Assessing the reach and effectiveness of mHealth: evidence from a reproductive health program for adolescent girls in Ghana

While mobile health (mHealth) programs are increasingly used to provide health information and deliver interventions, little is known regarding the relative reach and effectiveness of these programs across sociodemographic characteristics. We use data from a recent trial of a text-messaging intervention on adolescent sexual and reproductive health (SRH) to assess the degree to which mHealth programs reach target adolescent subpopulations who may be at higher risk of poor SRH outcomes.; The study was conducted among girls aged 14-24 in 22 secondary schools in Accra, Ghana. The mHealth intervention was an interactive mobile phone quiz in which participants could win phone credit for texting correct answers to SRH questions. We use detailed data on individuals' level of engagement with the program, SRH knowledge scores, and self-reported pregnancy collected as part of the original trial to assess the extent to which engagement and program impact vary across parental education, sexual experience, SRH knowledge deficit, and parental support.; Eighty-one percent of participants engaged with the mHealth program, with no evidence that the program disproportionally reached better-off groups. The program was effective at increasing knowledge of SRH across all strata. Higher levels of engagement were associated with higher knowledge scores up to year later. There was no significant impact of the program on self-reported pregnancy within subgroups.; mHealth programs for adolescents have the potential to engage and increase SRH knowledge of adolescent girls across sociodemographic strata, including those who may be at higher risk of poor SRH outcomes.; ClinicalTrials.gov NCT02031575 . Registered 07 Jan 2014

Effects of China's Rural Insurance Scheme on Objective Measures of Health

Background In 2003, the Chinese government established the New Cooperative Medical Scheme (NCMS) with the goal of improving health for the country’s 800 million mostly uninsured rural residents. Using new data on objective health measures, we analyzed the program’s effectiveness in improving health for enrollees. Methods Using longitudinal data from the China Health and Nutritional Survey from 2000 to 2009 (12 080 observations across four waves), we analyzed the impact of the NCMS on objective measures of health such as blood pressure, HbA1c, and cholesterol, as well as use of preventive care. In order to overcome inherent selection bias where less healthy people are more likely to enroll in the voluntary health insurance scheme, we used intent-to-treat and instrumental variable analysis strategies, and offered evidence that these approaches can mitigate this bias. Results For every additional year of NCMS coverage, the probability of seeking preventive health care increased by 0.6 percentage points (95% CI 0.1-1.0). However, we did not find evidence that the NCMS resulted in consistent improvements in objective measures of health. Sub-group analysis suggested that lower-income communities benefited more from the program, implying that the program may have resulted in some lessening of the wealth-based disparity in health. Conclusions The NCMS does not appear to significantly improve objective measures of health. This is consistent with evaluations of health insurance programs in other countries, but in contrast to some previously reported improvements in self-reported health resulting from the NCMS.Economic

The Impact of Text Message Reminders on Adherence to Antimalarial Treatment in Northern Ghana: A Randomized Trial

Background: Low rates of adherence to artemisinin-based combination therapy (ACT) regimens increase the risk of treatment failure and may lead to drug resistance, threatening the sustainability of current anti-malarial efforts. We assessed the impact of text message reminders on adherence to ACT regimens. Methods: Health workers at hospitals, clinics, pharmacies, and other stationary ACT distributors in Tamale, Ghana provided flyers advertising free mobile health information to individuals receiving malaria treatment. The messaging system automatically randomized self-enrolled individuals to the control group or the treatment group with equal probability; those in the treatment group were further randomly assigned to receive a simple text message reminder or the simple reminder plus an additional statement about adherence in 12-hour intervals. The main outcome was self-reported adherence based on follow-up interviews occurring three days after treatment initiation. We estimated the impact of the messages on treatment completion using logistic regression. Results: 1140 individuals enrolled in both the study and the text reminder system. Among individuals in the control group, 61.5% took the full course of treatment. The simple text message reminders increased the odds of adherence (adjusted OR 1.45, 95% CI [1.03 to 2.04], p-value 0.028). Receiving an additional message did not result in a significant change in adherence (adjusted OR 0.77, 95% CI [0.50 to 1.20], p-value 0.252). Conclusion: The results of this study suggest that a simple text message reminder can increase adherence to antimalarial treatment and that additional information included in messages does not have a significant impact on completion of ACT treatment. Further research is needed to develop the most effective text message content and frequency. Trial Registration ClinicalTrials.gov NCT0172273

Inference with difference-in-differences with a small number of groups: a review, simulation study, and empirical application using SHARE data

Difference-in-differences (DID) estimation has become increasingly popular as an approach to evaluate the effect of a group-level policy on individual-level outcomes. Several statistical methodologies have been proposed to correct for the within-group correlation of model errors resulting from the clustering of data. Little is known about how well these corrections perform with the often small number of groups observed in health research using longitudinal data.; First, we review the most commonly used modeling solutions in DID estimation for panel data, including generalized estimating equations (GEE), permutation tests, clustered standard errors (CSE), wild cluster bootstrapping, and aggregation. Second, we compare the empirical coverage rates and power of these methods using a Monte Carlo simulation study in scenarios in which we vary the degree of error correlation, the group size balance, and the proportion of treated groups. Third, we provide an empirical example using the Survey of Health, Ageing, and Retirement in Europe.; When the number of groups is small, CSE are systematically biased downwards in scenarios when data are unbalanced or when there is a low proportion of treated groups. This can result in over-rejection of the null even when data are composed of up to 50 groups. Aggregation, permutation tests, bias-adjusted GEE, and wild cluster bootstrap produce coverage rates close to the nominal rate for almost all scenarios, though GEE may suffer from low power.; In DID estimation with a small number of groups, analysis using aggregation, permutation tests, wild cluster bootstrap, or bias-adjusted GEE is recommended

