Browsing by Author "LeFevre, Amnesty"

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    Open Access
    Are stage-based health information messages effective and good value for money in improving maternal newborn and child health outcomes in India? Protocol for an individually randomized controlled trial
    (2019-05-15) LeFevre, Amnesty; Agarwal, Smisha; Chamberlain, Sara; Scott, Kerry; Godfrey, Anna; Chandra, Rakesh; Singh, Aditya; Shah, Neha; Dhar, Diva; Labrique, Alain; Bhatnagar, Aarushi; Mohan, Diwakar
    Background Evidence is limited on the effectiveness of mobile health programs which provide stage-based health information messages to pregnant and postpartum women. Kilkari is an outbound service that delivers weekly, stage-based audio messages about pregnancy, childbirth, and childcare directly to families in 13 states across India on their mobile phones. In this protocol we outline methods for measuring the effectiveness and cost-effectiveness of Kilkari. Methods The study is an individually randomized controlled trial (iRCT) with a parallel, partially concurrent, and unblinded design. Five thousand pregnant women will be enrolled from four districts of Madhya Pradesh and randomized to an intervention or control arm. The women in the intervention arm will receive Kilkari messages while the control group will not receive any Kilkari messages as part of the study. Women in both arms will be followed from enrollment in the second and early third trimesters of pregnancy until one year after delivery. Differences in primary outcomes across study arms including early and exclusive breastfeeding and the adoption of modern contraception at 1 year postpartum will be assessed using intention to treat methodology. Surveys will be administered at baseline and endline containing modules on phone ownership, geographical and demographic characteristics, knowledge, practices, respectful maternity care, and coverage for antenatal care, delivery, and postnatal care. In-depth interviews and focus group discussions will be carried out to understand user perceptions of Kilkari, and more broadly, experiences providing phone numbers and personal health information to health care providers. Costs and consequences will be estimated from a societal perspective for the 2018–2019 analytic time horizon. Discussion Kilkari is the largest maternal messaging program, in terms of absolute numbers, currently being implemented globally. Evaluations of similar initiatives elsewhere have been small in scale and focused on summative outcomes, presenting limited evidence on individual exposure to content. Drawing upon system-generated data, we explore linkages between successful receipt of calls, user engagement with calls, and reported outcomes. This is the first study of its kind in India and is anticipated to provide the most robust and comprehensive evidence to date on maternal messaging programs globally. Trial registration Clinicaltrials.gov, 90075552, NCT03576157 . Registered on 22 June 2018.
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    Open Access
    Digital tools for training frontline health workers in low and middle-income countries: A systematic review
    (2019) Schoeman, Fransien; Swartz, Alison; LeFevre, Amnesty
    The World Health Organization (WHO) has forecast a global shortage of health workers by 2030, predominantly affecting low- and middle-income countries (LMICs). This sits in tension with the United Nations’ (UN) Sustainable Development Goal 3 (healthy lives and well-being) through universal health coverage (UHC). To address this problem, the WHO encourages task shifting, recruitment, training, and deployment of health workers. In lowand middle-income countries (LMICs), frontline health workers (FLHWs) are responsible for expanding the reach of the health system and providing crucial reproductive, maternal, newborn and child health (RMNCH) services. Adequate and appropriate training is fundamental to the success of FLHWs, particularly in contexts where their scope of work may evolve or expand over time. Digital health solutions (defined as the use of digital, mobile and wireless technologies to support the achievement of health objectives) are increasingly being used to support the training of FLHWs. Strategies may rely on use of digital tools, including mobile phones, as the primary modality for training or as tools which augment traditional face-to-face instruction. Digital health has potential for FLHW training as it allows for listening, learning and teaching through interactive health content accessible even on basic mobile phones. This dissertation explored the literature on FLHWs in LMICs, digital health in LMICs, digital health used by FLHWs, and digital health used for training of FLHWs in LMICs. The journal “ready” component is a systematic review which discusses the various aspects of digital training for FLHWs in LMICs. For the purposes of the systematic review, seven electronic databases were searched for articles published in English from 2008-2018. Combinations of medical subheadings (MeSH) that were used were: “mHealth”, “health worker”, “community health worker” and “low- and middle-income country”. From a total of 2628 identified studies, abstracts were screened with four filters to identify studies about “training”, and eventually a total of 16 studies were included. The included studies were critically appraised and coded descriptively to enable a narrative synthesis of findings. Of the sixteen studies, twelve used mobile and/or smartphones for FLHW training. A wide range of digital platforms were used to provide information (and where relevant enable interaction). Duration of training programs varied from five days to six months. Training content was relevant to the various health services and practice areas the FLHWs worked in. Training focused on continuing education through in-service training of new content or in-service refresher courses. Three training pedagogies were used: 1) didactic training techniques – in four studies information was provided passively without an interactive component; 2) interactive training techniques – six studies used platforms to provide information along with an interactive component via multi-media; and, 3) blended-learning approach – six studies delivered training via didactic and interactive approaches by combining live and distance training. Consistent with the literature review, all studies reported increased knowledge and positive perceptions of digital health for FLHW training. Interactive and blended learning approaches, especially when accessed through mHealth technologies, are feasible, effective, appropriate, cost effective and scalable in LMICs. The conclusion from the literature and systematic reviews were that long-term effects (e.g. change in behaviour, improved service provision) need to be researched further.
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    Program assessment of efforts to improve the quality of postpartum counselling in health centers in Morogoro region, Tanzania
    (BioMed Central, 2018-07-04) LeFevre, Amnesty; Mpembeni, Rose; Kilewo, Charles; Yang, Ann; An, Selena; Mohan, Diwakar; Mosha, Idda; Besana, Giulia; Lipingu, Chrisostom; Callaghan-Koru, Jennifer; Silverman, Marissa; Winch, Peter J; George, Asha S
    Background The postpartum period represents a critical window where many maternal and child deaths occur. We assess the quality of postpartum care (PPC) as well as efforts to improve service delivery through additional training and supervision in Health Centers (HCs) in Morogoro Region, Tanzania. Methods Program implementers purposively selected nine program HCs for assessment with another nine HCs in the region remaining as comparison sites in a non-randomized program evaluation. PPC quality was assessed by examining structural inputs; provider and client profiles; processes (PNC counselling) and outcomes (patient knowledge) through direct observations of equipment, supplies and infrastructure (n = 18) and PPC counselling (n = 45); client exit interviews (n = 41); a provider survey (n = 62); and in-depth provider interviews (n = 10). Results While physical infrastructure, equipment and supplies were comparable across study sites (with water and electricity limitations), program areas had better availability of drugs and commodities. Overall, provider availability was also similar across study sites, with 63% of HCs following staffing norms, 17% of Reproductive and Child Health (RCH) providers absent and 14% of those providing PPC being unqualified to do so. In the program area, a median of 4 of 10 RCH providers received training. Despite training and supervisory inputs to program area HCs, provider and client knowledge of PPC was low and the content of PPC counseling provided limited to 3 of 80 PPC messages in over half the consultations observed. Among women attending PPC, 29 (71%) had delivered in a health facility and sought care a median of 13 days after delivery. Barriers to PPC care seeking included perceptions that PPC was of limited benefit to women and was primarily about child health, geographic distance, gaps in the continuity of care, and harsh facility treatment. Conclusions Program training and supervision activities had a modest effect on the quality of PPC. To achieve broader transformation in PPC quality, client perceptions about the value of PPC need to be changed; the content of recommended PPC messages reviewed along with the location for PPC services; gaps in the availability of human resources addressed; and increased provider-client contact encouraged.