Exploring the feasibility, acceptability and preliminary effects of a nurse delivered mhealth intervention for women living with HIV in South India: a pilot randomized controlled trial.

PURPOSE: We evaluated the feasibility, acceptability and preliminary efficacy of a standardized nurse delivered mobile phone intervention to improve adherence to antiretroviral treatment and clinical outcomes. METHODS: Feasibility and acceptability of the phone intervention was assessed with rates of eligibility, completed visits, and attritions. Intervention fidelity was assessed by checking recorded calls and feedback. Efficacy was assessed using a randomized controlled trial in which 120 women living with HIV and psychosocial vulnerabilities, were randomized to Treatment as Usual (TAU = 60) or TAU plus the mobile phone intervention (N = 60). Trained basic nurses delivered the theory-guided, standardized mobile phone intervention for mental health issues and psychosocial risk factors to improve antiretroviral treatment (ART) adherence and retention in care and improve clinical outcomes. Blind raters performed the assessments at 6, 12 and 24 weeks post-randomization. RESULTS: Adherence diminished over time in the TAU only group, while it was sustained in the TAU Plus group, only dropping at 24 weeks after the intervention had been discontinued. Among participants with depressive symptoms (CESD ≥ 16), the intervention had significant improvement in adherence rates (p < 0.01), psychological quality of life (p < 0.05) and illness perception (p < 0.05) compared to those in the TAU only group. Greater improvements of quality of life subscales were observed in the TAU Plus group among participants with less psychological vulnerability (PSV < 2). HIV RNA was not significantly different between the groups at week 24. CONCLUSIONS: The mobile-delivered counseling intervention was feasible and acceptable and shows promise among women living with HIV and psychosocial vulnerabilities in rural South India. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02319330 [Registered on: December 18, 2014].

Socio-Ecological determinants of myopia in rural school students in North India: Results from a nurse-led program.

Socio-ecological determinants of high myopia incidence among school students largely remain unexplored, especially in developing countries. A cross-sectional study was conducted in rural schools in North India to assess the relationship between these determinants and myopia among adolescent students. A public health nurse used a pre-tested questionnaire (demographics, family ocular status, and screen time) and Snellen's chart for testing visual acuity, and referred suspected cases for cycloplegic refraction assessment. Among the total of 955 students, the median (range) age was 14 (13-15) years. The prevalence of myopia was 5.03% (95% confidence interval [CI]: 4.99-5.07). Myopia was found to be associated with computer usage at school (P = 0.058), malnutrition (P = 0.001), and familial myopia (P = 0.079) in the bivariate analysis. Significant predictors of myopia in the regression model were females (odd ratio [OR]: 6.29; 95% CI: 2.69-14.72), higher maternal age (OR: 1.09; 95% CI: 1-1.17), and reading distance <20 cm (OR: 1.98; 95% CI: 1.01-3.87).

The effects of dual antiplatelet therapy (DAPT) adherence on survival in patients undergoing revascularization and the determinants of DAPT adherence.

BACKGROUND: The prevalence and burden of coronary heart disease (CHD) has increased substantially in India, accompanied with increasing need for percutaneous coronary interventions (PCI). Although a large government-funded insurance scheme in Maharashtra, India covered the cost of PCI for low-income patients, the high cost of post-PCI treatment, especially Dual Antiplatelet Therapy (DAPT), still caused many patients to prematurely discontinue the secondary prevention. Our study aimed to investigate the effectiveness of DAPT adherence on all-cause mortality among post-PCI patients and explore the potential determinants of DAPT adherence in India. METHOD: We collected clinical data of 4,595 patients undergoing PCI in 110 participating medical centers in Maharashtra, India from 2012 to 2015 by electronic medical records. We surveyed 2527 adult patients who were under the insurance scheme by telephone interview, usually between 6 to 12 months after their revascularization. Patients reporting DAPT continuation in the telephone survey were categorized as DAPT adherence. The outcome of the interest was all-cause mortality within 1 year after the index procedure. Multivariate Cox proportional hazard (PH) model with adjustment of potential confounders and standardization were used to explore the effects of DAPT adherence on all-cause mortality. We further used a multivariate logistic model to investigate the potential determinants of DAPT adherence. RESULTS: Out of the 2527 patients interviewed, 2064 patients were included in the analysis, of whom 470 (22.8%) discontinued DAPT prematurely within a year. After adjustment for baseline confounders, DAPT adherence was associated with lower one-year all-cause mortality compared to premature discontinuation (less than 6-month), with an adjusted hazard ratio (HR) of 0.52 (95% Confidence Interval (CI) = (0.36, 0.67)). We also found younger patients (OR per year was 0.99 (0.97, 1.00)) and male (vs. female, OR of 1.30 (0.99, 1.70)) had higher adherence to DAPT at one year as did patients taking antihypertensive medications (vs. non medication, OR of 1.57 (1.25, 1.95)). CONCLUSION: These findings suggest the protective effects of DAPT adherence on 1-year mortality among post-PCI patients in a low-income setting and indicate younger age, male sex and use of other preventive treatments were predictors of higher DAPT adherence.

