A nationwide mobile phone survey for tobacco use in Tanzania: Sample quality and representativeness compared to a household survey.

We investigated the feasibility of an interactive voice response (IVR) survey in Tanzania and compared its prevalence estimates for tobacco use to the estimates of the 'Global Adult Tobacco Survey (GATS) 2018'. IVR participants were enrolled by random digit dialing. Quota sampling was employed to achieve the required sample sizes of age-sex strata: sex (male/female) and age (18-29-, 30-44-, 45-59-, and ≥60-year-olds). GATS was a nationally representative survey and used a multistage stratified cluster sampling design. The IVR sample's weights were generated using the inverse proportional weighting (IPW) method with a logit model and the standard age-sex distribution of Tanzania. The IVR and GATS had 2362 and 4555 participants, respectively. Compared to GATS, the unweighted IVR sample had a higher proportion of males (58.7 % vs. 43.2 %), educated people (secondary/above education: 43.3 % vs. 21.1 %), and urban residents (56.5 % vs. 40 %). The weighted prevalence (95 % confidence interval (CI)) of current smoking was 4.99 % (4.11-6.04), 5.22 % (4.36-6.24), and 7.36 % (6.51-8.31) among IVR (IPW), IVR (age-sex standard), and GATS samples, respectively; the weighted prevalence (95 % CI) of smokeless tobacco use was similar: 3.54 % (2.73-4.57), 3.58 % (2.80-4.56), and 2.43 % (1.98-2.98), respectively. Most differences in point estimates for tobacco indicators were small (<2%). Overall, the odds of tobacco smoking indicators were lower in IVR than in GATS; however, the odds of smokeless tobacco use were reversed. Although we found under-/over-estimation of the prevalence of tobacco use in IVR than GATS, the estimates were close. Further research is required to increase the representativeness of IVR.

Recruiting hard-to-reach populations via respondent driven sampling for mobile phone surveys in Colombia: a qualitative study.

BACKGROUND: Uptake of mobile phone surveys (MPS) is increasing in many low- and middle-income countries, particularly within the context of data collection on non-communicable diseases (NCDs) behavioural risk factors. One barrier to collecting representative data through MPS is capturing data from older participants.Respondent driven sampling (RDS) consists of chain-referral strategies where existing study subjects recruit follow-up participants purposively based on predefined eligibility criteria. Adapting RDS strategies to MPS efforts could, theoretically, yield higher rates of participation for that age group. OBJECTIVE: To investigate factors that influence the perceived acceptability of a RDS recruitment method for MPS involving people over 45 years of age living in Colombia. METHODS: An MPS recruitment strategy deploying RDS techniques was piloted to increase participation of older populations. We conducted a qualitative study that drew from surveys with open and closed-ended items, semi-structured interviews for feedback, and focus group discussions to explore perceptions of the strategy and barriers to its application amongst MPS participants. RESULTS: The strategy's success is affected by factors such as cultural adaptation, institutional credibility and public trust, data protection, and challenges with mobile phone technology. These factors are relevant to individuals' willingness to facilitate RDS efforts targeting hard-to-reach people. Recruitment strategies are valuable in part because hard-to-reach populations are often most accessible through their contacts within their social network who can serve as trust liaisons and drive engagement. CONCLUSIONS: These findings may inform future studies where similar interventions are being considered to improve access to mobile phone-based data collection amongst hard-to-reach groups.

Landscape of team-based care to manage hypertension: results from two surveys in low/middle-income countries.

OBJECTIVES: Team-based care is essential for improving hypertension outcomes in low-resource settings. We assessed perceptions of country representatives and healthcare workers (HCWs) on team-based hypertension care in low/middle-income countries. DESIGN: Two cross-sectional surveys. SETTING: The first survey (Country Profile Survey) was conducted in 17 countries and eight in-country regions: Algeria, Bangladesh, Burundi, Chile, China (Beijing, Henan, Shandong), Cuba, Ethiopia, India (Kerala, Madhya Pradesh, Maharashtra, Punjab, Telangana), Nepal, Nigeria, Philippines, Saint Lucia, Sri Lanka, Thailand, Turkey, Uganda and Vietnam. The second survey (HCW Survey) was conducted in four countries: Bangladesh, China, Ethiopia and Nigeria. PARTICIPANTS: Using convenience sampling, participants for the Country Profile Survey were representatives from 17 countries and eight in-country regions, and the HCW Survey was administered to HCWs in Bangladesh, China, Ethiopia and Nigeria. OUTCOME MEASURES: Country-level use of team-based hypertension care framework, comprising administrative, basic and advanced clinical tasks. Current practices of different HCW cadres, perspectives on team-based management of hypertension, barriers and facilitators. RESULTS: In the Country Profile Survey, all (23/23, 100%) countries/regions surveyed integrated team-based care for basic clinical hypertension management tasks, less for advanced tasks (7/23, 30%). In the HCW Survey, 854 HCWs participated, 47% of whom worked in rural settings. Most HCWs in the sample acknowledged the value of team-based hypertension care. Although there were slight variations by country in the study sample, overall, barriers to team-based hypertension care were identified as inadequate training (83%); regulatory issues (76%); resistance by patients (56%), physicians (42%) and nurses (40%). Facilitators identified were use of treatment algorithms (94%), telehealth/m-health technology (92%) and adequate compensation for HCWs (80%). CONCLUSIONS: Our findings revealed key lessons for health systems and governments regarding team-based care implementation. Specifically, policies to facilitate additional training, optimise HCWs' roles within care teams, use of hypertension treatment protocols and telehealth/m-health technology will be essential to promote team-based care.

