Q109.A women’s health center where you can get 11 most of your basic health care, including 12 gynecological care, in one place Khawateen ki sehat markaz? 13 Q110.Trusted community member 14 Baradari? 15 Q111.A nurse or LHW (Not a physician/ surgeon/ 16 medical consultant) For peer review only 17 Q112.PublicHospital 18 Q113.Local female healer 19 Q114.Private Clinic 20 Q115.In general, how difficult have you found it to 1.Very difficult 2.Somewhat 2.Not too 3.Not 21 talk to health care providers about your personal difficult difficult difficult at all 22 health concerns? 23 doctor/nurse se baat krna apko kitna mushkil lagta hai? 24 Please rate the health practitioner services as 1.Excellent 2.Good 3.Fair 4.Poor 25 you have experienced them?
26 Q116.Listening to what you have to say 27 Kya apki baat ghor se suntay hain? 28 29 Q117.Talking to you in a respectful and caring 30 manner Kya ap se izzat se baat kartay hai? 31 32 Q118.Speaking to you in the language/ dialect you 33 understand better http://bmjopen.bmj.com/ 34 Kya apse apki madri zubaan mai baat krtay hai
35 Q119.Answering your questions clearly 36 Ap ke sawalon ka sahi se jawaab detay hai?
37 Q120.Giving you the opportunity to ask all of your 38 questions 39 Apko sawaal puchnay ka wakt detay hai? 40 41 Q121.Helping you to feel comfortable talking on September 30, 2021 by guest. Protected copyright. about your personal or sensitive health concerns 42 Kya ap asaani se unhe apnay masaael ke baray mai bata deti 43 hain? 44 45 Q122.Giving you complete health information Kya sehat se mutalik tamaam jankari detay hain? 46 47 Q123.Discussing alternative therapies, diet and 48 lifestyle 49 Kya ap se mutabadil therapy ya khuraq ya roz mara ki zindagi guzarnay kay tareekay pe tabadal e khayal kya hai? 50 51 Q124.Giving you complete information about any 52 tests or services 53 Test ke baray mai mukamal jaankari detay hain?
54 Q125.Giving you the results of your tests 55 Test ke nataij batatay hain? 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 35 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 4 Q126.Giving you complete information about all 5 your options for treatments 6 Kya ilaaj ke mutalik apko mukamal jaankari detay hai?
7 Q127.Giving you the opportunity to make 8 important decisions about your health care 9 Kya sehat se mutalik tamam faislay apko karnay detay hai?
10 Q128.Giving you written or printed information 11 when you need it 12 Malumaat likh kr dete hai? 13 Q129.Spending enough time with you during your 14 visits 15 Apko tasali bakhsh wakt detay hai? 16 For peer review only 17 Q130.Treating you like a partner in your health 18 care Apka sathi bun kr apki sehat ka khayal rakhtay hai? 19 Which are the primary/ most important sources Tick relevant 20 you depend on for making health decisions? options 21 Sehat se mutalik faislon ke liye ap kis se mashwara leti hai? 22 Q131.Husband 23 Q132.Mother in law 24 Q133.Other in-laws (list please) 25 Q134.Blood family (parents, siblings, children…) 26 Q135.Newspapers / magazines 27 Q136.Heath newsletter 28 Q137.TV 29 Q138.Radio 30 Q139.Microfinance provider 31 Q140.Internet 32 Q141.Mobile services http://bmjopen.bmj.com/ 33 Q142.Family/ friends 34 Q143.Community 35 Q144.Medical Practitioner 36 Q145.Local Healer 37 Q146.Local Imam/ religious leader 38 Q147.Other (Please list) 39 Current Health Risks 40 Q148.Do you currently smoke? 1.Yes 2.No on September 30, 2021 by guest. Protected copyright. 41 Kya app tambako noshi mein mulawis hain? 42 Q149.How many in a day? 43 Din ke kitnay ? 44 Q150.Does anyone else smoke in the house when 1.Yes 2.No If yes, who is this: 45 you/ children are in same room? 46 Kya koi aur tambako noshi mein mulawis hain 47 Q151.Do you feel anxious, stressed, depressed, 1.Yes 2.No Indicate which: suicidal? 48 Kya app kabhi bechain hotay hain ya zehni dabao ka shakar ya 49 khud kushi ka khayal aya hai? 50 Q152.Do you take any drugs (to relieve yourselves If yes, which ones: 51 of stress or an ailment? 1.Yes 2.No
52 Kya app in ke liye koi dawa laitay hain? 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 36 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 In the past 5 years, has a doctor ever told you Tick relevant 4 that you have any of the following conditions options 5 Kya pichlay paanch salon mai doctor ne aapko bataya ke apko 6 ye bemari hai? 7 8 Q153.Hypertension/ BP 9 High blood pressure 10 Q154.Heart disease 11 Dil ki bemari 12 Q155.High cholesterol 13 Q156.Diabetes 14 15 (sugar) 16 Q157.Depression For peer review only 17 Zehni dabao 18 Q158.Anxiety 19 Bechaini 20 Q159.Migraine headaches 21 (sar dard) 22 Q160.Arthritis 23 Joro ki dard 24 Q161.Osteoporosis 25 Q162.Obesity/ Over-weight problems 26 (mutapa) 27 Q163.Urinary incontinence 28 (pishaap ki takleef) 29 Q164.Cancer 30 Q165.Eating disorder like bulimia/ anorexia Khanay k hawaly se koi mushkil, jaisay bhook na lagna ya kha 31 k ulti kerna 32
Q166.Thyroid problems http://bmjopen.bmj.com/ 33 Q167.Malaria/ Dengue 34 Are you facing any disability which? 35 Kya aap kisi mazoori ka shikaar hain? 1.Yes 2.No 36 If yes, please describe this 37 Q168.Keeps you from participating fully in your disability: ability to take care of your family 38 Jiski waja se ap apnay ghar walon ka khayal na rakh sakain 39 40 If yes, please describe this Q169.Keeps you from participating fully in your on September 30, 2021 by guest. Protected copyright. 41 disability: ability to continue with your business 42 Apnay karobaar mai sahi se kaam na kr sakain 43 44 SECTION D 45 BASELINE NUTRITION AND FOOD 46 SECURITY SURVEY UNICEF 47 Q170.In the past 6 months did you find it too 1.Yes 2.No 48 expensive to purchase the foods you needed to 49 feed your family? 50 Pichlay 6 maah mai kya apko khaandan ko palnay ke liye khana 51 lenay mai mushkilaat hoti hai?
52 Q171.Did you find it too expensive to purchase 1.Yes 2.No 53 fruit? 54 Kya phal khareedna bohat mehnga hai? 55 Q172.Did you find it too expensive to purchase 56 1.Yes 2.No 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 37 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 vegetables? 4 Kya sabzi khareedna bohat mehnga hai? 5 Q173.Did you find it too expensive to purchase 6 1.Yes 2.No meat? 7 Kya gosht khareedna bohat mehnga hai? 8 9 Q174.Did you find it too expensive to purchase 1.Yes 2.No 10 eggs? 11 Kya anday khareedna bohat mehnga hai?
12 Q175.Did you find it too expensive to purchase 1.Yes 2.No 13 milk? 14 Kya doodh khareedna bohat mehnga hai?
15 Q176.Did you find it too expensive to purchase 1.Yes 2.No 16 wheat, for roti? For peer review only 17 Kya roti khareedna bohat mehnga hai? 18 Q177.In the last 3 months were you worried about 19 1.Yes 2.No running out of food because of high costs? 20 Pichlay 3 maah mai mehngai ki waja se khana na khareed 21 panay ka dart ha? 22 Q178.In the last 3 months did you run out of food 23 1.Yes 2.No because of expense? 24 Pichlay 3 maah mai kya mehngai ki waja se kabhi ghar mai 25 khana khatam ho gaya ho? 26 Q179.In the last 3 months did you or any other 27 1.Yes 2.No adult in the house skip meals because there was 28 not enough food? 29 Pichlay 3 maah mai aap ya kisi or ghar walay se khana kum 30 honay ki waja se khana na khaya ho? 31 Q180.In the last 3 months did you ever think your 1.Yes 2.No 32
children are still hungry because of not being fed http://bmjopen.bmj.com/ 33 enough food? 34 Pichlay 3 maah mai apko kabhi laga ke apkay bachay bhookay 35 hai kyunkay khana pura nai tha? 36 Q181.In the last 3 months did any of your children 1.Yes 2.No 37 go to bed hungry? 38 Pichlay 3 maah mai kya apkay bachay kabhi bhookay soe 39 houn? 40 SECTION E 41 WHO MULTI-COUNTRY STUDY ON WOMEN’S HEALTH AND DOMESTIC VIOLENCE AGAINST on September 30, 2021 by guest. Protected copyright. 42 WOMEN Psychological violence experienced at home 1.Yes 2.No If yes, who were these 43 household members? 44 Q182.Has someone in your home insulted you or 45 made you feel bad about yourself? 46 Kya ghar mai kisi ne apki bezati ki hai? 47 Q183.Has someone in your home belittled or 48 humiliated you in front of other people? 49 Kya ghar mai kisi ne apko dosron ke samnay hakeer dikhaya 50 hai? Q184.Has someone in your home done things to 51 scare or intimidate you on purpose? 52 Kya ghar mai kisi ne apko daraya hai? 53 Q185.Has someone in your home threatened to 54 hurt you or someone you care about? 55 Kisi ne apko damkhaya hai? 56 Physical violence experienced at home 1.Yes 2.No If yes, who were these 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 38 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 household members? 4 Q186.Has someone in your home slapped you or 5 thrown something at you that could hurt you? 6 Kya kisi ne apko thapar lagaya ho ya app e koi chiz phenki ho 7 jisse apko chot lagi ho? 8 Q187.Has someone in your home pushed or shoved you? 9 Ghar pe apko kisi ne dhaka diya hai? 10 Q188.Has someone in your home hit you with his 11 fist or with something else that could hurt you? 12 Kisi ne apko mukkay marain hai? 13 Q189.Has someone in your home kicked you, 14 dragged you or beaten you up? 15 Kisi ne apko laat mari ho ya ghaseeta ho? 16 Q190.Has someone in yourFor home choked peer or burnt review only 17 you on purpose? Kisi ne jaan bojh kr apka gala dabanay ki, ya jalanay ki koshish 18 ki hai? 19 Q191.Has he threatened to use or actually used a 20 gun, knife or other weapon against you? 21 Apkay khilaf koi hathyaar istemal kiya hai? 22 Sexual violence experienced at home 1.Yes 2.No 23 Q191.Has your husband physically forced you to 24 have sexual intercourse when you didn’t want to? 25 Kya apke shohar ne kisi kisam ka jinsi tushadad kiya hai? 26 Q192.Did you ever have sexual intercourse when 27 you didn’t want because you were afraid of what 28 your husband might do? Kiya app ne kabhi apnay shohar k darr se uss ke saath jinsi 29 taluqat rakhain hain? 30 Q193.Has your husband forced you to do 31 something sexual that you found degrading or 32 humiliating? 33 Kya apkay shohar ne kabhi app se aisay jinsi kaam keraye hain http://bmjopen.bmj.com/ 34 jin se app sharminda ya zilat mehsoos kerain? 35 SECTION F 36 SURVEY OF WORKPLACE VIOLENCE WHO 37 Q194.Describe where exactly your work takes 38 place, when outside of home 39 Ghar se bahir kahan kaam karti hai? 40 41 Q195.What kind of people do you interact with on September 30, 2021 by guest. Protected copyright. 42 mostly for work, outside of home (gender 43 Kam pe kis tarah ke log se mulakat hoi hai? 44 Q196.What are the hours that you are required to 45 work outside of home 46 Ghar se bahir kaam ke silsalay mai kitnay ghnatay lagtay hai? 47 Q197.Which security measure is available to you 48 outside of home in case of fear of violence (male 49 relative accompanying, phone, moving in 50 crowd…) 51 Tashadud ki soorat mai kaam pr koi hifazati intezam hotay hai? 52 Physical Violence (PV) at the workplace 53 Q198.In the last 12 months, have you been 1.Yes 2.No 54 physically attacked in your workplace/ when you 55 are working outside of home? 56 Ghar se bahir kaam kartay wakt kisi tarah ke tashadud ka shikar 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 39 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 hui hain? 4 Q199.Was this PV with a weapon? (If yes, what 5 kind) 6 Kya is tashadud ke liye koi aslaah istemal kiya gaya tha? 7 Q200.Is this a typical incident at your workplace/ 1.Yes 2.No 8 when you are working outside of home? 9 Kya is tarah ka tashadud kaam pr mamool ki baat hai? Q201.Who attacked you? 10 Kis ne app r tashadud kiya? 11 12 Q202.Where exactly did it take place? Tashadud kis jaga hua? 13 14 Q203.What time was it? 15 Kis wakt hua? 16 Q204.Do you think it could be prevented? 1.Yes 2.No Kya is tashadud roka ja sakta tha?For peer review only 17 1.Yes 2.No 18 Q205.Were you injured? Kya apko kisi kisam ki chot ai thi? 19 Q206.Did you require treatment for the injury? 1.Yes 2.No If yes, can you describe this treatment: 20 Kya is chot/zakham ke liye apko kisi ilaj ki zarorat hui? 21 22 Q207.How did you respond to the incident? 23 Tashadud ke natijay mai ap ne kya kiya? 24 25 Did you suffer any of the following due to PV: 26 Q208.Repeated, disturbing memories, thoughts, or 1.Yes 2.No 27 images of the attack? 28 Tashadud ke bad kya apko iske baray mai aksar khayalat atay 29 the? 30 31 Q209.Avoiding thinking about or talking about the 1.Yes 2.No 32 attack or avoiding having feelings related to it? 33 Kya is tashadud ke baray mai baat karne se ap ghabrati thi? http://bmjopen.bmj.com/ Q210.Being "super-alert" or watchful and on 1.Yes 2.No 34 guard? 35 Tashadud ke bad dar ke rehne lagi? 36 37 Q211.Feeling like everything you did was an 1.Yes 2.No 38 effort? 39 Har kaam mushkil ho gaya? 40 Verbal Violence (VV) at the workplace on September 30, 2021 by guest. Protected copyright. 41 Q212.In the last 12 months, have you been 1.Yes 2.No 42 verbally assaulted in your workplace/ when you 43 are working outside of home? 44 Kya pichlay 12 mah mai kaam pr kisi ne ap pr zabani tashadud 45 kiya hai? 1.Daily 2.About once 3.About once 4.Other 46 Q213.How often has this happened in the last 12 months? in a week in a month 47 Kitni dafa? 48 Q214.Is this a typical incident at your workplace/ 1.Yes 2.No 49 when you are working outside of home? 50 Kya ye kaam pr mamool ki baat hai? 51 Q215.Who abused you? 52 Kis ne aap per zabani tashadud kiya? 53 Q216.Where exactly did it take place? 54 Kahan kiya? 55 Q217.What time was it? 56 Kis wakt kiya? 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 40 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 Q218.Do you think it could be prevented? 1.Yes 2.No 4 Kya isse roka ja sakta tha? 5 Q219.How did you respond to the incident? 6 Iske natijay mai aap ne kya kiya? 7 8 Did you suffer any of the following due to VV: 9 Q220.Repeated, disturbing memories, thoughts, or 1.Yes 2.No 10 images of the attack? Tashadud ke bad kya apko iske baray mai aksar khayalat atay 11 the? 12 13 Q221.Avoiding thinking about or talking about the 1.Yes 2.No 14 attack or avoiding having feelings related to it? 15 Kya is tashadud ke baray mai baat karne se ap ghabrati thi? 16 Q222.Being "super-alert" orFor watchful andpeer on 1.Yesreview 2.No only 17 guard? 18 Tashadud ke bad dar ke rehne lagi? 19 20 Q223.Feeling like everything you did was an 1.Yes 2.No 21 effort? 22 Har kaam mushkil ho gaya? 23 24 Sexual Harassment (SH) at the workplace 25 Q224.In the last 12 months, have you been 1.Yes 2.No 26 sexually harassed in your workplace/ when you are 27 working outside of home? Kya pichlay 12 maheenay mein ap ko kisi kisam k jinsi 28 harasaan ka samna kerna parha hai? 29 Q225.How often have you been sexually harassed 1.Daily 2.About once 3.About once 4.Other 30 in the last 12 months? in a week in a month 31 Pichlay 12 maheenay mein yeh kitni dafa hua? 32 Q226.Is this a typical incident at your workplace/ 1.Yes 2.No 33 when you are working outside of home? http://bmjopen.bmj.com/ 34 Kya yeh kaam kernay wali jaga pe amoman hota hai?
