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Chandrasekar A, Warren E, Free C, Mbogua J, Curtin E, Gazeley U, Wong G, Church K, McCarthy O. mHealth interventions for postpartum family planning in LMICs: A realist review. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003432. [PMID: 39024319 PMCID: PMC11257288 DOI: 10.1371/journal.pgph.0003432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 06/26/2024] [Indexed: 07/20/2024]
Abstract
The unmet need for family planning is a pervasive public health concern in many low- and middle-income countries (LMICs). Mobile health (mHealth) interventions have been designed and implemented in LMIC settings to address this issue through health information dissemination via voice calls, apps, and short message services (SMS). Although the impact of mHealth programmes on postpartum family planning outcomes have been systematically reviewed, the contexts, conditions, and mechanisms underpinning programme engagement and their impact on outcomes remain unclear. This study aims to formulate hypotheses in the form of context-mechanism-outcome configurations (CMOCs) of whether, how, why, for whom, and in what contexts mHealth interventions implemented in LMICs influence postpartum family planning (PPFP) outcomes. We conducted a realist review of peer-reviewed and grey literature. Peer-reviewed literature was identified through MEDLINE, Embase, Global Health, Web of Science, and Google Scholar. Grey Literature was identified through The National Grey Literature Conference, FHI 360, Guttmacher Institute, Population Council, and MSI Reproductive Choices. Inclusion criteria were updated as the review progressed. Narrative data were analysed using dimensional analysis to build CMOCs. Two overarching concepts (underpinned by 12 CMOCs) emerged from the 37 included records: mobile phone access, use, and ownership as well as women's motivation. Women's confidence to independently own, access, and operate a mobile phone was a central mechanism leading to mHealth programme engagement and subsequent change in PPFP knowledge, awareness, and outcomes. Receiving family and social support positively interacted with this while low digital literacy and harmful gender norms pertaining to prescribed domestic duties and women's household influence were barriers to programme engagement. Intrinsic motivation for health improvement functioned at times both as a context and potential mechanism influencing mHealth programme engagement and PPFP outcomes. However, these contexts rarely occur in isolation and need to be evaluated as co-occurring phenomena. (Review registration: PROSPERO CRD42023386841).
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Affiliation(s)
- Abinaya Chandrasekar
- Department of Population Health, The London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Emily Warren
- Department of Public Health, Environments and Society, The London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Caroline Free
- Department of Population Health, The London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Judie Mbogua
- Department of Population Health, The London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Esther Curtin
- Department of Population Health, The London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Ursula Gazeley
- Department of Population Health, The London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Geoffrey Wong
- Nuffield Department of Primary Care Health Sciences, The University of Oxford, Oxford, United Kingdom
| | - Kathryn Church
- Department of Population Health, The London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Ona McCarthy
- Department of Population Health, The London School of Hygiene & Tropical Medicine, London, United Kingdom
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Clapp MA, Ray A, Liang P, James KE, Ganguli I, Cohen JL. Postpartum Primary Care Engagement Using Default Scheduling and Tailored Messaging: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2422500. [PMID: 39012630 PMCID: PMC11252898 DOI: 10.1001/jamanetworkopen.2024.22500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 05/02/2024] [Indexed: 07/17/2024] Open
Abstract
Importance More than 30% of pregnant people have at least 1 chronic medical condition, and nearly 20% develop gestational diabetes or pregnancy-related hypertension, increasing the risk of future chronic disease. While these individuals are often monitored closely during pregnancy, they face major barriers when transitioning to primary care following delivery, due in part to a lack of health care support for this transition. Objective To evaluate the impact of an intervention designed to improve postpartum primary care engagement by reducing patient administrative burden and information gaps. Design, Setting, and Participants An individual-level randomized clinical trial was conducted from November 3, 2022, to October 11, 2023, at 1 hospital-based and 5 community-based outpatient obstetric clinics affiliated with a large academic medical center. Participants included English- and Spanish-speaking pregnant or recently postpartum adults with obesity, anxiety, depression, diabetes, chronic hypertension, gestational diabetes, or pregnancy-related hypertension and a primary care practitioner (PCP) listed in their electronic health record. Intervention A behavioral economics-informed intervention bundle, including default scheduling of postpartum PCP appointments and tailored messages. Main Outcome and Measures Completion of a PCP visit for routine or chronic condition care within 4 months of delivery was the primary outcome, ascertained directly by reviewing the patient's electronic health record approximately 5 months after their estimated due date. Intention-to-treat analysis was conducted. Results A total of 360 patients were randomized (control, 176; intervention, 184). Individuals had a mean (SD) age of 34.1 (4.9) years and median gestational age of 36.3 (IQR, 34.0-38.6) weeks at enrollment. The distribution of self-reported race and ethnicity was 6.8% Asian, 7.4% Black, 68.6% White, and 15.0% multiple races or other. Most participants (75.4%) had anxiety or depression, 16.1% had a chronic or pregnancy-related hypertensive disorder, 19.5% had preexisting or gestational diabetes, and 40.8% had a prepregnancy body mass index of 30 or greater. Medicaid was the primary payer for 21.2% of patients. Primary care practitioner visit completion within 4 months occurred in 22.0% (95% CI, 6.4%-28.8%) of individuals in the control group and 40.0% (95% CI, 33.1%-47.4%) in the intervention group. In regression models accounting for randomization strata, the intervention increased PCP visit completion by 18.7 percentage points (95% CI, 9.1-28.2 percentage points). Intervention participants also had fewer postpartum readmissions (1.7% vs 5.8%) and increased receipt of the following services by a PCP: blood pressure screening (42.8% vs 28.3%), weight assessment (42.8% vs 27.7%), and depression screening (32.8% vs 16.8%). Conclusions and Relevance The findings of this randomized clinical trial suggest that the current lack of support for postpartum transitions to primary care is a missed opportunity to improve recently pregnant individual's short- and long-term health. Reducing patient administrative burdens may represent relatively low-resource, high-impact approaches to improving postpartum health and well-being. Trial Registration ClinicalTrials.gov Identifier: NCT05543265.
