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Pillay N, Ncube N, Moopelo K, Mothoagae G, Welte O, Shogole M, Gwiji N, Scott L, Moshani N, Tiffin N, Boulle A, Griffiths F, Fairlie L, Mehta U, LeFevre A, Scott K. Translating the consent form is the tip of the iceberg: using cognitive interviews to assess the barriers to informed consent in South African health facilities. Sex Reprod Health Matters 2023; 31:2302553. [PMID: 38277196 PMCID: PMC10823893 DOI: 10.1080/26410397.2024.2302553] [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] [Indexed: 01/27/2024] Open
Abstract
The increasing digitisation of personal health data has led to an increase in the demand for onward health data. This study sought to develop local language scripts for use in public sector maternity clinics to capture informed consent for onward health data use. The script considered five possible health data uses: 1. Sending of general health information content via mobile phones; 2. Delivery of personalised health information via mobile phones; 3. Use of women's anonymised health data; 4. Use of child's anonymised health data; and 5. Use of data for recontact. Qualitative interviews (n = 54) were conducted among women attending maternity services in three public health facilities in Gauteng and Western Cape, South Africa. Using cognitive interviewing techniques, interviews sought to:(1) explore understanding of the consent script in five South African languages, (2) assess women's understanding of what they were consenting to, and (3) improve the consent script. Multiple rounds of interviews were conducted, each followed by revisions to the consent script, until saturation was reached, and no additional cognitive failures identified. Cognitive failures were a result of: (1) words and phrases that did not translate easily in some languages, (2) cognitive mismatches that arose as a result of different world views and contexts, (3) linguistic gaps, and (4) asymmetrical power relations that influence how consent is understood and interpreted. Study activities resulted in the development of an informed consent script for onward health data use in five South African languages for use in maternity clinics.
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Affiliation(s)
- Nirvana Pillay
- Senior Lecturer, Department of Sociology, University of the Witwatersrand, Johannesburg, South Africa; Director, Sarraounia Public Health Trust, 20 4th Avenue, Parktown North, Johannesburg, 2193, South Africa. Correspondence:
| | - Nobukhosi Ncube
- Social Scientist, Sarraounia Public Health Trust, Johannesburg, South Africa
| | - Kearabetswe Moopelo
- Social Scientist, Sarraounia Public Health Trust, Johannesburg, South Africa
| | - Gaolatlhe Mothoagae
- Social Scientist, Sarraounia Public Health Trust, Johannesburg, South Africa
| | - Olivia Welte
- Social Scientist, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Manape Shogole
- Social Scientist, Sarraounia Public Health Trust, Johannesburg, South Africa
| | - Nasiphi Gwiji
- Social Scientist, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Lesley Scott
- School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Noma Moshani
- Social Scientist, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Nicki Tiffin
- Professor, Life Sciences Building, South African Bioinformatics Institute, University of the Western Cape, Bellville, South Africa
| | - Andrew Boulle
- Professor, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Frances Griffiths
- Professor, Warwick Medical School, UK; Professor, Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Lee Fairlie
- Director of Maternal and Child Health, Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ushma Mehta
- Associate Professor, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Amnesty LeFevre
- Associate Professor, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Kerry Scott
- Independent research consultant, Toronto, Canada; Associate Faculty, Johns Hopkins School of Public Health, Baltimore, MD, USA
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Umar N, Schellenberg J, Hill Z, Bhattacharya AA, Muzigaba M, Tunçalp Ö, Sambo NU, Shuaibu A, Marchant T. To call or not to call: exploring the validity of telephone interviews to derive maternal self-reports of experiences with facility childbirth care in northern Nigeria. BMJ Glob Health 2022; 7:bmjgh-2021-008017. [PMID: 35296464 PMCID: PMC8928249 DOI: 10.1136/bmjgh-2021-008017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 03/02/2022] [Indexed: 11/05/2022] Open
Abstract
Background To institutionalise respectful maternity care, frequent data on the experience of childbirth care is needed by health facility staff and managers. Telephone interviews have been proposed as a low-cost alternative to derive timely and actionable maternal self-reports of experience of care. However, evidence on the validity of telephone interviews for this purpose is limited. Methods Eight indicators of positive maternity care experience and 18 indicators of negative maternity care experience were investigated. We compared the responses from exit interviews with women about their childbirth care experience (reference standard) to follow-up telephone interviews with the same women 14 months after childbirth. We calculated individual-level validity metrics including, agreement, sensitivity, specificity, area under the receiver operating characteristic curve (AUC). We compared the characteristics of women included in the telephone follow-up interviews to those from the exit interviews. Results Demographic characteristics were similar between the original exit interview group (n=388) and those subsequently reached for telephone interview (n=294). Seven of the eight positive maternity care experience indicators had reported prevalence higher than 50% at both exit and telephone interviews. For these indicators, agreement between the exit and the telephone interviews ranged between 50% and 92%; seven positive indicators met the criteria for validation analysis, but all had an AUC below 0.6. Reported prevalence for 15 of the 18 negative maternity care experience indicators was lower than 5% at exit and telephone interviews. For these 15 indicators, agreement between exit and telephone interview was high at over 80%. Just three negative indicators met the criteria for validation analysis, and all had an AUC below 0.6. Conclusions The telephone interviews conducted 14 months after childbirth did not yield results that were consistent with exit interviews conducted at the time of facility discharge. Women’s reports of experience of childbirth care may be influenced by the location of reporting or changes in the recall of experiences of care over time.