35 Q227.Who attacked you? Hamla awar kaun tha? 36 37 Q228.Where exactly did it take place? 38 Yeh kis jaga pe hua? 39
40 Q229.What time was it?
Waqt kya tha? on September 30, 2021 by guest. Protected copyright. 41
42 Q230.Do you think it could be prevented? 1.Yes 2.No 43 Kya app isko rok sakti theen? 44 Q231.How did you respond to the incident? 45 Apnay iska samna kaisay kiya? 46 Did you suffer any of the following due to SH: 47 Q232.Repeated, disturbing memories, thoughts, or 1.Yes 2.No 48 images of the attack? 49 Kya apko iss hadsay k baad baar baar buray khaylat ya yaadain 50 pareshan kerti hain? 51 52 Q233.Avoiding thinking about or talking about the 1.Yes 2.No 53 attack or avoiding having feelings related to it? Kya app iss hadsay ko bhulanay ki koshih ya iskay baray mein 54 baat kernay se guraiz kertay hain? 55 Q234.Being "super-alert" or watchful and on 1.Yes 2.No 56 guard? 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 41 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 Kya app chak o chawbund rehtay hain? 4 Q235.Feeling like everything you did was an 1.Yes 2.No 5 effort? 6 Kya apko zehni dabao mehsoos hota hai? 7 Racial Harassment (RH) at the workplace 8 Q236.In the last 12 months, have you been racially 1.Yes 2.No 9 harassed in your workplace/ when you are working 10 outside of home? Pichlay 12 maah mai apki zaat ki waja se kisi ne apko harasaan 11 kiya hai? 12 Q237.How often have you been racially harassed 1.Daily 2.About once 3.About once 4.Other 13 in the last 12 months? in a week in a month 14 Kitni dafa? 15 Q238.Is this a typical incident at your workplace/ 1.Yes 2.No 16 when you are working outsideFor of home? peer review only 17 Ghar se bahir kaam pe kya ye aam ma’mool ki baat hai? 18 Q239.Who attacked you? Kis ne harasaan kiya? 19 20 Q240.Where exactly did it take place? 21 Kahan 22 23 Q241.What time was it? 24 Kis wakt? 25 Q242.Do you think it could be prevented? 1.Yes 2.No 26 Kya issay roka ja sakta tha? 27 Q243.How did you respond to the incident? 28 Iske natijay mai aap ne kya kiya?
29 Did you suffer any of the following due to RH: 30 Q244.Repeated, disturbing memories, thoughts, or 1.Yes 2.No 31 images of the attack? 32 Tashadud ke bad kya apko iske baray mai aksar khayalat atay http://bmjopen.bmj.com/ 33 the? 34 Q245.Avoiding thinking about or talking about the 1.Yes 2.No 35 attack or avoiding having feelings related to it? 36 Kya is tashadud ke baray mai baat karne se ap ghabrati thi? 1.Yes 2.No 37 Q246.Being "super-alert" or watchful and on 38 guard? Tashadud ke bad dar ke rehne lagi? 39 Q247.Feeling like everything you did was an 1.Yes 2.No 40
effort? on September 30, 2021 by guest. Protected copyright. 41 Har kaam mushkil ho gaya? 42 SECTION F 43 OPEN-ENDED QUESTIONS 44 Q248.What are the main health challenges you 45 face in the last 12 months? 46 Pichlay sal mein kaunsi sehat ki takleef thi apko? 47 Behtareen tibbi saholiyat ke wasool mai sub se eham 3 48 rukawatain? 49 Q249.What are the top 3 barriers preventing you 50 from access to health services? 51 52 Kaunsi theen chezay apko sehat ki sahulat laney mein rukawat 53 hai 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 42 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 4 5 6 7 8 Q250. What are the main problems which prevent 9 you from being satisfied with your health since 10 taking loan? Kaunsi sehat ke mutalik cheezay apko ----- ? 11 12 13 14 15 16 For peer review only 17 18 β- Punjabis (1), Pashtuns (2), Sindhis (3), Siddis (4), Saraikis (5), Muhajirs (6), Balochis (7), Hindkowans (8), Chitralis (9), Gujarati (10), Kashmiris 19 (11), Kalash (12), Burusho (13), Brahui (14), Khowar (15), Hazara (16), Shina (17), Kalyu (18), Balti (19), Afghan refugees (20), Other (21).
20 *- Doctors clinic (private/primary-secondary) (1), Hospital Clinic (tertiary) (2), LHW (3), BHU (4), Local Hakim (5), Homeopath (6), Other (7). 21 22 +- No money (1), not serious/ took care it of it myself (2), too busy (3), no childcare (4), no transport (5), too embarrassed (6), don’t have permission (7), prescription/ paperwork/ referral got lost (8), didn’t know where to get care (9), provider too far away (10), don’t like the local provider (11), 23 couldn’t find specific specialist (12), other (13). 24 25 # Physical violence refers to the use of physical force against another person or group, that results in physical harm, sexual or psychological harm. It 26 can include beating, kicking, slapping, stabbing, shooting, pushing, biting, and/or pinching, among others. Psychological violence is defined as: Intentional use of power, including threat of physical force, against another person or group, that can result in 27 harm to physical, mental, spiritual, moral or social development. Psychological violence includes verbal abuse, bullying/mobbing, harassment, and 28 threats. 29 Sexual Harassment refers to any unwanted, unreciprocated and unwelcome behavior of a sexual nature that is offensive to the person involved, and causes that person to be threatened, humiliated or embarrassed. 30 Racial Harassment refers to any threatening conduct that is based on race, color, language, national origin, religion, association with a minority, birth or 31 other status that is unreciprocated or unwanted and which affects the dignity of women and men at work. 32 @ took no action (1), tried to pretend it never happened (1), told the person to stop (1), tried to defend myself (1), told friends/family (1), sought http://bmjopen.bmj.com/ 33 counseling (1), told a colleague (1), reported it to a colleague (1), discussed/ complained to MF loan officer (1), sought help from MFP (1), sought help 34 from the union/community (1), pursued prosecution (1), other (1) 35 36 37 38 39 40 41 on September 30, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
Impact of microfinance health interventions on health- related outcomes among female informal workers in Pakistan: A retrospective quasi-experimental study ForJournal: peerBMJ Open review only Manuscript ID bmjopen-2020-043544.R1
Article Type: Original research
Date Submitted by the 02-Nov-2020 Author:
Complete List of Authors: Jafree, Sara; Forman Christian College Zakar, Rubeena; The University of Lahore Ahsan, Humna; Forman Christian College Mustafa, Mudasir; Utah State University Fischer, Florian; Charité Universitätsmedizin Berlin, Institute of Public Health; University of Applied Sciences Ravensburg-Weingarten, Doggenriedstraße
Primary Subject Public health Heading:
Secondary Subject Heading: Epidemiology, Evidence based practice, Global health http://bmjopen.bmj.com/ Health policy < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Keywords: PUBLIC HEALTH, EPIDEMIOLOGY
on September 30, 2021 by guest. Protected copyright.
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1 2 3 Impact of microfinance health interventions on health-related outcomes 4 5 6 among female informal workers in Pakistan: A retrospective quasi- 7 8 experimental study 9 10 11 Sara Rizvi Jafree, Rubeena Zakar, Humna Ahsan, Mudasir Mustafa, Florian Fischer 12 13 14 15 Dr. Sara Rizvi Jafree 16 For peer review only 17 Department of Sociology, Forman Christian College University, Lahore, Pakistan; 18 [email protected] 19 20 21 Prof. Dr. Rubeena Zakar 22 Institute of Social and Cultural Studies, University of the Punjab, Lahore, Pakistan; 23 [email protected] 24 25 26 Dr. Humna Ahsan 27 Department of Economics, Forman Christian College University, Lahore, Pakistan; 28 29 [email protected] 30 31 Mudasir Mustafa 32 33 Department of Sociology, Social Work, and Anthropology, Utah State University, Logan, United http://bmjopen.bmj.com/ 34 States of America; [email protected] 35 36 37 Dr. Florian Fischer 38 1) Institute of Public Health, Charité – Universitätsmedizin Berlin, Germany; 39 [email protected] 40 2) Institute of Gerontological Health Services and Nursing Research, Ravensburg-Weingarten on September 30, 2021 by guest. Protected copyright. 41 42 University of Applied Sciences, Germany; [email protected] 43 44 Corresponding author: 45 46 Dr. Florian Fischer 47 Charité – Universitätsmedizin Berlin 48 Institute of Public Health 49 50 Charitéplatz 1 51 10117 Berlin 52 E-Mail: [email protected] 53 54 55 Word count: 4,941 56 57 58 - 1 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 50 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 1 Abstract 4 5 6 2 Objective: The purpose of this study is to assess the impact of microfinance health interventions 7 8 3 (health insurance and health-awareness programmes) on health-related outcomes among female 9 10 4 informal workers in Pakistan. 11 12 Design: We conducted a retrospective, quasi-experimental study among a total of 442 female 13 5 14 15 6 borrowers from seven microfinance providers (MFPs) across four provinces of Pakistan in 2018. 16 For peer review only 17 7 A standardised tool was used for data collection. Probit regression was used to identify the 18 19 8 probability of female borrowers gaining improvements in health outcomes based on their socio- 20 21 22 9 demographic characteristics. Propensity score matching (PSM) was used to assess the overall 23 24 10 impact of health interventions. 25 26 11 Primary outcome measures: Four health-related outcomes reported by the women were used: 27 28 29 12 perception of good health overall, ability to visit a general practitioner, ability to purchase 30 31 13 prescribed medicine, and intake of multivitamins. 32 http://bmjopen.bmj.com/ 33 14 Results: We found that women receiving health interventions had a greater probability of better 34 35 health outcomes when they were from Punjab province, borrowing in groups, and attending 36 15 37 38 16 monthly meetings at MFPs. Even with a small loan amount, all four health-related outcomes were 39 40 17 significantly associated with receiving health insurance and health-awareness programmes. PSM 41 on September 30, 2021 by guest. Protected copyright. 42 18 results show a greater likelihood of overall perceived good health (NNM=17.4%; KM=11.8%) 43 44 45 19 when health insurance is provided and a significant improvement in the ability to purchase 46 47 20 prescribed medicine when a health-awareness programme is provided (NNM=10.1%; KM 48 49 21 =11.7%). 50 51 52 22 Conclusion: Health and social policies are vital to secure health and wellbeing among poor women 53 54 23 working in the informal sector. Targeting improved equity across female population groups for 55 56 57 58 - 2 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 50 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 24 health interventions will in the long run improve poor women’s health, income-earning abilities, 4 5 6 25 and capacity expansion for small businesses. 7 8 26 Keywords: borrow, informal sector, health insurance, health awareness, microfinance 9 10 27 11 12 Strengths and limitations of the study 13 28 14 15 29 This study uses a nationally representative sample of 442 female borrowers of 16 For peer review only 17 30 microfinance from four provinces in Pakistan. 18 19 20 31 It is the first study which focuses on female microfinance borrowers in Pakistan to assess 21 22 32 the impact of health interventions on health-related outcomes among poor women. 23 24 33 We were able to identify health improvements when women received health insurance and 25 26 27 34 health-awareness programmes. 28 29 35 Due to the cross-sectional study design and quasi-experimental analysis framework, the 30 31 36 results must be interpreted with caution. 32 33 http://bmjopen.bmj.com/ 34 37 Future studies need to consider additional burdens of loan repayment and small-business 35 36 38 investment. 37 38 39 39 40 41 on September 30, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 - 3 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 5 of 50 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 40 Introduction 4 5 6 41 More than half (57%) of the female population of Pakistan is illiterate. Less than a quarter (23%) 7 8 42 of women are employed, with a majority working in the informal sector [1]. Informal workers in 9 10 43 Pakistan are usually self-employed or involved in small-scale work. They are not protected by the 11 12 country’s labour laws and regulations. Therefore, they do not receive employment benefits like a 13 44 14 15 45 permanent contract, minimum wage, medical allowances, a pension or provident fund. There are 16 For peer review only 17 46 several problems to consider with regard to the health of female informal workers in Pakistan, 18 19 47 including high rates of poverty and low health literacy, as well as inadequate access to public 20 21 22 48 health services [2], reinforced by low government health budget allocations for this population 23 24 49 group [3]. In addition to the overall absence of universal health coverage, there is limited coverage 25 26 50 for public health emergencies like pandemics [4] and greater risks of acquiring infectious diseases 27 28 29 51 among female informal workers due to mostly unsanitary living conditions in disadvantaged 30 31 52 communities [5]. Pakistan has one of the largest out-of-pocket healthcare expenditures globally, 32 http://bmjopen.bmj.com/ 33 53 at an overwhelming proportion of 90% [6]. Although health insurance can become an important 34 35 support system for buffering the poor against out-of-pocket payments, so far it covers only 1% of 36 54 37 38 55 health expenditure in the country [2]. This is because health insurance is mainly used by richer and 39 40 56 urban populations. 41 on September 30, 2021 by guest. Protected copyright. 42 57 The efficacy and limitations of private providers of health interventions in Pakistan are not clear. 43 44 45 58 One of the few private providers offering health interventions to women employed in the informal 46 47 59 sector are microfinance providers (including banks, institutes and non-governmental organisations 48 49 60 [NGOs]) [7]. Microfinance providers (MFPs) are mainly operational in under-developed 50 51 52 61 communities, providing loans to the poorest women for small-business development [8]. There are 53 54 62 50 MFPs operating in Pakistan, with nearly 40 reporting some form of health intervention for 55 56 57 58 - 4 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 6 of 50 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 63 clients, including health insurance and health-awareness programmes [9]. The MFPs are regulated 4 5 6 64 either by the State Bank of Pakistan or the Securities Exchange Commission of Pakistan. An 7 8 65 inherent function of the original model of microfinance was to catalyse wider social development 9 10 66 for women, including improved health behaviour and, therefore, better health-related outcomes 11 12 [10]. It is in the interests of MFPs to couple health interventions with loan services because healthy 13 67 14 15 68 clients are more likely to repay loans and run successful businesses [11]. 16 For peer review only 17 69 The role of microfinance health interventions is critical in countries like Pakistan, where poverty 18 19 70 is high and out-of-pocket payments are not possible for impoverished families. Additionally, the 20 21 22 71 public sector does not have a dependable service structure for complete or quality healthcare and 23 24 72 universal financial protection for health coverage is absent [4]. More than two million poor women 25 26 73 are loan-takers of microfinance in the country [12]. As poor populations do not have the money to 27 28 29 74 take out traditional health insurance, microfinancing for health insurance becomes the only option 30 31 75 for them. However, small health insurance schemes have been severely criticised for their minimal 32 http://bmjopen.bmj.com/ 33 76 impact on clients’ lives due to their minimal coverage and the large burden of disease faced by 34 35 poor populations [13]. Evidence also suggests that poor populations holding minimal health 36 77 37 38 78 insurance, in the event of sustaining large healthcare costs, may resort to damaging practices such 39 40 79 as reducing household nutrition, removing children from school, and taking out more loans [14]. 41 on September 30, 2021 by guest. Protected copyright. 42 80 During the most recent times of the coronavirus pandemic, debt-ridden poor women attempting to 43 44 45 81 repay loans are facing even more challenges in generating income from small businesses due to 46 47 82 social isolation and lockdown [15]. Therefore, health security is a major concern among female 48 49 83 borrowers and there is a need to improve research and policy in order to financially protect poor 50 51 52 84 women and improve their health literacy [16]. 53 54 85 55 56 57 58 - 5 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 7 of 50 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 86 Aims of the study 4 5 6 87 To the best of our knowledge, there are no studies that have used female microfinance borrowers 7 8 88 as a sample to assess the impact of health interventions on health-related outcomes among poor 9 10 89 women [17]. Our objective for this study was to use a sample of female microfinance borrowers, 11 12 who are availing themselves of health insurance from a private provider, to help identify suitable 13 90 14 15 91 policies for disease prevention and health promotion in Pakistan. The following research questions 16 For peer review only 17 92 are addressed in this study: 1) Do female borrowers of microfinance who are provided with health 18 19 93 interventions show improved health-related outcomes? 