Exploring terminology for puerperal sepsis and its symptoms in urban Karachi, Pakistan to improve communication, care-seeking, and illness recognition.

Puerperal sepsis is an important cause of maternal morbidity and mortality in developing countries. Awareness of local terminology for its signs and symptoms may improve communication about this illness, what actions to take when symptoms appear, timely care seeking, and clinical outcomes. This formative research aimed to improve recognition and management of postpartum sepsis in Pakistan by eliciting local terms used for postpartum illnesses and symptoms. We conducted 32 in-depth interviews with recently delivered women, their relatives, traditional birth attendants, and health care providers to explore postpartum experiences. Terms for symptoms and illness are used interchangeably (i.e. bukhar, the Urdu word for fever), many variations exist for the same term, and gradations of severity for each term as not associated with different types of illnesses. The lack of a designated term for postpartum sepsis in Urdu delays care-seeking and proper diagnosis, particularly at the community level. Ideally, a common lexicon for symptoms and postpartum sepsis would be developed but this may not be feasible or appropriate given the nature of the Urdu language and local understandings of postpartum illness. These insights can inform how we approach educational campaigns, the development of clinical algorithms that focus on symptoms, and counselling protocols.

Validation of community health worker identification of maternal puerperal sepsis using a clinical diagnostic algorithm in Bangladesh and Pakistan.

BACKGROUND: Puerperal sepsis (PP sepsis) is a leading cause of maternal mortality globally. The majority of maternal sepsis cases and deaths occur at home and remain undiagnosed and under-reported. In this paper, we present findings from a nested case-control study in Bangladesh and Pakistan which sought to assess the validity of community health worker (CHW) identification of PP sepsis using a clinical diagnostic algorithm with physician assessment and classification used as the gold standard. METHODS: Up to 300 postpartum women were enrolled in each of the 3 sites 1) Sylhet, Bangladesh (n = 278), 2) Karachi, Pakistan (n = 278) and 3) Matiari, Pakistan (n = 300). Index cases were women with suspected PP Sepsis as diagnosed by CHWs clinical assessment of one or more of the following signs and symptoms: temperature (recorded fever ≥38.1°C, reported history of fever, lower abdominal or pelvic pain, and abnormal or foul-smelling discharge. Each case was matched with 3 control women who were diagnosed by CHWs to have no infection. Cases and controls were assessed by trained physicians using the same algorithm implemented by the CHWs. Using physician assessment as the gold standard, Kappa statistics for reliability and diagnostic validity (sensitivity and specificity) are presented with 95% CI. Sensitivity and specificity were adjusted for verification bias. RESULTS: The adjusted sensitivity and specificity of CHW identification of PP sepsis across all sites was 82% (Karachi: 78%, Matiari: 78%, Sylhet: 95%) and 90% (Karachi: 95%, Matiari: 85%, Sylhet: 90%) respectively. CHW-Physician agreement was highest for moderate and high fever (range across sites: K = 0.84-0.97) and lowest for lower abdominal pain (K = 0.30-0.34). The clinical signs and symptoms for other conditions were reported infrequently, however, the CHW-physician agreement was high for all symptoms except severe headache/ blurred vision (K = 0.13-0.38) and reported "lower abdominal pain without fever" (K = 0.39-0.57). CONCLUSION: In all sites, CHWs with limited training were able to identify signs and symptoms and to classify cases of PP sepsis with high validity. Integrating postpartum infection screening into existing community-based platforms and post-natal visits is a promising strategy to monitor women for PP sepsis - improving delivery of cohesive maternal and child health care in low resource settings.

Evaluation of a community-based mobile video breastfeeding intervention in Khayelitsha, South Africa: The Philani MOVIE cluster-randomized controlled trial.