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Affiliation(s)
- Mark A. Clapp
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Alaka Ray
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston
| | - Pichliya Liang
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston
| | - Kaitlyn E. James
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Brigham & Women’s Hospital, Boston, Massachusetts
| | - Jessica L. Cohen
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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Clapp MA, Ray A, Liang P, James KE, Ganguli I, Cohen J. Increasing Postpartum Primary Care Engagement through Default Scheduling and Tailored Messaging : A Randomized Clinical Trial. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.01.21.24301585. [PMID: 38633772 PMCID: PMC11023680 DOI: 10.1101/2024.01.21.24301585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Importance Over 30% of pregnant people have at least one chronic medical condition, and nearly 20% develop gestational diabetes or pregnancy-related hypertension, increasing the risk of future chronic disease. While these individuals are often monitored closely during pregnancy, they face significant barriers when transitioning to primary care following delivery, due in part to a lack of health care support for this transition. Objective To evaluate the impact of an intervention designed to improve postpartum primary care engagement by reducing patient administrative burden and information gaps. Design Individual-level randomized controlled trial conducted from November 3, 2022 to October 11, 2023. Setting One hospital-based and five community-based outpatient obstetric clinics affiliated with a large academic medical center. Participants Participants included English- and Spanish-speaking pregnant or recently postpartum adults with obesity, anxiety, depression, diabetes mellitus, chronic hypertension, gestational diabetes, or pregnancy-related hypertension, and a primary care practitioner (PCP) listed in their electronic health record (EHR). Intervention A behavioral economics-informed intervention bundle, including default scheduling of postpartum PCP appointments and tailored messages. Main Outcome Completion of a PCP visit for routine or chronic condition care within 4 months of delivery. Results 360 patients were randomized (Control: N=176, Intervention: N=184). Individuals had mean (SD) age 34.1 (4.9) years and median gestational age of 36.3 weeks (interquartile range (IQR) 34.0-38.6 weeks) at enrollment. The distribution of self-reported races was 7.4% Asian, 6.8% Black, 15.0% multiple races or "Other," and 68.6% White. Most (75.8%) participants had anxiety or depression, 15.9% had a chronic or pregnancy-related hypertensive disorder, 19.8% had pre-existing or gestational diabetes, and 40.4% had a pre-pregnancy BMI ≥30 kg/m2. Medicaid was the primary payer for 21.9% of patients. PCP visit completion within 4 months occurred in 22.0% in the control group and 40.0% in the intervention group. In regression models accounting for randomization strata, the intervention increased PCP visit completion by 18.7 percentage points (95%CI 10.7-29.1). Intervention participants also had fewer postpartum readmissions (1.7 vs. 5.8%) and increased receipt of the following services by a PCP: blood pressure screening (42.8 vs. 28.3%), weight assessment (42.8 vs. 27.7%), and depression screening (32.8 vs. 16.8%). Conclusions and Relevance In this randomized trial of pregnant individuals with or at risk for chronic health conditions, default PCP visit scheduling, tailored messages, and reminders substantially improved postpartum primary care engagement. The current lack of support for postpartum transitions to primary care is a missed opportunity to improve recently pregnant individual's short- and long-term health. Reducing patient administrative burdens may represent relatively low-resource, high-impact approaches to improving postpartum health and wellbeing. Trial Registration NCT05543265.