2) What are the socio-demographic, 20 21 22 94 household, and loan portfolio characteristics of female borrowers of microfinance that are 23 24 95 associated with improved health-related outcomes? 25 26 96 27 28 29 97 Methods 30 31 98 This study is part of a larger, mixed-methods study on the wellbeing of female microfinance 32 http://bmjopen.bmj.com/ 33 99 borrowers. The qualitative part has already been published [18]. The results presented here are 34 35 based on a cross-sectional survey, in which women who had been borrowers of microfinance for 36 100 37 38 101 more than one year were interviewed using a structured, quantitative questionnaire. We used the 39 40 102 framework of a quasi-experimental study to estimate the impact of microfinance health 41 on September 30, 2021 by guest. Protected copyright. 42 103 interventions. The data was analysed using SPSS and STATA. 43 44 45 104 46 47 105 Sampling 48 49 106 We used a list available on the Pakistan Microfinance Network to contact the 20 MFPs across 50 51 52 107 Pakistan. Seven MFPs agreed to provide permission to interview their clients. The sampling took 53 54 108 place in all four provinces of Pakistan (Punjab, Sindh, Balochistan, and Khyber Pakhtunkhwa 55 56 57 58 - 6 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 8 of 50 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 109 [KPK]), but not in the two autonomous territories or the federal territory of Islamabad. The 4 5 6 110 sampling frame at the level of individual women took the population weightage of the provinces 7 8 111 into account. We were able to contact 500 women randomly, as they visited the MFP offices to 9 10 112 make their monthly loan repayment. A final total of 442 women were willing to participate and 11 12 provided informed written consent, which is a response rate of 88.4%. These women were sampled 13 113 14 15 114 from seven cities within the four provinces, based on MFP permission and access (Punjab: n=252 16 For peer review only 17 115 [cities: Gujranwala, Lahore, Khanewal, Sheikhapura]; Sindh: n=100 [city: Matiari]; Balochistan: 18 19 116 n=50 [city: Lasbela]; KPK: n=40 [city: Abbottabad]. Study participants received financial support 20 21 22 117 from the following types of MFPs: four microfinance banks (n=340), one microfinance institute 23 24 118 (n=41), one government microfinance scheme (n=50), and one Islamic microfinance organisation 25 26 119 (n=11). 27 28 29 120 Information related to the services provided by the sampled MFPs in this study is presented in 30 31 121 Table 1. None of the MFPs provide mandatory health insurance schemes. Neither the government 32 http://bmjopen.bmj.com/ 33 122 scheme nor the Islamic finance provider were offering health insurance, but they were providing 34 35 health awareness interventions. The government scheme offered a separate health insurance 36 123 37 38 124 scheme (called the Sehat Sahulat Programme), but none of the study participants was enrolled in 39 40 125 this scheme. Women borrowing from banks have the option to take out health insurance for 41 on September 30, 2021 by guest. Protected copyright. 42 126 themselves and any family members. They have to pay a premium ranging from PKR 490–990 43 44 1 45 127 (USD 3.00–6.08) per person and are insured only in the event of hospital admission. However, 46 47 128 the insurance does not cover hospital costs but instead pays the client the amount of daily wages 48 49 129 lost, ranging from PKR 2,000–4,000 (USD 12.28–24.56) daily. The scheme also covers a one-off 50 51 52 130 payment in the event of death, ranging from PKR 25,000–50,000 (USD 153.55–307.10). Female 53 54 55 56 1 All PKR to USD conversions in this study have made done at the rate of 1 USD = 162.805 PKR. 57 58 - 7 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 9 of 50 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 131 borrowers from the microfinance institute are only covered for themselves and their spouse. They 4 5 6 132 have to pay a premium of PKR 1,200 (USD 7.37) if unmarried or PKR 1,850 (USD 11.36) if 7 8 133 married. Clients are provided with a one-off payment of PKR 30,000 (USD 184.25) in the event 9 10 134 of hospitalisation. 11 12 13 135 14 15 136 Table 1: Health insurance schemes of microfinance providers sampled in this study 16 Microfinance Government ForMicrofinance peer bank review only Islamic finance 17 institute scheme (n=340) (n=11) 18 (n=41) (n=50) 19 Coverage Female borrower and Female borrower and - - 20 any family member spouse 21 Term One year One year - - 22 Premium PKR 490–990 per PKR 1,200 (if - - 23 family member unmarried); 24 PKR 1,850 (if 25 married) 26 Insurance Only hospitalization Only hospitalization - - 27 (PKR 2,000–4,000 PKR 30,000 (one-off 28 daily) payment) 29 Limit Between 10–30 days One-off payment - - 30 Life insurance PKR 25,000–50,000 - - - 31 in case of death 32 Other Option to take Health clinic in 33 government Sehat Lahore only; http://bmjopen.bmj.com/ 34 Sahulat Program treating patients 35 with diabetes and 36 heart disease 37 137 Information in this table is based on data from MFPs sampled in this study 38 39 138 40 41 139 Data collection on September 30, 2021 by guest. Protected copyright. 42 43 140 Data collection took place between February and November 2018. Each city had one research team 44 45 46 141 leader and two assistants in the data collection team, comprising a total of 21 people undertaking 47 48 142 data collection. The assistants were all MPhil graduates who had experience of field research and 49 50 143 were hired through the assistance of the universities in each city. Training of the data collection 51 52 144 team took place over a two-week period and was conducted either in person or through video calls. 53 54 55 145 Data collection took place in face-to-face interviews in a private space at the MFP premises, in 56 57 58 - 8 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 10 of 50 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 146 order to preserve the women’s privacy due to the personal nature of the questions. The structured 4 5 6 147 surveys were completed on behalf of the female respondents with the assistance of the trained 7 8 148 research team. During pilot-testing, we utilised both a self-administered and researcher- 9 10 149 administered approach, and found that the latter showed lower rates of non-response. This could 11 12 be due to the length of the questionnaire and the low literacy rate among the interviewed women. 13 150 14 15 151 Although the questionnaire was translated into Urdu, women having less than eight years of 16 For peer review only 17 152 schooling required assistance to read and fill in the questionnaire. 18 19 153 20 21 22 154 Measures 23 24 155 A structured interview schedule was used for data collection (Supplementary File 1). Questions in 25 26 156 this tool were taken from instruments used in various studies, such as the Women’s Healthcare 27 28 29 157 Experiences Survey [19], the Baseline Nutrition and Food Security Survey developed by UNICEF 30 31 158 [20], the WHO Multi-Country Study on Women’s Health and Domestic Violence against Women 32 http://bmjopen.bmj.com/ 33 159 [21], and the WHO Survey on Workplace Violence [22]. 34 35 36 160 37 38 161 Dependent variables: Health outcomes 39 40 162 This study assesses the association of health interventions offered by MFPs with four dependent 41 on September 30, 2021 by guest. Protected copyright. 42 163 health-related outcome variables: 1) women perceive health to be good overall, 2) women visited 43 44 45 164 a general practitioner in the last year, 3) women had the ability to purchase prescribed medicine in 46 47 165 the last year, and 4) women’s intake of multivitamins has improved in the last year. The four 48 49 166 dependent variables were categorised as binominal and coded as either “Yes” (1) or “No” (0). 50 51 52 167 53 54 55 56 57 58 - 9 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 11 of 50 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 168 Independent variables: Socio-demographic and loan characteristics 4 5 6 169 Several socio-demographic variables, such as age (0=less than 30 years; 1=30 years and older), 7 8 170 religion (0=Muslim; 1=Other than Muslim), literacy of the female borrower (0=Illiterate; 9 10 171 1=Literate), literacy of the spouse (0=Illiterate; 1=Literate), house ownership (0=Yes; 1=No), and 11 12 number of dependent children living in the house (0=None; 1=One or more) were assessed as 13 172 14 15 173 confounding variables. It is necessary to control for these variables because they have an impact 16 For peer review only 17 174 on each of the dependent variables mentioned above. Province is also controlled because the region 18 19 175 is a proxy for socio-cultural norms that would impact upon how women perceive their health and 20 21 22 176 whether they are able to visit a general practitioner or purchase medicine (0=Other than Punjab 23 24 177 [Sindh, Balochistan, or KPK]; 1=Punjab). 25 26 178 The other set of variables is related to microfinance provider services, such as: loan amount 27 28 29 179 (0=10,000–20,000 PKR; 1=21,000 PKR or more), monthly meetings (0=No; 1=Yes), interest rate, 30 31 180 which is the amount charged on top of the principal by a lender to a borrower (0=2.5–10%; 1=11% 32 http://bmjopen.bmj.com/ 33 181 or more), group loan, meaning that a group of customers are willing to guarantee each other for 34 35 the repayment of the loan (0=No; 1=Yes), and debt age (0=1–2 years; 1=3 or more years). These 36 182 37 38 183 have been included because they assess the impact of the provision of non-financial services on 39 40 184 each of the dependent variables. 41 on September 30, 2021 by guest. Protected copyright. 42 185 43 44 45 186 Independent variables: Health intervention 46 47 187 The three independent variables for microfinance health intervention are: 1) receiving health 48 49 188 insurance, 2) attended at least one health workshop, and 3) received health-related talks by loan 50 51 52 189 officers. The two independent variables of health workshop and health-related talks by loan 53 54 190 officers were compounded to make one variable indicating whether the women had attended a 55 56 57 58 - 10 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 12 of 50 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 191 health-awareness programme (0=No; 1=Yes). In this way, the control group for the study (T=0) 4 5 6 192 consists of female borrowers who lack the provision of a health intervention, and the treatment 7 8 193 group (T=1) includes female borrowers who are receiving a health intervention. 9 10 194 11 12 Comparison group 13 195 14 15 196 Using a quasi-experimental framework, the study estimates the impact of gaining access to health 16 For peer review only 17 197 interventions (health insurance and health-awareness programmes) against the counterfactual of 18 19 198 those women who are receiving a loan for small business mobilisation in the absence of health 20 21 22 199 interventions. 23 24 200 25 26 201 Probit analysis 27 28 29 202 The impacts of health insurance and health-awareness programmes provided by the MFP on the 30 31 203 four dependent, health-related variables have first been estimated using a probit estimation for the 32 http://bmjopen.bmj.com/ 33 204 following linear regression equation: 34 35 36 205 푌푖 = 훽0 + 훽1푇 + 훽2푋푖 + 훽3푍푖 + 훽4퐿푖 + 휀푖 37 38 206 where 푌푖 is the dependent variable measuring the four health-related outcomes. T is the treatment 39 40 41 207 variable (1 if “yes”, and 0 otherwise) measuring the three microfinance health interventions. 푋푖 is on September 30, 2021 by guest. Protected copyright. 42 43 208 a set of socio-demographic characteristics including age, religion, province, and literacy; 푍푖 is a 44 45 209 set of household characteristics, including house ownership and number of dependent children 46 47 48 210 living in the house; 퐿푖 is a set of loan portfolio characteristics including debt age, group loan, loan 49 50 211 amount, interest rate, and monthly meetings; and 휀푖 is the error term. 51 52 53 212 54 55 56 57 58 - 11 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 13 of 50 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 213 Propensity score matching 4 5 6 214 We used Propensity Score Matching (PSM) to estimate the unobserved counterfactuals and make 7 8 215 an impact analysis of health interventions. PSM is a non-parametric statistical method which 9 10 216 matches the treated (those receiving the health intervention) and the controlled on the basis of 11 12 conditional probability of participation, given the observable characteristics [23]. As we only have 13 217 14 15 218 cross-sectional data, we can compare the dependent variables related to women’s health in terms 16 For peer review only 17 219 of those who have access to non-financial, health-related services provided by the microfinance 18 19 220 provider (in this study called the “health-awareness programme”) and those who do not, as long 20 21 22 221 as these services are randomly distributed and there is no selection bias. The estimation of 23 24 222 instrumental variables is one technique that is frequently used within PSM. However, these results 25 26 223 are only robust if a valid instrument is being used. As it was not easy to find a valid instrument for 27 28 29 224 our study, we used statistical matching, which has also been widely used before [24-26]. 30 31 225 The study will be using the following functional form: 32 http://bmjopen.bmj.com/ 33 226 푌푖 = 훽0 + 훽1푇 + 훽1푋푖 + 휀푖 34 35 36 227 where 푌푖 is the dependent variable measuring the four health-related outcomes. T is the treatment 37 38 228 variable (1 if “yes”, and 0 otherwise) measuring the microfinance health interventions. 푋푖 are the 39 40 229 covariates used for matching the data, including age, religion, literacy, spouse’s literacy, house on September 30, 2021 by guest. Protected copyright. 41 42 43 230 ownership, access to drinking water, access to gutter drainage, access to toilet facility, children, 44 45 231 debt age, group loan, loan amount, interest rate, and monthly meetings, and 휀푖 is the error term. 46 47 232 These control variables have been used in a large and growing volume of studies [27]. 48 49 50 233 Our study satisfies the main conditions of PSM, which are: 1) using a rich set of control variables, 51 52 234 which are observable characteristics, 2) using the same survey for treated and control groups, and 53 54 235 3) having the same community belonging to the treated and control groups [28]. The PSM model 55 56 57 58 - 12 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 14 of 50 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 236 constructs a statistical comparison group based on the probability of participating in the treatment 4 5 6 237 T, conditional on observed characteristics, X, or the propensity score: 7 8 238 푝(푋) = 푃푟(푇 = 1│푋). 9 10 239 where T = {0, 1} is the indicator of exposure to treatment and X is the multidimensional vector of 11 12 13 240 pre-treatment characteristics. Following the estimation of the propensity score, the region for 14 15 241 common support is defined as being where distributions of the propensity score for the treatment 16 For peer review only 17 242 and comparison group overlap. Observations within the control and treatment group that lie outside 18 19 243 the region for common support are eliminated [29]. As PSM is intended to help in identifying the 20 21 22 244 impact of the health intervention, we used the computation of “average treatment effect on the 23 24 245 treated” (ATT). We used two matching criteria (Nearest Neighbour Matching [NNM] and Kernel 25 26 246 Matching [KM]), to assess statistical significance from different perspectives and to test the 27 28 29 247 robustness of the results [24]. NNM is used to evaluate absolute differences between propensity 30 31 248 scores, and KM is used to compare each treated unit to a weighted average of the outcomes of all 32 http://bmjopen.bmj.com/ 33 249 untreated units. 34 35 36 250 37 38 251 Patient and public involvement 39 40 252 This research was conducted without the involvement of the public or patients. However, the views 41 on September 30, 2021 by guest. Protected copyright. 42 253 of women from this study have been published elsewhere [18]. 43 44 45 254 46 47 255 Results 48 49 256 Sample characteristics 50 51 52 257 All the women in our sample earned less than $4.82 per day and belonged to the poorest stratum 53 54 258 of society. They were taking out loans for small business mobilisation in order to improve their 55 56 57 58 - 13 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 15 of 50 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 259 life opportunities. The majority of the women were Muslim, from Punjab, and illiterate. About 4 5 6 260 three-quarters had been borrowers for more than three years, were attending monthly meetings 7 8 261 with loan officers, and were paying interest rates of less than 10%. Out of the 442 female borrowers 9 10 262 in the sample, 64.2% (n=284) had taken out health insurance (Table 2) and 71.0% (n=314) had 11 12 participated in a health-awareness programme by attending a health workshop or receiving health 13 263 14 15 264 talks by loan officers (Table 3). 