Retention in HIV Care Among HIV-Seropositive Pregnant and Postpartum Women in Uganda: Results of a Randomized Controlled Trial.

We tested an intervention that aimed to increase retention in antiretroviral therapy (ART) among HIV-positive pregnant and postpartum women, a population shown to be vulnerable to poor ART outcomes. 133 pregnant women initiating ART at 2 hospitals in Uganda used real time-enabled wireless pill monitors (WPM) for 1 month, and were then randomized to receive text message reminders (triggered by late dose-taking) and data-informed counseling through 3 months postpartum or standard care. We assessed "full retention" (proportion attending all monthly clinic visits and delivering at a study facility; "visit retention" (proportion of clinic visits attended); and "postpartum retention" (proportion retained at 3 months postpartum). Intention-to-treat and per protocol analyses found that retention was relatively low and similar between groups, with no significant differences. Retention declined significantly post-delivery. The intervention was unsuccessful in this population, which experiences suboptimal ART retention and is in urgent need of effective interventions.

Verbal Autopsies for Out-of-Hospital Infant Deaths in Zambia.

OBJECTIVES: In Zambia, a significant number of infants die in the community. It is hypothesized that delays in care contribute to many of these so-called "brought in dead" infants. METHODS: We analyzed free-text narratives from verbal autopsies, in which families narrate the final series of events leading to each infant's death. Using the 3-delays model framework and working iteratively to achieve consensus, we coded each narrative using NVivo software to identify, characterize, and quantify the contribution of delays and other factors to the fatal outcome. RESULTS: Verbal autopsies were collected from 230 families of brought in dead infants younger than 6 months of age. As many as 82.8% of infants had 1 or more delays in care. The most-common delay was in the family's decision to seek care (54.8%), even as severe symptoms were frequently described. Similarly, 27.8% of infants died en route to a health care facility. Delays in receiving adequate care, including infants dying while waiting in line at a clinic or during referral from a clinic to a hospital, occurred in 24.7% of infants. A third of infants had been previously evaluated by a clinician in the days before their death. CONCLUSIONS: Delays in care were the rule rather than the exception in this population of Zambian infants. Accessing care requires families to navigate significant logistic barriers, and balance complex forces in deciding to seek care. Strategies to avoid such delays could save many infants lives.

Maternal vaccine knowledge in low- and middle-income countries-and why it matters.

Maternal vaccines have the potential to reduce the global burden of neonatal morbidity and mortality by accessing the infant immune system before a vaccine administered in childhood would be effective. Maternal vaccines for influenza, tetanus, and pertussis have been shown to reduce neonatal disease and mortality, and other candidate vaccines for group B streptococcus and respiratory syncytial virus are being developed to continue this trend. However, safe and effective maternal vaccines will only successfully reduce neonatal illness if mothers decide to receive them. Maternal knowledge, attitudes, and beliefs around vaccines are key determinants to vaccine acceptance or vaccine hesitancy, and yet this issue is often understudied in low and middle-income country settings. A deeper understanding of these factors and how they influence maternal decision-making will allow public health practitioners and global and national policymakers to design more effective interventions. Addressing barriers to immunization at the policy and programmatic levels such as mothers' knowledge, attitudes, and beliefs of maternal vaccines is essential to increasing vaccination rates at a global scale and reducing global vaccine-preventable neonatal deaths.

Motivating HIV Providers in Vietnam to Learn: A Mixed-Methods Analysis of a Mobile Health Continuing Medical Education Intervention.