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Affiliation(s)
- Mark A Clapp
- Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Alaka Ray
- Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - Kaitlyn E James
- Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Ishani Ganguli
- Harvard Medical School, Boston, MA
- Brigham & Women's Hospital, Boston MA
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Woofter R, Mboya J, Golub G, Sudhinaraset M. Intimate partner violence and postpartum healthcare access in Kenya: a cross-sectional study. BMC Pregnancy Childbirth 2024; 24:168. [PMID: 38409006 PMCID: PMC10898132 DOI: 10.1186/s12884-024-06342-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 02/10/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Intimate partner violence (IPV) impacts physical health, mental health, and healthcare use. IPV during pregnancy, in particular, is associated with lower rates of antenatal care, but no studies have assessed the association between IPV and postpartum healthcare. This study aims to examine the link between IPV (emotional, physical, and sexual) and two outcomes: postpartum healthcare use and access to family planning. METHODS This study uses data from a cross-sectional survey of 859 women in Nairobi and Kiambu counties in Kenya who gave birth during the COVID-19 pandemic in 2020. RESULTS In this sample, 36% of women reported ever experiencing IPV. Of those, 33% indicated the frequency of IPV stayed the same or increased during COVID-19. Nearly 17% of women avoided postpartum healthcare and 10% experienced issues accessing family planning. Those who experienced any form of IPV during pregnancy had approximately twice the odds of avoiding postpartum healthcare compared to those who did not experience any form of IPV. Compared to those who did not experience IPV during pregnancy, experiencing sexual IPV was associated with 2.25 times higher odds of reporting issues accessing family planning. Additionally, reporting fair or poor self-rated health was associated with both avoiding postpartum healthcare and reporting issues accessing family planning. Experiencing food insecurity was also associated with avoiding postpartum healthcare. CONCLUSIONS To our knowledge, this is the first study to establish the link between IPV during pregnancy and postpartum healthcare access. During COVID-19 in Kenya, postpartum women who had experienced IPV were at increased risk of disengagement with healthcare services. Women should be screened for IPV during pregnancy and postpartum in order to better support their healthcare needs. In times of crisis, such as pandemics, policymakers and healthcare providers must address barriers to healthcare for postpartum women.
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Affiliation(s)
- Rebecca Woofter
- Fielding School of Public Health, Department of Community Health Sciences, University of California Los Angeles, 650 Charles E. Young Dr. S, Los Angeles, CA, 90095, USA.
| | - John Mboya
- Innovations for Poverty Action, New York, USA
| | | | - May Sudhinaraset
- Fielding School of Public Health, Department of Community Health Sciences, University of California Los Angeles, 650 Charles E. Young Dr. S, Los Angeles, CA, 90095, USA
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Muriithi FG, Banke-Thomas A, Forbes G, Gakuo RW, Thomas E, Gallos ID, Devall A, Coomarasamy A, Lorencatto F. A systematic review of behaviour change interventions to improve maternal health outcomes in sub-Saharan Africa. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002950. [PMID: 38377077 PMCID: PMC10878526 DOI: 10.1371/journal.pgph.0002950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 01/29/2024] [Indexed: 02/22/2024]
Abstract
The rate of decline in the global burden of avoidable maternal deaths has stagnated and remains an issue of concern in many sub-Saharan Africa countries. As per the most recent evidence, an average maternal mortality ratio (MMR) of 223 deaths per 100,000 live births has been estimated globally, with sub-Saharan Africa's average MMR at 536 per 100,000 live births-more than twice the global average. Despite the high MMR, there is variation in MMR between and within sub-Saharan Africa countries. Differences in the behaviour of those accessing and/or delivering maternal healthcare may explain variations in outcomes and provide a basis for quality improvement in health systems. There is a gap in describing the landscape of interventions aimed at modifying the behaviours of those accessing and delivering maternal healthcare for improving maternal health outcomes in sub-Saharan Africa. Our objective was to extract and synthesise the target behaviours, component behaviour change strategies and outcomes of behaviour change interventions for improving maternal health outcomes in sub-Saharan Africa. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Our protocol was published a priori on PROSPERO (registration number CRD42022315130). We searched ten electronic databases (PsycINFO, Cochrane Database of Systematic Reviews, International Bibliography of Social Sciences, EMBASE, MEDLINE, Scopus, CINAHL PLUS, African Index Medicus, African Journals Online, and Web of Science) and included randomised trials and quasi-experimental studies. We extracted target behaviours and specified the behavioural interventions using the Action, Actor, Context, Time, and Target (AACTT) framework. We categorised the behaviour change strategies using the intervention functions described in the Behaviour Change Wheel (BCW). We reviewed 52 articles (26 randomized trials and 26 quasi-experimental studies). They had a mixed risk of bias. Out of these, 41 studies (78.8%) targeted behaviour change of those accessing maternal healthcare services, while seven studies (13.5%) focused on those delivering maternal healthcare. Four studies (7.7%) targeted mixed stakeholder groups. The studies employed a range of behaviour change strategies, including education 37 (33.3%), persuasion 20 (18%), training 19 (17.1%), enablement 16 (14.4%), environmental restructuring 8 (7.2%), modelling 6 (5.4%) and incentivisation 5 (4.5%). No studies used restriction or coercion strategies. Education was the most common strategy for changing the behaviour of those accessing maternal healthcare, while training was the most common strategy in studies targeting the behaviour of those delivering maternal healthcare. Of the 52 studies, 40 reported effective interventions, 7 were ineffective, and 5 were equivocal. A meta-analysis was not feasible due to methodological and clinical heterogeneity across the studies. In conclusion, there is evidence of effective behaviour change interventions targeted at those accessing and/or delivering maternal healthcare in sub-Saharan Africa. However, more focus should be placed on behaviour change by those delivering maternal healthcare within the health facilities to fast-track the reduction of the huge burden of avoidable maternal deaths in sub-Saharan Africa.