Large-scale staple food fortification as a complementary strategy to address vitamin and mineral vulnerabilities in India: A critical review.

The slow improvement in micronutrient malnutrition globally and in India warrants a need for scaling-up scientifically proven, cost-effective public health interventions. The present review discusses the potential of staple food fortification as a complementary strategy to tackle micronutrient deficiencies, while addressing the current concerns raised regarding its implementation. The review indicates the below par status of current strategies like dietary diversity and supplementation to address multiple micronutrients deficiencies in India and the need for complementary strategies to tackle this problem. Based on systematic reviews and meta-analysis, global and national evidence has identified staple food fortification as a proven and recognized cost-effective solution to address micronutrient deficiencies. The Government of India has shown a strong leadership to promote this proven intervention. Further, the paper addresses the concern that large-scale staple food fortification (LSFF) may lead to excessive nutrient intakes when delivered together with other interventions, e.g., supplementation, dietary diversity, among the same populations. A key message that emerges from this review is that LSFF is safe with current dietary intake and deficiencies and low coverage of other interventions. Given the current situation of food and nutrition insecurity which the COVID-19 pandemic has further exacerbated, and the critical role that nutrition plays in building immunity, it is even more important that health and nutrition of the population, especially vulnerable age groups, is not only safeguarded but also strengthened. LSFF should be implemented without any further delay to reach the most vulnerable segments of the population to reduce the dietary nutrient gap and prevent micronutrient deficiencies. Effective monitoring and regular dietary surveys will help ensure these interventions are being deployed correctly.

Compliance to spectacle use in children with refractive errors- a systematic review and meta-analysis.

BACKGROUND: Primary objective of this review was to measure compliance with spectacle use in children with refractive errors. Secondary objective was to understand the reasons for non-compliance. METHODS: The databases searched were Ovid, EMBASE, CINAHL and Pubmed. All studies up to March, 2018 were included. The search terms were- ((((((Compliance [Title/Abstract]) OR Adherence [Title/Abstract]) OR Compliant [Title/Abstract]) OR Adherent [Title/Abstract])) AND (((Spectacle [Title/Abstract]) OR Spectacles [Title/Abstract]) OR Eye Glasses [Title/Abstract])) AND ((((Child [Title/Abstract]) OR Children [Title/Abstract]) OR Adolescent [Title/Abstract]) OR Adolescents [Title/Abstract]). Two researchers independently searched the databases and initial screening obtained 33 articles. The PRISMA guidelines were followed for conducting and writing the systematic review. Two reviewers assessed data quality independently using the Quality Assessment tool for systematic reviews of observational studies (QATSO). Poor quality studies were those, which had a score of less than 33% on the QATSO tool. Sensitivity analysis was done to determine if poor quality studies effected compliance. Galbraith plot was used to investigate statistical heterogeneity amongst studies. A random effects model was used to pool compliance. RESULTS: Twenty-three studies were included in the review, of which 20 were included in the quantitative analysis. All the studies were cross sectional. The overall compliance with spectacle use was 40.14% (95% CI- 32.78-47.50). The compliance varied from 9.84% (95% CI = 2.36-17.31) to 78.57% (95% CI = 68.96-88.18). The compliance derived in sensitivity analysis was 40.09%. Reasons for non-compliance were broken/lost spectacles, forgetfulness, and parental disapproval. CONCLUSION: Appropriate remedial measures such as health education and strengthening vision care services will be required to address poor compliance with spectacle use among children.

The prevalence and determinants of depression among HIV-positive perinatal women receiving antiretroviral therapy in India.