BACKGROUND: The Mobile Continuing Medical Education Project (mCME V.2.0) was a randomized controlled trial designed to test the efficacy of a text messaging (short message service [SMS])-based distance learning program in Vietnam that included daily quiz questions, links to readings and online courses, and performance feedback. The trial resulted in significant increases in self-study behaviors and higher examination scores for intervention versus control participants. OBJECTIVE: The objective of this mixed-methods study was to conduct qualitative and quantitative investigations to understand participants' views of the intervention. We also developed an explanatory framework for future trial replication. METHODS: At the endline examination, all intervention participants completed a survey on their perspectives of mCME and self-study behaviors. We convened focus group discussions to assess their experiences with the intervention and attitudes toward continuing medical education. RESULTS: A total of 48 HIV specialists in the intervention group completed the endline survey, and 30 participated in the focus group discussions. Survey and focus group data suggested that most clinicians liked the daily quizzes, citing them as convenient mechanisms to convey information in a relevant manner. A total of 43 of the 48 (90%) participants reported that the daily quizzes provided motivation to study for continuing medical education purposes. Additionally, 83% (40/48) of intervention participants expressed that they were better prepared to care for patients with HIV in their communities, compared with 67% (32/48) at baseline. Participation in the online coursework component was low (only 32/48, 67% of intervention participants ever accessed the courses), but most of those who did participate thought the lectures were engaging (26/32, 81%) and relevant (29/32, 91%). Focus group discussions revealed that various factors influenced the clinicians' decision to engage in higher learning, or "lateral learning," including the participant's availability to study, professional relevance of the topic area, and feedback. These variables serve as modifying factors that fit within an adapted version of the health belief model, which can explain behavior change in this context. CONCLUSIONS: Qualitative and quantitative endline data suggested that mCME V.2.0 was highly acceptable. Participant behaviors during the trial fit within the health belief model and can explain the intervention's impact on improving self-study behaviors. The mCME platform is an evidence-based approach with the potential for adoption at a national scale as a method for promoting continuing medical education. TRIAL REGISTRATION: ClinicalTrials.gov NCT02381743; https://clinicaltrials.gov/ct2/show/NCT02381743.

Unpacking the "Black Box": How an SMS-Based Continuing Medical Education Intervention Improved Medical Knowledge Among HIV Clinicians in Vietnam.

BACKGROUND: A mobile-based continuing medical education (mCME) intervention implemented over 6 months between 2016 and 2017, consisting of daily SMS multiple choice quizzes and access to online daily readings and CME courses, was shown to be effective in increasing medical knowledge among HIV providers in Vietnam. We hypothesized this improvement was a result of "lateral learning," a process in which the daily SMS quizzes acted as a stimulus for interacting with other study materials. METHODS: We explored how study materials directly provided by the intervention-the daily readings and the online CME courses-and independent study behaviors, such as using medical textbooks and reviewing national guidelines, contributed to medical knowledge as measured by baseline and endline exams. At baseline, there were 53 participants each in the intervention and control groups (N=106). Using linear regression models, we estimated the association between intervention-prompted and independent study behaviors and endline test scores. We also conducted a series of interaction analyses to test the extent to which the effect of daily quiz performance on endline test scores depended on use of the intervention-prompted or independent study materials. Finally, we estimated the proportion of variance in endline test scores explained by each of the intervention-prompted behaviors. RESULTS: The average medical knowledge test score among all participants was 46% at baseline and 54% at endline. Among the intervention group, 82% of the daily quizzes were answered, although only about half were answered correctly. Responding to the daily quizzes (ß=0.24; P=.05), quiz performance (ß=0.42; P<.001), and accessing daily readings (ß=0.22; P=.06) were statistically significantly associated with higher endline test scores. While accessing the online CME courses and some of the independent study behaviors, such as use of medical textbooks, had positive associations with endline test scores, none reached statistical significance. Quiz performance explained 51% of the variation in endline test scores. Interaction analysis found that quiz performance had a stronger, but not statistically significant, association with endline test scores when both daily readings (ß=0.87; P=.08) and online CME courses (ß=0.25; P=.09) were accessed more frequently. CONCLUSION: In mCME interventions, daily SMS quizzes can effectively act as a stimulus for uptake of study behaviors when paired with access to relevant readings and online courses. While further investigation is needed to more fully understand the role of outside study materials, we believe this model has the potential for further use in Vietnam and other low-resource settings.

"When you are injected, the baby is protected:" Assessing the acceptability of a maternal Tdap vaccine based on mothers' knowledge, attitudes, and beliefs of pertussis and vaccinations in Lusaka, Zambia.