Developing digital tools for health surveys in low- and middle-income countries: Comparing findings of two mobile phone surveys with a nationally representative in-person survey in Bangladesh.

Non-communicable disease (NCD) risk factor data from low- and middle-income countries (LMICs) are inadequate, mostly due to the cost and burden of collecting in-person population-level estimates. High-income countries regularly use phone-based surveys, and with increasing mobile phone subscription in developing countries, mobile phone surveys (MPS) could complement in-person surveys in LMICs. We compared the representativeness and prevalence estimates of two MPS (i.e., interactive voice response (IVR) and computer-assisted telephone interview (CATI)) with a nationally representative household survey in Bangladesh-the STEPwise approach to NCD risk factor surveillance (STEPs) 2018. This cross-sectional study included 18-69-year-old respondents. CATI and IVR recruitments were done by random digit dialing, while STEPs used multistage cluster sampling design. The prevalence of NCD risk factors related to tobacco, alcohol, diet, and hypertension was reported and compared by prevalence differences (PD) and prevalence ratios (PR). We included 2355 (57% males), 1942 (62% males), and 8185 (47% males) respondents in the CATI, IVR, and STEPs, respectively. CATI (28%) and IVR (52%) had a higher proportion of secondary/above-educated people than STEPs (13%). Most prevalence estimates differed by survey mode; however, CATI estimates were closer to STEPs than IVR. For instance, in CATI, IVR, and STEPs, respectively, the prevalence was 21.4%, 17.9%, and 23.5% for current smoking; and 1.6%, 2.2%, and 1.5% for alcohol drinking in past month. Compared to STEPs, the PD ranged from '-56.6% to 0.4%' in CATI and '-41.0% to 8.4%' in IVR; the PR ranged from '0.3 to 1.1' in CATI and '0.3 to 1.6' in IVR. There were some differences and some similarities in NCD indicators produced by MPS and STEPs with differences likely due to differences in socioeconomic characteristics between survey participants.

Self-paced online learning to improve knowledge competencies for hypertension among medical students in Uganda: A pre-post study.

The growing burden of hypertension (HT) is projected to reach 1.56 billion globally by 2025 and is an increasing public health concern, even for low- and middle-income countries (LMIC) like Uganda, where the prevalence of HT is 31.5%. The objective of this study was to test the effectiveness of a freely available HT online course on knowledge competencies for medical students in Uganda. The online course was developed by a multidisciplinary team at Johns Hopkins University to address HT control in resource-constrained healthcare settings. Students in the 3rd, 4th, and 5th years of medical school were randomly selected to participate in the online course. Pre and post knowledge tests were administered using an online survey system. Of the 201 invited students, 121 (60.2%) completed the study. Significant improvements in mean knowledge scores were evident following the online course completion for Module 1, Fundamentals of HT (21.9±2.5 to 23.7±2.5, p<0.001), and Module 2, Basics of HT Management (14.9±3.3 to 18.5±4.3, p<0.001). No statistically significant differences were evident by gender or school year. Students who took a shorter duration to complete the course had significantly higher mean score improvement between pre- and post-test (mean score improvement 7.0 if <4 weeks, 3.6 if 4-8 weeks, and 3.7 if >8 weeks, p<0.003). Students recognized information on blood pressure measurement (32.2%) and HT management (22.3%) as the most important concept addressed in the course. A self-paced online course, complementing medical school training, improved knowledge on HT burden and management in Uganda.

Examination of the demographic representativeness of a cross-sectional mobile phone survey in collecting health data in Colombia using random digit dialling.