To assess the prevalence and correlates of perinatal depression, 200 HIV-positive pregnant/post-partum women receiving antiretroviral therapy (ART) were interviewed at eight government ART centers in four states across India. 52.5% (105) participants had depressive symptomology (Edinburgh Postnatal Depression Scale score > 13) while 23% of the participants reported thoughts of self-harm; there was no difference between pregnant and postpartum participants. Poor illness perception was associated with depression (AOR, 1.09; 95%CI, 1.05, 1.14); there was no association between adherence and depression in this population.

I have no peace of mind-psychosocial distress expressed by rural women living with HIV in India as part of a mobile health intervention-a qualitative study.

This qualitative study assessed psychosocial concerns that rural women with HIV who had multiple psychosocial vulnerabilities were able to express and communicate during a mobile phone intervention delivered by nurses. The study is part of a pilot randomised controlled trial of an mHealth self-care intervention by nurses for women living with HIV in rural India. For the trial, 60 women were randomised to receive the mHealth intervention. All calls were recorded and call logs were maintained. Call logs of 59 women based on 1186 calls were scanned for psychosocial themes. Audio recordings of 400 calls rich in content were then transcribed and translated for analysis. Themes and subthemes were identified by two independent raters. Majority of the women had low literacy and more than half were widowed. Clinical depression was found in 18.6%. Of the 1186 call logs analysed, 932 calls had a record of at least one psychosocial concern and 493 calls recorded two psychosocial concerns. Some of the major themes that women discussed with nurses included worries about their own and their children's future; loneliness; stigma; inadvertent disclosure; death and dying; abandonment by partner; financial difficulties; body image; poor social support; emotions such as sadness, guilt, and anger; and need for social services. Almost all expressed appreciation for the intervention. Findings indicate the usefulness of mHealth-based self-care interventions delivered by nurses in hard to reach women in low- and middle-income countries, especially those with multiple psychosocial vulnerabilities.

Feasibility of implementing cervical cancer screening program using smartphone imaging as a training aid for nurses in rural India.

BACKGROUND: The Indian national program stresses implementation of cervical cancer screening by health workers/nurses using VIA (Visual Inspection under Acetic acid). We demonstrate its feasibility and reliability in rural setting, assessing the role of smartphone-imaging for continuous training of nurses. DESIGN: A cross-sectional design to assess the reliability of the nurse-led VIA test. To assess feasibility, VIA positive patients were observed till confirmative diagnosis was made. SAMPLE: Hospital-based purposive sampling was used to recruit participants. MEASURES: A structured questionnaire for recording participants' details, VIA findings and follow-up information; and an observational checklist to record implementation parameters during each clinic. An expert assessed the nurse's judgment using smartphone-images of cervix. RESULTS: During October 2016-June 2017, 2758 patients attended the weekly clinic; 238 (8.6%) met the criteria, of those 180 (75.6%) tested after consent. Nurse reported 25 (13.8%) VIA-positive cases, but only 19 accessed the referral service. Kappa statistic: 0.45 (CI: 0.26-0.63) suggested moderate nurse-expert agreement. Image retrieval and quality affected expert's evaluation. Implementation challenges include low awareness among the population and referral link-up. CONCLUSION: Appropriately trained nurses can reliably conduct screening. Real-time expert feedback might improve reporting. Rigorous awareness activities and on-site treatment can reduce drop-outs. The medical institute's involvement and administrative will were instrumental.

Minority Men Who Have Sex with Men Demonstrate Increased Risk for HIV Transmission.

Black and Hispanic (minority) MSM have a higher incidence of HIV than white MSM. Multiple sexual partners, being under the influence of drugs and/or alcohol during sex, having a detectable HIV-1 RNA, and non-condom use are factors associated with HIV transmission. Using data from the Veterans Aging Cohort Study, we consider minority status and sexual orientation jointly to characterize and compare these factors. White non-MSM had the lowest prevalence of these factors (p < 0.001) and were used as the comparator group in calculating odds ratios (OR). Both MSM groups were more likely to report multiple sex partners (white MSM OR 7.50; 95 % CI 5.26, 10.71; minority MSM OR 10.24; 95 % CI 7.44, 14.08), and more likely to be under the influence during sex (white MSM OR 2.15; 95 % CI 1.49, 3.11; minority MSM OR 2.94; 95 % CI 2.16, 4.01). Only minority MSM were more likely to have detectable HIV-1 RNA (OR 1.87; 95 % CI 1.12, 3.11). Both MSM groups were more likely to use condoms than white non-MSM. These analyses suggest that tailored interventions to prevent HIV transmission among minority MSM are needed, with awareness of the potential co-occurrence of risk factors.

