The Invisible Fishers

Not Applicable

Completed

• Conditions: Anemia
• Interventions: Behavioral: Mobile phone audio messaging; Behavioral: Peer-to-peer learning; Behavioral: Conditional cash transfer; Behavioral: Improved smoke ovens; Behavioral: Entrepreneurship training; Behavioral: Market price information

• Registration Number: NCT03498755
• Lead Sponsor: University of Michigan

Brief Summary

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

Detailed Description

Anemia among women of reproductive age remains an intractable public health problem in many low- and middle-income countries, especially in sub-Saharan Africa (SSA) where more than one-third of women of reproductive age are anemic. The complex etiology of anemia suggests the importance of designing interventions that address both nutritional deficiencies and environmental drivers of anemia risk. This proposed research builds on new knowledge generated from ongoing formative research by our investigator team aimed at understanding the potential for interventions into animal-source food (ASF) value chains to influence anemia among adolescent girls and women in Ghana. The investigators have identified fisheries value chains in Ghana as a uniquely promising sector for intervention to mitigate anemia among women. Specifically, our research indicates that fish processing is the most promising focal area for intervention within fisheries value chains to address anemia among women. Therefore, the overall research objective of this proposed research is to develop, adapt, and pilot test a set of interventions into fisheries value chains in Ghana aimed at mitigating anemia among women. Specifically, the investigators aim to: 1) define the scope, feasibility, and scalability of priority intervention strategies that have been identified through our ongoing formative research, 2) adapt the interventions to the proposed study contexts, and 3) design and pilot test specific implementation strategies, as well as a monitoring and evaluation (M\&E) framework for assessing intervention delivery, uptake, impacts, and mechanisms of impact at multiple loci along hypothesized program impact pathways.

Our ongoing formative research and an extended consultation process with stakeholders and community participants have identified priority strategies for intervention within fisheries value chains in Ghana that are feasible, scalable, likely to reduce anemia through multiple mechanisms, and for which there is clear potential for sustainability of impact. The investigators expect that the pilot testing of these interventions and the associated M\&E framework will directly inform the design, implementation and evaluation of a full randomized controlled trial (RCT) that will evaluate the effectiveness of these interventions on anemia mitigation among women in Ghana. As such, the design of this pilot research will mimic that of a RCT with three distinct treatments delivered to women in separate study arms, each arm reflecting the priority intervention strategies identified through our ongoing formative research:

* Treatment Arm 1 (TA1): a multi-sectoral anemia behavior change intervention focused on promoting a diversity of anemia-mitigating behaviors including consumption of micronutrient-rich ASFs, malaria and soil-transmitted helminth control practices, and water, sanitation and hygiene best practices (TA1 is also a component of Treatment Arms 2 and 3);

* Treatment Arm 2 (TA2): an intervention aimed at strengthening women fish processors' engagement with markets through a group-based microcredit scheme, providing entrepreneurship training, and facilitating enhanced access to market price information;

* Treatment Arm 3 (TA3): an intervention introducing improved fish smoking technology and practices to women processors aimed both at improving earnings and reducing harmful occupational exposures associated with fish smoking.

The investigators will recruit a total of 120 total participants from 12 communites in two regions of Ghana that represent marine and fresh water small-scale fisheries systems. Participants will be recruited into a nine-month pilot intervention with data collection occurring at baseline prior to the start of the intervention, at the middle point of intervention implementation, and at endline immediately following completion of intervention implementation. The investigators will use survey-based instruments, direct observation, participant diaries, anthropometric and dietary assessment, occupational exposure assessment, as well as analysis of blood and stool specimens to evaluate changes in anemia, micronutrient status, inflammation and infection, as well as changes in participants' knowledge, attitudes, behaviors, and exposures that the investigators hypothesize are linked to intervention exposure. Such an analysis is critical for understanding the relative importance of different mechanisms of impact for each intervention. The investigators will further carry out qualitative, semi-structured interviews with study participants and project implementation staff to understand their perceptions of the interventions, factors that facilitated or prevented successful implementation and uptake of interventions, and their perceptions of positive and negative changes resulting from participation in the project. These insights will be important for addressing our proposed research questions related to defining the scope of the proposed interventions, and assessing the feasibility of intervention uptake and implementation. A final project assessment workshop will also be carried out to internally assess the strengths and limitations of the project's M\&E framework.

Smoked fish value chains in Ghana have clear potential to influence anemia risk among women fish smokers via multiple, potentially interconnected and contradictory mechanisms. More broadly, these value chains also have significant potential to affect the nutrition and health status of coastal and lake communities and of consumers across the country whose diets are profoundly shaped by these value chains. The investigators expect that the findings of this research will significantly contribute to understanding how best to design, implement, and evaluate interventions into fisheries and other ASF value chains in Ghana and across SSA to address anemia and related nutrition and health concerns.

