Implementing the QUALI-DEC project in Argentina, Burkina Faso, Thailand and Viet Nam: a process delineation and theory-driven process evaluation protocol.

The project 'Quality Decision-making by women and providers' (QUALI-DEC) combines four non-clinical interventions to promote informed decision-making surrounding mode of birth, improve women's birth experiences, and reduce caesarean sections among low-risk women. QUALI-DEC is currently being implemented in 32 healthcare facilities across Argentina, Burkina Faso, Thailand, and Viet Nam. In this paper, we detail implementation processes and the planned process evaluation, which aims to assess how and for whom QUALI-DEC worked, the mechanisms of change and their interactions with context and setting; adaptations to intervention and implementation strategies, feasibility of scaling-up, and cost-effectiveness of the intervention. We developed a project theory of change illustrating how QUALI-DEC might lead to impact. The theory of change, together with on the ground observations of implementation processes, guided the process evaluation strategy including what research questions and perspectives to prioritise. Main data sources will include: 1) regular monitoring visits in healthcare facilities, 2) quantitative process and output indicators, 3) a before and after cross-sectional survey among post-partum women, 4) qualitative interviews with all opinion leaders, and 5) qualitative interviews with postpartum women and health workers in two healthcare facilities per country, as part of a case study approach. We foresee that the QUALI-DEC process evaluation will generate valuable information that will improve interpretation of the effectiveness evaluation. At the policy level, we anticipate that important lessons and methodological insights will be drawn, with application to other settings and stakeholders looking to implement complex interventions aiming to improve maternal and newborn health and wellbeing.Trial registration: ISRCTN67214403.

Provision and utilization of maternal health services during the COVID-19 pandemic in 16 hospitals in sub-Saharan Africa.

Objective: Maintaining provision and utilization of maternal healthcare services is susceptible to external influences. This study describes how maternity care was provided during the COVID-19 pandemic and assesses patterns of service utilization and perinatal health outcomes in 16 referral hospitals (four each) in Benin, Malawi, Tanzania and Uganda. Methods: We used an embedded case-study design and two data sources. Responses to open-ended questions in a health-facility assessment survey were analyzed with content analysis. We described categories of adaptations and care provision modalities during the pandemic at the hospital and maternity ward levels. Aggregate monthly service statistics on antenatal care, delivery, caesarean section, maternal deaths, and stillbirths covering 24 months (2019 and 2020; pre-COVID-19 and COVID-19) were examined. Results: Declines in the number of antenatal care consultations were documented in Tanzania, Malawi, and Uganda in 2020 compared to 2019. Deliveries declined in 2020 compared to 2019 in Tanzania and Uganda. Caesarean section rates decreased in Benin and increased in Tanzania in 2020 compared to 2019. Increases in maternal mortality ratio and stillbirth rate were noted in some months of 2020 in Benin and Uganda, with variability noted between hospitals. At the hospital level, teams were assigned to respond to the COVID-19 pandemic, routine meetings were cancelled, and maternal death reviews and quality improvement initiatives were interrupted. In maternity wards, staff shortages were reported during lockdowns in Uganda. Clinical guidelines and protocols were not updated formally; the number of allowed companions and visitors was reduced. Conclusion: Varying approaches within and between countries demonstrate the importance of a contextualized response to the COVID-19 pandemic. Maternal care utilization and the ability to provide quality care fluctuated with lockdowns and travel bans. Women's and maternal health workers' needs should be prioritized to avoid interruptions in the continuum of care and prevent the deterioration of perinatal health outcomes.

Children Immunization App (CIMA): A Non-randomized Controlled Trial Among Syrian Refugees in Zaatari Camp, Jordan.

Approximately 20 million children are not vaccinated, especially among refugees. There is a growing access to smartphones, among refugees, which can help in improving their vaccination. We assessed the impact of an app for the vaccination follow-up visit among refugees in Jordan. We developed an app and tested it through a non-randomized trial at the Zaatari refugees camp in Jordan. The study was conducted during March - December 2019 at three vaccination clinics inside the camp. The study included two study groups (intervention and control groups) for refugees living at the camp. The intervention group included parents who own an Android smartphone and have one newborn that require between one and four first vaccination doses and they accepted to participate in the study, during their regular visit to the vaccination clinics. The control group was for the usual care. We compared both study groups for returning back to one follow-up visit, using Kaplan-Meier survival analysis. We recruited 936 babies (n = 471; 50.3% in the intervention group, both study groups were similar at baseline). The majority of mothers were literate (94.2%) with a median age of 24. The majority of the babies had a vaccination card (n = 878, 94%). One quarter (26%) of mother-babies pairs of the intervention group came back within one week (versus 22% for control group); When it comes to lost-follow-up, 22% and 28% did not have a history of returning back (intervention and control groups respectively, p = 0.06) (Relative risk reduction: 19%). The Kaplan-Meier Survival Analysis showed a statistically significant progressive reduction in the duration of coming back late for the follow-up vaccine visit. We tested a vaccination app for the first time, in a refugee population setting. The app can be used as a reminder for parents to come back on time for their children's vaccine follow-up visits.