OBJECTIVES: As mobile phone ownership becomes more widespread in low-income and middle-income countries, mobile phone surveys (MPSs) present an opportunity to collect data on health more cost-effectively. However, selectivity and coverage biases in MPS are concerns, and there is limited information about the population-level representativeness of these surveys compared with household surveys. This study aims at comparing the sociodemographic characteristics of the respondents of an MPS on non-communicable disease risk factors to a household survey in Colombia. DESIGN: Cross-sectional study. We used a random digit dialling method to select the samples for calling mobile phone numbers. The survey was conducted using two modalities: computer-assisted telephone interviews (CATIs) and interactive voice response (IVR). The participants were assigned randomly to one of the survey modalities based on a targeted sampling quota stratified by age and sex. The Quality-of-Life Survey (ECV), a nationally representative survey conducted in the same year of the MPS, was used as a reference to compare the sample distributions by sociodemographic characteristics of the MPS data. Univariate and bivariate analyses were performed to evaluate the population representativeness between the ECV and the MPSs. SETTING: The study was conducted in Colombia in 2021. PARTICIPANTS: Population at least 18 years old with a mobile phone. RESULTS: We completed 1926 and 2983 interviews for CATI and IVR, respectively. We found that the MPS data have a similar (within 10% points) age-sex data distribution compared with the ECV dataset for some subpopulations, mainly for young populations, people with none/primary and secondary education levels, and people who live in urban and rural areas. CONCLUSIONS: This study shows that MPS could collect similar data to household surveys in terms of age, sex, high school education level and geographical area for some population categories. Strategies are needed to improve representativeness of the under-represented groups.

Improving success of non-communicable diseases mobile phone surveys: Results of two randomized trials testing interviewer gender and message valence in Bangladesh and Uganda.

INTRODUCTION: Although interactive voice response (IVR) is a promising mobile phone survey (MPS) method for public health data collection in low- and middle-income countries (LMICs), participation rates for this method remain lower than traditional methods. This study tested whether using different introductory messages increases the participation rates of IVR surveys in two LMICs, Bangladesh and Uganda. METHODS: We conducted two randomized, controlled micro-trials using fully-automated random digit dialing to test the impact of (1) the gender of the speaker recording the survey (i.e., survey voice); and (2) the valence of the invitation to participate in the survey (i.e., survey introduction) on response and cooperation rates. Participants indicated their consent by using the keypad of cellphones. Four study arms were compared: (1) male and informational (MI); (2) female and information (FI); (3) male and motivational (MM); and (4) female and motivational (FM). RESULTS: Bangladesh and Uganda had 1705 and 1732 complete surveys, respectively. In both countries, a majority of the respondents were males, young adults (i.e., 18-29-year-olds), urban residents, and had O-level/above education level. In Bangladesh, the contact rate was higher in FI (48.9%), MM (50.0%), and FM (55.2%) groups than in MI (43.0%); the response rate was higher in FI (32.3%) and FM (33.1%) but not in MM (27.2%) and MI (27.1%). Some differences in cooperation and refusal rates were also observed. In Uganda, MM (65.4%) and FM (67.9%) had higher contact rates than MI (60.8%). The response rate was only higher in MI (52.5%) compared to MI (45.9%). Refusal and cooperation rates were similar. In Bangladesh, after pooling by introductions, female arms had higher contact (52.1% vs 46.5%), response (32.7% vs 27.1%), and cooperation (47.8% vs 40.4%) rates than male arms. Pooling by gender showed higher contact (52.3% vs 45.6%) and refusal (22.5% vs 16.3%) rates but lower cooperation rate (40.0% vs 48.2%) in motivational arms than informational arms. In Uganda, pooling intros did not show any difference in survey rates by gender; however, pooling by intros showed higher contact (66.5% vs 61.5%) and response (50.0% vs 45.2%) rates in motivational arms than informational arms. CONCLUSION: Overall, we found higher survey rates among female voice and motivational introduction arms compared to male voice and informational introduction arm in Bangladesh. However, Uganda had higher rates for motivational intro arms only compared to informational arms. Gender and valence must be considered for successful IVR surveys. TRIAL REGISTRATION: Name of the registry: ClinicalTrials.gov. Trial registration number: NCT03772431. Date of registration: 12/11/2018, Retrospectively Registered. URL of trial registry record: https://clinicaltrials.gov/ct2/show/NCT03772431?term=03772431&cond=Non-Communicable+Disease&draw=2&rank=1. Protocol Availability: https://www.researchprotocols.org/2017/5/e81.

Effect of the Data Collection Method on Mobile Phone Survey Participation in Bangladesh and Tanzania: Secondary Analyses of a Randomized Crossover Trial.