Quality of HIV Care and Mortality Rates in HIV-Infected Patients.

BACKGROUND: The Patient Protection and Affordable Care Act encourages healthcare systems to track quality-of-care measures; little is known about their impact on mortality rates. The objective of this study was to assess associations between HIV quality of care and mortality rates. METHODS: A longitudinal survival analysis of the Veterans Aging Cohort Study included 3038 human immunodeficiency virus (HIV)-infected patients enrolled between June 2002 and July 2008. The independent variable was receipt of ≥80% of 9 HIV quality indicators (QIs) abstracted from medical records in the 12 months after enrollment. Overall mortality rates through 2014 were assessed from the Veterans Health Administration, Medicare, and Social Security National Death Index records. We assessed associations between receiving ≥80% of HIV QIs and mortality rates using Kaplan-Meier survival analysis and adjusted Cox proportional hazards models. Results were stratified by unhealthy alcohol and illicit drug use. RESULTS: The majority of participants were male (97.5%) and black (66.8%), with a mean (standard deviation) age of 49.0 (8.8) years. Overall, 25.9% reported past-year unhealthy alcohol use and 28.4% reported past-year illicit drug use. During 24 805 person-years of follow-up (mean [standard deviation], 8.2 [3.3] years), those who received ≥80% of QIs experienced lower age-adjusted mortality rates (adjusted hazard ratio, 0.75; 95% confidence interval, .65-.86). Adjustment for disease severity attenuated the association. CONCLUSIONS: Receipt of ≥80% of select HIV QIs is associated with improved survival in a sample of predominantly male, black, HIV-infected patients but was insufficient to overcome adjustment for disease severity. Interventions to ensure high-quality care and address underlying chronic illness may improve survival in HIV-infected patients.

MAHILA: a protocol for evaluating a nurse-delivered mHealth intervention for women with HIV and psychosocial risk factors in India.

BACKGROUND: Women living with HIV are vulnerable to a variety of psychosocial barriers that limit access and adherence to treatment. There is little evidence supporting interventions for improving access and treatment adherence among vulnerable groups of women in low- and middle-income countries. The M obile Phone-Based A pproach for H ealth I mprovement, L iteracy and A dherence (MAHILA) trial is assessing the feasibility, acceptability and preliminary efficacy of a novel, theory-guided mobile health intervention delivered by nurses for enhancing self-care and treatment adherence among HIV-infected women in India. METHODS/DESIGN: Women (n = 120) with HIV infection who screen positive for depressive symptoms and/or other psychosocial vulnerabilities are randomly assigned in equal numbers to one of two treatment arms: treatment as usual plus the mobile phone intervention (experimental group) or treatment as usual (control group). In addition to treatment as usual, the experimental group receives nurse-delivered self-care counselling via mobile phone at fixed intervals over 16 weeks. Outcome measures are collected at baseline and at 4, 12, 24 and 36 weeks post-baseline. Outcomes include antiretroviral treatment adherence, HIV-1 RNA, depressive symptoms, illness perceptions, internalized stigma and quality of life. DISCUSSION: The MAHILA trial will provide information about how a mobile health counselling intervention delivered by non specialist nurses may improve access to care and support the adherence and clinical outcomes of women with HIV infection living in low- and middle-income countries such as India. TRIAL REGISTRATION: NCT02319330 (First received: July 30, 2014; Last verified: January 2016).

Development and Performance of an Algorithm to Estimate the Child-Turcotte-Pugh Score From a National Electronic Healthcare Database.

