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Targeted client communication to improve timely antenatal care utilization : Assessment, development and evaluation
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Rettidige svangerskapskontroller reduserer sykelighet og dødelighet hos mor og nyfødt ved at gravide med økt risiko for svangerskapsrelaterte komplikasjoner kan identifiseres i tide, sikres adekvat behandling og oppfølging og kan henvises videre til riktig omsorgsnivå ved behov. I Bangladesh er både kvaliteten på svangerskapsomsorgen, og andelen gravide som benytter seg av helsetjenesten, svært lav. Verdens helseorganisasjon (WHO) publiserte i 2019 anbefalinger for digitale helseintervensjoner (DHIs) som kan komplementere og forbedre helsesystemfunksjoner ved å styrke informasjonsutvekslingen. Målrettet klientkommunikasjon (targeted client communication, TCC) har vist seg å gi økt oppmøte i svangerskapsomsorgen i lav- og mellominntektsland. En nylig publisert systematisk Cochrane-gjennomgang fra 2020 konkluderte imidlertid med lav sannsynlighet for at TCC har positiv effekt på rettidigheten av svangerskapskontroller. eRegistry-studien i Matlab gav en unik mulighet til å utvikle teoribasert TCC, og til å evaluere effekten av intervensjonen implementert i helsetjenesten i en lavressurs-setting.
Mål
Det overordnede målet med denne doktoravhandlingen er å produsere kunnskapsbasert bevis for TCC som en effektiv, digital helseintervensjon. I tre artikler i denne avhandlingen beskrives; 1) dekning av rettidige svangerskapskontroller, faktorer som assosieres med rettidige svangerskapskontroller og hvilke typer klinikker kvinner benytter seg av i svangerskapsomsorgen (Artikkel I); 2) hvordan teorier om atferdsendring benyttes for vurdering av kvinners oppfatninger om svangerskapsomsorg og svangerskapskomplikasjoner, for deretter å utvikle SMS-basert TCC for å adressere deres respektive oppfatninger (Artikkel II); og 3) evaluering av effekten av SMS-basert TCC i et digitalt helseregister, på rettidig oppmøte ved første svangerskapskontroll, påfølgende svangerskapskontroller, andel fødsler i helseinstitusjon, perinatal dødelighet og alvorlig, perinatal sykelighet i Matlab, Bangladesh (Artikkel III).
Metoder
Avhandlingen er en del av et større prosjekt i en klyngerandomisert, kontrollert studie (eRegMat). eRegMat-studien evaluerte effekten av å innføre et longitudinelt klientsporingssystem med DHIs (eRegistry) på dekning av svangerskapsomsorg i primærhelsetjenesten, andel fødsler i helseinstitusjon, høy risiko-henvisninger, perinatal dødelighet og alvorlig, perinatal sykelighet. Effekten ble vurdert i en to-armet klyngerandomisert, kontrollert studie (eRegMat) i primærhelsetjenesten. I intervensjonsarmen ble det innført et eRegistry med tre digitale helseintervensjoner; beslutningsstøtte til helsepersonell, tilbakemeldingspanel med handlingspunkter, og målrettet klientkommunikasjon ved bruk av SMS. De digitale pasientjournalene til kvinnene i intervensjonsarmen var tilgjengelige for ulike helsepersonell. I kontrollarmen var pasientjournalene ikke tilgjengelige for andre helsepersonell og definert som ikke-kommuniserbare, digitale pasientjournaler uten digitale helseintervensjoner. Utfallsdata ble hentet fra eRegistry og fra en husholdningsundersøkelse som ble foretatt blant mødrene postpartum. I doktorgradsprosjektet brukte vi et blandet studiedesign for å vurdere status for benyttelse av svangerskapstilbudet, utvikle en intervensjon for TCC ved bruk av SMS, og for å evaluere TCC. For å vurdere den nåværende dekningen av rettidige svangerskapskontroller, andelen fødsler i helseinstitusjon, - og faktorer som påvirket utfallet, benyttet vi en tverrsnittsundersøkelse med data fra husholdningsundersøkelsen (Artikkel I). Vi gjennomførte univariat og multivariat logistisk regresjonsanalyse for å vurdere avgjørende faktorer for svangerskapsomsorg og helseinstitusjonsfødsler. Deretter benyttet vi kvalitative metoder for å utvikle TCC-intervensjonen (Artikkel II). Vi brukte en formålsbestemt utvalgsstrategi for utvelgelse av deltakere. Vi gjennomførte dybdeintervjuer med 24 studiedeltakere for å utforske deres erfaringer med svangerskapsomsorg og oppfatninger om svangerskapskomplikasjoner, og benyttet co-design metoder for å utvikle TCC. Til slutt evaluerte vi effekten av digital TCC på rettidige svangerskapskontroller, andelen fødsler i helseinstitusjon, perinatal dødelighet og alvorlig, perinatal sykelighet i en toarmet klyngerandomisert, kontrollert studie (Artikkel III). Vi inkluderte data fra eRegistry og postpartum-undersøkelsen av gravide kvinner som ble inkludert i studien mellom oktober 2018 og juni 2020. Vi utførte en intensjon-til-å-behandle-analyse, og vi brukte generaliserte, lineære modeller med blandede effekter for å estimere relativ risiko for dekning av svangerskapsomsorg, andelen fødsler i helseinstitusjon, perinatal dødelighet og alvorlig, perinatal sykelighet.