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Affiliation(s)
- Francis G. Muriithi
- WHO Collaborating Centre for Global Women’s Health, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Aduragbemi Banke-Thomas
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
- School of Human Sciences, University of Greenwich, Old Royal Naval College, Park Row, Greenwich, London, United Kingdom
| | - Gillian Forbes
- Centre for Behaviour Change, University College London, London, United Kingdom
| | - Ruth W. Gakuo
- Department of Nursing, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Lenton, Nottingham, United Kingdom
| | - Eleanor Thomas
- WHO Collaborating Centre for Global Women’s Health, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Ioannis D. Gallos
- WHO Collaborating Centre for Global Women’s Health, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, Birmingham, United Kingdom
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Adam Devall
- WHO Collaborating Centre for Global Women’s Health, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Arri Coomarasamy
- WHO Collaborating Centre for Global Women’s Health, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Fabiana Lorencatto
- Centre for Behaviour Change, University College London, London, United Kingdom
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Prince H, Khader YS, Halasa-Rappel YA, Khudair SA, Alyahya M, Al-Sheyab N, Shattnawi KK, AlHamawi R, Ready K. The Impact of Behavioral Economics-Based Counseling and Mobile Phone Text Educational and Reminder Messages on the Use of Modern Family Planning in Jordan: A Cluster Randomized Controlled Trial. Healthcare (Basel) 2023; 11:healthcare11091314. [PMID: 37174856 PMCID: PMC10178716 DOI: 10.3390/healthcare11091314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 04/20/2023] [Accepted: 04/27/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Favorable attitudes toward modern family planning methods (MFPMs) among Jordanian and Syrian women do not always translate into behavioral changes, and the availability and cost of MFPMs do not appear to be related to either prior stalls in fertility rates in Jordan or to the current and likely temporary decline in fertility rates. This study aimed to determine whether behavioral economics (BE)-based family planning interventions influence the use of any family planning method, MFPMs use, continuation of MFPMs use, and pregnancy rates among women in Jordan. The BE-based family planning interventions included personalized text messaging and augmented counseling based on framing and identity-priming BE principles, with their effects tested over a 9-month period in the postpartum period following the birth of a child. METHODS A parallel-group cluster randomized controlled trial was conducted to compare two interventions, augmented counseling based on framing and identity-priming BE principles and personalized mobile phone text messages reminders, aiming to improve the utilization of MFPMs among postpartum women over status quo family planning services in comprehensive health centers in the north of Jordan. RESULTS In total, 1032 participated in the study: 295 women in the control group; 326 women in Intervention Group 1, which received only augmented counseling; and 411 women in intervention Group 2, which received augmented counseling and monthly text messages. The rates of using MFPMs in the counseling group and the counseling and messages group 3 months (54.7% and 57.1%, respectively), 6 months (50.0% and 51.7%, respectively), and 9 months (49.5% and 52.0%, respectively) were significantly higher than the rates among women in the control group (40.6% at 3 months, 37.6% at 6 months, and 34.3% at 9 months). Overall, 26.8% of women in the control group, 42.1% of women in the counseling-only group, and 45.2% of women in the counseling and messages group used MFPMs continuously for all 9 months. At 9 months, the pregnancy rate was significantly much higher in the control group (13.7%) compared to women in the counseling-only group (7.0%) and to women in the counseling and messages group (7.4%). CONCLUSIONS Simple BE-based interventions can be effective methods for enhancing the use of MFPMs and maintaining the anticipated decline in Jordan's total fertility rate.