BACKGROUND & METHODS: The Child-Turcotte-Pugh (CTP) score is a widely used and validated predictor of long-term survival in cirrhosis. The CTP score is a composite of 5 subscores, 3 based on objective clinical laboratory values and 2 subjective variables quantifying the severity of ascites and hepatic encephalopathy. To date, no system to quantify CTP score from administrative databases has been validated. The Veterans Outcomes and Costs Associated with Liver Disease study is a multicenter collaborative study to evaluate the outcomes and costs of hepatocellular carcinoma in the U.S. Veterans Health Administration. We developed and validated an algorithm to calculate electronic CTP (eCTP) scores by using data from the Veterans Health Administration Corporate Data Warehouse. METHODS: Multiple algorithms for determining each CTP subscore from International Classification of Diseases version 9, Common Procedural Terminology, pharmacy, and laboratory data were devised and tested in 2 patient cohorts. For each cohort, 6 site investigators (Boston, Bronx, Brooklyn, Philadelphia, Minneapolis, and West Haven VA Medical Centers) were provided cases from which to determine validity of diagnosis, laboratory data, and clinical assessment of ascites and encephalopathy. The optimal algorithm (designated eCTP) was then applied to 30,840 cirrhotic patients alive in the first quarter of 2008 for whom 5-year overall and transplant-free survival data were available. The ability of the eCTP score and other disease severity scores (Charlson-Deyo index, Veterans Aging Cohort Study index, Model for End-Stage Liver Disease score, and Cirrhosis Comorbidity) to predict survival was then assessed by Cox proportional hazards regression. RESULTS: Spearman correlations for administrative and investigator validated laboratory data in the HCC and cirrhotic cohorts, respectively, were 0.85 and 0.92 for bilirubin, 0.92 and 0.87 for albumin, and 0.84 and 0.86 for international normalized ratio. In the HCC cohort, the overall eCTP score matched 96% of patients to within 1 point of the chart-validated CTP score (Spearman correlation, 0.81). In the cirrhosis cohort, 98% were matched to within 1 point of their actual CTP score (Spearman, 0.85). When applied to a cohort of 30,840 patients with cirrhosis, each unit change in eCTP was associated with 39% increase in the relative risk of death or transplantation. The Harrell C statistic for the eCTP (0.678) was numerically higher than those for other disease severity indices for predicting 5-year transplant-free survival. Adding other predictive models to the eCTP resulted in minimal differences in its predictive performance. CONCLUSION: We developed and validated an algorithm to extrapolate an eCTP score from data in a large administrative database with excellent correlation to actual CTP score on chart review. When applied to an administrative database, this algorithm is a highly useful predictor of survival when compared with multiple other published liver disease severity indices.

Diabetes is affecting everyone everywhere.

The article titled "Accessibility and Utilization of Healthcare Services Among Diabetic Patients: Is Diabetes a Poor Man's Ailment?" gave insights into a pandemic systemic disease known as diabetes mellitus. This modern-era pandemic affects everyone, regardless of their financial background. As a result, diabetes is not a systemic disease which just involves people of low socioeconomic status.

Sex disparities in overall burden of disease among HIV-infected individuals in the Veterans Affairs healthcare system.

BACKGROUND: Whether sex disparities exist in overall burden of disease among human immunodeficiency virus (HIV)-infected individuals in the Veterans Affairs healthcare system (VA) is unknown. OBJECTIVE: To determine whether sex differences exist in overall burden of disease after 1 year of combined antiretroviral therapy (ART) among HIV-infected individuals in VA. DESIGN: Retrospective cohort study. PARTICIPANTS: Among patients in the Veterans Aging Cohort Study Virtual Cohort (VACS-VC), all ART-naïve HIV-infected Veterans who received VA-based HIV care between 1996 and 2009. MAIN MEASURES: Overall burden of disease was measured using the VACS Index, an index that incorporates HIV (e.g. CD4 cell count) and non-HIV biomarkers (e.g. hemoglobin) and is highly predictive of all-cause mortality. Possible scores range from 0 to 164, although scores typically range from 0 to 50 for 80 % of patients in VACS-VC. A higher score indicates greater burden of disease (each additional five points indicates approximately 20 % increased 5-year mortality risk). ART adherence was measured using pharmacy data. KEY RESULTS: Complete data were available for 227 women and 8,073 men. At ART initiation, compared with men, women were younger and more likely to be Black, less likely to have liver dysfunction, but more likely to have lower hemoglobin levels. Median VACS Index scores changed from ART initiation to 1 year after ART initiation: women's scores went from 41 to 28 for women (13 point improvement) and men's from 42 to 27 for men (15 point improvement). In multivariable regression, women had 3.6 point worse scores than men after 1 year on ART (p = 0.002); this difference decreased to 3.2 points after adjusting for adherence (p = 0.004). CONCLUSIONS: In VA, compared to men, women experienced less improvement in overall burden of disease after 1 year of HIV treatment. Further study is needed to elucidate the modifiable factors that may explain this disparity.