BACKGROUND: In South Africa, breastfeeding promotion is a national health priority. Regular perinatal home visits by community health workers (CHWs) have helped promote exclusive breastfeeding (EBF) in underresourced settings. Innovative, digital approaches including mobile video content have also shown promise, especially as access to mobile technology increases among CHWs. We measured the effects of an animated, mobile video series, the Philani MObile Video Intervention for Exclusive breastfeeding (MOVIE), delivered by a cadre of CHWs ("mentor mothers"). METHODS AND FINDINGS: We conducted a stratified, cluster-randomized controlled trial from November 2018 to March 2020 in Khayelitsha, South Africa. The trial was conducted in collaboration with the Philani Maternal Child Health and Nutrition Trust, a nongovernmental community health organization. We quantified the effect of the MOVIE intervention on EBF at 1 and 5 months (primary outcomes), and on other infant feeding practices and maternal knowledge (secondary outcomes). We randomized 1,502 pregnant women in 84 clusters 1:1 to 2 study arms. Participants' median age was 26 years, 36.9% had completed secondary school, and 18.3% were employed. Mentor mothers in the video intervention arm provided standard-of-care counseling plus the MOVIE intervention; mentor mothers in the control arm provided standard of care only. Within the causal impact evaluation, we nested a mixed-methods performance evaluation measuring mentor mothers' time use and eliciting their subjective experiences through in-depth interviews. At both points of follow-up, we observed no statistically significant differences between the video intervention and the control arm with regard to EBF rates and other infant feeding practices [EBF in the last 24 hours at 1 month: RR 0.93 (95% CI 0.86 to 1.01, P = 0.091); EBF in the last 24 hours at 5 months: RR 0.90 (95% CI 0.77 to 1.04, P = 0.152)]. We observed a small, but significant improvement in maternal knowledge at the 1-month follow-up, but not at the 5-month follow-up. The interpretation of the results from this causal impact evaluation changes when we consider the results of the nested mixed-methods performance evaluation. The mean time spent per home visit was similar across study arms, but the intervention group spent approximately 40% of their visit time viewing videos. The absence of difference in effects on primary and secondary endpoints implies that, for the same time investment, the video intervention was as effective as face-to-face counseling with a mentor mother. The videos were also highly valued by mentor mothers and participants. Study limitations include a high loss to follow-up at 5 months after premature termination of the trial due to the COVID-19 pandemic and changes in mentor mother service demarcations. CONCLUSIONS: This trial measured the effect of a video-based, mobile health (mHealth) intervention, delivered by CHWs during home visits in an underresourced setting. The videos replaced about two-fifths of CHWs' direct engagement time with participants in the intervention arm. The similar outcomes in the 2 study arms thus suggest that the videos were as effective as face-to-face counselling, when CHWs used them to replace a portion of that counselling. Where CHWs are scarce, mHealth video interventions could be a feasible and practical solution, supporting the delivery and scaling of community health promotion services. TRIAL REGISTRATION: The study and its outcomes were registered at clinicaltrials.gov (#NCT03688217) on September 27, 2018.

Multiple pathways to scaling up and sustainability: an exploration of digital health solutions in South Africa.

BACKGROUND: With the aim to support further understanding of scaling up and sustaining digital health, we explore digital health solutions that have or are anticipated to reach national scale in South Africa: the Perinatal Problem Identification Programme (PPIP) and Child Healthcare Problem Identification Programme (Child PIP) (mortality audit reporting and visualisation tools), MomConnect (a direct to consumer maternal messaging and feedback service) and CommCare (a community health worker data capture and decision-support application). RESULTS: A framework integrating complexity and scaling up processes was used to conceptually orient the study. Findings are presented by case in four domains: value proposition, actors, technology and organisational context. The scale and use of PPIP and Child PIP were driven by 'champions'; clinicians who developed technically simple tools to digitise clinical audit data. Top-down political will at the national level drove the scaling of MomConnect, supported by ongoing financial and technical support from donors and technical partners. Donor preferences played a significant role in the selection of CommCare as the platform to digitise community health worker service information, with a focus on HIV and TB. A key driver of scale across cases is leadership that recognises and advocates for the value of the digital health solution. The technology need not be complex but must navigate the complexity of operating within an overburdened and fragmented South African health system. Inadequate and unsustained investment from donors and government, particularly in human resource capacity and robust monitioring and evaluation, continue to threaten the sustainability of digital health solutions. CONCLUSIONS: There is no single pathway to achieving scale up or sustainability, and there will be successes and challenges regardless of the configuration of the domains of value proposition, technology, actors and organisational context. While scaling and sustaining digital solutions has its technological challenges, perhaps more complex are the idiosyncratic factors and nature of the relationships between actors involved. Scaling up and sustaining digital solutions need to account for the interplay of the various technical and social dimensions involved in supporting digital solutions to succeed, particularly in health systems that are themselves social and political dynamic systems.

Reported infant feeding practices and contextual influences on breastfeeding: qualitative interviews with women registered to MomConnect in three South African provinces.