Improving Reproductive Health: Assessing Determinants and Measuring Policy Impacts

In this thesis, I investigate policies and programs to improve reproductive health. My thesis makes a substantive contribution to reproductive health policy and a methodological contribution to quasi-experimental research. In chapter 1, I evaluate the impact of a mobile phone intervention for adolescent girls. I design and implement a randomized controlled trial in Ghana to test whether sending information via mobile phones is an effective way to improve girls’ knowledge of sexual health and to ultimately reduce teenage pregnancy. I find that mobile phone programs are effective not only in increasing knowledge, but also in decreasing risk of pregnancy among sexually active adolescents. I discuss the results in the context of sexual education policy in Ghana. In chapter 2, I explore the complex interactions between migration and reproductive health. I reconstruct the complete migration and reproductive health histories of women residing in the urban slums of Accra, Ghana. Using individual fixed effects to reduce selection bias, I find an increased risk of pregnancy, miscarriage, and abortion in the 48 months after migration, with no significant increase in the chance of live birth during this time period. With half of abortions in Ghana classified as unsafe, these results suggest that policies which target the rapidly growing number of urban migrants by providing access to contraception and public hospital services may reduce unsafe abortion and improve maternal health outcomes. In chapter 3, I investigate the bias of standard errors in difference-in-difference estimation, which typically evaluates the effect of a group-level intervention on individual data. Common modeling adjustments for grouped data, such as cluster-robust standard errors, are biased when the number of clusters is small. I run Monte Carlo simulations to investigate both the coverage and power of a wide variety of modeling solutions from the econometric and biostatistics fields, while varying the balance of cluster sizes, the degree of error correlation, and the proportion of treated clusters. I then apply my results to re-evaluate a recently published study on the effect of emergency contraception on adolescent sexual behavior. I find that the study’s results claiming that emergency contraception increases risky sexual behavior may be spurious once proper adjustments for grouped data are applied.Health Polic

The context of emergency contraception use among young unmarried women in Accra, Ghana: a qualitative study

Abstract Background Over the past decade, awareness and use of emergency contraceptive pills (ECPs) among young women has rapidly increased in Ghana; however, the rate of unintended pregnancy among this group remains high. We conducted a qualitative study to better understand the context and patterns of ECP use among young unmarried women in Ghana. Methods We conducted in-depth interviews with unmarried sexually active women aged 18–24 in Accra, Ghana to explore their perceptions, experiences, and opinions regarding sexual relationships and contraceptive methods, and to examine the factors that influence choice of ECPs. A total of 32 young women participated in the study. Results Most participants had used ECPs at least once. Participants described being unable to plan for sexual encounters, and as a result preferred ECPs as a convenient post-coital method. Despite being widely and repeatedly used, women feared the disruptive effects of ECPs on the menstrual cycle and were concerned about long-term side-effects. ECPs were sometimes used as a back-up in cases of perceived failure of traditional methods like withdrawal. Misinformation about which drugs were ECPs, correct dosage, and safe usage were prevalent, and sometimes spread by pharmacists. Myths about pregnancy prevention techniques such as urinating or washing after sex were commonly believed, even among women who regularly used ECPs, and coincided with a misunderstanding about how hormonal contraception works. Conclusions ECPs appear to be a popular contraceptive choice among young urban women in Ghana, yet misinformation about their correct usage and safety is widespread. While more research on ECP use among young people is needed, these initial results point to the need to incorporate information about ECPs into adolescent comprehensive sexuality education and youth-friendly services and programmes

Heterogeneity in early life investments: a longitudinal analysis of children's time use

Early life investments in children promote skills and capabilities, and subsequently influence a variety of health, social, and economic outcomes in later life. In this paper, we examine heterogeneity in children’s time use using diary data from two waves of a nationally representative longitudinal cohort study. Children from disadvantaged households spend significantly less time reading and engaging in sport than their counterparts, and more time in unstructured activities and using media. Though gaps are relatively small at age 9, they widen considerably over time. At age 13, girls in households with low maternal education spend on average 6 minutes per day reading (95% CI 3-10) and 12 minutes per day in sport (95% CI 8-16), while girls in households with high maternal education spend 14 minutes reading (95% CI 11-17) and 27 minutes in sport (95% CI 23-31). Similar differences were found for boys. Using a decomposition analysis, we find that resources, preferences, initial endowments, and differential costs all play a role in explaining time use concentration across households, indicating that disadvantaged families may be constrained in how they choose their preferred time use options. Given the important role of extra-curricular activities in promoting cognitive and non-cognitive skill development, the systematic differences in time use we document in this paper are likely to contribute to cumulative disadvantage and widening skill gaps over adolescence and into adulthood