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Affiliation(s)
- Heath Prince
- Ray Marshall Center for the Study of Human Resources, Lyndon B. Johnson School of Public Affairs, The University of Texas at Austin, Lake Austin Blvd., Austin, TX 78712, USA
| | - Yousef S Khader
- Department of Community Medicine, Public Health and Family Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan
| | | | - Sara Abu Khudair
- Eastern Mediterranean Public Health Network, Amman 11196, Jordan
| | - Mohammad Alyahya
- Department of Health Management and Policy, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Nihaya Al-Sheyab
- Allied Medical Sciences Department, Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Khulood K Shattnawi
- Maternal & Child Health Nursing Department, Faculty of Nursing, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Rana AlHamawi
- Eastern Mediterranean Public Health Network, Amman 11196, Jordan
| | - Kelley Ready
- Ray Marshall Center for the Study of Human Resources, Lyndon B. Johnson School of Public Affairs, The University of Texas at Austin, Lake Austin Blvd., Austin, TX 78712, USA
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Sze YY, Berendes S, Russel S, Bellam L, Smith C, Cameron S, Free CJ. A systematic review of randomised controlled trials of the effects of digital health interventions on postpartum contraception use. BMJ SEXUAL & REPRODUCTIVE HEALTH 2023; 49:50-59. [PMID: 36307185 DOI: 10.1136/bmjsrh-2022-201468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 09/17/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Digital health interventions (DHI) have been used to enhance the uptake of postpartum contraception and reduce unmet contraception needs. We conducted a systematic review of the effectiveness of DHI on postpartum contraceptive use and repeated pregnancy. METHOD We searched MEDLINE, Embase, Global Health, CINAHL and Cochrane CENTRAL (January 1990-July 2020). Randomised controlled trials (RCTs) of DHI promoting contraception among pregnant or postpartum women were included. Two researchers screened articles and extracted data. We assessed the risk of bias, certainty of evidence (CoE) and conducted meta-analyses following Cochrane guidance. RESULTS Twelve trials with 5527 women were included. Interventions were delivered by video (four trials), mobile phone counselling (three trials), short message services (SMS) (four trials) and computer (one trial). During pregnancy or the postpartum period, mobile phone counselling had an uncertain effect on the use of postpartum contraception (risk ratio (RR) 1.37, 95% CI 0.82 to 2.29, very low CoE); video-based education may moderately improve contraception use (RR 1.48, 95% CI 1.01 to 2.17, low CoE); while SMS education probably modestly increased contraception use (RR 1.12, 95% CI 1.01 to 1.23, moderate CoE). Mobile phone counselling probably increased long-acting reversible contraception (LARC) use (RR 4.23, 95% CI 3.01 to 5.93, moderate CoE). Both mobile phone counselling (RR 0.27, 95% CI 0.01 to 5.77, very low CoE) and videos (RR 1.25, 95% CI 0.24 to 6.53, very low CoE) had uncertain effects on repeated pregnancy. CONCLUSIONS During pregnancy or in the postpartum period, videos may moderately increase postpartum contraception use and SMS probably modestly increase postpartum contraception use. The effects of DHI on repeated pregnancy are uncertain. Further well-conducted RCTs of DHI would strengthen the evidence of effects on contraception use and pregnancy.
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Affiliation(s)
- Yik Yan Sze
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Faculty of Medicine, University of Hong Kong Faculty of Medicine, Hong Kong
| | - Sima Berendes
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Sophie Russel
- Medical Student, Manchester University, North Manchester, Indiana, USA
| | - Laura Bellam
- Medical Student, Manchester University, North Manchester, Indiana, USA
| | - Chris Smith
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Sharon Cameron
- Sexual and Reproductive Health, NHS Lothian, Edinburgh, UK
- University of Edinburgh Division of Health Sciences, Edinburgh, UK
| | - Caroline J Free
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Baynes C, Steyn P, Soi C, Dinis A, Tembe S, Mehrtash H, Narasimhan M, Kiarie J, Sherr K. Use of implementation science to advance family planning programs in low- and middle-income countries: A systematic review. Front Glob Womens Health 2022; 3:1038297. [PMID: 36561275 PMCID: PMC9763469 DOI: 10.3389/fgwh.2022.1038297] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/11/2022] [Indexed: 12/12/2022] Open
Abstract
Objective As environmental and economic pressures converge with demands to achieve sustainability development goals, low- and middle-income countries (LMIC) increasingly require strategies to strengthen and scale-up evidence-based practices (EBP) related to family planning (FP). Implementation science (IS) can help these efforts. The purpose of this article is to elucidate patterns in the use of IS in FP research and identify ways to maximize the potential of IS to advance FP in LMIC. Design and methods We conducted a systematic review that describes how IS concepts and principles have been operationalized in LMIC FP research published from 2007-2021. We searched six databases for implementation studies of LMIC FP interventions. Our review synthesizes the characteristics of implementation strategies and research efforts used to enhance the performance of FP-related EBP in these settings, identifying gaps, strengths and lessons learned. Results Four-hundred and seventy-two studies were eligible for full-text review. Ninety-two percent of studies were carried out in one region only, whereas 8 percent were multi-country studies that took place across multiple regions. 37 percent of studies were conducted in East Africa, 21 percent in West and Central Africa, 19 percent in Southern Africa and South Asia, respectively, and fewer than 5 percent in other Asian countries, Latin America and Middle East and North Africa, respectively. Fifty-four percent were on strategies that promoted individuals' uptake of FP. Far fewer were on strategies to enhance the coverage, implementation, spread or sustainability of FP programs. Most studies used quantitative methods only and evaluated user-level outcomes over implementation outcomes. Thirty percent measured processes and outcomes of strategies, 15 percent measured changes in implementation outcomes, and 31 percent report on the effect of contextual factors. Eighteen percent reported that they were situated within decision-making processes to address locally identified implementation issues. Fourteen percent of studies described measures to involve stakeholders in the research process. Only 7 percent of studies reported that implementation was led by LMIC delivery systems or implementation partners. Conclusions IS has potential to further advance LMIC FP programs, although its impact will be limited unless its concepts and principles are incorporated more systematically. To support this, stakeholders must focus on strategies that address a wider range of implementation outcomes; adapt research designs and blend methods to evaluate outcomes and processes; and establish collaborative research efforts across implementation, policy, and research domains. Doing so will expand opportunities for learning and applying new knowledge in pragmatic research paradigms where research is embedded in usual implementation conditions and addresses critical issues such as scale up and sustainability of evidence-informed FP interventions.Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier: CRD42020199353.