BACKGROUND: Global guidelines recommend exclusive breastfeeding (EBF) for the first 6 months of life. South African EBF rates have steadily increased but still only average 32% for infants below 6 months of age. Malnutrition and developmental delays continue to contribute substantially to the morbidity and mortality of South African children. MomConnect, a national mHealth messaging system used to send infant and maternal health messages during and after pregnancy, has a specific focus on improving rates of breastfeeding and has achieved high rates of population coverage. METHODS: For this qualitative study, we interviewed women who were registered to MomConnect to investigate their breastfeeding and other infant feeding practices, decision-making pre- and post-delivery, and the role of the health system, family members and the wider community in supporting or detracting from breastfeeding intentions. Data were collected from February-March 2018 in South Africa's KwaZulu-Natal, Free State and Gauteng provinces. Framework analysis was conducted to identify common themes. RESULTS: Most women interviewed had breastfed, including HIV-positive women. Even when women had delivered by caesarean section, they had usually been able to initiate breastfeeding a few hours after birth. Understandings of EBF varied in thoroughness and there was some confusion about the best way to cease breastfeeding. Most women felt well-equipped to make infant feeding decisions and to stick to their intentions, but returning to work or school sometimes prevented 6 months of EBF. Advice from the health system (both via clinics and MomConnect) was considered helpful and supportive in encouraging EBF to 6 months, although family influences could thwart these intentions, especially for younger women. Mothers reported a range of breastfeeding information sources that influenced their choices, including social media. CONCLUSIONS: Efforts to improve EBF rates must include consideration of the social and economic environment surrounding women. Interventions that focus only on improving women's knowledge are valuable but insufficient on their own. Attention should also be paid to infant behaviors, and how these affect women's breastfeeding choices. Finally, although there is strong local policy support for EBF, more rigorous implementation of these and other broader changes to create a more enabling structural environment ought to be prioritized.

Using Machine Learning to Optimize the Quality of Survey Data: Protocol for a Use Case in India.

BACKGROUND: Data quality is vital for ensuring the accuracy, reliability, and validity of survey findings. Strategies for ensuring survey data quality have traditionally used quality assurance procedures. Data analytics is an increasingly vital part of survey quality assurance, particularly in light of the increasing use of tablets and other electronic tools, which enable rapid, if not real-time, data access. Routine data analytics are most often concerned with outlier analyses that monitor a series of data quality indicators, including response rates, missing data, and reliability of coefficients for test-retest interviews. Machine learning is emerging as a possible tool for enhancing real-time data monitoring by identifying trends in the data collection, which could compromise quality. OBJECTIVE: This study aimed to describe methods for the quality assessment of a household survey using both traditional methods as well as machine learning analytics. METHODS: In the Kilkari impact evaluation's end-line survey amongst postpartum women (n=5095) in Madhya Pradesh, India, we plan to use both traditional and machine learning-based quality assurance procedures to improve the quality of survey data captured on maternal and child health knowledge, care-seeking, and practices. The quality assurance strategy aims to identify biases and other impediments to data quality and includes seven main components: (1) tool development, (2) enumerator recruitment and training, (3) field coordination, (4) field monitoring, (5) data analytics, (6) feedback loops for decision making, and (7) outcomes assessment. Analyses will include basic descriptive and outlier analyses using machine learning algorithms, which will involve creating features from time-stamps, "don't know" rates, and skip rates. We will also obtain labeled data from self-filled surveys, and build models using k-folds cross-validation on a training data set using both supervised and unsupervised learning algorithms. Based on these models, results will be fed back to the field through various feedback loops. RESULTS: Data collection began in late October 2019 and will span through March 2020. We expect to submit quality assurance results by August 2020. CONCLUSIONS: Machine learning is underutilized as a tool to improve survey data quality in low resource settings. Study findings are anticipated to improve the overall quality of Kilkari survey data and, in turn, enhance the robustness of the impact evaluation. More broadly, the proposed quality assurance approach has implications for data capture applications used for special surveys as well as in the routine collection of health information by health workers. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/17619.

Does having a mobile phone matter? Linking phone access among women to health in India: An exploratory analysis of the National Family Health Survey.