BACKGROUND: Mobile phone surveys provide a novel opportunity to collect population-based estimates of public health risk factors; however, nonresponse and low participation challenge the goal of collecting unbiased survey estimates. OBJECTIVE: This study compares the performance of computer-assisted telephone interview (CATI) and interactive voice response (IVR) survey modalities for noncommunicable disease risk factors in Bangladesh and Tanzania. METHODS: This study used secondary data from a randomized crossover trial. Between June 2017 and August 2017, study participants were identified using the random digit dialing method. Mobile phone numbers were randomly allocated to either a CATI or IVR survey. The analysis examined survey completion, contact, response, refusal, and cooperation rates of those who received the CATI and IVR surveys. Differences in survey outcomes between modes were assessed using multilevel, multivariable logistic regression models to adjust for confounding covariates. These analyses were adjusted for clustering effects by mobile network providers. RESULTS: For the CATI surveys, 7044 and 4399 phone numbers were contacted in Bangladesh and Tanzania, respectively, and 60,863 and 51,685 phone numbers, respectively, were contacted for the IVR survey. The total numbers of completed interviews in Bangladesh were 949 for CATI and 1026 for IVR and in Tanzania were 447 for CATI and 801 for IVR. Response rates for CATI were 5.4% (377/7044) in Bangladesh and 8.6% (376/4391) in Tanzania; response rates for IVR were 0.8% (498/60,377) in Bangladesh and 1.1% (586/51,483) in Tanzania. The distribution of the survey population was significantly different from the census distribution. In both countries, IVR respondents were younger, were predominantly male, and had higher education levels than CATI respondents. IVR respondents had a lower response rate than CATI respondents in Bangladesh (adjusted odds ratio [AOR]=0.73, 95% CI 0.54-0.99) and Tanzania (AOR=0.32, 95% CI 0.16-0.60). The cooperation rate was also lower with IVR than with CATI in Bangladesh (AOR=0.12, 95% CI 0.07-0.20) and Tanzania (AOR=0.28, 95% CI 0.14-0.56). Both in Bangladesh (AOR=0.33, 95% CI 0.25-0.43) and Tanzania (AOR=0.09, 95% CI 0.06-0.14), there were fewer completed interviews with IVR than with CATI; however, there were more partial interviews with IVR than with CATI in both countries. CONCLUSIONS: There were lower completion, response, and cooperation rates with IVR than with CATI in both countries. This finding suggests that, to increase representativeness in certain settings, a selective approach may be needed to design and deploy mobile phone surveys to increase population representativeness. Overall, CATI surveys may offer a promising approach for surveying potentially under-represented groups like women, rural residents, and participants with lower levels of education in some countries.

Remote consent approaches for mobile phone surveys of non-communicable disease risk factors in Colombia and Uganda: A randomized study.

INTRODUCTION: Automated mobile phone surveys (MPS) can be used to collect public health data of various types to inform health policy and programs globally. One challenge in administering MPS is identification of an appropriate and effective participant consent process. This study investigated the impact of different survey consent approaches on participant disposition (response characteristics and understanding of the purpose of the survey) within the context of an MPS that measured noncommunicable disease (NCD) risk factors across Colombia and Uganda. METHODS: Participants were randomized to one of five consent approaches, with consent modules varying by the consent disclosure and mode of authorization. The control arm consisted of a standard consent disclosure and a combined opt-in/opt-out mode of authorization. The other four arms consist of a modified consent disclosure and one of four different forms of authorization (i.e., opt-in, opt-out, combined opt-in/opt-out, or implied). Data related to respondent disposition and respondent understanding of the survey purpose were analyzed. RESULTS: Among 1889 completed surveys in Colombia, differences in contact, response, refusal, and cooperation rates by study arms were found. About 68% of respondents correctly identified the survey purpose, with no significant difference by study arm. Participants reporting higher levels of education and urban residency were more likely to identify the purpose correctly. Participants were also more likely to accurately identify the survey purpose after completing several survey modules, compared to immediately following the consent disclosure (78.8% vs 54.2% correct, p<0.001). In Uganda, 1890 completed surveys were collected. Though there were differences in contact, refusal, and cooperation rates by study arm, response rates were similar across arms. About 37% of respondents identified the survey purpose correctly, with no difference by arm. Those with higher levels of education and who completed the survey in English were able to more accurately identify the survey purpose. Again, participants were more likely to accurately identify the purpose of the survey after completing several NCD modules, compared to immediately following the consent module (42.0% vs 32.2% correct, p = 0.013). CONCLUSION: This study contributes to the limited available evidence regarding consent procedures for automated MPS. Future studies should develop and trial additional interventions to enhance consent for automated public health surveys, and measure other dimensions of participant engagement and understanding.

Promised and Lottery Airtime Incentives to Improve Interactive Voice Response Survey Participation Among Adults in Bangladesh and Uganda: Randomized Controlled Trial.