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Affiliation(s)
- Colin Baynes
- Department of Global Health, University of Washington, Seattle, WA, United States,Correspondence: Colin Baynes
| | - Petrus Steyn
- Department of Sexual and Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Geneva, Switzerland
| | - Caroline Soi
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Aneth Dinis
- Department of Global Health, University of Washington, Seattle, WA, United States,The National Directorate of Public Health, Ministry of Health of Mozambique, Maputo, Mozambique
| | - Stelio Tembe
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Hedieh Mehrtash
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Manjulaa Narasimhan
- Department of Sexual and Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Geneva, Switzerland
| | - James Kiarie
- Department of Sexual and Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Geneva, Switzerland
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, United States,Department of Epidemiology, University of Washington, Seattle, WA, United States,Department of Industrial and Systems Engineering, University of Washington, Seattle, WA, United States
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Sarkar R, George TS. Using Behavioural Economics to Analyse and Enhance Contraception Usage Decisions. JOURNAL OF HEALTH MANAGEMENT 2022. [DOI: 10.1177/09720634221128394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Existent literature helped narrow down variables influencing modern contraceptive adoption (usage), a behaviour carrying enormous positive externality. Using finite population sample size formula and probability proportional to size method of sample selection, primary data was collected from participants using inclusion and exclusion criterions. Binary logistic regression model was used to predict probability of occurrence of dependent variable ‘usage of modern method of contraception’ being treated at a dichotomous outcome level. Predictor variables after confirming association by cross tabulation were introduced stepwise to build model subject to elimination of those variables adding insignificantly to the overall predictability of the model. Variables such as gender, education level, spousal influence, extended family influence, financial well-being and contraceptive information were found to significantly predict the probability of occurrence of the dependent variable. Except for financial well-being with three sub-categories, other independent variables were treated at dichotomous level. Income level was found to be an important predictor although found statistically insignificant. Non-contributory factors such as age, occupation and years of marriage were dropped. Post-model construction, borrowing ‘nudges’ from behavioural economics (BE) domain, strategies to nurture the significant context specific influencing variables, were articulated. BE was particularly preferred for its openness to the paradigm of non-rational behavioural choices.
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Affiliation(s)
- Rupa Sarkar
- Department of Management and Commerce, PES University, EC Campus, Hosur Road, Bangalore, Karnataka, India
| | - Tony Sam George
- Department of Psychology, CHRIST (Deemed to be University), Hosur Road, Bangalore, Karnataka, India
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Leight J, Hensly C, Chissano M, Safran E, Ali L, Dustan D, Jamison J. The effects of text reminders on the use of family planning services: evidence from a randomised controlled trial in urban Mozambique. BMJ Glob Health 2022; 7:bmjgh-2021-007862. [PMID: 35428679 PMCID: PMC9014002 DOI: 10.1136/bmjgh-2021-007862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 04/05/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction Reduction of unmet need for contraception is associated with enhanced health outcomes. We conducted a randomised controlled trial in Mozambique analysing the effects of text messages encouraging use of family planning services. Methods This trial was conducted within a sample of women served by the Integrated Family Planning Program implemented by Population Services International, in which community health workers provide clinic referrals for family planning services. The evaluation enrolled 5370 women between 20 January and 18 December 2020 who received a referral, reported access to a mobile phone and provided consent. Women were randomly assigned to a treatment group that received a series of text message reminders encouraging them to visit a clinic or to a control arm. An intention-to-treat analysis was conducted to analyse the effect of reminders on the probability of a clinic visit and contraceptive uptake. The final analysis includes 3623 women; 1747 women were lost to follow-up. Results Women assigned to receive the text reminders are weakly more likely to visit a clinic (risk difference 2.3 percentage points, p=0.081) and to receive a contraceptive method at a clinic (2.2 percentage points, p=0.091), relative to a base rate of 48.0% and 46.9%, respectively. The effect on clinic visits is larger and statistically significant in the prespecified subsample of women enrolled prior to the COVID-19-related state of emergency (3.2 percentage points, p=0.042). Conclusion Evidence from this trial suggests that text message reminders are a promising nudge that increases the probability that women receive contraception. Trial registration number AEARCTR-0005383.