Personal health record use and its association with antiretroviral adherence: survey and medical record data from 1871 US veterans infected with HIV.

Patient electronic personal health record (PHR) use has been associated with improved patient outcomes in diabetes and depression care. Little is known about the effect of PHR use on HIV care processes and outcomes. We evaluated whether there was an association between patient PHR use and antiretroviral adherence. Data came from the Veterans Aging Cohort Study and included cross-sectional survey and medical record data from 1871 HIV+ veterans. Our adherence measure was an antiretroviral medication possession ratio, dichotomized at 0.90, and based on pharmacy refill data. In our sample 44 % did not use the internet, 14 % used internet but not for health, 27 % used internet for health but not the PHR, and 14 % used the PHR. In multivariable analysis PHR use was associated with ≥90 % adherence after controlling for socio-demographic variables. Findings provide support for longitudinal studies and studies that identify which PHR functions (e.g. online medication refills, viewing lab results, secure messaging with providers) are most closely associated with medication adherence.

A translational study for detection of cardiac autonomic neuropathy using fractal features: A bench to bedside approach.

Cardiac autonomic Neuropathy (CAN) is an acute complication of Diabetes mellitus (DM) that does not exhibit overt symptoms in the subclinical stage. Researchers have developed several techniques that have proved to give higher efficiency in classification using software tools. The challenge in implementing the same using hardware for diagnosis fails when classification boundaries are mismatched, as there are more chances of misinterpreting the classes. In this study, we have introduced translational research between the complexity analysis using software and verifying the same by deploying it in hardware using a controller board by investigating the error percentage in classifying normal (N) and early CAN (E). The study reveals that among the segments specific to CAN diagnosis, RR and ST show more error percentages (12±8 %). In contrast, PR and QT show a lesser error percentage (6±4 %) between software and hardware implementation of Fractal dimension (FD) values.

Perception of college-going girls towards corneal donation in North India: A latent class analysis study.

Purpose: To assess the perception of college-going girls toward corneal donation in Northern India. Methods: An online survey with a pre-structured, pre-validated questionnaire was conducted on 1721 college-going girls in Northern India. The knowledge and attitude scores were regressed, and latent class analysis was carried out. Results: The average of scores for all participants was computed individually for the knowledge questions and the attitude questions, and based on this score, total participants were divided into two groups: Better corneal donation behaviors (BCDB) and poor corneal donation behaviors. The binomial logistic regression model of knowledge domain for predicting BCDB, age of the participant, their awareness about corneal donation, and willingness to discuss eye donation among family members were found significant. Similarly, for the attitude domain, awareness about corneal donation, knowledge about hours within which ideal eye donation needs to be undertaken, and knowledge about eye donation during coronavirus disease 2019 (COVID-19) pandemic were found to be significant. Latent class analysis identified one subset of participants having poorer knowledge and attitude scores and that they were more from a rural background, were having more than first order as birth order, were belonging to SC/ST classes, had illiterate or secondary education of father and mother, and were living in rented houses. Conclusion: The findings of the study significantly contribute to devising a mechanism to improve knowledge and influencing the attitude about eye donation among the youth, especially young women, who can act as counselors and motivators for the masses as well as their own families, in the generations to come.

User Acceptability and Perceived Impact of a Mobile Interactive Education and Support Group Intervention to Improve Postnatal Health Care in Northern India: A Qualitative Study.

