Developing targeted client communication messages to pregnant women in Bangladesh: a qualitative study

AbstractBackground:Timely and appropriate evidence-based practices during antenatal care improve maternal andneonatal health. There is a lack of information on how pregnant women and families perceive antenatal care inBangladesh. The aim of our study was to develop targeted client communication via text messages for increasingantenatal care utilization, as part of an implementation of an electronic registry for maternal and child health.Methods:Using a phenomenological approach, we conducted this qualitative study from May to June 2017 in two sub-districts of Chandpur district, Bangladesh. We selected study participants by purposive sampling. A total of 24 in-depthinterviews were conductedwithpregnantwomen(n= 10), lactating women (n=5),husbands(n= 5), and mothers-in-law(n= 4). The Health Belief Model (HBM) was used to guide the datacollection. Thematic analysis was carried out manuallyaccording to the HBM constructs. We used behavior change techniques to inform the development of targeted clientcommunication based on the thematic results.Results:Almost no respondents mentioned antenatal care as a preventive form of care, and only perceived it as necessary ifany complications developed during pregnancy. Knowledge of the content of antenatal care (ANC) and pregnancycomplications was low. Women reported avariety of reasons for not attending ANC, including the lack of information onthe timing of ANC; lack of decision-making power; long-distance to access care; being busy with household chores, and notbeing satisfied with the treatment by health care providers. Study participants recommended phone calls as their preferredcommunication strategy when asked to choose between thephone call and text message, but saw text messages as afeasible option. Based on the findings, we developed a library of 43 automatically customizable text messages to increaseANC utilization.Conclusions:Pregnant women and family members had limited knowledge about antenatal care and pregnancycomplications. Effective health information through text messages could increase awareness of antenatal careamong the pregnant women in Bangladesh. This study presents an example of designing targeted clientcommunication to increase antenatal care utilization within formal scientific frameworks, including a taxonomy ofbehavior change techniques.publishedVersio

A digital health registry with clinical decision support for improving quality of antenatal care in Palestine (eRegQual): a pragmatic, cluster-randomised, controlled, superiority trial

Background Health worker compliance with clinical guidelines is enhanced by digital clinical decision support at the point of care. The Palestinian public health system is implementing a digital maternal and child health eRegistry with clinical decision support. We aimed to compare the quality of antenatal care between clinics using the eRegistry and those using paper-based records. Methods The eRegQual cluster-randomised controlled trial was done in primary health-care clinics offering routine antenatal care in the West Bank, Palestine. The intervention was the eRegistry with clinical decision support for antenatal care, implemented in District Health Information Systems 2 (DHIS2) Tracker software. 133 clinics forming 120 clusters were included and randomised; clusters were randomly assigned (1:1) to either the control (paper-based documentation) or intervention (eRegistry with clinical decision support) groups. The primary process outcomes were appropriate screening and management of anaemia, hypertension, and diabetes during pregnancy and foetal growth monitoring. The primary health outcome at delivery was a composite of moderate or severe anaemia; severe hypertension; large-for-gestational-age baby; malpresentation and small-for-gestational-age baby undetected before delivery. Data were analysed with mixed-effects logistic regression, accounting for clustering within clinics and pregnancies as appropriate. This trial is registered with the ISRCTN registry (ISRCTN18008445). Findings Between Jan 15 and Sept 15, 2017, 3219 pregnant women received care in the intervention clinics (n=60 clusters) and 3148 pregnant women received care in the control primary health-care clinics (n=59 clusters). Compared with the control group, the intervention led to higher guideline adherence for screening and management of anaemia (1535 [28·9%] of 5320 vs 2297 [44·3%] of 5182; adjusted odds ratio [OR] 1·88 [95% CI 1·52–2·32]), hypertension (7555 [94·7%] of 7982 vs 7314 [96·6%] of 7569; adjusted OR 1·62 [95% CI 1·29–2·05]), and gestational diabetes (1726 (39·7%) of 4348 vs 2189 (50·7%) of 4321; adjusted OR 1·45 [95% CI 1·14–1·83]) at eligible antenatal contacts. Only 599 (9·4%) of 6367 women attended the full antenatal care schedule, and better care provision did not translate to fewer adverse health outcomes in the intervention clusters (700 cases; 21·7%) compared to the control clusters (688 cases; 21·9%; adjusted OR 0·99; 95% CI 0·87–1·12). Interpretation Clinical decision support for antenatal care in the eRegistry was superior for most process outcomes but had no effect on the adverse health outcomes. The improvements in process outcomes strengthen the evidence for the WHO guideline for digital client tracking with clinical decision support in lower-middle-income settings. Digital health interventions to address gaps in attendance might help achieve effective coverage of antenatal care.publishedVersio