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Affiliation(s)
- Jessica Leight
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, District of Columbia, USA
| | - Catherine Hensly
- Economics Department, American University, Washington, District of Columbia, USA
| | | | - Elana Safran
- Office of Evaluation Sciences, Washington, District of Columbia, USA
| | - Liza Ali
- Population Services International, Maputo, Mozambique
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Aikpitanyi J, Okonofua F, Ntoimo L, Tubeuf S. Locus of Control and Self-Esteem as Predictors of Maternal and Child Healthcare Services Utilization in Nigeria. FRONTIERS IN HEALTH SERVICES 2022; 2:847721. [PMID: 36925792 PMCID: PMC10012786 DOI: 10.3389/frhs.2022.847721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 04/07/2022] [Indexed: 11/13/2022]
Abstract
This study investigated the influence of locus of control and self-esteem on the utilization of maternal and child healthcare services in Nigeria. Specifically, it explored the differences in utilization of antenatal care, skilled birth care, postnatal care, and child vaccination by women having internal and external locus of control and women having high and low self-esteem. It also examined the association between utilization of maternal and child healthcare on other sociodemographic characteristics. We collected information on non-cognitive traits of 1,411 randomly selected women along with information on utilization of various indicators of maternal and child healthcare services. We estimated logistic regression models for various components of maternal and child healthcare services utilization and found that women's internal locus of control was a significant predictor of utilization of antenatal care, skilled birth care and completion of child vaccination. We also found that having a high self-esteem was a significant predictor of utilization of antenatal care, postnatal care and completion of child vaccination after adjusting for other control variables. By improving our understanding of non-cognitive traits as possible barriers to maternal and child healthcare utilization, our findings offer important insights for enhancing participants' engagement in intervention programs that are initiated to improve maternal and child health outcomes in lower-middle-income countries.
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Affiliation(s)
- Josephine Aikpitanyi
- Institute of Health Research and Society (IRSS), Université catholique de Louvain, Ottignies-Louvain-la-Neuve, Belgium.,Centre of Excellence in Reproductive Health Innovation, University of Benin, Benin, Nigeria
| | - Friday Okonofua
- Centre of Excellence in Reproductive Health Innovation, University of Benin, Benin, Nigeria
| | - Lorretta Ntoimo
- Department of Demography and Statistics, Federal University Oye Ekiti, Ekiti, Nigeria
| | - Sandy Tubeuf
- Institute of Health Research and Society (IRSS), Université catholique de Louvain, Ottignies-Louvain-la-Neuve, Belgium.,Institute of Economic and Social Research (IRES), Université catholique de Louvain, Ottignies-Louvain-la-Neuve, Belgium
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Chang W, Tumlinson K. Free Access to a Broad Contraceptive Method Mix and Women's Contraceptive Choice: Evidence from Sub-Saharan Africa. Stud Fam Plann 2021; 52:3-22. [PMID: 33533061 PMCID: PMC7990714 DOI: 10.1111/sifp.12144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Financial barriers may restrict women's ability to use their preferred contraceptive methods, especially long-acting reversible contraceptives (LARC). Providing free access to a broad contraceptive method mix, including both LARC and short-acting reversible contraceptives (SARC), may increase contraceptive use, meet women's various fertility needs, and increase their agency in contraceptive decisions. Linking facility and individual data from eight countries in sub-Saharan Africa, we use a propensity score approach combined with machine learning techniques to examine how free access to a broad contraceptive method mix affects women's contraceptive choice. Free access to both LARC and SARC was associated with an increase of 3.2 percentage points (95 percent confidence interval: 0.006, 0.058) in the likelihood of contraceptive use, driven by greater use of SARC. Among contraceptive users, free access did not prompt women to switch to LARC and had no effect on contraceptive decision-making. The price effects were larger among older and more educated women, but free access was associated with lower contraceptive use among adolescents. While free access to contraceptives is associated with a modest increase in contraceptive use for some women, removing user fees alone does not address all barriers women face, especially for the most vulnerable groups of women.
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Affiliation(s)
- Wei Chang
- Wei Chang, Postdoctoral Research Fellow, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Katherine Tumlinson
- Katherine Tumlinson, Assistant Professor, Department of Maternal and Child Health and Faculty Fellow, Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Karim AM, Guichon D, Yihun BY, Zemichael NF, Lorenzana K, Barofsky J, Betemariam W. Application of behavioral economics principles to reduce injectable contraceptive discontinuation in rural Ethiopia: A stratified-pair, cluster-randomized field trial. Gates Open Res 2019; 3:1494. [PMID: 32803127 PMCID: PMC7416084 DOI: 10.12688/gatesopenres.12987.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2019] [Indexed: 11/20/2022] Open
Abstract
Background: Contraceptive prevalence in Ethiopia jumped from 6% in 2000 to 36% in 2016, mainly due to increased injectable method use. However, discontinuation rates among injectable users were high (38%). Given that the public sector is the major source for injectable contraceptives, John Snow Inc. (JSI) in collaboration with ideas42 worked with Ethiopia's flagship Health Extension Program to apply behavioral design to mitigate discontinuation of injectable contraceptives. Methods: We applied behavioral economics insights to mitigate the discontinuation of injectable contraceptives. This process created an intervention package, consisting of a health worker planning calendar, a client counseling job aid, and client appointment cards. A stratified-pair cluster-randomized field trial tested the effectiveness of the intervention. The study area included two districts from the four regions where JSI was implementing a family planning program. One district from each region was randomly allocated to the intervention arm. Women visiting health posts to use injectable contraceptives were enrolled in the study. Regression methods, adjusted for study design, participants' backgrounds, and contextual factors, estimated the intervention's effect on discontinuation rates. Results: A behavioral design methodology was feasibly implemented in a rural, low-resource setting in Ethiopia. The resultant intervention package was successfully delivered in 19 satellite health posts in four districts. Intervention adherence was high for the appointment cards and counseling job aid, but not for the planning calendar. The injectable discontinuation rate was 10.8 % (95% confidence interval: 2.2, 19.3) points lower in the intervention area compared to the control area during the post-intervention follow-up survey. Conclusion: The use of two tools informed by behavioral economics -the appointment card and counseling job aid-effectively decreased injectable discontinuation even with the presence of other health system bottlenecks. Behavioral economics insights and the behavioral design methodology have the potential to enhance family planning programs in Ethiopia and elsewhere.