Background: Postnatal care, crucial for preventing and assessing complications after birth, remains low in India. An interactive mHealth community-based postnatal intervention was implemented to promote healthy maternal behaviors through knowledge and social support in rural Northern India. However, there is limited information on how virtual health interventions in resource-constrained settings are perceived by the users and which elements influence their engagement and sustained participation. Objective: We explored the user perceptions of acceptability and impact of a virtual interactive maternal and child health intervention pilot tested in Punjab State, India, including their perspectives on barriers and facilitators to engage with this intervention. Methods: This qualitative study was embedded within extensive mixed-method research, and oriented by the Realist Evaluation approach. Sixteen participants were recruited from the parent study. They were identified by purposive sampling to cover diverse levels of attendance and engagement with the intervention. In-depth interviews were conducted by phone. Following translation, a framework analysis was completed to search for the main themes. Feedback was requested from intervention moderators during the process to prioritize local interpretation. Results: Study participants reported overall satisfaction with the intervention. The mothers appreciated the educational material provided and the communication with other participants and health professionals. Across context, intervention, and actor domains, the barriers most commented on were network and connectivity challenges, lack of time due to household responsibilities, and feeling uncomfortable sharing personal experiences. Family buy-in and support were fundamental for overcoming the high domestic workload and baby care. Another facilitator mentioned was moderators' guidance on using the different intervention modalities. Regarding perceived impact, participants shared that MeSSSSage increased their capability and motivation to breastfeed, seek care as needed, and use contraception according to their preferences. Finally, participants suggested adding more topics to the educational content and adjusting the dynamics within the group calls to improve the intervention. Conclusions: This study identifies the high acceptability and perceived impact of a novel postnatal care program in a rural setting, including the users' perceived barriers to engaging with the intervention and possible solutions to overcome them. These findings enable refinement of the ongoing intervention, providing a more robust framing for its scalability and long-term sustainability. On a larger scale, conclusions from this research provide new insights and encouragement to global stakeholders who aspire to improve maternal and neonatal outcomes in low-income and middle-income countries through mHealth.

A qualitative study to understand sociocultural beliefs around perinatal and neonatal health in rural areas of Mohali, Punjab, India.

Introduction: Globally, 600,000 mothers (15-49 years) die every year due to pregnancy and childbirth-related complications. Wide variations are seen in cultural practices and beliefs surrounding this period of a woman's life. The present study explores the cultural beliefs and practices of women and families during pregnancy and the postnatal period in order to understand what behavioral management strategies are required to improve maternal and infant outcomes during pregnancy and the postpartum period. Methods: The study was conducted in a rural area of Punjab, from December 2019 to March 2021. A total of 20 women (up to 3 months postpartum, age >18 years, were interviewed. Results: In general, women described eating varied and fairly healthy diets during pregnancy, especially nutritious warm food, following traditional practices. Other cultural practices included restrictions on movement and mobile phone use and the use of unsafe home remedies to promote infant safety and wellbeing, such as using gripe water, applying black pencil to the baby's eyes, and feeding the baby honey. A few were not inclined to engage with these and other cultural expectations, preferring instead to follow contemporary practices influenced by social media. These practices included being accompanied by a family member during delivery, celebrating the baby's birth regardless of sex, and early bathing post-delivery. Discussion: It can be concluded that while many traditional practices are still followed in India, there are new beliefs and behaviors arising from an intersection between culture and technology. Developing strategies that acknowledge older beliefs and modern approaches is essential to promoting better antenatal and postpartum care.

Preliminary impact of an mHealth education and social support intervention on maternal health knowledge and outcomes among postpartum mothers in Punjab, India.

Background: Significant disruptions in the perinatal continuum of care occur postpartum in India, despite it being a critical time to optimize maternal health and wellbeing. Group-oriented mHealth approaches may help mitigate the impact of limited access to care and the lack of social support that characterize this period. Our team developed and pilot tested a provider-moderated group intervention to increase education, communication with providers, to refer participants to in-person care, and to connect them with a virtual social support group of other mothers with similarly aged infants through weekly calls and text chat. Methods: We analyzed the preliminary effectiveness of the pilot intervention on maternal health knowledge through 6 months postpartum among 135 participants in Punjab, India who responded to baseline and endline surveys. We described change in knowledge of maternal danger signs, birth preparedness, postpartum care use, postpartum physical and mental health, and family planning use over time between individuals in group call (synchronous), other intervention (asynchronous), and control groups. Results: Participant knowledge regarding danger signs was low overall regarding pregnancy, childbirth and the postpartum period (mean range of 1.13 to 2.05 at baseline and 0.79 to 2.10 at endline). Group call participants had a significantly higher increase over time in knowledge of danger signs than other intervention and control group participants. Birth preparedness knowledge ranged from mean 0.89-1.20 at baseline to 1.31-2.07 at baseline, with group call participants having significantly greater increases in comparison to the control group. Group call participants had nearly three-fold increased odds of postpartum health check with a clinical provider than other intervention participants (OR 2.88, 95% CI 1.07-7.74). No differences were noted in postpartum depressive and anxiety symptoms. Conclusions: Preliminary effectiveness results are promising, yet further robust testing of the MeSSSSage intervention effectiveness is needed. Further development of strategies to support health knowledge and behaviors and overcoming barriers to postpartum care access can improve maternal health among this population.