BACKGROUND: The disruptive potential of mobile phones in catalyzing development is increasingly being recognized. However, numerous gaps remain in access to phones and their influence on health care utilization. In this cross-sectional study from India, we assess the gaps in women's access to phones, their influencing factors, and their influence on health care utilization. METHODS: Data drawn from the 2015 National Family Health Survey (NFHS) in India included a national sample of 45,231 women with data on phone access. Survey design weighted estimates of household phone ownership and women's access among different population sub-groups are presented. Multilevel logistic models explored the association of phone access with a wide range of maternal and child health indicators. Blinder-Oaxaca (BO) decomposition is used to decompose the gaps between women with and without phone access in health care utilization into components explained by background characteristics influencing phone access (endowments) and unexplained components (coefficients), potentially attributable to phone access itself. FINDINGS: Phone ownership at the household level was 92·8% (95% CI: 92·6-93·0%), with rural ownership at 91·1% (90·8-91·4%) and urban at 97.1% (96·7-97·3%). Women's access to phones was 47·8% (46·7-48·8%); 41·6% in rural areas (40·5-42·6%) and 62·7% (60·4-64·8%) in urban. Phone access in urban areas was positively associated with skilled birth attendance, postnatal care and use of modern contraceptives and negatively associated with early antenatal care. Phone access was not associated with improvements in utilization indicators in rural settings. Phone access (coefficient components) explained large gaps in the use of modern contraceptives, moderate gaps in postnatal care and early antenatal care, and smaller differences in the use of skilled birth attendance and immunization. For full antenatal car, phone access was associated with reducing gaps in utilization. INTERPRETATION: Women of reproductive age have significantly lower phone access use than the households they belong to and marginalized women have the least phone access. Existing phone access for rural women did not improve their health care utilization but was associated with greater utilization for urban women. Without addressing these biases, digital health programs may be at risk of worsening existing health inequities.

Does women's mobile phone ownership matter for health? Evidence from 15 countries.

Mobile phones have the potential to increase access to health information, improve patient-provider communication, and influence the content and quality of health services received. Evidence on the gender gap in ownership of mobile phones is limited, and efforts to link phone ownership among women to care-seeking and practices for reproductive maternal newborn and child health (RMNCH) have yet to be made. This analysis aims to assess household and women's access to phones and its effects on RMNCH health outcomes in 15 countries for which Demographic and Health Surveys data on phone ownership are available. Multilevel logistic regression models were used to explore factors associated with women's phone ownership, along with the association of phone ownership to a wide range of RMNCH indicators. Study findings suggest that (1) gender gaps in mobile phone ownership vary, but they can be substantial, with less than half of women owning mobile phones in several countries; (2) the gender gap in phone ownership is larger for rural and poorer women; (3) women's phone ownership is generally associated with better RMNCH indicators; (4) among women phone owners, utilisation of RMNCH care-seeking and practices differs based on their income status; and (5) more could be done to unleash the potential of mobile phones on women's health if data gaps and varied metrics are addressed. Findings reinforce the notion that without addressing the gender gap in phone ownership, digital health programmes may be at risk of worsening existing health inequities.

Antenatal care in rural Bangladesh: current state of costs, content and recommendations for effective service delivery.

BACKGROUND: Measurement of antenatal care (ANC) service coverage is often limited to the number of contacts or type of providers, reflecting a gap in the assessment of quality as well as cost estimations and health impact. The study aims to determine service subcomponents and provider and patient costs of ANC services and compares them between community (i.e. satellite clinics) and facility care (i.e. primary and secondary health centers) settings in rural Bangladesh. METHODS: Service contents and cost data were collected by one researcher and four interviewers in various community and facility health care settings in Gaibandha district between September and December 2016. We conducted structured interviews with organization managers, observational studies of ANC service provision (n = 70) for service contents and provider costs (service and drug costs) and exit interviews with pregnant women (n = 70) for patient costs (direct and indirect costs) in health clinics at community and facility levels. Fisher's exact tests were used to determine any different patient characteristics between community and facility settings. ANC service contents were assessed by 63 subitems categorized into 11 groups and compared within and across community and facility settings. Provider and patient costs were collected in Bangladesh taka and analyzed as 2016 US Dollars (0.013 exchange rate). RESULTS: We found generally similar provider and patient characteristics between the community and facility settings except in clients' gestational age. High compliance (> 50%) of service subcomponents were observed in blood pressure monitoring, weight measurement, iron and folate supplementation given, and tetanus vaccine, while lower compliance of service subcomponents (< 50%) were observed in some physical examinations such as edema and ultrasonogram and routine tests such as blood test and urine test. Average unit costs of ANC service provision were about double at the facility level ($2.75) compared with community-based care ($1.62). ANC patient costs at facilities ($2.66) were about three times higher than in the community ($0.78). CONCLUSION: The study reveals a delay in pregnant women's initial ANC care seeking, gaps in compliance of ANC subcomponents and difference of provider and patient costs between facility and community settings.

Costs and cost-effectiveness analyses of mCARE strategies for promoting care seeking of maternal and newborn health services in rural Bangladesh.