16 For peer review only 17 265 18 19 266 Table 2: Descriptive statistics of women borrowers with regard to health insurance 20 Not receiving Receiving 21 health insurance health insurance Chi-square Variable 22 n (%) n (%) test1 23 (n=158) (n=284) 24 Age 25 <29 years 86 (54.4%) 165 (58.1%) 0.557 26 ≥30 years 72 (45.6%) 119 (41.9%) 27 Religion 28 Muslim 137 (86.7%) 254 (89.4%) 0.740 29 Other 21 (13.3%) 30 (10.6%) 30 Province 31 Punjab 62 (39.2%) 197 (69.4%) 37.977*** 32 Other 96 (60.8%) 87 (30.6%) 33 Literacy http://bmjopen.bmj.com/ 34 Illiterate 94 (59.5%) 195 (68.7%) 3.770* 35 Literate 64 (40.5%) 89 (31.3%) 36 Spouse literacy 37 Illiterate 86 (54.4%) 191 (67.3%) 7.135** 38 Literate 72 (45.6%) 93 (32.7%) 39 House ownership 40 Other 104 (65.8%) 225 (79.2%) 9.583** 41 Owned 54 (34.2%) 59 (20.8%) on September 30, 2021 by guest. Protected copyright. 42 Children 43 None 54 (34.2%) 116 (40.8%) 1.907 One or more 104 (65.8%) 168 (59.2%) 44 Debt age 45 1–2 years 71 (44.9%) 75 (26.4%) 15.755*** 46 ≥3 years 87 (55.1%) 209 (73.6%) 47 Group loan 48 No 91 (57.6%) 168 (59.2%) 0.102 49 Yes 67 (42.4%) 116 (40.8%) 50 Loan amount 51 PKR 10,000–20,000 (USD 61.42-122.84) 31 (19.6%) 123 (43.3%) 25.096*** 52 PKR 21,000–100,000 (USD 129.45-616.41) 127 (80.4%) 161 (56.7%) 53 Interest rate 54 2.5–10% 105 (66.5%) 202 (71.7%) 1.044 55 ≥11% 53 (33.5%) 82 (28.9%) 56 57 58 - 14 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 16 of 50 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 Monthly meeting 4 No 41 (25.9%) 70 (24.6%) 0.091 5 Yes 117 (74.1%) 214 (75.4%) 6 Overall perceived good health 7 No 120 (75.9%) 185 (65.1%) 5.545** 8 Yes 38 (24.1%) 99 (34.9%) 9 Improved ability to visit general practitioner 10 No 67 (42.4%) 124 (43.7%) 0.065 11 Yes 91 (57.6%) 160 (56.3%) 12 Improved ability to purchase prescribed 13 medicine 14 No 118 (74.7%) 152 (53.5%) 19.127*** 15 Yes 40 (25.3%) 132 (46.5%) 16 Improved intake of multivitaminsFor peer review only 17 No 120 (75.9%) 182 (64.1%) 6.6040** 18 Yes 38 (24.1%) 102 (35.9%) 19 267 1 *** Significant at 1% level, ** Significant at 5% level, * Significant at 10% level 20 268 21 269 Table 3: Descriptive statistics of women borrowers with regard to health awareness 22 Not receiving Receiving health awareness health awareness Chi-square 23 Variable 24 n (%) n (%) test1 25 (n=128) (n=314) 26 Age 27 <29 years 74 (57.8%) 177 (56.4%) 0.077 28 ≥30 years 54 (42.2%) 137 (43.6%) 29 Religion 30 Muslim 115 (89.8%) 276 (87.9%) 0.337 31 Other 13 (10.2%) 38 (12.1%) 32 Province Punjab 56 (43.8%) 203 (64.6%) 16.372*** http://bmjopen.bmj.com/ 33 Other 72 (56.3%) 111 (35.4%) 34 Literacy 35 Illiterate 70 (54.7%) 219 (69.7%) 9.109** 36 Literate 58 (45.3%) 95 (30.3%) 37 Spouse literacy 38 Illiterate 78 (60.9%) 199 (63.4%) 0.231 39 Literate 50 (39.1%) 115 (36.6%) 40
House ownership on September 30, 2021 by guest. Protected copyright. 41 Other 96 (75.0%) 233 (74.2%) 0.030 42 Owned 32 (25.0%) 81 (25.8%) 43 Children 44 None 49 (38.3%) 121 (38.5%) 0.002 45 One or more 79 (61.7%) 193 (61.5%) 46 Debt age 47 1–2 years 63 (49.2%) 83 (26.4%) 21.342*** 48 ≥3 years 65 (50.8%) 231 (73.6%) 49 Group loan 50 No 86 (67.2%) 173 (55.1%) 5.480** 51 Yes 42 (32.8%) 141 (44.9%) 52 Loan amount 53 PKR 10,000–20,000 (USD 61.42-122.84) 33 (25.8%) 121 (38.5%) 6.515** 54 PKR 21,000–100,000 (USD 129.45-616.41) 95 (74.2%) 193 (61.5%) 55 Interest rate 56 2.5–10% 70 (54.7%) 237 (75.5%) 18.527*** 57 58 - 15 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 17 of 50 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 ≥11% 58 (45.3%) 77 (24.5%) 4 Monthly meeting 5 No 38 (29.7%) 73 (23.2%) 2.005 6 Yes 90 (70.3%) 241 (76.8%) 7 Overall perceived good health 8 No 89 (69.5%) 216 (68.8%) 0.023 9 Yes 39 (30.5%) 98 (31.2%) 10 Improved ability to visit general practitioner 11 No 64 (50.0%) 127 (40.4%) 3.383* 12 Yes 64 (50.0%) 187 (59.6%) 13 Improved ability to purchase prescribed 14 medicine 15 No 95 (74.2%) 175 (55.7%) 13.073*** 16 Yes For peer review33 (25.8%) only139 (44.3%) 17 Improved intake of multivitamins 18 No 88 (68.8%) 214 (68.2%) 0.015 19 Yes 40 (31.3%) 100 (31.8%) 20 270 21 22 271 Determinants of health-related outcomes after the health insurance intervention 23 24 Table 4 presents the determinants of health-related outcomes for recipients of health insurance. 25 272 26 27 273 Overall, perceived good health was significantly associated with group borrowers, small loan 28 29 274 amounts, and lower interest rates. Improved ability to visit a general practitioner shows a positive 30 31 275 correlation with female borrowers from Punjab province, who attending monthly meetings, had a 32 33 http://bmjopen.bmj.com/ 34 276 group loan, and a smaller loan amount. Women had a significantly improved ability to purchase 35 36 277 prescribed medicine when they were from Punjab, took out smaller loans, and owned a house. The 37 38 278 uptake of multivitamins was increased among women with smaller loans, who owned a house, had 39 40 41 279 been borrowers for no longer than two years, and were attending monthly meetings. Therefore, on September 30, 2021 by guest. Protected copyright. 42 43 280 only a small loan amount was a significant determinant in all four health-related outcomes among 44 45 281 recipients of health insurance. 46 47 282 48 49 50 51 52 53 54 55 56 57 58 - 16 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 18 of 50 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 283 Table 4: Probit analysis on determinants of health-related outcomes among recipients of health insurance 4 5 Overall perceived Improved ability to Improved ability to Improved 6 good health visit general purchase prescribed multivitamin 7 practitioner medicine uptake Z- Z- Z- Z- 8 Coeff. Coeff. Coeff. Coeff. Score Score Score Score 9 Age -0.2588 -1.43 0.2754 1.39 -0.2915 -1.51 0.0703 0.36 10 Religion 0.4079 1.37 -0.2711 -0.97 0.4165 1.46 -0.0102 -0.03 11 Province -0.2676 -1.04 0.9990*** 4.05 1.043*** 4.21 0.0315 0.12 12 Literacy -0.0999 -0.49 0.2018 0.96 0.0828 0.42 0.1994 0.98 13 Spouse literacy 0.2410 1.18 0.1779 0.85 0.2424 1.20 0.1323 0.64 14 House ownership 0.1550 0.69 -0.3397 -1.45 -0.6825** -2.65 -0.5699** -2.17 15 Children 0.2094 1.15 0.2213 1.20 0.1530 0.85 0.2829 1.54 16 Debt age For-0.4130 peer-0.16 review0.1650 0.63 only0.3807 1.50 -0.6088** -2.41 17 Group loan 0.8582*** 3.76 0.4813** 2.25 0.1567 0.73 -0.3705* -1.69 18 Loan amount -0.7765*** -3.27 -0.8863** -3.50 -1.2028*** -5.05 -1.9933*** -4.13 19 Interest rate 0.7250** 2.94 0.2777 1.12 -0.0691 -0.28 0.2345 0.98 20 Monthly meetings 0.1370 0.61 0.7753*** 3.58 0.0166 0.08 -0.4233* -1.84 21 No. of observations 284 284 284 284 22 Wald Chi2 42.74 76.93 64.57 53.15 23 Prob> Chi2 0.0001 0.0000 0.0000 0.0000 24 Log likelihood -158.6116 -146.0385 -157.5241 -153.7125 25 284 *** Significant at 1% level, ** Significant at 5% level, * Significant at 10% level 26 285 27 28 29 286 Determinants of health-related outcomes after the health-awareness intervention 30 31 287 In Table 5, the determinants for all four health-related outcomes among recipients of a health- 32 http://bmjopen.bmj.com/ 33 288 awareness programme are presented. Women with the following characteristics have a greater 34 35 36 289 probability of overall perceived good health: group borrowers, smaller loans, lower interest rates, 37 38 290 younger women, and those with literate spouses. The ability to visit a general practitioner for 39 40
291 regular check-ups during the previous year was higher among women from Punjab province, with on September 30, 2021 by guest. Protected copyright. 41 42 43 292 smaller loans, attending monthly meetings, above 29 years of age, and who were non-Muslim. 44 45 293 Similarly, women from Punjab province, having smaller loans, owning their house, and younger 46 47 294 women had a higher probability of improved ability to purchase prescribed medicine. The 48 49 295 probability of increased uptake of multivitamins was greater in women who took out smaller loans, 50 51 52 296 had not been in debt for more than two years, were group borrowers, and who attended monthly 53 54 55 56 57 58 - 17 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 19 of 50 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 297 meetings. The only variable that was significantly associated with all four health-related outcomes 4 5 6 298 among recipients of a health-awareness programme was the small loan amount. 7 8 299 9 10 300 Table 5: Probit analysis on determinants of health-related outcomes among recipients of health awareness 11 301 programs 12 Overall perceived Improved ability to Improved ability to Improved 13 good health visit general purchase prescribed multivitamin 14 practitioner medicine uptake 15 Z- Z- Z- Z- Coeff. Coeff. Coeff. Coeff. 16 For peerScore reviewScore only Score Score 17 Age -0.3747* -1.70 0.3781* 1.70 -0.4329* -2.02 0.1058 0.48 18 Religion 0.5185 1.59 -0.5503* -1.76 0.3880 1.24 0.1904 0.56 19 Province -0.3898 -1.24 1.3048*** 4.39 1.029*** 3.83 0.1983 0.65 20 Literacy -0.1537 -0.65 0.2229 0.91 0.1405 0.61 0.3411 1.43 21 Spouse literacy 0.4163* 1.80 0.2546 1.09 0.0860 0.38 0.2310 1.00 22 House ownership 0.3495 1.42 -0.2453 -0.96 -0.6360** -2.48 -0.4271 -1.54 23 Children 0.3209 1.55 0.2765 1.33 0.2424 1.21 0.2833 1.36 24 Debt age -0.0066 -0.02 0.4529 1.49 0.3817 1.36 -0.7164** -2.51 25 Group loan 0.8817*** 3.33 0.3640 1.51 0.1030 0.43 -0.6352** -2.55 26 Loan amount -0.7199** -2.65 -0.6511** -2.28 -1.9361*** -3.52 -0.9170*** -3.35 27 Interest rate 0.6739** 2.23 0.3860 1.28 0.2428 0.83 0.3726 1.26 28 Monthly meetings 0.2357 0.88 0.7689** 3.08 -0.0556 -0.22 -0.5816** -2.10 29 No. of observations 314 314 314 314 2 30 Wald Chi 35.68 64.57 53.25 48.79 2 31 Prob> Chi 0.0004 0.0000 0.0000 0.0000 32 Log likelihood -126.4054 -116.6811 -128.2105 -121.2616 33 302 *** Significant at 1% level, ** Significant at 5% level, * Significant at 10% level http://bmjopen.bmj.com/ 34 303 35 36 304 Balancing covariates and common support diagnostics 37 38 305 Figure 1(a) exhibits the Kernel Density graphs for the propensity score of treated and control 39 40
306 groups before matching, while Figure 1(b) exhibits it after matching. It can be clearly seen that the on September 30, 2021 by guest. Protected copyright. 41 42 43 307 kernel densities are significantly overlapping in the latter, indicating that the treatment and control 44 45 308 groups have a comparable propensity score as estimated using the covariates. A similar 46 47 309 comparison of treatment and control groups can be observed in Figures 2(a) and 2(b) using 48 49 histograms. 50 310 51 52 53 54 55 56 57 58 - 18 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 20 of 50 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 311 Figures 3(a) and 3(b) exhibit the common support between the control and treatment groups. While 4 5 6 312 in Figure 3(a) we can see that certain observations in the treated group are not matched, in Figure 7 8 313 3(b) all the observations in the treated and control groups are successfully matched. 9 10 314 The balancing of covariates can also be observed using standardised mean difference and ratio of 11 12 variances. Table 6 gives the standardised mean difference and ratio of variances for the control 13 315 14 15 316 and treatment groups before and after matching. It can be observed that the standardised mean 16 For peer review only 17 317 difference in the matched sample is much improved and close to zero for all covariates. The ratio 18 19 318 of variances is approximately equal to one in the matched sample for all covariates except monthly 20 21 22 319 meetings. Using these diagnostics, we can infer that the sample has matched well using propensity 23 24 320 score matching. 25 26 321 27 28 322 Table 6:Balancing of covariates using standardized mean difference and ratio of variances 29 30 Standardized differences Variance ratio 31 Raw Matched Raw Matched 32
Age -0.1320698 -0.1058939 0.9619896 0.9611875 http://bmjopen.bmj.com/ 33 34 Religion 0.1586396 -0.0071039 1.451878 0.9828996 35 Literacy -0.3073917 -0.1159204 0.7931779 0.9171598 36 Spouse literacy -0.0719588 0.027969 0.9641836 1.014213 37 Earning month -0.0491266 0.0305069 1.129418 0.9202911 38 House ownership 0.2189877 0.1585524 0.7669609 0.8061959 39 Drinking water 0.2226595 0.0116275 0.6952835 0.9813404 40 41 Toilet Facility 0.0445714 0.1247478 0.9471727 0.8276644 on September 30, 2021 by guest. Protected copyright. 42 Gutter drainage -0.0290293 0.0423519 1.035531 0.9496166 43 Group loan 0.0250079 0.0549512 1.01166 1.017812 44 Loan amount -0.6030964 -0.1454947 1.331749 1.081931 45 Interest rate -0.0851667 0.0594108 1.075376 0.9483068 46 Monthly meetings 0.5404452 0.337374 0.4480249 0.6085328 47 48 323 49 50 324 Impact of the interventions on health-related outcomes 51 52 53 325 The descriptive statistics for comparison between control and treatment group for health insurance 54 55 326 (Supplementary Table 1) and the health-awareness programme (Supplementary Table 2), before 56 57 58 - 19 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 21 of 50 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 327 and after matching, depict the elimination of imbalance with respect to almost all covariates before 4 5 6 328 and after matching. Table 7 shows that women receiving health insurance had a significantly 7 8 329 greater chance of overall perceived good health. According to NNM, 17.4% of women with health 9 10 330 insurance had a greater likelihood of overall perceived good health; the results for KM showed a 11 12 greater likelihood in 11.8%. Female borrowers receiving a health-awareness programme from the 13 331 14 15 332 MFP in the form of a health workshop or health talk by the loan officer show a significant 16 For peer review only 17 333 improvement in their ability to purchase prescribed medicine (NNM=10.1%; KM=11.7%). For the 18 19 334 other two outcomes, neither of the interventions showed a significant effect. 20 21 22 335 23 24 336 Table 7: Impact of interventions on health-related outcomes based on propensity score matching 25 Overall Improved ability to Improved ability to Improved 26 perceived visit general purchase prescribed multivitamin 27 good health practitioner medicine uptake 28 Z- Z- Z- Z- Coeff. Coeff. Coeff. Coeff. 29 Score Score Score Score 30 Nearest Neighbor Matching 31 Health insurance 0.1740*** 3.45 0.0038 0.04 0.1271 1.46 0.0343 0.38 32 Health awareness program 0.0599 0.97 0.0141 0.23 0.1016* 1.70 0.0291 0.42 http://bmjopen.bmj.com/ 33 34 35 Kernel Matching 36 Health insurance 0.1175* 1.67 -0.0256 -0.32 0.1062 1.21 0.0775 1.09 37 Health awareness program 0.0240 0.42 0.0292 0.41 0.1167** 2.08 0.0703 1.15 38 337 *** Significant at 1% level, ** Significant at 5% level, * Significant at 10% level 39 338 Note: The covariates used for matching include age, religion, literacy, spouse literacy house ownership, access to 40 339 drinking water, access to gutter drainage, access to toilet facility, children, debt age, group loan, loan amount, 41 340 interest rate, and monthly meetings. on September 30, 2021 by guest. Protected copyright. 42 341 Matching is performed with 1 nearest neighbor in terms of propensity score. 43 44 342 45 46 343 Discussion 47 48 49 344 In the absence of universal health coverage or compulsory educational enrolment, poor and 50 51 345 predominantly illiterate female informal workers and borrowers of microfinance are dependent 52 53 346 upon MFP for receiving health coverage and promoting health. This study has measured four 54 55 56 57 58 - 20 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 22 of 50 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 347 health-related outcomes in female borrowers. The results show that there is inequity in the uptake 4 5 6 348 of health insurance and health-related outcomes. 7 8 349 Women from Punjab have better health-related outcomes compared to women from Sindh, 9 10 350 Balochistan and KPK. National health surveys of Pakistan also report that Punjab has better health- 11 12 related outcomes compared to other provinces, because the provincial government of Punjab has 13 351 14 15 352 a greater budget allocation for running health-awareness campaigns [30]. The fact that our results 16 For peer review only 17 353 show that older women and non-Muslim women have a greater likelihood of improved ability to 18 19 354 visit a general practitioner after receiving a health-awareness intervention indicates that younger 20 21 22 355 Muslim women face barriers to healthcare access due to regressive norms [31]. Muslim families 23 24 356 are known to prevent fertile women from accessing healthcare in an attempt to control their 25 26 357 reproductive choices and health options. Our results align with other research, which suggests that 27 28 29 358 Muslims suffer from health disparities due to religious fallacies [32]. 30 31 359 Conversely, younger women show better overall perceived health and ability to purchase 32 http://bmjopen.bmj.com/ 33 360 prescribed medicine. This may be because at a younger age fewer health issues occur, and also 34 35 because of greater state and NGO efforts directed towards maternal healthcare [33]. Our results 36 361 37 38 362 confirm that women under the age of 29 years receive privileged support in a patriarchal society 39 40 363 during their prime childbearing years to consume maternal-health-related medication [34]. Women 41 on September 30, 2021 by guest. Protected copyright. 