INTRODUCTION: Severe and fatal pertussis infections are concentrated among infants who are too young to be protected through routine vaccinations. Maternal Tdap (mTdap), which is now the standard of care in the US and UK, is considered to be the most effective way to address this gap in preventative care. Little is known about how pregnant women in low-resource settings might view mTdap. To inform strategies for mTdap implementation in these contexts, public health researchers sought to understand knowledge, attitudes, and beliefs toward pertussis and maternal vaccines and assess the barriers to vaccine acceptance. METHODS: We conducted focus group discussions (FGDs) among mothers who participated in a longitudinal birth cohort study at the Chawama primary health center in Lusaka, Zambia. Since SAMIPS was not a clinical trial, but instead an observational cohort study, registration on clinicaltrials.gov was not required. Trained interviewers conducted the FGDs in January 2016 using a semi-structured interview guide, exploring participants' knowledge, attitudes and beliefs toward pertussis and vaccines. We analyzed the transcripts using Nvivo v.11 software. RESULTS: Fifty mothers participated across 7 FGDs. Mothers had limited knowledge of pertussis and vaccines, yet expressed generally positive views of vaccinating themselves and their children. Participants conveyed very little vaccine hesitancy around maternal vaccinations, and discussed how they could protect their children's health. Mothers also highlighted barriers and facilitators to vaccine uptake, which included partner involvement, feelings of maternal authority over healthcare decision-making, and community rumors about Western medicine. CONCLUSION: Mothers viewed vaccinations as an important method to keep their children healthy, despite cultural myths and misconceptions about pertussis and vaccines. FGD results suggest that vaccine acceptability is high in Zambia, which is a critical factor to vaccine uptake. A strategy addressing myths and misconceptions should be prioritized if and when mTdap is introduced across low-resource settings.

mCME project V.2.0: randomised controlled trial of a revised SMS-based continuing medical education intervention among HIV clinicians in Vietnam.

BACKGROUND: Continuing medical education (CME) is indispensable, but costs are a barrier. We tested the effectiveness of a novel mHealth intervention (mCME V.2.0) promoting CME among Vietnamese HIV clinicians. METHODS: We enrolled HIV clinicians from three provinces near Hanoi. The 6-month intervention consisted of (1) daily short message service multiple-choice quiz questions, (2) daily linked readings, (3) links to online CME courses and (4) feedback messages describing the performance of the participant relative to the group. Control participants had equal access to the online CME courses. Our primary endpoint was utilisation of the online CME courses; secondary endpoints were self-study behaviour, performance on a standardised medical exam and job satisfaction. RESULTS: From 121 total HIV clinicians in the three provinces, 106 (87.6%) enrolled, and 48/53 intervention (90%) and 47/53 control (89%) participants completed the endline evaluations. Compared with controls, intervention participants were more likely to use the CME courses (risk ratio (RR) 2.3, 95% CI 1.4 to 3.8, accounting for 83% of course use (P<0.001)). Intervention participants increased self-study behaviours over controls in terms of use of medical textbooks (P<0.01), consulting with colleagues (P<0.01), searching on the internet (P<0.001), using specialist websites (P=0.02), consulting the Vietnam HIV/AIDS treatment guidelines (P=0.02) and searching the scientific literature (P=0.09). Intervention participants outperformed controls on the exam (+23% vs +12% score gains, P=0.05) and had higher job satisfaction. CONCLUSION: The mCME V.2.0 intervention improved self-study behaviour, medical knowledge and job satisfaction. This approach has potential for expansion in Vietnam and similar settings. TRIAL REGISTRATION NUMBER: NCT02381743.

Benefits and Limitations of Text Messages to Stimulate Higher Learning Among Community Providers: Participants' Views of an mHealth Intervention to Support Continuing Medical Education in Vietnam.