OBJECTIVE: We examined the incremental cost-effectiveness between two mHealth programs, implemented from 2011 to 2015 in rural Bangladesh: (1) Comprehensive mCARE package as an intervention group and (2) Basic mCARE package as a control group. METHODS: Both programs included a core package of census enumeration and pregnancy surveillance provided by an established cadre of digitally enabled community health workers (CHWs). In the comprehensive mCARE package, short message service (SMS) and home visit reminders were additionally sent to pregnant women (n = 610) and CHWs (n = 70) to promote the pregnant women's care-seeking of essential maternal and newborn care services. Economic costs were assessed from a program perspective inclusive of development, start-up, and implementation phases. Effects were calculated as disability adjusted life years (DALYs) and the number of newborn deaths averted. For comparative purposes, we normalized our evaluation to estimate total costs and total newborn deaths averted per 1 million people in a community for both groups. Uncertainty was assessed using probabilistic sensitivity analyses with Monte Carlo simulation. RESULTS: The addition of SMS and home visit reminders based on a mobile phone-facilitated pregnancy surveillance system was highly cost effective at a cost per DALY averted of $31 (95% uncertainty range: $19-81). The comprehensive mCARE program had at least 88% probability of being highly cost-effective as compared to the basic mCARE program based on the threshold of Bangladesh's GDP per capita. CONCLUSION: mHealth strategies such as SMS and home visit reminders on a well-established pregnancy surveillance system may improve service utilization and program cost-effectiveness in low-resource settings.

Development of a Phone Survey Tool to Measure Respectful Maternity Care During Pregnancy and Childbirth in India: Study Protocol.

BACKGROUND: Respectful maternity care (RMC) is a key barometer of the underlying quality of care women receive during pregnancy and childbirth. Efforts to measure RMC have largely been qualitative, although validated quantitative tools are emerging. Available tools have been limited to the measurement of RMC during childbirth and confined to observational and face-to-face survey modes. Phone surveys are less invasive, low cost, and rapid alternatives to traditional face-to-face methods, yet little is known about their validity and reliability. OBJECTIVE: The primary objective of this study was to develop validated face-to-face and phone survey tools for measuring RMC during pregnancy and childbirth for use in India and other low resource settings. The secondary objective was to optimize strategies for improving the delivery of phone surveys for use in measuring RMC. METHODS: To develop face-to-face and phone surveys for measuring RMC, we describe procedures for assessing content, criterion, and construct validity as well as reliability analyses. To optimize the delivery of phone surveys, we outline plans for substudies, which aim to assess the effect of survey modality, and content on survey response, completion, and attrition rates. RESULTS: Data collection will be carried out in 4 districts of Madhya Pradesh, India, from July 2018 to March 2019. CONCLUSIONS: To our knowledge, this is the first RMC phone survey tool developed for India, which may provide an opportunity for the rapid, routine collection of data essential for improving the quality of care during pregnancy and childbirth. Elsewhere, phone survey tools are emerging; however, efforts to develop these surveys are often not inclusive of rigorous pretesting activities essential for ensuring quality data, including cognitive, reliability, and validity testing. In the absence of these activities, emerging data could overestimate or underestimate the burden of disease and health care practices under assessment. In the context of RMC, poor quality data could have adverse consequences including the naming and shaming of providers. By outlining a blueprint of the minimum activities required to generate reliable and valid survey tools, we hope to improve efforts to develop and deploy face-to-face and phone surveys in the health sector. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/12173.

The Philani MOVIE study: a cluster-randomized controlled trial of a mobile video entertainment-education intervention to promote exclusive breastfeeding in South Africa.