An Electronic Registry for Improving the Quality of Antenatal Care in Rural Bangladesh (eRegMat): Protocol for a Cluster Randomized Controlled Trial

Background: Digital health interventions (DHIs) can alleviate several barriers to achieving better maternal and child health. The World Health Organization’s guideline recommendations for DHIs emphasize the need to integrate multiple DHIs for maximizing impact. The complex health system of Bangladesh provides a unique setting for evaluating and understanding the role of an electronic registry (eRegistry) for antenatal care, with multiple integrated DHIs for strengthening the health system as well as improving the quality and utilization of the public health care system. Objective: The aim of this study is to assess the effect of an eRegistry with DHIs compared with a simple digital data entry tool without DHIs in the community and frontline health facilities. Methods: The eRegMat is a cluster-randomized controlled trial conducted in the Matlab North and Matlab South subdistricts in the Chandpur district, Bangladesh, where health facilities are currently using the eRegistry for digital tracking of the health status of pregnant women longitudinally. The intervention arm received 3 superimposed data-driven DHIs: health worker clinical decision support, health worker feedback dashboards with action items, and targeted client communication to pregnant women. The primary outcomes are appropriate screening as well as management of hypertension during pregnancy and timely antenatal care attendance. The secondary outcomes include morbidity and mortality in the perinatal period as well as timely first antenatal care visit; successful referrals for anemia, diabetes, or hypertension during pregnancy; and facility delivery. Results: The eRegistry and DHIs were co-designed with end users between 2016 and 2018. The eRegistry was implemented in the study area in July 2018. Recruitment for the trial started in October 2018 and ended in June 2020, followed by an 8-month follow-up period to capture outcome data until February 2021. Trial results will be available for publication in June 2021. Conclusions: This trial allows the simultaneous assessment of multiple integrated DHIs for strengthening the health system and aims to provide evidence for its implementation. The study design and outcomes are geared toward informing the living review process of the guidelines for implementing DHIs.publishedVersio

HYDROLOGICAL STUDIES OF CHANNEL MODIFICATIONS AT CAUVERY RIVER, INDIA.

研究概要:The study deals with hydrological aspects of palaeo-courses of Cauvery River, India resulted from channel modification. Detailed studies have been conducted in two sectors located in the river basin in areas around Talakad and Manchanahalli, Palaeochannels have been demarcated and delineated by using remote sensing technique. Later the hydrological parameters were estimated for analyzing the hydrological signatures of palaeochannels resulted from channel modification. It has been observed that these parameters are unique in areas, which are located at or near palaeochannels

Attributes and consequences of health information systems data for antenatal care : Health status, health system performance and policy