Scaling the Children Immunization App (CIMA) to Support Child Refugees and Parents in the Time of the COVID-19 Pandemic: A Social Capital Approach to Scale a Smartphone Application in Zaatari Camp, Jordan.

BACKGROUND: Children vaccination is a key intervention for their survival, especially among refugees. Yet, children vaccination registration is done manually in refugees camps and there is no possibility to send reminders to parents to come back on time. We aimed to boost the parental registration of children's vaccination records on a Children Immunization app (CIMA) while also availing the parents with useful parenting skills under COVID-19-related stress. METHODS: We incorporated United Nations Office on Drugs and Crime (UNODC) Parenting Skills under COVID-19 information material, through CIMA in Arabic and English languages. We recruited 1100 children in February-March 2021, through a community health promotion dissemination approach. A team of two nurses from the local population and two volunteers (one trained nurse and one trained social worker), from the camp, was formed. They promoted the CIMA app at two clinics and through households visits in Zaatari refugee camp. Qualitative data on impressions and observations of the interactions with the Zaatari camp community were also collected. RESULTS: A total of 1100 children, up to 15 months of age, eligible for vaccination were enrolled in CIMA, whereby the staff explained the content of the app in terms of vaccination schedule, health promotion materials for vaccination and parenting skills to their caregivers. During the household visits, the volunteers identified a total of 70 children that have incomplete history of vaccination records (n = 42/70 girls, 60%). Also, opportunities and challenges for scaling the app were documented. CONCLUSION: The scaling of CIMA as an innovative means of dissemination of risk and health information in challenging context such as refugee camps was feasible. In the context of vaccination needs for children, in refugee settings, such a need is more eminent, particularly in the context of COVID-19.

Structural barriers to knowledge transfer and exchange among men and women in low-, middle- and high-income countries: an international cross-sectional study with vaccine researchers in 44 countries.

BACKGROUND: Globally, women constitute 30% of researchers. Despite an increasing proportion of women in research, they are still less likely to have international collaborations. Literature on barriers to knowledge transfer and exchange (KTE) between men and women remains limited. This study aimed to assess perceived gender barriers to KTE activities in vaccination-related research in low-, middle- and high-income countries. METHODS: This was a cross-sectional data assessment from a self-administered questionnaire distributed to researchers in the field of vaccination research. The administered questionnaire was developed and validated by WHO and McMaster University. Descriptive statistics were carried out. Structural factors of KTE were assessed using 12 statements measured with a five-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). An index ranging from 12 to 60 points was created to assess structural factors of KTE, with higher score indicating fewer perceived barriers. Multivariable linear regression modelling was applied to examine the association between KTE barriers and gender. RESULTS: A total of 158 researchers were included in the analysis. Regardless of gender and country of affiliation, researchers experienced challenges with respect to KTE activities; particularly factors related to the availability of human and financial resources and level of technical expertise among their target audience. We were also able to identify perceived facilitators among men and women, such as the presence of structures that link researchers and target audiences, the investment of target audiences in KTE efforts and the presence of stable contacts among target audiences. Our linear regression analysis showed that women perceived more barriers than men (R2 = 0.014; B = -1.069; 95% CI -4.035; 1.897). CONCLUSIONS: Men and women shared common perspectives on barriers to KTE. KTE activities could be strengthened by improving structural efforts to reduce gender differences and increase collaborations between researchers and their target audience.

Children Immunization App (CImA), Low-Cost Digital Solution for Supporting Syrian Refugees in Zaatari Camp in Jordan - General Description.

Mobile applications (apps) can improve health outcomes. In this study, we have described an app developed for documenting the history of vaccination among Syrian children in one of the largest refugees' camps in the Middle East region. This app includes health education information and automated reminders for parents, using a visual tool for parents with low literacy level. We have emphasized on the usability and technical concerns and have described the interdependency of technical and human considerations for such health app solution in a marginalized context.

Barriers to post exposure prophylaxis use among men who have sex with men in sub-Saharan Africa: An online cross-sectional survey.