42 364 with literate spouses also show improvements in overall general health after receiving health 43 44 45 365 insurance. This may be because spouse literacy has a direct effect on women’s improved healthcare 46 47 366 behaviour and mental health [35]. 48 49 367 Women who take out their loan in groups show better health-related outcomes compared to women 50 51 52 368 who are single borrowers. Our results suggest that women in groups share their healthcare 53 54 369 knowledge and encourage each other towards improved healthcare behaviour [36]. Similarly, 55 56 57 58 - 21 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 23 of 50 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 370 women who attend monthly meetings with loan officers have better health-related outcomes. The 4 5 6 371 results suggest that caring loan officers are fulfilling an important responsibility in supporting 7 8 372 female borrowers to engage in improved health behaviour and health-related outcomes. Given the 9 10 373 conservative culture of Pakistan and the disadvantaged backgrounds of these female borrowers, 11 12 loan-taking women might not be able to utilise healthcare services due to issues of permission or 13 374 14 15 375 ignorance. 16 For peer review only 17 376 Women who receive smaller microfinance loans and do not have a long debt age show improved 18 19 377 health-related outcomes. The finding that only women who receive smaller loans show 20 21 22 378 significantly better health-related outcomes may be seen as an endogenous result (i.e., because 23 24 379 individuals who need only a small loan may be better off to start with in terms of health), and 25 26 380 difficult to interpret in terms of causality, given the cross-sectional nature of the data. However, 27 28 29 381 we have only sampled women from the poorest stratum, and they have taken out small loans 30 31 382 because they are not eligible for bigger loans. Therefore, one can expect that there is no association 32 http://bmjopen.bmj.com/ 33 383 between health condition at the time of loan-taking and the loan amount. 34 35 Furthermore, the finding related to debt age suggests that women with a debt burden over a longer 36 384 37 38 385 period of time may be suffering from debt fatigue, which is converting to declining health-related 39 40 386 outcomes [37]. Women and their families who own their houses also have better health-related 41 on September 30, 2021 by guest. Protected copyright. 42 387 outcomes, specifically related to the ability to visit general practitioners and improved uptake of 43 44 45 388 multivitamins. The results imply that the provision of health insurance and not having to pay 46 47 389 household rents on a monthly basis translates into better health-related outcomes. Impoverished 48 49 390 families who have to pay high rents for accommodation are usually employed in multiple jobs and 50 51 52 391 have little time for health and wellbeing [38]. 53 54 55 56 57 58 - 22 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 24 of 50 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 392 The impact of microfinance is only visible on two health-related variables. Although there are no 4 5 6 393 effects on general practitioner visits or uptake of multivitamins, we found that microfinance health 7 8 394 insurance has an impact by creating an improved perception of general health. This shows that 9 10 395 being insured is an emotional support and wellbeing facilitator for poor women. The emotional 11 12 buttress provided by health insurance can go a long way towards improving perceived wellbeing, 13 396 14 15 397 which can translate into a greater commitment to self, family, and business development among 16 For peer review only 17 398 poor women from disadvantaged backgrounds [39]. In addition, microfinance health-awareness 18 19 399 interventions have an impact by improving the purchase of prescribed medicine. Many poor 20 21 22 400 women in Pakistan do not take prescribed medicine unless it is freely available due to the greater 23 24 401 need to prioritise the purchase of basic necessities and household consumption [40]. The impact 25 26 402 of microfinance interventions is comparable to previous research. A review highlighted that most 27 28 29 403 interventions combined microfinance with health education. However, positive effects were 30 31 404 mainly found for health knowledge and behaviour, but not health status [41]. A meta-analysis 32 http://bmjopen.bmj.com/ 33 405 indicated the potential for women and girls, because microfinance may lead to changes in the use 34 35 of contraceptives, strengthen female empowerment and improve children’s nutrition [42]. 36 406 37 38 407 However, for female borrowers of microfinance, there might be additional burdens in the form of 39 40 408 loan repayments and small-business investment. Our results suggest that illiterate and poor women 41 on September 30, 2021 by guest. Protected copyright. 42 409 in the country are benefiting from health awareness by recognising that if they do not consume 43 44 45 410 prescribed medicine for chronic ailments (heart disease, cholesterol, or diabetes) it can have 46 47 411 serious consequences for their own lives and the future livelihood of their families. There needs to 48 49 412 be an urgent recognition that a triadic health insurance safety net is necessary, instead of 50 51 52 413 dependency on private providers to protect informal working women in Pakistan. Employers and 53 54 414 the government must join forces to ensure universal health insurance and – particularly in these 55 56 57 58 - 23 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 25 of 50 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 415 times of the coronavirus pandemic – infectious disease outbreak insurance for health emergencies. 4 5 6 416 State financing of healthcare is essential through an increased allocation of gross domestic product 7 8 417 (GDP), government-run business profits, and increasing the income and corporate tax base from 9 10 418 the elite. 11 12 With regard to female microfinance borrowers, we recommend microfinance regulatory bodies to 13 419 14 15 420 urgently legislate the following reforms: (i) coverage for children and other dependents, maternity 16 For peer review only 17 421 costs, and non-hospitalisation costs, (ii) expand coverage for religious and ethnic minorities, (iii) 18 19 422 reduce interest rates for those paying high housing rents and introduce home ownership loans, (iv) 20 21 22 423 introduce mandatory group borrowing and monthly meetings with loan officers, and (iv) alter 23 24 424 repayment timelines and interest-rate packages for women taking out bigger loans. 25 26 425 We recommend the following urgent social policy improvements, which would join in helping 27 28 29 426 health policy efforts: (i) the development of public primary healthcare services for women in the 30 31 427 communities, with a mandatory quarterly general practitioner meeting, (ii) the upgrading of 32 http://bmjopen.bmj.com/ 33 428 poverty alleviation programmes to support poor women, (iii) the capping of housing rents and 34 35 improvements in neighbourhood sanitation to curb infection, (iv) the advancement of home-based 36 429 37 38 430 business opportunities for informal female workers to assist in maintaining incomes, including 39 40 431 digitalisation and internet access in their homes, and (v) income supplementation and cash 41 on September 30, 2021 by guest. Protected copyright. 42 432 transfers for multivitamins and food nutritional intake to improve overall immunity and health 43 44 45 433 [43]. 46 47 434 48 49 435 Limitations 50 51 52 436 This study has some limitations, most importantly the cross-sectional design. Although we were 53 54 437 able to compare the effects of an intervention because of the quasi-experimental analysis 55 56 57 58 - 24 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 26 of 50 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 438 framework, two-group cross-sectional designs suffer from the limitations related to a single 4 5 6 439 measurement for all subjects. Therefore, within-person changes over time are not observable. 7 8 440 Without repeated measures in a two-group design, causality cannot be identified, because temporal 9 10 441 sequencing on the intervention and outcomes cannot be established. For that reason, we 11 12 recommend longitudinal data collection in future studies. This study focused on comparatively 13 442 14 15 443 small loans. Therefore, the impact of larger loans (> PKR 100,000) on health is not known. 16 For peer review only 17 444 Furthermore, the results need to be interpreted with caution, because the four health-related 18 19 445 outcomes are non-homogeneous and dependent on socio-environmental factors that are specific to 20 21 22 446 the region and community where the interventions are taking place. In addition, outcome data are 23 24 447 based on self-reporting, which can lead to potential measurement errors. Despite these limitations, 25 26 448 we feel that this study is significant for the development of microfinance health services in Pakistan 27 28 29 449 and the role of state and interest-free microfinance health interventions. 30 31 450 32 http://bmjopen.bmj.com/ 33 451 Conclusion 34 35 452 It is critical to assess the health needs of women employed in the informal sector. As primary 36 37 38 453 caregivers at home as well as primary contributors to household income, women’s health assumes 39 40 454 a salience that could place the structures of both the family and the economy at risk. Health policy 41 on September 30, 2021 by guest. Protected copyright. 42 455 must consider several social policies for protecting disadvantaged women, who are poverty-ridden, 43 44 45 456 illiterate or semi-literate, and loan takers. Health insurance schemes and health promotion in the 46 47 457 workplace must be made mandatory for employers, microfinance providers, and the government, 48 49 458 given the cultural barriers to uptake for women. Targeting improved equity across female 50 51 52 459 population groups for health interventions will in the long run improve women’s health, capacity 53 54 460 expansion and income-earning abilities. 55 56 57 58 - 25 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 27 of 50 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 461 Designing and implementing a health and social policy protection net for female informal workers 4 5 6 462 requires empirical evidence regarding which health interventions and socio-demographic 7 8 463 characteristics impact upon health outcomes. Since public-sector and health-sector shortages and 9 10 464 inefficiencies are a concern in Pakistan, the ‘health card’ must be accepted in both the private and 11 12 public sector, whichever is able to serve the poor first. As Pakistan is struggling with a low GDP 13 465 14 15 466 and tax collection base, we recommend more research into options for social franchising, and 16 For peer review only 17 467 partnerships with independent health insurance companies to serve disadvantaged women. 18 19 468 20 21 22 469 Acknowledgements 23 470 We thank the female borrowers who consented and gave their time to participate in the study. We 24 25 471 are grateful to our research team members in charge of logistical planning and coordination for 26 27 472 data collection across Pakistan including Rizwan Haider and Amir Naseem. Individual data 28 29 473 collection heads for each city are thanked for their efforts, especially for resolving gate keeping 30 474 issues, including Nida Abbas (Lahore), Zainab Asif (Abbotabad), Hina Bukhari (Gujranwala), 31 32 475 Sadia BiBi (Khanewal), Ansari Abbass (Sheikhapura), Azra Shakeel and Shumaila Sadique 33 http://bmjopen.bmj.com/ 34 476 (Matari), and Javaria Imran (Lasbela). The research assistant Bilal Asghar is also thanked for 35 entering all data. 36 477 37 478 We acknowledge support from the German Research Foundation (DFG) and the Open Access 38 39 479 Publication Fund of Charité – Universitätsmedizin Berlin. 40 41 480 on September 30, 2021 by guest. Protected copyright. 42 481 Competing interests 43 44 482 The authors declare that no competing interests exist. 45 46 483 47 48 484 Funding 49 485 This study received funding by the Office of Research, Innovation and Commercialization at 50 51 486 Forman Christian College. The grant number is IRB-180/04-2017. The funding body was not 52 53 487 involved in data collection, data analysis, or data interpretation and presentation. 54 488 55 56 57 58 - 26 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 28 of 50 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 489 Data sharing 4 5 490 Data is available upon reasonable request from the corresponding author. 6 7 491 8 Ethical considerations 9 492 10 493 Ethical approval for this study was taken from the Institutional Review Board of the Forman 11 12 494 Christian College University. Study participants were informed about the aims of the study and 13 14 495 provided informed consent either in written form or through thumb impression. 15 496 16 For peer review only 17 497 Author’s contributions 18 19 498 SRJ designed the study and was responsible for the research project, including data collection and 20 21 499 analysis; FF supervised this process. HA and MM supported in data collection. RZ and FF 22 500 contributed to the interpretation of the data. SRJ drafted the manuscript; all authors revised it 23 24 501 critically for important intellectual content. All authors approved the final version of this 25 26 502 manuscript. 27 503 28 29 30 504 References 31 505 32 http://bmjopen.bmj.com/ 33 506 1. United Nations Pakistan. One United Nations Programme III 2018-2022. United Nations 34 35 507 Sustainable Development Framework for Pakistan; 2018. 36 2. Malik MA. Universal health coverage assessment Pakistan. Karachi: Aga Khan University; 37 508 38 509 2015. 39 40 510 3. Nishtar S. Choked pipes: reforming Pakistan’s mixed health system: Oxford University 41 on September 30, 2021 by guest. Protected copyright. 42 511 Press Karachi; 2010. 43 512 4. Nishtar S, Bhutta ZA, Jafar TH, et al. Health reform in Pakistan: a call to action. Lancet 44 45 513 2013;381(9885):2291–7. 46 47 514 5. Nishtar S, Boerma T, Amjad S, et al. Pakistan’s health system: performance and prospects 48 49 515 after the 18th Constitutional Amendment. Lancet 2013;381(9884):2193–206. 50 516 6. Pakistan Bureau of Statistics. Pakistan National Health Accounts 2013-14. Islamabad: 51 52 517 Pakistan Bureau of Statistics; 2014. 53 54 518 7. Garikipati S, Johnson S, Guérin I, Szafarz A. Microfinance and gender: Issues, challenges 55 and the road ahead. The Journal of Development Studies 2017;53(5):641–8. 56 519 57 58 - 27 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 29 of 50 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 520 8. Salim MM. Revealed objective functions of microfinance institutions: evidence from 4 5 521 Bangladesh. Journal of Development Economics 2013;104:34–55. 6 7 522 9. Saba A, Saquiba A. Conceptualizing Health and Microfinance Nexus in Pakistan; 2017. 8 URL: http://www.pmn.org.pk/assets/articles/69106cec5d4f0132b45673990ab4622d.pdf 9 523 10 524 (accessed August 1, 2020). 11 12 525 10. Al-Shami SSA, Majid IBA, Rashid NA, Hamid MSRBA. Conceptual framework: The role 13 14 526 of microfinance on the wellbeing of poor people cases studies from Malaysia and Yemen. 15 527 Asian Social Science 2014;10(1):230. 16 For peer review only 17 528 11. Leatherman S, Dunford C. Linking health to microfinance to reduce poverty. Bull World 18 19 529 Health Organ 2010;88(6):470-1. 20 21 530 12. Zulfiqar G. Does microfinance enhance gender equity in access to finance? Evidence from 22 531 Pakistan. Feminist Economics 2017;23(1):160–85. 23 24 532 13. Escobar M-L, Griffin CC, Shaw RP. The impact of health insurance in low-and middle- 25 26 533 income countries. Brookings Institution Press; 2011. 27 534 14. Heltberg R, del Ninno C, Dorosh P, et al. Social protection in Pakistan: Managing 28 29 535 household risks and vulnerability. Washington, DC: Human Development Unit, South Asia 30 31 536 Region, World Bank; 2007. 32 33 537 15. Malik K, Meki M, Morduch J, Ogden T, Quinn S, Said F. COVID-19 and the Future of http://bmjopen.bmj.com/ 34 538 Microfinance: Evidence and Insights from Pakistan. Oxford Review of Economic Policy; 35 36 539 2020 37 38 540 16. Mersland R, Strøm RØ. Microfinance: Costs, lending rates, and profitability. In: Caprio G, 39 40 541 Arner DW, Beck T, et al., eds. Handbook of key global financial markets, institutions, and on September 30, 2021 by guest. Protected copyright. 41 542 infrastructure. London: Academic Press 2016:489–99. 42 43 543 17. O’Malley T, Burke J. A systematic review of microfinance and women’s health literature: 44 45 544 Directions for future research. Global Pub Health 2017;12(11):1433–60. 46 545 18. Jafree SR, Mustafa M. The triple burden of disease, destitution, and debt: Small business- 47 48 546 women’s voices about health challenges after becoming debt-ridden. Health Care Women 49 50 547 Int Published Online First: 30 January 2020. doi: 10.1080/07399332.2020.1716236. 