Background: A routine health information system (RHIS) serves as an important source of data for monitoring health of clients and health system performance. All countries use RHIS data for some form of priority setting; the extent of use varies across settings depending on the nature and availability of data. In the West Bank, Palestine, the paper-based routine health information system consisting of manually aggregated data is currently undergoing a transformation to an electronic health registry (eRegistry) consisting of individual-level data collected at the point-of-care for antenatal care services in primary healthcare. Aim: The overall aim of the present study was to examine the consequences of the transformation from the existing RHIS based on manual aggregation, to an RHIS based on clinical records data for calculations of routine indicators and health system performance indicators. Various aspects of anticipated data-related changes were examined in the three papers constituting this PhD dissertation. In paper I, we calculated the routinely reported indicators from individual-level clinical data from antenatal paper records, and compared the values to the existing aggregate RHIS reports. In paper II, we calculated the coverage of at least one screening, coverage of appropriate number of screenings, and effective coverage of timely and appropriate screening of antenatal care interventions in public primary healthcare clinics, and explored selected infrastructure-related and maternal sociodemographic factors potentially associated with effective coverage. In paper III, we assessed the implications of using different available data sources in the health data ecosystem for modeling the scale up of antenatal care interventions in the Lives Saved Tool. Materials and methods: Four data sources were used. First, manually aggregated RHIS reports submitted by care providers for primary healthcare clinics were retrieved (2015). Second, a cross-sectional study was conducted, where data were extracted from paper-based clinical records of women attending antenatal care (2015) from a random sample of public primary healthcare clinics. Third, secondary data were exported from the eRegistry electronic clinical records (2017). Fourth, data were obtained from the Palestinian multiple indicator cluster survey (2014). Using the paper-based clinical records data, routinely reported indicators were calculated and compared to the aggregate RHIS reports (paper I). Data from paper-based clinical records were also used to generate coverage of clinical antenatal care interventions (paper II). All four sources of data were used to calculate distinct sets of values of input indicators in the Lives Saved Tool, and the mortality and morbidity averted through the scale-up of antenatal care interventions was modeled (paper III). Results: Paper I: The values of the routinely reported indicators were significantly different when computed with clinical records data, compared to aggregate RHIS reports. The magnitude of the difference varied across indicators. There was divergence in the coverage of anemia screening between the clinical records data and aggregate RHIS reports. Paper II: Effective coverage of antenatal care interventions was considerably lower than the coverage of at least one screening and coverage of the appropriate number of screenings for antenatal care interventions. Timely attendance at antenatal care in the clinics was low. Effective coverage of antenatal care interventions was higher in clinics with laboratory and ultrasound. Paper III: All indicators required for input in the Lives Saved Tool could be calculated directly from the clinical records. The various sources of data yielded notably different results for the number of deaths averted. With clinical records data, the number of maternal deaths, stillbirths, and anemia cases that could be averted with the scale-up of health interventions were higher compared to the RHIS aggregate reports and the multiple indicator cluster survey. Each of the data sources also yielded varying compositions of antenatal care interventions averting deaths. Conclusions: The transition from an RHIS based on manual aggregations to an RHIS based on individual-level clinical records data will lead to significant changes in the values of routinely-reported indicators, and the understanding of health system performance of antenatal care. Health systems managers should be aware of the underlying mechanisms of data-related changes. Paper I: Reliable and complete routine indicators can be generated when clinical records data are directly used for automated computations. In such a system, transcription errors involved in diagnosis and referral, and manual counting and application of indicator definitions are minimized, and the existing complex reporting structure can be circumvented. Paper II: The metric used to quantify antenatal care service provision has consequences for the understanding of health system performance. Effective coverage of antenatal care interventions in public clinics can be increased by improving the provision of care according to recommended guidelines, including timely ANC attendance. Paper III: The demonstrated variability in the Lives Saved Tool model output from using the various data sources highlights the importance of understanding the characteristics of data available in a health information system by program managers that use such planning tools for decision-making

Antenatal care data sources and their policy and planning implications: a Palestinian example using the Lives Saved Tool