BACKGROUND: In South Africa, rates of exclusive breastfeeding remain low and breastfeeding promotion is a national health priority. Mobile health and narrative entertainment-education are recognized strategies for health promotion. In-home counseling by community health workers (CHWs) is a proven breastfeeding promotion strategy. This protocol outlines a cluster-randomized controlled trial with a nested mixed-methods evaluation of the MObile Video Intervention for Exclusive breastfeeding (MOVIE) program. The evaluation will quantify the causal effect of the MOVIE program and generate a detailed understanding of the context in which the intervention took place and the mechanisms through which it enacted change. Findings from the study will inform the anticipated scale-up of mobile video health interventions in South Africa and the wider sub-Saharan region. METHODS: We will conduct a stratified cluster-randomized controlled trial in urban communities of the Western Cape, to measure the effect of the MOVIE intervention on exclusive breastfeeding and other infant feeding practices. Eighty-four mentor-mothers (CHWs employed by the Philani Maternal Child Health and Nutrition Trust) will be randomized 1:1 into intervention and control arms, stratified by neighborhood type. Mentor-mothers in the control arm will provide standard of care (SoC) perinatal in-home counseling. Mentor-mothers in the intervention arm will provide SoC plus the MOVIE intervention. At least 1008 pregnant participants will be enrolled in the study and mother-child pairs will be followed until 5 months post-delivery. The primary outcomes of the study are exclusive breastfeeding at 1 and 5 months of age. Secondary outcomes are other infant feeding practices and maternal knowledge. In order to capture human-centered underpinnings of the intervention, we will conduct interviews with stakeholders engaged in the intervention design. To contextualize quantitative findings and understand the mechanisms through which the intervention enacted change, end-line focus groups with mentor-mothers will be conducted. DISCUSSION: This trial will be among the first to explore a video-based, entertainment-education intervention delivered by CHWs and created using a community-based, human-centered design approach. As such, it could inform health policy, with regards to both the routine adoption of this intervention and, more broadly, the development of other entertainment-education interventions for health promotion in under-resourced settings. TRIAL REGISTRATION: The study and its outcomes were registered at clinicaltrials.gov ( #NCT03688217 ) on September 27th, 2018.

Simulation-based low-dose, high-frequency plus mobile mentoring versus traditional group-based training approaches on day of birth care among maternal and newborn healthcare providers in Ebonyi and Kogi States, Nigeria; a randomized controlled trial.

BACKGROUND: There is limited information from low and middle-income countries on learning outcomes, provider satisfaction and cost-effectiveness on the day of birth care among maternal and newborn health workers trained using onsite simulation-based low-dose high frequency (LDHF) plus mentoring approach compared to the commonly employed offsite traditional group-based training (TRAD). The LDHF approach uses in-service learning updates to deliver information based on local needs during short, structured, onsite, interactive learning activities that involve the entire team and are spaced over time to optimize learning. The aim of this study will be to compare the effectiveness and cost of LDHF versus TRAD approaches in improving knowledge and skill in maternal and newborn care and to determine trainees' satisfaction with the approaches in Ebonyi and Kogi states, Nigeria. METHODS: This will be a prospective cluster randomized control trial. Sixty health facilities will be randomly assigned for day of birth care health providers training through either LDHF plus mobile mentoring (intervention arm) or TRAD (control arm). There will be 150 trainees in each arm. Multiple choices questionnaires (MCQs), objective structured clinical examinations (OSCEs), cost and satisfaction surveys will be administered before and after the trainings. Quantitative data collection will be done at months 0 (baseline), 3 and 12. Qualitative data will also be collected at 12-month from the LDHF arm only. Descriptive and inferential statistics will be used as appropriate. Composite scores will be computed for selected variables to determine areas where service providers have good skills as against areas where their skills are poor and to compare skills and knowledge outcomes between the two groups at 0.05 level of statistical significance. DISCUSSION: There is some evidence that LDHF, simulation and practice-based training approach plus mobile mentoring results in improved skills and health outcomes and is cost-effective. By comparing intervention and control arms the authors hope to replicate similar results, evaluate the approach in Nigeria and provide evidence to Ministry of Health on how and which training approach, frequency and setting will result in the greatest return on investment. TRIAL REGISTRATION: The trial was retrospectively registered on 24th August, 2017 at ClinicalTrials.Gov: NCT03269240 .

Can community action improve equity for maternal health and how does it do so? Research findings from Gujarat, India.