Resultater
Artikkel I: Vi inkluderte data fra 3293 kvinner i studien. Mer enn halvparten av kvinnene oppsøkte første svangerskapskontroll til rett tid, mens færre enn fem prosent hadde fire rettidige svangerskapskontroller gjennom svangerskapet. Tre fjerdedeler av kvinnene fødte på helseinstitusjon. Kvinner som oppsøkte offentlig helsetjeneste for sin første svangerskapskontroll, flyttet gradvis over til privat helsetjeneste for sine påfølgende svangerskapskontroller og for fødsel. Rettidig første svangerskapskontroll og fødsel i helseinstitusjon var assosiert med kvinners alder, paritet, ektefelles utdanning og husholdningsformue. Ingen av disse sosioøkonomiske faktorene var imidlertid assosiert med fire rettidige svangerskapskontroller.
Artikkel II: Vi utførte en tematisk analyse i henhold til Helseoppfatningsmodellen (the Health Belief Model (HBM)). TCC ble utviklet basert på HBM og en teoribasert taksonomi om teknikker for atferdsendring. Et utvalg tekstmeldinger ble utviklet på engelsk og oversatt til bengali. Vi opprettet algoritmer i eRegistry-databasen for å tilpasse individ-basert TCC til de gravide kvinnene, basert på spesifikke kriterier.
Artikkel III: 5769 kvinner (intervensjon: n=3023 og kontroll: n=2746) ble inkludert i studien. Det ble ikke observert statistiske forskjeller mellom intervensjons- og kontrollarmen for rettidig oppmøte i svangerskapsomsorgen (aRR 0.96, CI: 0.89-1.05), rettidig oppmøte for første svangerskapskontroll (aRR 0.97, CI: 0.84-1.11) og fødsel i helseinstitusjon (aRR 0.95, CI: 0.82-1.11). Vi observerte en statistisk signifikant reduksjon i det sammensatte sekundærutfallet perinatal dødelighet og alvorlig, perinatal sykelighet (aRR 0.73, CI: 0.58-0.96). Studien hadde flere implementeringsutfordringer, og resultatene hadde ikke tilstrekkelig statistisk presisjon til å gjøre konkluderende tolkninger av effekt.
Konklusjon
Studien observerte lav dekning av rettidige svangerskapskontroller i rurale Matlab, Bangladesh, ved oppstart av studien. Co-design av TCC ved bruk av SMS ble gjort i samråd med klienter, med mål om å implementere en intervensjon som var tilpasset målgruppen. Teoribasert TCC ved bruk av SMS ble evaluert i en klyngerandomisert, kontrollert studie. TCC hadde ingen effekt på rettidig oppmøte til svangerskapskontroller eller til fødsel i helseinstitusjon, men vi observerte, med lav tillit i dokumentasjonen, en effekt på perinatal dødelighet og alvorlig, perinatal sykelighet.
Artikkel I: Studien observerte variasjon i dekning i svangerskapsomsorgen og andelen fødsler i helseinstitusjon for utvalgte sosiodemografiske variabler. Mødrehelseprogrammer bør prioritere kvinner med ektefeller med lav utdanning. Lav sosio-økonomisk status og ung alder for å øke bruken av helsetjenester i svangerskap og fødsel.
Artikkel II: Studien representerer et eksempel på utvikling av teoribaserte TCC-meldinger gjennom behovsanalyse av kunnskap om svangerskapsomsorg og svangerskapskomplikasjoner, for å øke opptak og bruk av helsetjenester i svangerskapsomsorgen.
Artikkel III: TCC ved bruk av SMS påvirket ikke rettidigheten av svangerskapskontroller eller andelen fødsler i helseinstitusjon. Studien ble forstyrret av COVID-19 pandemien, og vi fant ikke effekter av intervensjonen på primære utfall.Background
Timely attendance at antenatal care (ANC) reduces maternal and neonatal illnesses and deaths by providing an opportunity to identify women at increased risk of developing pregnancy-related complications, ensuring referral to an appropriate level of care, and treating complications. In Bangladesh, timely ANC utilization is very low. The WHO published a set of recommendations for digital health interventions (DHIs) in 2019 that can complement and augment health system functions through the enhanced exchange of information, although these are not replacements for a functioning health system. Targeted client communication (TCC) has been shown to increase ANC attendance in low-resource settings. However, a recent Cochrane systematic review from 2020 reported low certainty evidence for TCC to increase timely ANC attendance. The eRegistry study at Matlab provided a unique opportunity to develop theory-based TCC and evaluate the effectiveness of this intervention in a health system in a low-resource setting.