Study Timeline

• Study First Submitted: 2018-03-12
• Study First Submitted QC: 2018-04-13
• Study First Posted: 2018-04-17
• Study Start: 2018-05-21
• Status Verified: 2019-08
• Primary Completion: 2019-08-17
• Study Completion: 2019-08-17
• Last Update Submitted: 2019-08-22
• Last Update Posted: 2019-08-26

Recruitment & Eligibility

• Status: COMPLETED
• Sex: Female
• Target Recruitment: 120

Inclusion Criteria

• Not pregnant
• Not planning to move from the community during the project period
• Engaged in fish processing as primary livelihood

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Exclusion Criteria

• Pregnant
• Planning to move from the community during the project period
• Not engaged in fish processing as primary livelihood

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Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Multi-sectoral anemia behavior change	Mobile phone audio messaging	Address multiple behavioral determinants of anemia by promoting the identification, knowledge, valuation and practice of four behavioral domains: 1) consumption of micronutrient-rich animal-source foods; 2) malaria and soil-transmitted helminth infection control practices; 3) water, sanitation and hygiene (WASH) best practices; and 4) women's autonomy in decision-making and control of the use of earned income.
Strengthening market engagement of fish processors	Peer-to-peer learning	Assist women in overcoming limited access to credit, inadequate storage facilities, and insufficient information about market prices, which constrain the timeliness and amount of market-ready product available for sale, through a three-pronged approach that includes: 1) a conditional cash transfer; 2) entrepreneurship training; and 3) enhanced access to market price information.
Strengthening market engagement of fish processors	Mobile phone audio messaging	Assist women in overcoming limited access to credit, inadequate storage facilities, and insufficient information about market prices, which constrain the timeliness and amount of market-ready product available for sale, through a three-pronged approach that includes: 1) a conditional cash transfer; 2) entrepreneurship training; and 3) enhanced access to market price information.
Strengthening market engagement of fish processors	Entrepreneurship training	Assist women in overcoming limited access to credit, inadequate storage facilities, and insufficient information about market prices, which constrain the timeliness and amount of market-ready product available for sale, through a three-pronged approach that includes: 1) a conditional cash transfer; 2) entrepreneurship training; and 3) enhanced access to market price information.
Strengthening market engagement of fish processors	Market price information	Assist women in overcoming limited access to credit, inadequate storage facilities, and insufficient information about market prices, which constrain the timeliness and amount of market-ready product available for sale, through a three-pronged approach that includes: 1) a conditional cash transfer; 2) entrepreneurship training; and 3) enhanced access to market price information.
Improving fish smoking technology and practices	Mobile phone audio messaging	Introduce and promote a recently developed fish smoking oven known as the Ahotor, which was explicitly designed to reduce emission from biomass fuel combustion, decrease polycyclic aromatic hydrocarbon (PAH) levels of smoked fish, and increase fuel efficiency. Use of this oven will reduce workload, increase earnings, and reduce harmful occupational exposures. Introduction of this improved fish smoking oven will be combined with behavior change education focused on promoting optimal fish smoking and handling practices.
Multi-sectoral anemia behavior change	Peer-to-peer learning	Address multiple behavioral determinants of anemia by promoting the identification, knowledge, valuation and practice of four behavioral domains: 1) consumption of micronutrient-rich animal-source foods; 2) malaria and soil-transmitted helminth infection control practices; 3) water, sanitation and hygiene (WASH) best practices; and 4) women's autonomy in decision-making and control of the use of earned income.
Improving fish smoking technology and practices	Peer-to-peer learning	Introduce and promote a recently developed fish smoking oven known as the Ahotor, which was explicitly designed to reduce emission from biomass fuel combustion, decrease polycyclic aromatic hydrocarbon (PAH) levels of smoked fish, and increase fuel efficiency. Use of this oven will reduce workload, increase earnings, and reduce harmful occupational exposures. Introduction of this improved fish smoking oven will be combined with behavior change education focused on promoting optimal fish smoking and handling practices.
Strengthening market engagement of fish processors	Conditional cash transfer	Assist women in overcoming limited access to credit, inadequate storage facilities, and insufficient information about market prices, which constrain the timeliness and amount of market-ready product available for sale, through a three-pronged approach that includes: 1) a conditional cash transfer; 2) entrepreneurship training; and 3) enhanced access to market price information.
Improving fish smoking technology and practices	Improved smoke ovens	Introduce and promote a recently developed fish smoking oven known as the Ahotor, which was explicitly designed to reduce emission from biomass fuel combustion, decrease polycyclic aromatic hydrocarbon (PAH) levels of smoked fish, and increase fuel efficiency. Use of this oven will reduce workload, increase earnings, and reduce harmful occupational exposures. Introduction of this improved fish smoking oven will be combined with behavior change education focused on promoting optimal fish smoking and handling practices.