BACKGROUND: Efforts to work with civil society to strengthen community participation and action for health are particularly important in Gujarat, India, given that the state has resources and capacity, but faces challenges in ensuring that services reach those most in need. To contribute to the knowledge base on accountability and maternal health, this study examines the equity effects of community action for maternal health led by Non-Government Organizations (NGOs) on facility deliveries. It then examines the underlying implementation processes with implications for strengthening accountability of maternity care across three districts of Gujarat, India. Community action for maternal health entailed NGOs a) working with community collectives to raise awareness about maternal health entitlements, b) supporting community monitoring of outreach government services, and c) facilitating dialogue with government providers and authorities with report cards based on community monitoring of maternal health. METHODS: The study combined qualitative data (project documents and 56 stakeholder interviews thematically analyzed) with quantitative data (2395 women's self-reported receipt of information on entitlements and use of services over 3 years of implementation monitored prospectively through household visits). Multivariable logistic regression examined delivery care seeking and equity. RESULTS: In the marginalised districts, women reported substantial increases in receipt of information of entitlements and utilization of antenatal and delivery care. In the marginalized and wealthier districts, a switch from private facilities to public ones was observed for the most vulnerable. Supportive implementation factors included a) alignment among NGO organizational missions, b) participatory development of project tools, c) repeated capacity building and d) government interest in improving utilization and recognition of NGO contributions. Initial challenges included a) confidence and turnover of volunteers, b) complexity of the monitoring tool and c) scepticism from both communities and providers. CONCLUSION: With capacity and trust building, NGOs supporting community based collectives to monitor health services and engage with health providers and local authorities, over time overcame implementation challenges to strengthen public sector services. These accountability efforts resulted in improvements in utilisation of public sector services and a shift away from private care seeking, particularly for the marginalised.

Hubris, humility and humanity: expanding evidence approaches for improving and sustaining community health programmes.

Community-based approaches are a critical foundation for many health outcomes, including reproductive, maternal, newborn and child health (RMNCH). Evidence is a vital part of strengthening that foundation, but largely focuses on the technical content of what must be done, rather than on how disparate community actors continuously interpret, implement and adapt interventions in dynamic and varied community health systems. We argue that efforts to strengthen evidence for community programmes must guard against the hubris of relying on a single approach or hierarchy of evidence for the range of research questions that arise when sustaining community programmes at scale. Moving forward we need a broader evidence agenda that better addresses the implementation realities influencing the scale and sustainability of community programmes and the partnerships underpinning them if future gains in community RMNCH are to be realised. This will require humility in understanding communities as social systems, the complexity of the interventions they engage with and the heterogeneity of evidence needs that address the implementation challenges faced. It also entails building common ground across epistemological word views to strengthen the robustness of implementation research by improving the use of conceptual frameworks, addressing uncertainty and fostering collaboration. Given the complexity of scaling up and sustaining community RMNCH, ensuring that evidence translates into action will require the ongoing brokering of relationships to support the human creativity, scepticism and scaffolding that together build layers of evidence, critical thinking and collaborative learning to effect change.

Mobile health messaging service and helpdesk for South African mothers (MomConnect): history, successes and challenges.

MomConnect is a flagship programme of the South African National Department of Health that has reached over 1.5 million pregnant women. Using mobile technology, MomConnect provides pregnant and postpartum women with twice-weekly health information text messages as well as access to a helpdesk for patient queries and feedback. In just 3 years, MomConnect has been taken to scale to reach over 95% of public health facilities and has reached 63% of all pregnant women attending their first antenatal appointment. The helpdesk has received over 300 000 queries at an average of 250 per day from 6% of MomConnect users. The service is entirely free to its users. The rapid deployment of MomConnect has been facilitated by strong government leadership, and an ecosystem of mobile health implementers who had experience of much of the content and technology required. An early decision to design MomConnect for universal coverage has required the use of text-based technologies (short messaging service and Unstructured Supplementary Service Data) that are accessible via even the most basic mobile phones, but cumbersome to use and costly at scale. Unlike previous mobile messaging services in South Africa, MomConnect collects the user's identification number and facility code during registration, enabling future linkages with other health and population databases and geolocated feedback. MomConnect has catalysed additional efforts to strengthen South Africa's digital health architecture. The rapid growth in smartphone penetration presents new opportunities to reduce costs, increase real-time data collection and expand the reach and scope of MomConnect to serve health workers and other patient groups.

Unpacking the performance of a mobile health information messaging program for mothers (MomConnect) in South Africa: evidence on program reach and messaging exposure.

Despite calls to address broader evidence gaps in linking digital technologies to outcome and impact level health indicators, limited attention has been paid to measuring processes pertaining to the performance of programs. In this paper, we assess the program reach and message exposure of a mobile health information messaging program for mothers (MomConnect) in South Africa. In this descriptive study, we draw from system generated data to measure exposure to the program through registration attempts and conversions, message delivery, opt-outs and drop-outs. Using a logit model, we additionally explore determinants for early registration, opt-outs and drop-outs. From August 2014 to April 2017, 1 159 431 women were registered to MomConnect; corresponding to half of women attending antenatal care 1 (ANC1) and nearly 60% of those attending ANC1 estimated to own a mobile phone. In 2016, 26% of registrations started to get women onto MomConnect did not succeed. If registration attempts were converted to successful registrations, coverage of ANC1 attendees would have been 74% in 2016 and 86% in 2017. When considered as percentage of ANC1 attendees with access to a mobile phone, addressing conversion challenges bring registration coverage to an estimated 83%-89% in 2016 and 97%-100% in 2017. Among women registered, nearly 80% of expected short messaging service messages were received. While registration coverage and message delivery success rates exceed those observed for mobile messaging programs elsewhere, study findings highlight opportunities for program improvement and reinforce the need for rigorous and continuous monitoring of delivery systems.