BACKGROUND: Curbing new HIV infections among MSM in SSA remains problematic, due to cultural beliefs, norms that oppose same-sex acts, and criminalization of same-sex acts. No study focused on barriers to PEP use in SSA region has been conducted. Our study focused on identifying barriers to Post-Exposure Prophylaxis (PEP) use among MSM in sub-Saharan Africa (SSA). METHODS: An online cross-sectional survey was sent out to members of 14 Lesbian, Gay, Transgender, Bisexual, Queer (LGBTQ) associations in SSA, to identify barriers to PEP utilization in MSM. A total of 207 MSM from 22 countries in SSA completed the survey between 8 January 2019 and 23 February 2019. Descriptive statistics were generated, chi-square and backward stepwise logistic regression analysis were performed to evaluate the association between the outcome "PEP use" and other variables. RESULTS: Most of the MSM were aged 18 to 30, and the majority (220, 74.6%) described themselves as gay. Rwanda had the highest number of respondents (117, 39.7% of the total), followed by Nigeria, Ghana and South-Africa.The majority of respondents reported having heard about PEP (234, 80.7%), and the average PEP correct knowledge level was 59%.Five characteristics were associated with increased odds of using PEP: Age, having vocational education, having heard of PEP, knowledge of where to get PEP, and having been refused housing. CONCLUSION: There is a need for a collaborative effort between policy makers, key players in HIV prevention, and MSM associations in SSA to remove barriers to PEP uptake to promote optimal PEP utilization amongst MSM.

Children Immunization App (CImA) Among Syrian Refugees in Zaatari Camp, Jordan: Protocol for a Cluster Randomized Controlled Pilot Trial Intervention Study.

BACKGROUND: There are up to 19.4 million children who are still unvaccinated and face unnecessary deaths, especially among refugees. However, growing access to smartphones, among refugees, can be a leading factor to improve vaccination rates. OBJECTIVE: This study aims to determine whether a smartphone app can improve the vaccination uptake among refugees and determine the app's effectiveness in improving the documentation of vaccination records. METHODS: We developed and planned to test an app through a cluster randomized trial that will be carried out at the Zaatari refugee camp in Jordan. The study will be open to all parents who carry Android smartphones, have at least one child, and agree to participate in the study. The parents will be recruited to the study by trained volunteers at the vaccination sites around the Zaatari camp. Inclusion criteria will be the following: having at least one child of 0 to 5 years, being a local resident of the camp, and having an Android smartphone. RESULTS: The intervention includes an app that will allow storing Jordanian vaccination records, per child, on the parents' smartphones in Arabic and English (in an interchangeable fashion). Every record will have a set of automated reminders before the appointment of each child. The app will summarize immunization records in form of due, taken, or overdue appointments, labeled in orange, green, and red, respectively. Baseline will include the collection of our primary and secondary outcomes that are needed for the pre and postdata measurements. This includes social demographic data, any previous vaccination history, and electronic health literacy. Participants, in both study arms, will be monitored for their follow-up visits to the clinic for vaccination doses. For the study outcome measures, we will measure any differences in the uptake of vaccinations. The secondary outcome is to analyze the effect of the children immunization app on visits for follow-up doses. CONCLUSIONS: Owing to the limited evidence of effective interventions for childhood vaccination among refugees, research in this area is greatly needed. The project will have a significant impact on the health of refugees and the public health system. In Jordan and the Middle East, the vaccination level is low. Given the influx of refugees from the area, it is crucial to ensure a high vaccination level among the children. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/13557.

Effectiveness of digital technologies at improving vaccine uptake and series completion - A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Recent outbreaks and renewed concerns about immunization coverage call for new and effective interventions to improve vaccine uptake. Digital technologies have the potential to help address both suboptimal vaccine uptake and series completion. However, the effectiveness of pushing information and reminders to patients through digital technologies to address vaccination is not known. OBJECTIVE(S): The aim of this study is to determine if digital push interventions are effective in increasing vaccine uptake and series completion compared to non-digital interventions. METHODS: We searched for RCTs where adults or parents of children were eligible for vaccination, the intervention was digital-push and the comparison group was non-digital. We included outcomes of vaccine uptake or series completion. We estimated summary effect sizes, heterogeneity using the χ2 test and quantified using the I2 statistic. Where heterogeneity remained significant, we conducted subgroup analyses. We assessed risk of bias, certainty of evidence and publication bias. RESULTS: The search identified 159 peer-reviewed scientific publications. After review, a total of 12 manuscripts representing 13 empirical studies published between 2012 and 2016 were included. When comparing digital push interventions to non-digital ones, patients had 1.18[1.11,1.25] the odds of receiving vaccination or series completion compared to controls. In parents of children aged 18 and younger, those receiving digital push had a 1.22[1.15,1.30] increased odds compared to controls. Both analyses had high statistical heterogeneity, with I2 values of 86% and 79% respectively. The risk of bias was low with 10 of 13 studies considered low risk in five or more domains. The certainty of evidence for series completion was very low and for vaccine uptake was assessed to be moderate. CONCLUSION: This study provides evidence that digital push technologies have a modest, positive impact on vaccine uptake and series completion compared to non-digital interventions.