Abstract Background Policy making in healthcare requires reliable and local data. Different sources of coverage data for health interventions can be utilized to populate the Lives Saved Tool (LiST), a commonly used policy-planning tool for women and children’s health. We have evaluated four existing sources of antenatal care data in Palestine to discuss the implications of their use in LiST. Methods We identified all intervention coverage and health status indicators around the antenatal period that could be used to populate LiST. These indicators were calculated from 1) routine reported data, 2) a Multiple Indicator Cluster Survey (MICS), 3) paper-based antenatal records and 4) the eRegistry (an electronic health information system) for public clinics in the West Bank, Palestine for the most recent year available. We scaled coverage of each indicator to 90%, in public clinics only, and compared this to a no-change scenario for a seven-year period. Results Eight intervention coverage and health status indicators needed to populate the antenatal section of LiST could be calculated from both paper-based antenatal records and the eRegistry. Only two could be calculated from routine reports and three from a national survey. Maternal lives saved over seven years ranged from 5 to 39, with percent reduction in the maternal mortality ratio (MMR) ranging from 1 to 6%. Pre-eclampsia management accounted for 25 to 100% of these lives saved. Conclusions The choice of data source for antenatal indicators will affect policy-based decisions when used to populate LiST. Although all data sources have their purpose, clinical data collected directly in an electronic registry during antenatal contacts may provide the most reliable and complete data to populate currently unavailable but needed indicators around specific antenatal care interventions

Prevalence and risk factors for hearing loss in high-risk neonates in Germany

Aim Hearing loss in infants is often diagnosed late, despite universal screening programmes. Risk factors of hearing impairment in high-risk neonates, identified from population-based studies, can inform policy around targeted screening. Our aim was to determine the prevalence and the risk factors of hearing loss in a high-risk neonatal population. Methods This was a retrospective cohort study of neonates hospitalised at the University Hospital Cologne, Germany from January 2009 to December 2014 and were part of the newborn hearing screening programme. Multivariable regression analyses using the lasso approach was performed. Results Data were available for 4512 (43% female) neonates with a mean gestational age at birth of 35.5 weeks. The prevalence of hearing loss was 1.6%, and 42 (0.9%) neonates had permanent hearing loss. Craniofacial anomalies, hyperbilirubinaemia requiring exchange transfusion, oxygen supplementation after 36 weeks of gestation and hydrops fetalis showed associations with permanent hearing loss. Conclusion Our findings of risk factors for hearing loss were consistent with other studies. However, some commonly demonstrated risk factors such as perinatal infections, meningitis, sepsis and ototoxic drugs did not show significant associations in our cohort. Targeted screening based on risk factors may help early identification of hearing loss in neonates

eRegQual—an electronic health registry with interactive checklists and clinical decision support for improving quality of antenatal care: study protocol for a cluster randomized trial

Abstract Background Health worker compliance with established best-practice clinical and public health guidelines may be enhanced by customized checklists of care and clinical decision support driven by point-of-care data entry into an electronic health registry. The public health system of Palestine is currently implementing a national electronic registry (eRegistry) for maternal and child health. This trial is embedded in the national implementation and aims to assess the effectiveness of the eRegistry’s interactive checklists and clinical decision support, compared with the existing paper based records, on improving the quality of care for pregnant women. Methods This two-arm cluster randomized controlled trial is conducted in the West Bank, Palestine, and includes 120 clusters (primary healthcare clinics) with an average annual enrollment of 60 pregnancies. The intervention tool is the eRegistry’s interactive checklists and clinical decision support implemented within the District Health Information System 2 (DHIS2) Tracker software, developed and customized for the Palestinian context. The primary outcomes reflect the processes of essential interventions, namely timely and appropriate screening and management of: 1) anemia in pregnancy; 2) hypertension in pregnancy; 3) abnormal fetal growth; 4) and diabetes mellitus in pregnancy. The composite primary health outcome encompasses five conditions representing risk for the mother or baby that could have been detected or prevented by high-quality antenatal care: moderate or severe anemia at admission for labor; severe hypertension at admission for labor; malpresentation at delivery undetected during pregnancy; small for gestational age baby at delivery undetected during pregnancy; and large for gestational age baby at delivery. Primary analysis at the individual level taking the design effect of the clustering into account will be performed as intention-to-treat. Discussion This trial, embedded in the national implementation of the eRegistry in Palestine, allows the assessment of process and health outcomes in a large-scale pragmatic setting. Findings will inform the use of interactive checklists and clinical decision support driven by point-of-care data entry into an eRegistry as a health systems-strengthening approach. Trial registration ISRCTN trial registration number, ISRCTN18008445 . Registered on 6 April 2017