A Call to Digital Health Practitioners: New Guidelines Can Help Improve the Quality of Digital Health Evidence.

BACKGROUND: Despite the rapid proliferation of health interventions that employ digital tools, the evidence on the effectiveness of such approaches remains insufficient and of variable quality. To address gaps in the comprehensiveness and quality of reporting on the effectiveness of digital programs, the mHealth Technical Evidence Review Group (mTERG), convened by the World Health Organization, proposed the mHealth Evidence Reporting and Assessment (mERA) checklist to address existing gaps in the comprehensiveness and quality of reporting on the effectiveness of digital health programs. OBJECTIVE: We present an overview of the mERA checklist and encourage researchers working in the digital health space to use the mERA checklist for reporting their research. METHODS: The development of the mERA checklist consisted of convening an expert group to recommend an appropriate approach, convening a global expert review panel for checklist development, and pilot-testing the checklist. RESULTS: The mERA checklist consists of 16 core mHealth items that define what the mHealth intervention is (content), where it is being implemented (context), and how it was implemented (technical features). Additionally, a 29-item methodology checklist guides authors on reporting critical aspects of the research methodology employed in the study. We recommend that the core mERA checklist is used in conjunction with an appropriate study-design specific checklist. CONCLUSIONS: The mERA checklist aims to assist authors in reporting on digital health research, guide reviewers and policymakers in synthesizing evidence, and guide journal editors in assessing the completeness in reporting on digital health studies. An increase in transparent and rigorous reporting can help identify gaps in the conduct of research and understand the effects of digital health interventions as a field of inquiry.

Cost-effectiveness analysis of the diarrhea alleviation through zinc and oral rehydration therapy (DAZT) program in rural Gujarat India: an application of the net-benefit regression framework.

BACKGROUND: This study evaluates the cost-effectiveness of the DAZT program for scaling up treatment of acute child diarrhea in Gujarat India using a net-benefit regression framework. METHODS: Costs were calculated from societal and caregivers' perspectives and effectiveness was assessed in terms of coverage of zinc and both zinc and Oral Rehydration Salt. Regression models were tested in simple linear regression, with a specified set of covariates, and with a specified set of covariates and interaction terms using linear regression with endogenous treatment effects was used as the reference case. RESULTS: The DAZT program was cost-effective with over 95% certainty above $5.50 and $7.50 per appropriately treated child in the unadjusted and adjusted models respectively, with specifications including interaction terms being cost-effective with 85-97% certainty. DISCUSSION: Findings from this study should be combined with other evidence when considering decisions to scale up programs such as the DAZT program to promote the use of ORS and zinc to treat child diarrhea.

Defining a staged-based process for economic and financial evaluations of mHealth programs.

Mobile and wireless technology for health (mHealth) has the potential to improve health outcomes by addressing critical health systems constraints that impede coverage, utilization, and effectiveness of health services. To date, few mHealth programs have been implemented at scale and there remains a paucity of evidence on their effectiveness and value for money. This paper aims to improve understanding among mHealth program managers and key stakeholders of how to select methods for economic evaluation (comparative analysis for determining value for money) and financial evaluation (determination of the cost of implementing an intervention, estimation of costs for sustaining or expanding an intervention, and assessment of its affordability). We outline a 6 stage-based process for selecting and integrating economic and financial evaluation methods into the monitoring and evaluation of mHealth solutions including (1) defining the program strategy and linkages with key outcomes, (2) assessment of effectiveness, (3) full economic evaluation or partial evaluation, (4) sub-group analyses, (5) estimating resource requirements for expansion, (6) affordability assessment and identification of models for financial sustainability. While application of these stages optimally occurs linearly, finite resources, limited technical expertise, and the timing of evaluation initiation may impede this. We recommend that analysts prioritize economic and financial evaluation methods based on programmatic linkages with health outcomes; alignment with an mHealth solution's broader stage of maturity and stage of evaluation; overarching monitoring and evaluation activities; stakeholder evidence needs; time point of initiation; and available resources for evaluations.