51 52 548 19. Women’s and Children’s Health Policy Center. Women’s Health Care Experiences Survey. 53 549 Baltimore: Hopkins University Bloomberg School of Public Health; 2000. 54 55 56 57 58 - 28 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 30 of 50 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 550 20. Quinn VJ, Kennedy E. Food security and nutrition monitoring systems in Africa: A review 4 5 551 of country experiences and lessons learned. Food Policy 1994;19(3):234–54. 6 7 552 21. World Health Organization. WHO multi-country study on women's health and domestic 8 violence against women: summary report of initial results on prevalence, health outcomes 9 553 10 554 and women's responses. Geneva: World Health Organization; 2005. 11 12 555 22. Di Martino V. Relationship between work stress and workplace violence in the health 13 14 556 sector. Geneva: World Health Organization; 2003. 15 557 23. Rosenbaum PR, Rubin DB. The central role of the propensity score in observational studies 16 For peer review only 17 558 for causal effects. Biometrika 1983;70(1):41–55. 18 19 559 24. Becker SO, Ichino A. Estimation of average treatment effects based on propensity scores. 20 21 560 The Stata Journal 2002;2(4):358–77. 22 561 25. Dehejia R. Practical propensity score matching: a reply to Smith and Todd. Journal of 23 24 562 Econometrics 2005;125(1-2):355–64. 25 26 563 26. Dehejia RH, Wahba S. Propensity score-matching methods for nonexperimental causal 27 564 studies. Review of Economics and Statistics 2002;84(1):151–61. 28 29 565 27. Thuong NTT. Impact of health insurance on healthcare utilisation patterns in Vietnam: a 30 31 566 survey-based analysis with propensity score matching method. BMJ Open 32 33 567 2020;10:e040062. http://bmjopen.bmj.com/ 34 568 28. Abadie A, Imbens GW. Matching on the estimated propensity score. Econometrica 35 36 569 2016;84(2):781–807. 37 38 570 29. Caliendo M, Kopeinig S. Some practical guidance for the implementation of propensity 39 40 571 score matching. Journal of Economic Surveys 2008;22(1):31–72. on September 30, 2021 by guest. Protected copyright. 41 572 30. Akram M, Khan FJ. Health care services and government spending in Pakistan. PIDE- 42 43 573 Working Papers 32. Pakistan Institute of Development Economics. 44 45 574 31. Mumtaz Z, Salway S. ‘I never go anywhere’: extricating the links between women's 46 575 mobility and uptake of reproductive health services in Pakistan. Soc Sci Med 47 48 576 2005;60(8):1751–65. 49 50 577 32. Padela AI, Zaidi D. The Islamic tradition and health inequities: A preliminary conceptual 51 52 578 model based on a systematic literature review of Muslim health-care disparities. Avicenna 53 579 J Med 2018;8(1):1–13. 54 55 56 57 58 - 29 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 31 of 50 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 580 33. Bhutta ZA, Hafeez A, Rizvi A, et al. Reproductive, maternal, newborn, and child health in 4 5 581 Pakistan: challenges and opportunities. Lancet 2013;381(9884):2207–18. 6 7 582 34. Hafeez A, Mohamud BK, Shiekh MR, Shah SAI, Jooma R. Lady health workers 8 programme in Pakistan: challenges, achievements and the way forward. Journal of the 9 583 10 584 Pakistan Medical Association 2011;61(3):210. 11 12 585 35. Hamid SA, Roberts J, Mosley P. Evaluating the health effects of micro health insurance 13 14 586 placement: Evidence from Bangladesh. World Development 2011;39(3):399–411. 15 587 36. Prost A, Colbourn T, Seward N, et al. Women’s groups practising participatory learning 16 For peer review only 17 588 and action to improve maternal and newborn health in low-resource settings: a systematic 18 19 589 review and meta-analysis. Lancet 2013;381(9879):1736–46. 20 21 590 37. Jacoby MB. Does indebtedness influence health? A preliminary inquiry. The Journal of 22 591 Law, Medicine & Ethics 2002;30(4):560–71. 23 24 592 38. Taylor L. Housing and Health: An Overview Of The Literature. Health Affairs Health 25 26 593 Policy Brief. 7 June 2019. doi: 10.1377/hpb20180313.396577. 27 594 39. Bauhoff S, Hotchkiss DR, Smith O. The impact of medical insurance for the poor in 28 29 595 Georgia: a regression discontinuity approach. Health Economics 2011;20(11):1362–78. 30 31 596 40. Zaidi S, Bigdeli M, Aleem N, Rashidian A. Access to essential medicines in Pakistan: 32 33 597 policy and health systems research concerns. PloS One 2013;8(5):e63515. http://bmjopen.bmj.com/ 34 598 41. Lorenzetti LMJ. Evaluating the effect of integrated microfinance and health interventions: 35 36 599 an updated review of the evidence. Health Policy Plan 2017;32(5):732–56. 37 38 600 42. Gichuru W, Ojha S, Smith S, Smyth AR, Szatkowski L. Is microfinance associated with 39 40 601 changes in women's well-being and children's nutrition? A systematic review and meta- on September 30, 2021 by guest. Protected copyright. 41 602 analysis. BMJ Open 2019;9(1):e023658. 42 43 603 43. Saha S. Provision of health services for microfinance clients: Analysis of evidence from 44 45 604 India. International Journal of Medicine and Public Health 2011;1(1):1–5. 46 47 48 49 50 51 52 53 54 55 56 57 58 - 30 - 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 32 of 50 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 For peer review only 17 18 19 20 Figure 1: Kernel Density balancing plot (a) before and (b) after matching 21 22 255x104mm (144 x 144 DPI) 23 24 25 26 27 28 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 30, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 33 of 50 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 For peer review only 17 18 19 20 Figure 2: Density balancing plot (a) before and (b) after matching 21 22 256x106mm (144 x 144 DPI) 23 24 25 26 27 28 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 30, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 34 of 50 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 For peer review only 17 18 19 20 Figure 3: Common support graph of propensity scores (a) before and (b) after matching 21 22 256x104mm (144 x 144 DPI) 23 24 25 26 27 28 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 30, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 35 of 50 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 4 Relationship between Microfinance, Social Development and 5 6 Women’s Health 7 8 9 10 Cover Letter for Participants 11 12 Questionnaire Information for Women Microfinance Borrowers 13 14 Researcher: Dr. Sara Rizvi Jafree, e-mail: [email protected]; 0300 400 5740 15 16 Thank you for yourFor valuable peertime! Your namereview is not required only and all research analysis will be 17 18 undertaken with confidentiality and complete anonymity. At any point during the interview you 19 may leave, if you wish to do so. 20 21 (Translation in Roman Urdu: Apka Bohat Shukirya apke eemtay waat ke liye! Apke Nam Ka Bharna Zaruri 22 Nahi Hai Aur Yeh Tehkeek Ko Khoofiya Rakha Jaye Ga. Interview ke doran ap kabhi bhi uth ke jaana chahey to apko puri ijazat hai.) 23 24 25 The questionnaire has been designed to collect information about your loan portfolio and your 26 self-rated health. Our aim is to understand your needs and challenges, and ultimately try to 27 improve your loan portfolio and health access and services. 28 29 ((Translation in Roman Urdu: Is questionnaire Ka Masad Hai ke apse chand sawal loan aur sehat ke bare mein 30 puchna. Humara masad ye hai ke apke arze ki sahuliyat aur sehat dono ko behtar kiya jaye.) 31 32
Your honest and reliable answers will be appreciated, so that we can recommend the best http://bmjopen.bmj.com/ 33 solutions with regard to optimal loan portfolios and health satisfaction. 34
35 ((Translation in Roman Urdu: Apke Sache Aur Ba Aitibar Jawab Ke Shukarguzar Honge, Thake loan aur sehat ke 36 hawale se hum apke mushkilay ya rukawaton ko Samajh Sake.) 37 38 39 In the event that you feel disturbed or upset after answering questions or recalling memories 40 related to health problems or experiences of violence/ harassment, you may call or text the 41 researcher for free consultation services from trained female psychologists. on September 30, 2021 by guest. Protected copyright. 42 43 ((Translation in Roman Urdu: Agar apko in sawal aur jawab ki wajeh se koi preshani ho ya koi aisa waiya yad a 44 jaye jo apki zehni pareshani mein izafa kare, tho ap upar diye gaye number par call ya text kar ke rabta kar le. Hum 45 apki muft mein madat zanana mahir-e-nafsiyat se karwayenge.) 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 36 of 50 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 4 5 6 7 Sign or Thumb Impression for Written Consent 8 9 Instrument 10 11 The questionnaire will be read out and completed by the researcher, on behalf of the participant. 12 13 14 Province/City: ______Microfinance 15 Provider:______16 Area/locality: For peer review only Participant Code: 17 18 SECTION A: Code 19 SOCIO-DEMOGRAPHIC Entry 20 CHARACHTERISTICS 21 Q1.Age 1.20-29 2.30-39 3.40-49 4.50+ 22 Umar? 23 Q2.Religion 1.Muslim 2.Christian 3.Hindu 4.Other 24 Mazhab 25 Q3.Province 1.Punjabi 2.Sindhi 3.Baluchi 4.KPK 26 Sooba? 1.Lahore 3.Karachi 1.Quetta 1.Peshawar 27 Q4.City Shehr? 28 2.Islamabad 4.Hyderabad 29 Q5.City-Area 30
31 Q6.Language spoken at home with family Madri zubaan? 32 Q7.Race (β) http://bmjopen.bmj.com/ 33 Zaat 34 Q8.Marital Status 1.Married 2.Single 3.Divorced 4.Seperated 35 Kya ap shadi shuda hain? 36 Q9.Literacy 1.None 2.Primary 3.Secondary 4.Graduate 37 Taleem-i-qabiliyat
38 Q10.Occupation Pesha 39 1.None 2.Primary 3.Secondary 4.Graduate 40 Q10.Spouse literacy
Aapkay khaawand ki taleemi qabiliyat kya hai? on September 30, 2021 by guest. Protected copyright. 41 Q12.Spouse Occupation 42 Apkay khawand ka pesha kya hai? 43 Q13.Your earning in last month 1.Less than 5k 2.>5k-10k 2.>10k-20k 4.Other 44 Pichlay mahinay aap ki kamai kitni thi? 45 Q14.Your earning in last year 1.Less than 50k 2.>50k-70k 2.>70k-90k 4.Other 46 Pichlay saal apki kitni kamai thi? 47 Q15.Combined household income in a month (on 1.Less than 10k 2.>10k-15k 2.>15k-20k 4.Other 48 average) 49 Tamaam ghar ki amdani kitni hai? 1.Owned 2.Rented 3.Living with 4.Other 50 Q16.House Ownership Ghar ka malik kaun hai? someone 51 Q17.Number of children 1. None 2. 1-2 3. 3-5 4. >6 52 Apkay kitnay bachay hain? 53 Q18.Age of last child 54 Akhri bachay ki umar? 55 Q19.Number of people living in house 1. 1-2 2. 3-5 3. 6-9 4. >10 56 Ghar mai kitnay afraad rehte hain? 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 37 of 50 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 Q20.Number of rooms in house 1. 1 2. 2-3 3. 4-5 4. >6 4 Ghar mai kitnay kamray hain? 5 Q21.Are you currently taking care of a disabled/ 1.No 2.Yes If Yes, who: 6 dependent family member 7 Kya apkay ghar mai koi mazoor/jiska ap par inhasaar ho, 8 shakhs hai? Q22.Source of drinking water 1.Plain Tap 2.Filtered 3.Local 4.Other 9 Pani penay ka kya zarya hai? Pump 10 Q23.Type of energy used for cooking in house 1.Gas 2.Wood 3.Electricity 4.Other 11 Ghar mai khana pakanay ke liye kis chiz ka istemaal kartay 12 hain? (gas, coal, electric etc.) 13 Q24.Do you have toilet facility in house 1.Yes 2.No If No, what do you use 14 Apkay ghar mai bait-ul-khala hai? 15 Q25.How many toilets in the house 1. None 2. 1-2 3. 3-5 4. >6 16 Ghar mai kitnay bait-ul-khala hain? For peer 1.Yesreview 2.No onlyIf No, what do you use 17 Q26.Does the toilet have a flush Bait-ul-khala mai flush hai? 18 Q27.Is the drainage and gutter system of your 1.Yes 2.No 19 house satisfactory 20 Ganday pani ke ikhraj ka nizaam darust hai? 21 Q28.How do you dispose of the garbage 1.Throw it on 2.Garbage 3.Set Fire 4.Other 22 Ghar ki gandagi kahan phenkhtay hain? street/ far away collectors from home come to house 23 Q29.Are you taking any health insurance (not 1.Yes 2.No If Yes, who 24 provided by the microfinance provider)? (If so, 25 from where, how much installment) 26 Sehat ke liye insurance le rae hain? 27 SECTION B: 28 MICROFINANCE LOAN 29 CHARACHTERISTICS 30 Q30.Why are you taking loan (describe your work 31 type, hours of work, working conditions in detail) 32 Aap karz kyun le rahe hain? (kis tarah ka kaam hai, kitnay ghantay kaam kartay hain, jahan kaam kartay hain uskay halaat) http://bmjopen.bmj.com/ 33 34 35 36 Q31.What type of loan are you currently taking/ duration 37 Kis tarah ka karz le rahay hain/kitnay arsay se? 38 Q32.How long have you been a microfinance 1. 1-2 years 2. 3-5 years 3. 6-9 years 4. >10 39 borrower for years 40 Kitne arsay se karz le rahay hain? on September 30, 2021 by guest. Protected copyright. 41 Q33.Is it a group loan 1.Yes 2.No If Yes, who 42 Kya ap ne kisi ke sath mil ke karz liya hai? 43 Q34.How much is the loan for 44 Kitna karz liya hai? 45 Q35.What is the installment rate per month 46 Karz ko ada karnay ki mahana kist kya hai? 47 Q36.Do you attend monthly meetings with loan 1.Yes 2.No 48 officers Karz denay walay officer se kya apki mahwar mulakaat hoti 49 hai? 50 Q37.Do you attend weekly meetings with loan 1.Yes 2.No 51 officers 52 Karz dene walay officer se kya apki haftawar mulkaat hoti hai? 53 Q38.Who helps you in loan repayment 1.No one 2.Husband 3.Parents 4.Other 54 Karz ada karnay mai kya koi apki madad karta hai? 55 Q39.What exactly has the loan been used for 1.Business 2.Household 3.Old 4.Health 4.Other Ap karz kis liye istemal karti hain? expenditure Loans Costs 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 38 of 50 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 Q40.How much of the loan taken has been 1.All 2.Half 3.Quarter 4.Other 4 invested in business 5 Karz ka kitna hissa karobar mai kharch kiya hai? 6 Q41.Are you satisfied with loan amount 1.Yes 2.No 7 Kya aap karz ki rakam se mutmaeen hai? 8 Q42.Are you satisfied with loan repayment rate 1.Yes 2.No 9 Kya ap karz ki adaigi ki kist se mutmaeen hai? Q43.Will you be renewing loan 1.Yes 2.No 10 Kya aap karz dobara lena chahain gae? 11 Q44.Have you received any skill development 1.Yes 2.No 12 training 13 Kya apki silahiyaton ko barhanay ki koi tarbiyat mili hai? 14 Q45.Have you participated in any health 1.Yes 2.No 15 workshop/awareness campaign/talk… 16 Kya sehat se mutalik ap kisi agahi mohim ka hissa banay hai? For peer 1.Yesreview 2.No only 17 Q46.Has your loan officer or center ever talked to 18 you about health awareness or access Kya karz denay walay officer ne ap se sehat ke mutalik koi 19 agahi di hai? 20 Q47.Have you been offered saving insurance by 1.Yes 2.No 21 your MFP 22 Kya idaray ne apko bachat insurance ki peshkash ki hai? 23 Q48.Are you taking saving insurance with your 1.Yes 2.No 24 MFP 25 Kya idara ap ko bachat insurance de raha hai? 26 Q49.Have you been offered health insurance by 1.Yes 2.No 27 your MFP Kya idara aap ko sehat insurance deta hai? 28 Q50.Are you taking health insurance with your 1.Yes 2.No 29 MFP 30 Kya ap idaray se sehat insurance le rahay hain? 31 Q51.Has the loan so far satisfied your business 1.Yes 2.No 32 needs 33 Kya karz ki rakam ne apki karobari zaroriyat ko pura kiya hai? http://bmjopen.bmj.com/ 34 Q52.Has your loan taking from MF enabled you to 1.Yes 2.No 35 visit a trained private general practitioner, if 36 needed in last 12 months 37 Karzay k baad pichlay 12 maheenay mein kya app private doctor ko dekhanay gaye hain? 38 Q53.Has your employment from MF loan enabled 1.Yes 2.No 39 you to visit a trained private specialist practitioner, 40
if needed in last 12 months on September 30, 2021 by guest. Protected copyright. 41 Karzay k baad pichlay 12 maheenay mein kya app baday doctor 42 ko dekhanay gaye hain? 43 Q54.How is your ability to purchase prescribed 1.Very Good 2.Good 3.Fair 4.Poor 44 medicines (in case recommended by doctor) since 45 loan-taking? Kya karz lene ke bad dawayan khareednay ki istata’at mai koi 46 tabdeeli ai hai? 47 SECTION C 48 WOMEN’S HEALTH CARE EXPERIENCES 49 SURVEY 50 Q55. How would you rate your health in general? 1.Very Good 2.Good 3.Fair 4.Poor 51 Apki sehat kis mayar ki hai? 52 Q56.Compared to other women your age, how 1.Very Good 2.Good 3.Fair 4.Poor 53 would you rate your health 54 Apni hum umar auraton ki nisbat aap apni sehat ka kya mayaar samjhtay hain? 55 Q57. Do you feel your health could be better than 1.Yes 2.No If yes, could you say why/ 56 how: 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 39 of 50 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 it is presently? 4 Kya apki sehat ke mayaar mai koi behtari lai ja sakti hai? 5 6 7 Q58.Does your husband/ male relative/in-laws 1.Yes 2. I decide If yes, can you specify decide/ give approval when you or your children myself which relatives: 8 independently 9 need consultation from a medical practitioner Kya apka khawand/susral apko doctor pe janay ki ijazat deta 10 hai? Kya ye faisla bhi apka susral/khawand krta hai? 11 12 Q59.Does your husband/ male relative/in-laws 1.Yes 2. I decide If yes, can you specify 13 decide/ give approval when you or your children myself which relatives: independently 14 need to visit a clinic/ hospital 15 Kya apka khawand/susral apko hospital janay ki ijazat deta hai 16 or kya ye faisla kaun leta hai? For peer review only 17 18 Please indicate if you have experienced any of 1.Yes 2.No 19 the following health issues in the last 12 20 months? 21 Q60.Minor illness like the flu or an infection 22 Pichlay 12 mahinay mai apko nazla ya infection hua hai?