BACKGROUND: Increased mobile phone penetration allows the interviewing of respondents using interactive voice response surveys in low- and middle-income countries. However, there has been little investigation of the best type of incentive to obtain data from a representative sample in these countries. OBJECTIVE: We assessed the effect of different airtime incentives options on cooperation and response rates of an interactive voice response survey in Bangladesh and Uganda. METHODS: The open-label randomized controlled trial had three arms: (1) no incentive (control), (2) promised airtime incentive of 50 Bangladeshi Taka (US $0.60; 1 BDT is approximately equivalent to US $0.012) or 5000 Ugandan Shilling (US $1.35; 1 UGX is approximately equivalent to US $0.00028), and (3) lottery incentive (500 BDT and 100,000 UGX), in which the odds of winning were 1:20. Fully automated random-digit dialing was used to sample eligible participants aged ≥18 years. The risk ratios (RRs) with 95% confidence intervals for primary outcomes of response and cooperation rates were obtained using log-binomial regression. RESULTS: Between June 14 and July 14, 2017, a total of 546,746 phone calls were made in Bangladesh, with 1165 complete interviews being conducted. Between March 26 and April 22, 2017, a total of 178,572 phone calls were made in Uganda, with 1248 complete interviews being conducted. Cooperation rates were significantly higher for the promised incentive (Bangladesh: 39.3%; RR 1.38, 95% CI 1.24-1.55, P<.001; Uganda: 59.9%; RR 1.47, 95% CI 1.33-1.62, P<.001) and the lottery incentive arms (Bangladesh: 36.6%; RR 1.28, 95% CI 1.15-1.45, P<.001; Uganda: 54.6%; RR 1.34, 95% CI 1.21-1.48, P<.001) than those for the control arm (Bangladesh: 28.4%; Uganda: 40.9%). Similarly, response rates were significantly higher for the promised incentive (Bangladesh: 26.5%%; RR 1.26, 95% CI 1.14-1.39, P<.001; Uganda: 41.2%; RR 1.27, 95% CI 1.16-1.39, P<.001) and lottery incentive arms (Bangladesh: 24.5%%; RR 1.17, 95% CI 1.06-1.29, P=.002; Uganda: 37.9%%; RR 1.17, 95% CI 1.06-1.29, P=.001) than those for the control arm (Bangladesh: 21.0%; Uganda: 32.4%). CONCLUSIONS: Promised or lottery airtime incentives improved survey participation and facilitated a large sample within a short period in 2 countries. TRIAL REGISTRATION: ClinicalTrials.gov NCT03773146; http://clinicaltrials.gov/ct2/show/NCT03773146.

Understanding child disability: Factors associated with child disability at the Iganga-Mayuge Health and Demographic Surveillance Site in Uganda.

INTRODUCTION: There is scarcity of data on children with disabilities living in low-and-middle-income countries, including Uganda. This study describes disability prevalence and explores factors associated with different disability categories. It highlights the value of using a standardized, easy-to-use tool to determine disability in children and contextualizing disability in children in light of their developmental needs. METHODS: A cross-sectional study was conducted between September 2018-January 2019 at the Iganga-Mayuge Health and Demographic Surveillance Site in Uganda. Respondents were caregivers of children between 5-17 years and were administered an in-depth Child Functioning Module (CFM). The outcome variable, disability, was defined as an ordered categorical variable with three categories-mild, moderate, and severe. Generalized ordered logit model was applied to explore factors associated with disability categories. RESULTS: Out of 1,842 caregivers approached for the study, 1,439 (response: 78.1%) agreed to participate in the study. Out of these 1,439, some level of disability was reported by 67.89% (n = 977) of caregivers. Of these 977 children with disability, 48.01% (n = 692) had mild disability and 15.84% (n = 228) had moderate disability, while 3.96% (n = 57) had severe disability. The mean (SD) score for mild disability was 2.22±1.17, with a median of 2. The mean and median for moderate disability was 5.26±3.28 and 4 (IQR:3-6), and for severe disability was 14.23±9.51 and 12 (IQR:6-22). The most common disabilities reported were depression (54.83%) and anxiety (50.87%). Statistically significant association was found for completion of immunization status and school enrollment when controlled for a child's age, sex, having a primary caregiver, age of mother at child's birth, family system, family size and household wealth quintile. CONCLUSION: This study suggests association between incomplete immunization status and school enrollment for children with disability. These are areas for further exploration to ensure inclusive health and inclusive education of children with disabilities in Uganda.

Community health workers at the dawn of a new era: 2. Planning, coordination, and partnerships.

BACKGROUND: Community health workers (CHWs) play a critical role in grassroots healthcare and are essential for achieving the health-related Sustainable Development Goals. While there is a critical shortage of essential health workers in low- and middle-income countries, WHO and international partners have reached a consensus on the need to expand and strengthen CHW programmes as a key element in achieving Universal Health Coverage (UHC). The COVID-19 pandemic has further revealed that emerging health challenges require quick local responses such as those utilizing CHWs. This is the second paper of our 11-paper supplement, "Community health workers at the dawn of a new era". Our objective here is to highlight questions, challenges, and strategies for stakeholders to consider while planning the introduction, expansion, or strengthening of a large-scale CHW programme and the complex array of coordination and partnerships that need to be considered. METHODS: The authors draw on the outcomes of discussions during key consultations with various government leaders and experts from across policy, implementation, research, and development organizations in which the authors have engaged in the past decade. These include global consultations on CHWs and global forums on human resources for health (HRH) conferences between 2010 and 2014 (Montreux, Bangkok, Recife, Washington DC). They also build on the authors' direct involvement with the Global Health Workforce Alliance. RESULTS: Weak health systems, poor planning, lack of coordination, and failed partnerships have produced lacklustre CHW programmes in countries. This paper highlights the three issues that are generally agreed as being critical to the long-term effectiveness of national CHW programmes-planning, coordination, and partnerships. Mechanisms are available in many countries such as the UHC2030 (formerly International Health Partnership), country coordinating mechanisms (CCMs), and those focusing on the health workforce such as the national Human Resources for Health Observatory and the Country Coordination and Facilitation (CCF) initiatives introduced by the Global Health Workforce Alliance. CONCLUSION: It is imperative to integrate CHW initiatives into formal health systems. Multidimensional interventions and multisectoral partnerships are required to holistically address the challenges at national and local levels, thereby ensuring synergy among the actions of partners and stakeholders. In order to establish robust and institutionalized processes, coordination is required to provide a workable platform and conducive environment, engaging all partners and stakeholders to yield tangible results.