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Affiliation(s)
- Ali Mehryar Karim
- Global Development, Bill & Melinda Gates Foundation, Addis Ababa, Ethiopia
| | | | - Bantalem Yeshanew Yihun
- The Last Ten Kilometers Project 2020, JSI Research & Training Institute, Inc., Addis Ababa, Ethiopia
| | - Nebreed Fesseha Zemichael
- The Last Ten Kilometers Project 2020, JSI Research & Training Institute, Inc., Addis Ababa, Ethiopia
| | | | | | - Wuleta Betemariam
- The Last Ten Kilometers Project 2020, JSI Research & Training Institute, Inc., Addis Ababa, Ethiopia
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Karim AM, Guichon D, Yihun BY, Zemichael NF, Lorenzana K, Barofsky J, Betemariam W. Application of behavioral economics principles to reduce injectable contraceptive discontinuation in rural Ethiopia: A stratified-pair, cluster-randomized field trial. Gates Open Res 2019; 3:1494. [PMID: 32803127 PMCID: PMC7416084 DOI: 10.12688/gatesopenres.12987.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2019] [Indexed: 11/12/2023] Open
Abstract
Background: Contraceptive prevalence in Ethiopia jumped from 6% in 2000 to 36% in 2016, mainly due to increased injectable method use. However, discontinuation rates among injectable users were high (38%). Given that the public sector is the major source for injectable contraceptives, John Snow Inc. (JSI) in collaboration with ideas42 worked with Ethiopia's flagship Health Extension Program to apply behavioral economics informed approaches to mitigate discontinuation of injectable contraceptives. Methods: Behavioral diagnosis was conducted to identify the primary drivers of discontinuation of injectable contraceptives. Using these insights, a user-centered behavioral design approach was implemented to create an intervention package, consisting of a health worker planning calendar, a client counseling job aid, and client appointment cards. The study area included two districts from the four regions where JSI was implementing a family planning program. One district from each region was randomly allocated to the intervention arm. Women visiting health posts to use injectable contraceptives were enrolled in the study. Regression methods adjusted for study design, participants' backgrounds, and contextual factors, were used to estimate the intervention's effect on discontinuation rates. Results: Intervention adherence was high for the appointment cards and counseling job aid, but not for the planning calendar. This was not surprising as using appointment cards and the job aid was within the routine workflow of health extension workers, but using the planner was not. The injectable discontinuation rate was 10.8 % points lower in the intervention area compared to the control area during the post intervention follow-up survey. Conclusion: The use of two behavioral economics informed tools-the appointment card and counseling job aid-effectively decreased injectable discontinuation even with the presence of other health system bottlenecks. Behavioral economics approaches have the potential to enhance family planning programs in Ethiopia and elsewhere. Trial registration: ISRCTN ISRCTN17390653 (10/04/2019).
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Affiliation(s)
- Ali Mehryar Karim
- Global Development, Bill & Melinda Gates Foundation, Addis Ababa, Ethiopia
| | | | - Bantalem Yeshanew Yihun
- The Last Ten Kilometers Project 2020, JSI Research & Training Institute, Inc., Addis Ababa, Ethiopia
| | - Nebreed Fesseha Zemichael
- The Last Ten Kilometers Project 2020, JSI Research & Training Institute, Inc., Addis Ababa, Ethiopia
| | | | | | - Wuleta Betemariam
- The Last Ten Kilometers Project 2020, JSI Research & Training Institute, Inc., Addis Ababa, Ethiopia
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Dulli L. Mobile Technology for Sexual and Reproductive Health Interventions in Low- and Middle-Income Countries. Am J Public Health 2019; 109:836-837. [PMID: 31067087 DOI: 10.2105/ajph.2019.305094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Lisa Dulli
- Lisa Dulli is with the Division of Health Services Research, Program Sciences and Technical Support Department, Family Health International (FHI 360), Durham, NC
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