23 Q61.Had to go for a checkup or routine physical 24 exam Jismani muaaenay ke liye gae hain? 25 Q62.Were you pregnant? 26 Kya app hamla theen? 27 Q63.Did you need family planning or 28 preconceptional services? 29 Kya apko munsoba bandi ki zaroorat thee? 30 Q64.Did you have an injury that you have not 31 already mentioned? 32 Kya apko koi chot lagi hai?
http://bmjopen.bmj.com/ 33 Q65.Did you need care for a chronic health problem, (that is one that goes on for a long time)? 34 Kya apko kisi taweel bemari ke liye hospital jana para hai? 35 Q66.Did you need surgery for a condition not If yes, what? 36 already mentioned?
37 Kya apko operation keranay ki zaroorat parhi?
38 Q67.Were you feeling depressed, anxious, or Could you pinpoint why? 39 highly stressed?
40 Kya iski waja se apko kisi kisam ka zehni dabao ya bechaini on September 30, 2021 by guest. Protected copyright. 41 mehsoos hui hai? 42 Have you had one of the following tests in the 1.Yes 2.No 43 last 12 months? 44 Q68.Colon cancer screening, such as a check for 45 blood in your stool, sigmoidoscopy, or 46 colonoscopy 47 Q69.Test for glaucoma or pressure in the eye 48 Q70.Blood cholesterol test 49 Q71.Check for high blood pressure 50 Q72.Test for diabetes 51 Q73.Breast exam by a doctor or nurse 52 Q74.Mammogram 53 Q75.Pap test 54 Q76.Bone density test (for osteoporosis) 55 Q77.Genetic screening test 56 Q78.Screening for HIV/AIDS 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 40 of 50 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 Q79.Screening for other sexually transmitted 4 diseases 5 Q80.Dental exam 6 Q81.Shot for flu or pneumonia 7 Q82.Pregnancy test 8 Q83.Family planning services or contraception 9 Q84.Tests for infertility 10 Q85.Abortion information or services 11 Q86.Alcohol or drug abuse counseling or 12 treatment 13 In the past 12 months, did any of your health 1.Yes 2.No If yes, can you specify 14 care providers or microfinance loan managers who gave you this 15 talk with you or give you information about? information: 16 (pichlay 12 mahino maiFor kya apkay peer review only 17 doctor/nurse ya apkay karz dene walay 18 19 officer ne aap se in chizon ke baray mai 20 maloomat di hain?) 21 Q87.Smoking, second-hand smoke, or quitting 22 smoking Tambako noshi, kisi aisay shaks k saath bethtna/rehna jo 23 tambako noshi mein mulawis ho, ya tambako noshi chorna 24 Q88.Nutrition or diet 25 (Khuraak) 26 Q89.Alcohol or drug use 27 Shraab ya adviyaat? 28 Q90.Physical fitness or exercise 29 Jismani sehat ya warzish? Q91.Menopause or hormone replacement therapy 30 San – e - yaas ya hormone tabdeeli therapy? 31 Q92.Violence in the home or workplace 32 Kya ghar ya kaam pe kisi tashadud ka shikar hue hain? http://bmjopen.bmj.com/ 33 Q93.Work or financial problems 34 Kaam ya muaashi mushkilaat ka samna hua hai? 35 Q94.Family or relationship problems 36 Ghar walon ya rishtadaron ke masa’il? 37 Q95.Importance of child health and nutrition Bachon ki sehat or khuraak ki ehmiyat? 38 Q96.Stress management 39 Zehani dabao ko kum karna 40 Q97.Preventing unintended pregnancies & birth on September 30, 2021 by guest. Protected copyright. 41 spacing 42 Bachon ke darmiya wakfa? 43 Q98.Using alternative therapies, such as herbs or 44 acupuncture 45 Q99.Preventing osteoporosis 46 Hadion ke dard se bachao 1.Yes 2.No 47 Are there any dietary supplements that you have used in the last 12 months? 48 49
50 Q100.Vitamin C
51 Q101.Vitamin D
52 Q102.Vitamin E
53 Q103.B Complex
54 Q104.Calcium
55 Q105.Pregnancy Vitamin
56 Q106.Lactation Vitamin 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 41 of 50 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 Q107.General Multi-vitamin 4 What is your personal preference for health 1.Yes 2.No 3.Indfferent 5 services? 6 Tibbi saholiyat se mutalik apki zaati tarjihaat kya hain? 7 Q108.Family (e.g. mother/ mother-in-law/ aunt) If Yes, 8 Ghar walay? describe who: 9 10 Q109.A women’s health center where you can get 11 most of your basic health care, including 12 gynecological care, in one place Khawateen ki sehat markaz? 13 Q110.Trusted community member 14 Baradari? 15 Q111.A nurse or LHW (Not a physician/ surgeon/ 16 medical consultant) For peer review only 17 Q112.PublicHospital 18 Q113.Local female healer 19 Q114.Private Clinic 20 Q115.In general, how difficult have you found it to 1.Very difficult 2.Somewhat 2.Not too 3.Not 21 talk to health care providers about your personal difficult difficult difficult at all 22 health concerns? 23 doctor/nurse se baat krna apko kitna mushkil lagta hai? 24 Please rate the health practitioner services as 1.Excellent 2.Good 3.Fair 4.Poor 25 you have experienced them?
26 Q116.Listening to what you have to say 27 Kya apki baat ghor se suntay hain? 28 29 Q117.Talking to you in a respectful and caring 30 manner Kya ap se izzat se baat kartay hai? 31 32 Q118.Speaking to you in the language/ dialect you 33 understand better http://bmjopen.bmj.com/ 34 Kya apse apki madri zubaan mai baat krtay hai
35 Q119.Answering your questions clearly 36 Ap ke sawalon ka sahi se jawaab detay hai?
37 Q120.Giving you the opportunity to ask all of your 38 questions 39 Apko sawaal puchnay ka wakt detay hai? 40 41 Q121.Helping you to feel comfortable talking on September 30, 2021 by guest. Protected copyright. about your personal or sensitive health concerns 42 Kya ap asaani se unhe apnay masaael ke baray mai bata deti 43 hain? 44 45 Q122.Giving you complete health information Kya sehat se mutalik tamaam jankari detay hain? 46 47 Q123.Discussing alternative therapies, diet and 48 lifestyle 49 Kya ap se mutabadil therapy ya khuraq ya roz mara ki zindagi guzarnay kay tareekay pe tabadal e khayal kya hai? 50 51 Q124.Giving you complete information about any 52 tests or services 53 Test ke baray mai mukamal jaankari detay hain?
54 Q125.Giving you the results of your tests 55 Test ke nataij batatay hain? 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 42 of 50 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 4 Q126.Giving you complete information about all 5 your options for treatments 6 Kya ilaaj ke mutalik apko mukamal jaankari detay hai?
7 Q127.Giving you the opportunity to make 8 important decisions about your health care 9 Kya sehat se mutalik tamam faislay apko karnay detay hai?
10 Q128.Giving you written or printed information 11 when you need it 12 Malumaat likh kr dete hai? 13 Q129.Spending enough time with you during your 14 visits 15 Apko tasali bakhsh wakt detay hai? 16 For peer review only 17 Q130.Treating you like a partner in your health 18 care Apka sathi bun kr apki sehat ka khayal rakhtay hai? 19 Which are the primary/ most important sources Tick relevant 20 you depend on for making health decisions? options 21 Sehat se mutalik faislon ke liye ap kis se mashwara leti hai? 22 Q131.Husband 23 Q132.Mother in law 24 Q133.Other in-laws (list please) 25 Q134.Blood family (parents, siblings, children…) 26 Q135.Newspapers / magazines 27 Q136.Heath newsletter 28 Q137.TV 29 Q138.Radio 30 Q139.Microfinance provider 31 Q140.Internet 32 Q141.Mobile services http://bmjopen.bmj.com/ 33 Q142.Family/ friends 34 Q143.Community 35 Q144.Medical Practitioner 36 Q145.Local Healer 37 Q146.Local Imam/ religious leader 38 Q147.Other (Please list) 39 Current Health Risks 40 Q148.Do you currently smoke? 1.Yes 2.No on September 30, 2021 by guest. Protected copyright. 41 Kya app tambako noshi mein mulawis hain? 42 Q149.How many in a day? 43 Din ke kitnay ? 44 Q150.Does anyone else smoke in the house when 1.Yes 2.No If yes, who is this: 45 you/ children are in same room? 46 Kya koi aur tambako noshi mein mulawis hain 47 Q151.Do you feel anxious, stressed, depressed, 1.Yes 2.No Indicate which: suicidal? 48 Kya app kabhi bechain hotay hain ya zehni dabao ka shakar ya 49 khud kushi ka khayal aya hai? 50 Q152.Do you take any drugs (to relieve yourselves If yes, which ones: 51 of stress or an ailment? 1.Yes 2.No
52 Kya app in ke liye koi dawa laitay hain? 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 43 of 50 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 In the past 5 years, has a doctor ever told you Tick relevant 4 that you have any of the following conditions options 5 Kya pichlay paanch salon mai doctor ne aapko bataya ke apko 6 ye bemari hai? 7 8 Q153.Hypertension/ BP 9 High blood pressure 10 Q154.Heart disease 11 Dil ki bemari 12 Q155.High cholesterol 13 Q156.Diabetes 14 15 (sugar) 16 Q157.Depression For peer review only 17 Zehni dabao 18 Q158.Anxiety 19 Bechaini 20 Q159.Migraine headaches 21 (sar dard) 22 Q160.Arthritis 23 Joro ki dard 24 Q161.Osteoporosis 25 Q162.Obesity/ Over-weight problems 26 (mutapa) 27 Q163.Urinary incontinence 28 (pishaap ki takleef) 29 Q164.Cancer 30 Q165.Eating disorder like bulimia/ anorexia Khanay k hawaly se koi mushkil, jaisay bhook na lagna ya kha 31 k ulti kerna 32
Q166.Thyroid problems http://bmjopen.bmj.com/ 33 Q167.Malaria/ Dengue 34 Are you facing any disability which? 35 Kya aap kisi mazoori ka shikaar hain? 1.Yes 2.No 36 If yes, please describe this 37 Q168.Keeps you from participating fully in your disability: ability to take care of your family 38 Jiski waja se ap apnay ghar walon ka khayal na rakh sakain 39 40 If yes, please describe this Q169.Keeps you from participating fully in your on September 30, 2021 by guest. Protected copyright. 41 disability: ability to continue with your business 42 Apnay karobaar mai sahi se kaam na kr sakain 43 44 SECTION D 45 BASELINE NUTRITION AND FOOD 46 SECURITY SURVEY UNICEF 47 Q170.In the past 6 months did you find it too 1.Yes 2.No 48 expensive to purchase the foods you needed to 49 feed your family? 50 Pichlay 6 maah mai kya apko khaandan ko palnay ke liye khana 51 lenay mai mushkilaat hoti hai?
52 Q171.Did you find it too expensive to purchase 1.Yes 2.No 53 fruit? 54 Kya phal khareedna bohat mehnga hai? 55 Q172.Did you find it too expensive to purchase 56 1.Yes 2.No 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 44 of 50 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 vegetables? 4 Kya sabzi khareedna bohat mehnga hai? 5 Q173.Did you find it too expensive to purchase 6 1.Yes 2.No meat? 7 Kya gosht khareedna bohat mehnga hai? 8 9 Q174.Did you find it too expensive to purchase 1.Yes 2.No 10 eggs? 11 Kya anday khareedna bohat mehnga hai?