Primary Outcome Measures

Name	Time	Method
Change in anemia over time	Change from baseline anemia status over the 9 months of the intervention	Hemoglobin (Hb) \<120 g/L, based on analysis of blood and stool samples

Secondary Outcome Measures

Name	Time	Method
Change in type of fish smoking oven used	Change from baseline oven used over the 9 months of the intervention	Assessed from observational data
Change in amount of processed fish kept for own consumption	Change from baseline amount of fish over the 9 months of the intervention	Collected daily using participants' business diaries
Change in fish sales and income generation from fish sales	Change from baseline sales over the 9 months of the intervention	Assessed from daily business diaries and participant recall for cross-validation
Change in knowledge of entrepreneurial skills and best business practices	Change from baseline knowledge and practices over the 9 months of the intervention	Examined using assessment tool that evaluates knowledge of customer care, calculating profits, managing inventory, and accounting
Change in knowledge of optimal fish handling and smoking practices for enhancing product quality	Change from baseline knowledge over the 9 months of the intervention	Assessed using custom tool based on the content of community promotional activities and one-on-one counseling sessions
Differences in home cooking patterns following adoption of new ovens	At the end of study (10 months)	Assessed using a semi-structured interview guide through in-person interview with subsample of participants in treatment arm 3
Change in knowledge and value of animal-source foods for health over time	Change from baseline knowledge over the 9 months of the intervention	Evaluated from participants' responses to assessment related to content of audio messages and peer-to-peer learning
Change in animal-source food purchases	Change from baseline purchases over the 9 months of the intervention	Collected using a seven-day animal-source food expenditure questionnaire
Change in women's autonomy in decision-making and control over earned income	Change from baseline autonomy over the 9 months of the intervention	Measure of women's access to productive capital and the role of women in household decision-making related to agricultural production and income generation, as assessed by a questionnaire of the Women's Empowerment in Agriculture Index
Change in exposure to PM2.5 (particulate matter less than 2.5 microns in aerodynamic diameter) and CO (carbon monoxide)	Change from baseline exposure over the 9 months of the intervention	Primary exposure will be calculated as the mean of recorded concentrations during fish smoking activities (determined by participant time use diaries and corroborated with observational data). Secondary exposure will be calculated as the mean of recorded concentrations during the full 48-hour exposure measurement period
Women's perceptions of the ease of use of Ahotor oven relative to their prior stoves	At the end of study (10 months)	Assessed using a semi-structured interview guide through in-person interview with subsample of participants in treatment arm 3
Change in consumption of animal-source food	Change from baseline consumption over the 9 months of the intervention	Collected using a 24-hour dietary recall questionnaire on three non-consecutive days in a one-week period
Change in understanding and valuation of the importance of specific practices for improving environmental and personal hygiene and minimizing risk of infection	Change from baseline understanding over the 9 months of the intervention	Participant recall and observation of use of insecticide-treated bed nets for sleeping, recent anti-malaria indoor residual spraying of household, frequency and location of barefoot travel, handwashing with soap, safe disposal of stool, treatment of drinking water, safe food and storage preparation practices, and personal hygiene
Change in smoked fish production and processing capacity	Change from baseline production and capacity over the 9 months of the intervention	Assessed from daily business diaries and participant recall for cross-validation
Change in fuelwood and other fish processing business-related expenditures	Change from baseline expenditures over the 9 months of the intervention	Assessed from daily business diaries and participant recall for cross-validation
Change in perceptions of positive and negative changes resulting from participation in interventions	Change from baseline perceptions over the 9 months of the intervention	Measured from extent to which women used market price information that was disseminated via mobile phones, changes in women's business practices, and women's perceptions of the reasons for changes in fish processing, sales, and/or income from fish sales
Women's perceptions of the functionality of the new oven	At the end of study (10 months)	Assessed using a semi-structured interview guide through in-person interview with subsample of participants in treatment arm 3
Change in work environments during fish processing including individuals participating in processing activities	Change from baseline environments over the 9 months of the intervention	Assessed from observation data

Trial Locations

Locations (1)

University of Ghana, Legon; 🇬🇭 Accra, Ghana