Caregivers' estimate of early childhood developmental status in rural Uganda: a cross-sectional study.

OBJECTIVE: To characterise developmental milestones among young children living in rural communities in Uganda. DESIGN: Cross-sectional study. SETTING: Iganga-Mayuge Health and Demographic Surveillance Site in rural eastern Uganda. PARTICIPANTS: A total of 720 caregivers of children aged 3-4 years old from a health and demographic surveillance site in rural eastern Uganda were recruited into this study. Caregivers reported on their child's developmental skills and behaviours using the 10-item Early Childhood Development Index (ECDI) developed by UNICEF. Childhood development was characterised based on the ECDI's four domains: literacy-numeracy, learning/cognition, physical and socioemotional development. As an exploratory analysis, we implemented a hierarchical agglomerative cluster analysis to identify homogenous subgroups of children based on the features assessed. The cluster analysis was performed to identify potential subgroups of children who may be at risk of developmental problems. RESULTS: Between November 2017 and June 2018, 720 caregivers of children aged 3-4 years completed the ECDI. The proportions of children at risk of delay in each domain were as follows: literacy-numeracy: 75% (n=538); socioemotional development: 22% (n=157); physical: 3% (n=22); and cognitive: 4% (n=32). The cluster analysis revealed a three-cluster solution that included 93% of children assigned to a low-risk group, 4% assigned to a moderate-risk group and 3% assigned to a high-risk group characterised by low scores in almost all domains. CONCLUSION: The findings suggest that a high proportion of children in rural eastern Uganda demonstrate poor literacy-numeracy skills. These results underscore the need to improve population-based screening and intervention efforts to improve early childhood developmental outcomes, particularly in literacy and socioemotional domains, in low-income and middle-income countries such as Uganda.

A cost study for mobile phone health surveys using interactive voice response for assessing risk factors of noncommunicable diseases.

BACKGROUND: This is the first study to examine the costs of conducting a mobile phone survey (MPS) through interactive voice response (IVR) to collect information on risk factors for noncommunicable diseases (NCD) in three low- and middle-income countries (LMIC); Bangladesh, Colombia, and Uganda. METHODS: This is a micro-costing study conducted from the perspective of the payer/funder with a 1-year horizon. The study evaluates the fixed costs and variable costs of implementing one nationally representative MPS for NCD risk factors of the adult population. In this costing study, we estimated the sample size of calls required to achieve a population-representative survey and associated incentives. Cost inputs were obtained from direct economic costs incurred by a central study team, from country-specific collaborators, and from platform developers who participated in the deployment of these MPS during 2017. Costs were reported in US dollars (USD). A sensitivity analysis was conducted assessing different scenarios of pricing and incentive strategies. Also, costs were calculated for a survey deployed targeting only adults younger than 45 years. RESULTS: We estimated the fixed costs ranging between $47,000 USD and $74,000 USD. Variable costs were found to be between $32,000 USD and $129,000 USD per nationally representative survey. The main cost driver was the number of calls required to meet the sample size, and its variability largely depends on the extent of mobile phone coverage and access in the country. Therefore, a larger number of calls were estimated to survey specific harder-to-reach sub-populations. CONCLUSION: Mobile phone surveys have the potential to be a relatively less expensive and timely method of collecting survey information than face-to-face surveys, allowing decision-makers to deploy survey-based monitoring or evaluation programs more frequently than it would be possible having only face-to-face contact. The main driver of variable costs is survey time, and most of the variability across countries is attributable to the sampling differences associated to reaching out to population subgroups with low mobile phone ownership or access.

Curbing the Rise of Noncommunicable Diseases in Uganda: Perspectives of Policy Actors.