12 Q175.Did you find it too expensive to purchase 1.Yes 2.No 13 milk? 14 Kya doodh khareedna bohat mehnga hai?
15 Q176.Did you find it too expensive to purchase 1.Yes 2.No 16 wheat, for roti? For peer review only 17 Kya roti khareedna bohat mehnga hai? 18 Q177.In the last 3 months were you worried about 19 1.Yes 2.No running out of food because of high costs? 20 Pichlay 3 maah mai mehngai ki waja se khana na khareed 21 panay ka dart ha? 22 Q178.In the last 3 months did you run out of food 23 1.Yes 2.No because of expense? 24 Pichlay 3 maah mai kya mehngai ki waja se kabhi ghar mai 25 khana khatam ho gaya ho? 26 Q179.In the last 3 months did you or any other 27 1.Yes 2.No adult in the house skip meals because there was 28 not enough food? 29 Pichlay 3 maah mai aap ya kisi or ghar walay se khana kum 30 honay ki waja se khana na khaya ho? 31 Q180.In the last 3 months did you ever think your 1.Yes 2.No 32
children are still hungry because of not being fed http://bmjopen.bmj.com/ 33 enough food? 34 Pichlay 3 maah mai apko kabhi laga ke apkay bachay bhookay 35 hai kyunkay khana pura nai tha? 36 Q181.In the last 3 months did any of your children 1.Yes 2.No 37 go to bed hungry? 38 Pichlay 3 maah mai kya apkay bachay kabhi bhookay soe 39 houn? 40 SECTION E 41 WHO MULTI-COUNTRY STUDY ON WOMEN’S HEALTH AND DOMESTIC VIOLENCE AGAINST on September 30, 2021 by guest. Protected copyright. 42 WOMEN Psychological violence experienced at home 1.Yes 2.No If yes, who were these 43 household members? 44 Q182.Has someone in your home insulted you or 45 made you feel bad about yourself? 46 Kya ghar mai kisi ne apki bezati ki hai? 47 Q183.Has someone in your home belittled or 48 humiliated you in front of other people? 49 Kya ghar mai kisi ne apko dosron ke samnay hakeer dikhaya 50 hai? Q184.Has someone in your home done things to 51 scare or intimidate you on purpose? 52 Kya ghar mai kisi ne apko daraya hai? 53 Q185.Has someone in your home threatened to 54 hurt you or someone you care about? 55 Kisi ne apko damkhaya hai? 56 Physical violence experienced at home 1.Yes 2.No If yes, who were these 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 45 of 50 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 household members? 4 Q186.Has someone in your home slapped you or 5 thrown something at you that could hurt you? 6 Kya kisi ne apko thapar lagaya ho ya app e koi chiz phenki ho 7 jisse apko chot lagi ho? 8 Q187.Has someone in your home pushed or shoved you? 9 Ghar pe apko kisi ne dhaka diya hai? 10 Q188.Has someone in your home hit you with his 11 fist or with something else that could hurt you? 12 Kisi ne apko mukkay marain hai? 13 Q189.Has someone in your home kicked you, 14 dragged you or beaten you up? 15 Kisi ne apko laat mari ho ya ghaseeta ho? 16 Q190.Has someone in yourFor home choked peer or burnt review only 17 you on purpose? Kisi ne jaan bojh kr apka gala dabanay ki, ya jalanay ki koshish 18 ki hai? 19 Q191.Has he threatened to use or actually used a 20 gun, knife or other weapon against you? 21 Apkay khilaf koi hathyaar istemal kiya hai? 22 Sexual violence experienced at home 1.Yes 2.No 23 Q191.Has your husband physically forced you to 24 have sexual intercourse when you didn’t want to? 25 Kya apke shohar ne kisi kisam ka jinsi tushadad kiya hai? 26 Q192.Did you ever have sexual intercourse when 27 you didn’t want because you were afraid of what 28 your husband might do? Kiya app ne kabhi apnay shohar k darr se uss ke saath jinsi 29 taluqat rakhain hain? 30 Q193.Has your husband forced you to do 31 something sexual that you found degrading or 32 humiliating? 33 Kya apkay shohar ne kabhi app se aisay jinsi kaam keraye hain http://bmjopen.bmj.com/ 34 jin se app sharminda ya zilat mehsoos kerain? 35 SECTION F 36 SURVEY OF WORKPLACE VIOLENCE WHO 37 Q194.Describe where exactly your work takes 38 place, when outside of home 39 Ghar se bahir kahan kaam karti hai? 40 41 Q195.What kind of people do you interact with on September 30, 2021 by guest. Protected copyright. 42 mostly for work, outside of home (gender 43 Kam pe kis tarah ke log se mulakat hoi hai? 44 Q196.What are the hours that you are required to 45 work outside of home 46 Ghar se bahir kaam ke silsalay mai kitnay ghnatay lagtay hai? 47 Q197.Which security measure is available to you 48 outside of home in case of fear of violence (male 49 relative accompanying, phone, moving in 50 crowd…) 51 Tashadud ki soorat mai kaam pr koi hifazati intezam hotay hai? 52 Physical Violence (PV) at the workplace 53 Q198.In the last 12 months, have you been 1.Yes 2.No 54 physically attacked in your workplace/ when you 55 are working outside of home? 56 Ghar se bahir kaam kartay wakt kisi tarah ke tashadud ka shikar 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 46 of 50 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 hui hain? 4 Q199.Was this PV with a weapon? (If yes, what 5 kind) 6 Kya is tashadud ke liye koi aslaah istemal kiya gaya tha? 7 Q200.Is this a typical incident at your workplace/ 1.Yes 2.No 8 when you are working outside of home? 9 Kya is tarah ka tashadud kaam pr mamool ki baat hai? Q201.Who attacked you? 10 Kis ne app r tashadud kiya? 11 12 Q202.Where exactly did it take place? Tashadud kis jaga hua? 13 14 Q203.What time was it? 15 Kis wakt hua? 16 Q204.Do you think it could be prevented? 1.Yes 2.No Kya is tashadud roka ja sakta tha?For peer review only 17 1.Yes 2.No 18 Q205.Were you injured? Kya apko kisi kisam ki chot ai thi? 19 Q206.Did you require treatment for the injury? 1.Yes 2.No If yes, can you describe this treatment: 20 Kya is chot/zakham ke liye apko kisi ilaj ki zarorat hui? 21 22 Q207.How did you respond to the incident? 23 Tashadud ke natijay mai ap ne kya kiya? 24 25 Did you suffer any of the following due to PV: 26 Q208.Repeated, disturbing memories, thoughts, or 1.Yes 2.No 27 images of the attack? 28 Tashadud ke bad kya apko iske baray mai aksar khayalat atay 29 the? 30 31 Q209.Avoiding thinking about or talking about the 1.Yes 2.No 32 attack or avoiding having feelings related to it? 33 Kya is tashadud ke baray mai baat karne se ap ghabrati thi? http://bmjopen.bmj.com/ Q210.Being "super-alert" or watchful and on 1.Yes 2.No 34 guard? 35 Tashadud ke bad dar ke rehne lagi? 36 37 Q211.Feeling like everything you did was an 1.Yes 2.No 38 effort? 39 Har kaam mushkil ho gaya? 40 Verbal Violence (VV) at the workplace on September 30, 2021 by guest. Protected copyright. 41 Q212.In the last 12 months, have you been 1.Yes 2.No 42 verbally assaulted in your workplace/ when you 43 are working outside of home? 44 Kya pichlay 12 mah mai kaam pr kisi ne ap pr zabani tashadud 45 kiya hai? 1.Daily 2.About once 3.About once 4.Other 46 Q213.How often has this happened in the last 12 months? in a week in a month 47 Kitni dafa? 48 Q214.Is this a typical incident at your workplace/ 1.Yes 2.No 49 when you are working outside of home? 50 Kya ye kaam pr mamool ki baat hai? 51 Q215.Who abused you? 52 Kis ne aap per zabani tashadud kiya? 53 Q216.Where exactly did it take place? 54 Kahan kiya? 55 Q217.What time was it? 56 Kis wakt kiya? 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 47 of 50 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 Q218.Do you think it could be prevented? 1.Yes 2.No 4 Kya isse roka ja sakta tha? 5 Q219.How did you respond to the incident? 6 Iske natijay mai aap ne kya kiya? 7 8 Did you suffer any of the following due to VV: 9 Q220.Repeated, disturbing memories, thoughts, or 1.Yes 2.No 10 images of the attack? Tashadud ke bad kya apko iske baray mai aksar khayalat atay 11 the? 12 13 Q221.Avoiding thinking about or talking about the 1.Yes 2.No 14 attack or avoiding having feelings related to it? 15 Kya is tashadud ke baray mai baat karne se ap ghabrati thi? 16 Q222.Being "super-alert" orFor watchful andpeer on 1.Yesreview 2.No only 17 guard? 18 Tashadud ke bad dar ke rehne lagi? 19 20 Q223.Feeling like everything you did was an 1.Yes 2.No 21 effort? 22 Har kaam mushkil ho gaya? 23 24 Sexual Harassment (SH) at the workplace 25 Q224.In the last 12 months, have you been 1.Yes 2.No 26 sexually harassed in your workplace/ when you are 27 working outside of home? Kya pichlay 12 maheenay mein ap ko kisi kisam k jinsi 28 harasaan ka samna kerna parha hai? 29 Q225.How often have you been sexually harassed 1.Daily 2.About once 3.About once 4.Other 30 in the last 12 months? in a week in a month 31 Pichlay 12 maheenay mein yeh kitni dafa hua? 32 Q226.Is this a typical incident at your workplace/ 1.Yes 2.No 33 when you are working outside of home? http://bmjopen.bmj.com/ 34 Kya yeh kaam kernay wali jaga pe amoman hota hai?
35 Q227.Who attacked you? Hamla awar kaun tha? 36 37 Q228.Where exactly did it take place? 38 Yeh kis jaga pe hua? 39
40 Q229.What time was it?
Waqt kya tha? on September 30, 2021 by guest. Protected copyright. 41
42 Q230.Do you think it could be prevented? 1.Yes 2.No 43 Kya app isko rok sakti theen? 44 Q231.How did you respond to the incident? 45 Apnay iska samna kaisay kiya? 46 Did you suffer any of the following due to SH: 47 Q232.Repeated, disturbing memories, thoughts, or 1.Yes 2.No 48 images of the attack? 49 Kya apko iss hadsay k baad baar baar buray khaylat ya yaadain 50 pareshan kerti hain? 51 52 Q233.Avoiding thinking about or talking about the 1.Yes 2.No 53 attack or avoiding having feelings related to it? Kya app iss hadsay ko bhulanay ki koshih ya iskay baray mein 54 baat kernay se guraiz kertay hain? 55 Q234.Being "super-alert" or watchful and on 1.Yes 2.No 56 guard? 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 48 of 50 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 Kya app chak o chawbund rehtay hain? 4 Q235.Feeling like everything you did was an 1.Yes 2.No 5 effort? 6 Kya apko zehni dabao mehsoos hota hai? 7 Racial Harassment (RH) at the workplace 8 Q236.In the last 12 months, have you been racially 1.Yes 2.No 9 harassed in your workplace/ when you are working 10 outside of home? Pichlay 12 maah mai apki zaat ki waja se kisi ne apko harasaan 11 kiya hai? 12 Q237.How often have you been racially harassed 1.Daily 2.About once 3.About once 4.Other 13 in the last 12 months? in a week in a month 14 Kitni dafa? 15 Q238.Is this a typical incident at your workplace/ 1.Yes 2.No 16 when you are working outsideFor of home? peer review only 17 Ghar se bahir kaam pe kya ye aam ma’mool ki baat hai? 18 Q239.Who attacked you? Kis ne harasaan kiya? 19 20 Q240.Where exactly did it take place? 21 Kahan 22 23 Q241.What time was it? 24 Kis wakt? 25 Q242.Do you think it could be prevented? 1.Yes 2.No 26 Kya issay roka ja sakta tha? 27 Q243.How did you respond to the incident? 28 Iske natijay mai aap ne kya kiya?
29 Did you suffer any of the following due to RH: 30 Q244.Repeated, disturbing memories, thoughts, or 1.Yes 2.No 31 images of the attack? 32 Tashadud ke bad kya apko iske baray mai aksar khayalat atay http://bmjopen.bmj.com/ 33 the? 34 Q245.Avoiding thinking about or talking about the 1.Yes 2.No 35 attack or avoiding having feelings related to it? 36 Kya is tashadud ke baray mai baat karne se ap ghabrati thi? 1.Yes 2.No 37 Q246.Being "super-alert" or watchful and on 38 guard? Tashadud ke bad dar ke rehne lagi? 39 Q247.Feeling like everything you did was an 1.Yes 2.No 40
effort? on September 30, 2021 by guest. Protected copyright. 41 Har kaam mushkil ho gaya? 42 SECTION F 43 OPEN-ENDED QUESTIONS 44 Q248.What are the main health challenges you 45 face in the last 12 months? 46 Pichlay sal mein kaunsi sehat ki takleef thi apko? 47 Behtareen tibbi saholiyat ke wasool mai sub se eham 3 48 rukawatain? 49 Q249.What are the top 3 barriers preventing you 50 from access to health services? 51 52 Kaunsi theen chezay apko sehat ki sahulat laney mein rukawat 53 hai 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 49 of 50 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from
1 2 3 4 5 6 7 8 Q250. What are the main problems which prevent 9 you from being satisfied with your health since 10 taking loan? Kaunsi sehat ke mutalik cheezay apko ----- ? 11 12 13 14 15 16 For peer review only 17 18 β- Punjabis (1), Pashtuns (2), Sindhis (3), Siddis (4), Saraikis (5), Muhajirs (6), Balochis (7), Hindkowans (8), Chitralis (9), Gujarati (10), Kashmiris 19 (11), Kalash (12), Burusho (13), Brahui (14), Khowar (15), Hazara (16), Shina (17), Kalyu (18), Balti (19), Afghan refugees (20), Other (21).
20 *- Doctors clinic (private/primary-secondary) (1), Hospital Clinic (tertiary) (2), LHW (3), BHU (4), Local Hakim (5), Homeopath (6), Other (7). 21 22 +- No money (1), not serious/ took care it of it myself (2), too busy (3), no childcare (4), no transport (5), too embarrassed (6), don’t have permission (7), prescription/ paperwork/ referral got lost (8), didn’t know where to get care (9), provider too far away (10), don’t like the local provider (11), 23 couldn’t find specific specialist (12), other (13). 24 25 # Physical violence refers to the use of physical force against another person or group, that results in physical harm, sexual or psychological harm. It 26 can include beating, kicking, slapping, stabbing, shooting, pushing, biting, and/or pinching, among others. Psychological violence is defined as: Intentional use of power, including threat of physical force, against another person or group, that can result in 27 harm to physical, mental, spiritual, moral or social development. Psychological violence includes verbal abuse, bullying/mobbing, harassment, and 28 threats. 29 Sexual Harassment refers to any unwanted, unreciprocated and unwelcome behavior of a sexual nature that is offensive to the person involved, and causes that person to be threatened, humiliated or embarrassed. 30 Racial Harassment refers to any threatening conduct that is based on race, color, language, national origin, religion, association with a minority, birth or 31 other status that is unreciprocated or unwanted and which affects the dignity of women and men at work. 32 @ took no action (1), tried to pretend it never happened (1), told the person to stop (1), tried to defend myself (1), told friends/family (1), sought http://bmjopen.bmj.com/ 33 counseling (1), told a colleague (1), reported it to a colleague (1), discussed/ complained to MF loan officer (1), sought help from MFP (1), sought help 34 from the union/community (1), pursued prosecution (1), other (1) 35 36 37 38 39 40 41 on September 30, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 50 of 50
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Supplementary Table 1a: Descriptive statistics before matching for health insurance (T=0 and T=1) BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from 4 5 Variable No health insurance Health insurance 6 (T=0) (T=1) 7 Mean SD Mean SD Difference p-value 8 Age 0.455 0.499 0.390 0.489 0.065 0.188 9 Religion 0.097 0.297 0.150 0.358 -0.052 0.103 10 Literacy 0.396 0.490 0.253 0.436 0.142 0.003 11 Spouse Literacy 0.385 0.488 0.351 0.479 0.035 0.473 12 House ownership 0.712 0.454 0.805 0.397 -0.093 0.032 13 Children 0.563 0.497 0.714 0.453 -0.152 0.002 14 Drinking water 0.771 0.421 0.857 0.351 -0.086 0.034 15 Toilet facility 0.760 0.428 0.779 0.416 -0.019 0.657 16 Gutter drainage 0.747 0.436 0.733 0.443 0.013 0.771 17 Debt age 0.670 0.471 0.669 0.472 0.001 0.978 18 Group loan For0.410 peer0.493 review0.422 0 .49only6 -0.012 0.802 19 Loan amount 0.750 0.433 0.468 0.501 0.283 <0.001 Interest rate 0.708 0.455 0.669 0.472 0.040 0.391 20 Monthly meetings 0.674 0.470 0.890 0.314 -0.216 <0.001 21
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24 Supplementary Table 1b: Descriptive statistics after matching for health insurance (T=0 and T=1) 25 26 Variable No health insurance Health insurance 27 (T=0) (T=1) 28 Mean SD Mean SD Difference p-value 29 Age 0.450 0.500 0.433 0.498 0.017 0.796 30 Religion 0.125 0.332 0.150 0.359 -0.025 0.576 31 Literacy 0.308 0.464 0.308 0.464 0 1.000 32 Spouse literacy 0.425 0.496 0.375 0.486 0.050 0.431 33 House ownership 0.825 0.382 0.792 0.408 0.033 0.514 34 Children 0.650 0.479 0.642 0.482 0.008 0.893 35 Drinking water 0.833 0.374 0.817 0.389 0.017 0.735 36 Toilet facility 0.842 0.367 0.792 0.408 0.050 0.319 37 Gutter drainage 0.725 0.448 0.750 0.435 -0.025 0.662 http://bmjopen.bmj.com/ 38 Debt age 0.658 0.476 0.683 0.467 -0.025 0.682 39 Group loan 0.467 0.501 0.400 0.492 0.067 0.299 40 Loan amount 0.475 0.501 0.483 0.502 -0.008 0.898 41 Interest rate 0.667 0.473 0.625 0.486 0.042 0.502 42 Monthly meetings 0.892 0.312 0.858 0.350 0.333 0.437 43 44
on September 30, 2021 by guest. Protected copyright. 45
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Supplementary Table 2a: Descriptive statistics before matching for health awareness programme (T=0 BMJ Open: first published as 10.1136/bmjopen-2020-043544 on 5 January 2021. Downloaded from 4 and T=1) 5 6 Variable No health awareness Health awareness 7 programme programme 8 (T=0) (T=1) 9 Mean SD Mean SD Difference p-value 10 Age 0.476 0.501 0.394 0.490 0.082 0.084 11 Religion 0.087 0.283 0.140 0.348 -0.05 0.086 12 Literacy 0.383 0.487 0.314 0.465 0.070 0.124 13 Spouse literacy 0.379 0.486 0.369 0.483 0.010 0.829 14 House ownership 0.762 0.427 0.729 0.446 0.033 0.424 15 Children 0.573 0.496 0.653 0.477 -0.080 0.086 16 Drinking water 0.820 0.385 0.784 0.412 0.037 0.034 17 Toilet facility 0.728 0.446 0.801 0.400 -0.727 0.072 18 Gutter drainage For0.699 peer0.460 review0.780 0.415 only -0.081 0.053 19 Debt age 0.636 0.482 0.699 0.460 -0.063 0.159 Group loan 0.442 0.498 0.390 0.489 0.052 0.270 20 Loan amount 0.767 0.424 0.551 0.498 0.216 0.000 21 Interest rate 0.660 0.475 0.725 0.448 -0.064 0.143 22 Monthly meetings 0.626 0.485 0.856 0.352 -0.230 <0.001 23
24 25 26 Supplementary Table 2b: Descriptive statistics after matching for health awareness programme (T=0 27 and T=1) 28 29 Variable No health awareness Health awareness 30 programme programme 31 (T=0) (T=1) 32 Mean SD Mean SD Difference p-value 33 Age 0.469 0.502 0.424 0.496 0.045 0.923 34 Religion 0.135 0.343 0.139 0.347 -0.003 0.940 35 Literacy 0.344 0.477 0.285 0.453 0.059 0.334 36 Spouse literacy 0.375 0.487 0.417 0.495 -0.042 0.521 37 House ownership 0.833 0.375 0.792 0.408 0.042 0.424 http://bmjopen.bmj.com/ 38 Children 0.604 0.491 0.674 0.471 -0.069 0.272 39 Drinking water 0.813 0.392 0.833 0.374 -0.021 0.679 40 Toilet facility 0.781 0.416 0.840 0.368 -0.059 0.249 41 Gutter drainage 0.677 0.477 0.778 0.417 -0.101 0.083 42 Debt age 0.667 0.474 0.674 0.470 -0.007 0.911 43 Group loan 0.448 0.500 0.424 0.496 0.024 0.711 Loan amount 0.573 0.497 0.417 0.495 0.156 0.018 44
Interest rate 0.667 0.474 0.632 0.484 0.035 0.584 on September 30, 2021 by guest. Protected copyright. 45 Monthly meetings 0.854 0.355 0.889 0.315 -0.035 0.428 46
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