BACKGROUND: A randomized controlled trial was conducted in 2015 to evaluate a mobile continuing medical education (mCME) intervention that provided daily text messages to community-based physicians' assistants (CBPAs) in Thai Nguyen Province, Vietnam. Although the intervention failed to improve medical knowledge over a 6-month period, a companion qualitative study provided insights on the views and experiences of intervention participants. METHODS: We conducted focus group discussions (FGDs) and in-depth interviews (IDIs) among participants randomized to receive text messages containing either simple medical facts or quiz questions. Trained interviewers collected data immediately following the conclusion of the trial in December 2015. Using semi-structured question guides, respondents were queried on their views of the intervention, positive and negative, and perceived impacts of the intervention. During analysis, after learning that the intervention had failed to increase knowledge among participants, we also examined reasons for lack of improvement in medical knowledge. All analyses were performed in NVivo using a thematic approach. RESULTS: A total of 70 CBPAs engaged in one of 8 FGDs or an IDI. One-half were men; average age among all respondents was 40 years. Most (81%) practiced in rural settings and most (51%) focused on general medicine. The mean length of work experience was 3 years. All respondents made positive comments about the intervention; convenience, relevance, and quick feedback (quiz format) were praised. Downsides encompassed lack of depth of information, weak interaction, technology challenges, and challenging/irrelevant messages. Respondents described perceived impacts encompassing increased motivation, knowledge, collegial discussions, Internet use to search for more information, and clinical skills. Overall, they expressed a desire for the intervention to continue and recommended expansion to other medical professionals. Overreliance on the text messages, lack of effective self-study, and technical/language-based barriers may be potential explanations for intervention failure. CONCLUSION: As a form of mCME, daily text messages were well-received by community-level health care providers in Vietnam. This mCME approach appears very promising in low-resource environments or where traditional forms of CME are impractical. Future models might consider enhancements to foster linkages to relevant medical materials, improve interaction with medical experts, and tailor medical content to the daily activities of medical staff.

The mCME Project: A Randomized Controlled Trial of an SMS-Based Continuing Medical Education Intervention for Improving Medical Knowledge among Vietnamese Community Based Physicians' Assistants.

BACKGROUND: Community health workers (CHWs) provide critical services to underserved populations in low and middle-income countries, but maintaining CHW's clinical knowledge through formal continuing medical education (CME) activities is challenging and rarely occurs. We tested whether a Short Message Service (SMS)-based mobile CME (mCME) intervention could improve medical knowledge among a cadre of Vietnamese CHWs (Community Based Physician's Assistants-CBPAs) who are the leading providers of primary medical care for rural underserved populations. METHODS: The mCME Project was a three arm randomized controlled trial. Group 1 served as controls while Groups 2 and 3 experienced two models of the mCME intervention. Group 2 (passive model) participants received a daily SMS bullet point, and were required to reply to the text to acknowledge receipt; Group 3 (interactive model) participants received an SMS in multiple choice question format addressing the same thematic area as Group 2, entering an answer (A, B, C or D) in their response. The server provided feedback immediately informing the participant whether the answer was correct. Effectiveness was based on standardized examination scores measured at baseline and endline (six months later). Secondary outcomes included job satisfaction and self-efficacy. RESULTS: 638 CBPAs were enrolled, randomized, and tested at baseline, with 592 returning at endline (93.7%). Baseline scores were similar across all three groups. Over the next six months, participation of Groups 2 and 3 remained high; they responded to >75% of messages. Group 3 participants answered 43% of the daily SMS questions correctly, but their performance did not improve over time. At endline, the CBPAs reported high satisfaction with the mCME intervention, and deemed the SMS messages highly relevant. However, endline exam scores did not increase over baseline, and did not differ between the three groups. Job satisfaction and self-efficacy scores also did not improve. Average times spent on self-study per week did not increase, and the kinds of knowledge resources used by the CBPAs did not differ between the three groups; textbooks, while widely available, were seldom used. CONCLUSIONS: The SMS-based mCME intervention, while feasible and acceptable, did not result in increased medical knowledge. We hypothesize that this was because the intervention failed to stimulate lateral learning. For an intervention of this kind to be effective, it will be essential to find more effective ways to couple SMS as a stimulus to promote increased self-study behaviors. TRIAL REGISTRATION: ClinicalTrials.gov NCT02381743.