BACKGROUND: Uganda faces a complex policy landscape as it simultaneously addresses infectious diseases and noncommunicable diseases (NCDs). The health system has been overwhelmed by the growing burden of NCDs across all socioeconomic strata. In this study, we sought to understand the policy context around NCDs in Uganda, the roles of actors both within and external to the government, and the factors shaping the development and implementation of NCD policies and programs in Uganda. METHODS: We conducted in-depth interviews with 30 policy actors from the Ugandan Ministry of Health (MOH), nongovernmental organizations, and academia to understand the roles of different actors in the Ugandan NCD space, the programs and policy measures in discussion, and how to bridge any identified gaps. A thematic data analysis was conducted. RESULTS: All national actors viewed funding constraints as a critical barrier to developing and executing an NCD strategic plan and as a barrier to leading and coordinating NCD prevention and control efforts in Uganda. The crowding of nongovernment actors was found to fragment NCD efforts, particularly due to the weak implementation of a framework for action among NCD actors. Relatedly, limited recruitment of technical experts on NCDs within the MOH was viewed to further diminish the government's role in leading policy and program formulation and implementation. Though recent MOH efforts have aimed at addressing these concerns, some skepticism remains about the government's commitment to increase budgetary allocations for NCDs and to address the technical and human resources gaps needed to achieve NCD policy aims in Uganda. CONCLUSIONS: This study highlights the immediate need to mobilize more resources, reduce fragmented efforts in the NCD space, and prioritize investment in NCD prevention and management in Uganda.

Informed Consent for Mobile Phone Health Surveys in Colombia: A Qualitative Study.

Public health surveys deployed through automated mobile phone calls raise a set of ethical challenges, including succinctly communicating information necessary to obtain respondent informed consent. This study aimed to capture the perspectives of key stakeholders, both experts and community members, on consent processes and preferences for participation in automated mobile phone surveys (MPS) of non-communicable disease risk factors in Colombia. We conducted semi-structured interviews with ethics and digital health experts and focus group discussions with community representatives. There was meaningful disagreement within both groups regarding the necessity of consent, when the purpose of a survey is to contribute to the formulation of public policies. Respondents who favored consent emphasized that consent communications ought to promote understanding and voluntariness, and implicitly suggested that information disclosure conform to a reasonable person standard. Given the automated and unsolicited nature of the phone calls and concerns regarding fraud, trust building was emphasized as important, especially for national MPS deployment. Community sensitization campaigns that provide relevant contextual information (such as the name of the administering institution) were thought to support trust-building. Additional ways to achieve the goals of consent while building trust in automated MPS for disease surveillance should be evaluated in order to inform ethical and effective practice.

Measuring child functioning: Assessing correlation and agreement between caregiver and child responses at the Iganga-Mayuge health and demographic surveillance site in Uganda.

INTRODUCTION: Empirical data is scare on assessment of concordance between caregiver-child responses on child functioning. OBJECTIVE: To assess correlation and agreement between children (11-17 years old) and their caregivers' responses to the UNICEF/Washington Group Child Functioning Module (CFM) at the Iganga-Mayuge Health and Demographic Surveillance Site (IM-HDSS) in Uganda. METHODS: CFM with 24-questions corresponding to 13 domains of functioning was administered to children between 11 and 17 years of age and their caregivers. Descriptive analyses of the child/caregiver responses were conducted. Correlation and agreement between caregiver and child responses were assessed. RESULTS: Of the 217 caregiver/child pairs eligible for this study, 181 pairs agreed to participate (83.4%). The mean age of children was 13.9 ± 1.9 years, and 56.4% were males. Cronbach's alpha was 0.892 and 0.886 for the caregiver and child versions of CFM respectively, showing good internal consistency in both. There was a significant overall agreement between mean score of caregiver (5.36 ± 5.63 out of 39) and child (5.45 ± 5.34) pairs. Spearman's rank correlation between the pairs was 0.806 (strong positive correlation). Bland-Altman plots for CFM scores showed greater agreement between caregiver and child at lower scores. Percentage agreement between the pairs for overall disability was greater for mild (83.53%) and moderate (79.37%) categories as compared to the severe (66.67%) category. There was substantial agreement (kappa 0.623) for overall disability between the pairs. CONCLUSION: This study indicates that there is significant correlation and agreement between self-reported caregiver-child pair responses, opening the way for considering children as CFM respondents, when possible.

User Perceptions and Experiences of an Interactive Voice Response Mobile Phone Survey Pilot in Uganda: Qualitative Study.

BACKGROUND: With the growing burden of noncommunicable diseases in low- and middle- income countries, the World Health Organization recommended a stepwise approach of surveillance for noncommunicable diseases. This is expensive to conduct on a frequent basis and using interactive voice response mobile phone surveys has been put forth as an alternative. However, there is limited evidence on how to design and deliver interactive voice response calls that are robust and acceptable to respondents. OBJECTIVE: This study aimed to explore user perceptions and experiences of receiving and responding to an interactive voice response call in Uganda in order to adapt and refine the instrument prior to national deployment. METHODS: A qualitative study design was used and comprised a locally translated audiorecorded interactive voice response survey delivered in 4 languages to 59 purposively selected participants' mobile phones in 5 survey rounds guided by data saturation. The interactive voice response survey had modules on sociodemographic characteristics, physical activity, fruit and vegetable consumption, diabetes, and hypertension. After the interactive voice response survey, study staff called participants back and used a semistructured interview to collect information on the participant's perceptions of interactive voice response call audibility, instruction clarity, interview pace, language courtesy and appropriateness, the validity of questions, and the lottery incentive. Descriptive statistics were used for the interactive voice response survey, while a framework analysis was used to analyze qualitative data. RESULTS: Key findings that favored interactive voice response survey participation or completion included preference for brief surveys of 10 minutes or shorter, preference for evening calls between 6 PM and 10 PM, preference for courteous language, and favorable perceptions of the lottery-type incentive. While key findings curtailing participation were suspicion about the caller's identity, unclear voice, confusing skip patterns, difficulty with the phone interface such as for selecting inappropriate digits for both ordinary and smartphones, and poor network connectivity for remote and rural participants. CONCLUSIONS: Interactive voice response surveys should be as brief as possible and considerate of local preferences to increase completion rates. Caller credibility needs to be enhanced through either masking the caller or prior community mobilization. There is need to evaluate the preferred timing of interactive voice response calls, as the finding of evening call preference is inconclusive and might be contextual.