Aims
The overall aim of this dissertation is to generate evidence for TCC as a digital health intervention. In the three papers of this PhD dissertation, we describe 1) coverage of timely uptake of ANC, factors associated with timely ANC visits, and which type of facilities women utilized for their ANC services (Paper I); 2) how we used behavior change theories to assess women's perceptions of ANC services and pregnancy complications, and subsequently develop SMS-based TCC addressing their perceptions (Paper II); and 3) evaluation of the effectiveness of the SMS-based TCC in a digital health registry on timely attendance at first ANC visit, timely attendance at eligible ANC visits, facility delivery, perinatal mortality, and severe perinatal morbidities in Matlab, Bangladesh (Paper III).
Materials and methods
The dissertation is a part of a larger project undertaking a cluster-randomized controlled trial (eRegMat). The eRegMat trial implemented and evaluated the effect of a longitudinal client tracking system with DHIs (eRegistry) on ANC attendance, facility delivery, high-risk referrals, perinatal mortality, and severe perinatal morbidities. The effectiveness was assessed in the two-arm trial in primary health care facilities. The intervention arm received an eRegistry with three DHIs: health worker clinical decision support, feedback dashboards with action items, and targeted client communication via short message service (SMS). The digital client records of women in the intervention arm were accessible to different care providers. In the control arm, records were not accessible by other health care providers, defined as an unshared digital client record without any more DHIs. Outcome data were derived from the eRegistry and a postpartum household survey. In the PhD project, we used a mixed methods study design to assess the status of ANC utilization, develop an intervention using TCC via SMS, and evaluate TCC. To assess the current situation of timely utilization of ANC services, facility delivery, and their determinants, we used a cross-sectional study design using post-partum survey data (Paper I). We conducted univariate and multivariate logistic regression to assess ANC and facility delivery determinants. Then, we used qualitative methods to develop the TCC intervention (Paper II). A purposive sampling approach was used for the selection of participants. We conducted in-depth interviews with 24 study participants to explore their experiences of pregnancy care and perceptions regarding pregnancy complications and used co-design methods to develop TCC. Finally, we evaluated the effectiveness of digital TCC on timely attendance at eligible ANC visits, timely first ANC visit, facility delivery, and perinatal mortality and severe perinatal morbidities in a two-arm cluster-randomized controlled trial (Paper III). We included data from the eRegistry and the post-partum survey of pregnant women enrolled in the trial between October 2018 and June 2020. We performed an intention-to-treat analysis. We used mixed-effects generalized linear models to estimate the relative risk of ANC attendance, facility delivery, perinatal mortality, and severe perinatal morbidities.
Results
Paper I: We included data on 3293 women in this study. More than half of the women attended their first ANC in a timely manner, but less than five percent presented themselves for four timely ANC visits. Three-quarters of the women gave birth in a health facility. Women who started attending ANC in public health facilities gradually moved to private health facilities during their follow-up visits and for delivery. Timely first ANC attendance and facility delivery were associated with the woman's age, parity, husband's education, and household wealth index. None of these socio-economic factors were associated with four timely ANC visits.
Paper II: We performed a thematic analysis according to the constructs of the Health Belief Model (HBM). TCC was developed based on the HBM and a theory-linked taxonomy of behavior change techniques. A library of text messages was developed first in English and then translated into Bangla. We created algorithms in the eRegistry database to tailor TCC to individual pregnant women based on specific criteria.
Paper III: A total of 5769 women (intervention: n=3023 and control: n=2746) were enrolled in the trial. No statistical differences were observed between the intervention and control arms for timely attendance at eligible ANC visits (aRR 0.96, CI: 0.89-1.05), timely first ANC visit (aRR 0.97, CI: 0.84-1.11) and facility delivery (aRR 0.95, CI: 0.82-1.11). We observed a statistically significant reduction in the secondary composite outcome of perinatal mortality and severe perinatal morbidities (aRR 0.73, CI: 0.58-0.96). The trial had several implementation challenges and the results did not have adequate statistical precision to make conclusive interpretations of effect.
Conclusion
The study observed low levels of timely ANC utilization at baseline in rural Matlab Bangladesh. Co-design of TCC via SMS was done with clients, with the goal of implementing an intervention that was more acceptable to users. The theory-based TCC via SMS was evaluated in this cluster-randomized controlled trial. The TCC had no effect on timely ANC attendance or facility delivery, but we observed low certainty evidence of an impact on perinatal mortality and severe perinatal morbidities.
Paper I: The study observed the variation of ANC and delivery care utilization by selected socio-demographic characteristics. Maternal health care programs should prioritize women with husbands with low education, low socio-economic status, and younger age to increase the use of health services for ANC and delivery.
Paper II: The study represents an example of theory-driven TCC message development through gap analysis on knowledge of ANC and pregnancy complications to improve ANC service utilization.
Paper III: TCC via SMS did not affect timely ANC or facility delivery. This trial was interrupted by the COVID-19 pandemic, and we were unable to observe effects of our intervention on the primary outcomes.
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