Implementation of global health competencies: A scoping review on target audiences, levels, and pedagogy and assessment strategies.

BACKGROUND: As the field of global health expands, the recognition of structured training for field-based public health professionals has grown. Substantial effort has gone towards defining competency domains for public health professionals working globally. However, there is limited literature on how to implement competency-based training into learning curricula and evaluation strategies. OBJECTIVES: This scoping review seeks to collate the current status, degree of consensus, and best practices, as well as gaps and areas of divergence, related to the implementation of competencies in global health curricula. Specifically, we sought to examine (i) the target audience, (ii) the levels or milestones, and (iii) the pedagogy and assessment approaches. SOURCES OF EVIDENCE: A review of the published and grey literature was completed to identify published and grey literature sources that presented information on how to implement or support global health and public health competency-based education programs. In particular, we sought to capture any attempts to assign levels or milestones, any evaluation strategies, and the different pedagogical approaches. RESULTS: Out of 68 documents reviewed, 21 documents were included which contained data related to the implementation of competency-based training programs; of these, 18 were peer-reviewed and three were from the grey literature. Most of the sources focused on post-graduate public health students, professional trainees pursuing continuing education training, and clinical and allied health professionals working in global health. Two approaches were identified to defining skill level or milestones, namely: (i) defining levels of increasing ability or (ii) changing roles across career stages. Pedagogical approaches featured field experience, direct engagement, group work, and self-reflection. Assessment approaches included self-assessment surveys, evaluations by peers and supervisors, and mixed methods assessments. CONCLUSIONS: The implementation of global health competencies needs to respond to the needs of specific agencies or particular groups of learners. A milestones approach may aide these efforts while also support monitoring and evaluation. Further development is needed to understand how to assess competencies in a consistent and relevant manner.

Adaptation and validation of UNICEF/Washington group child functioning module at the Iganga-Mayuge health and demographic surveillance site in Uganda.

BACKGROUND: The UNICEF/Washington Group Child Functioning Module (CFM) assesses child functioning among children between 5 and 17 years of age. This study adapted and validated the CFM at the Iganga-Mayuge Health and Demographic Surveillance Site (IM-HDSS) in Uganda. METHODS: This cross-sectional study was conducted between September 2018-January 2019 at the IM-HDSS. Respondents were caregivers of children between 5 and 17 years of age who were administered modified Washington Group short set (mWG-SS) and CFM. The responses were recorded on a 4-point Likert scale. Descriptive analysis was conducted on child and caregiver demographic characteristics. Exploratory factor analysis (EFA) assessed underlying factor structure, dimensionality and factor loadings. Cronbach's alpha was reported as an assessment of internal consistency. Face validity was assessed during the translation process, and concurrent validity of CFM was assessed through comparison with disability short form. RESULTS: Out of 1842 caregivers approached, 1439 (78.1%) participated in the study. Mean age of children was 11.06 ± 3.59 years, 51.4% were males, and 86.1% had a primary caregiver. Based on EFA, vision, hearing, walking, self-care, communication, learning, remembering, concentrating, accepting change, behavior control, and making friends loaded on factor 1 - "Motor and Cognition," while anxiety and depression loaded on factor 2 - "Mood". Cronbach's alpha for the overall CFM was 0.899 (good internal consistency). Cronbach's alpha for each extracted factor was excellent, motor and cognition (0.904), and mood (0.902). CFM had acceptable face validity. Spearman's rank correlation between scores of CFM and modified WG short set was 0.51 (p-value < 0.001). The overall mean CFM score was 2.47 ± 3.82 out of 39. The mean score for Mood (1.35 ± 1.42 out of 6) was higher compared to Motor and Cognition (1.12 ± 3.06 out of 33). Comparing modified WG short set and CFM Likert responses, the percent agreement was greatest for "cannot do at all." CONCLUSION: CFM is a two-factor, valid and reliable scale for assessing disability in Uganda and can be applied to other similar settings to contribute towards disability data from the region. It is an easy-to-administer tool that can help in deeper understanding of context-specific burden and extent of disability in children between 5 and 17 years of age.