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Affiliation(s)
- Nasir Umar
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Joanna Schellenberg
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Zelee Hill
- Institute for Global Health, Department of Epidemiology and Public Health, University College London Research, London, UK
| | - Antoinette Alas Bhattacharya
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Moise Muzigaba
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneve, Switzerland
| | - Özge Tunçalp
- Sexual and Reproductive Health and Research, World Health Organizations, Geneva, Switzerland
| | | | - Abdulrahman Shuaibu
- Executive Office, State Primary Health Care Development Agency, Gombe, Nigeria
| | - Tanya Marchant
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
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Ng A, Mohan D, Shah N, Scott K, Ummer O, Chamberlain S, Bhatnagar A, Dhar D, Agarwal S, Ved R, LeFevre AE. Assessing the reliability of phone surveys to measure reproductive, maternal and child health knowledge among pregnant women in rural India: a feasibility study. BMJ Open 2022; 12:e056076. [PMID: 35273055 PMCID: PMC8915337 DOI: 10.1136/bmjopen-2021-056076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES Efforts to understand the factors influencing the uptake of reproductive, maternal, newborn, child health and nutrition (RMNCH&N) services in high disease burden low-resource settings have often focused on face-to-face surveys or direct observations of service delivery. Increasing access to mobile phones has led to growing interest in phone surveys as a rapid, low-cost alternatives to face-to-face surveys. We assess determinants of RMNCH&N knowledge among pregnant women with access to phones and examine the reliability of alternative modalities of survey delivery. PARTICIPANTS Women 5-7 months pregnant with access to a phone. SETTING Four districts of Madhya Pradesh, India. DESIGN Cross-sectional surveys administered face-to-face and within 2 weeks, the same surveys were repeated among two random subsamples of the original sample: face-to-face (n=205) and caller-attended telephone interviews (n=375). Bivariate analyses, multivariable linear regression, and prevalence and bias-adjusted kappa scores are presented. RESULTS Knowledge scores were low across domains: 52% for maternal nutrition and pregnancy danger signs, 58% for family planning, 47% for essential newborn care, 56% infant and young child feeding, and 58% for infant and young child care. Higher knowledge (≥1 composite score) was associated with older age; higher levels of education and literacy; living in a nuclear family; primary health decision-making; greater attendance in antenatal care and satisfaction with accredited social health activist services. Survey questions had low inter-rater and intermodal reliability (kappa<0.70) with a few exceptions. Questions with the lowest reliability included true/false questions and those with unprompted, multiple response options. Reliability may have been hampered by the sensitivity of the content, lack of privacy, enumerators' and respondents' profile differences, rapport, social desirability bias, and/or enumerator's ability to adequately convey concepts or probe. CONCLUSIONS Phone surveys are a reliable modality for generating population-level estimates data about pregnant women's knowledge, however, should not be used for individual-level tracking. TRIAL REGISTRATION NUMBER NCT03576157.
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Affiliation(s)
- Angela Ng
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Diwakar Mohan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Neha Shah
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Kerry Scott
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Osama Ummer
- Oxford Policy Management, New Delhi, Delhi, India
| | - Sara Chamberlain
- BBC Media Action, New Delhi, Delhi, India
- BBC Media Action, London, UK
| | - Aarushi Bhatnagar
- Health, Nutrition and Population, World Bank New Delhi Office, New Delhi, India
| | - Diva Dhar
- The Bill and Melinda Gates Foundation, Seattle, Washington, USA
| | - Smisha Agarwal
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Rajani Ved
- National Health Systems Resource Centre, New Delhi, Delhi, India
- The Bill and Melinda Gates Foundation, Delhi, India
| | - Amnesty Elizabeth LeFevre
- Division of Public Health and Family Medicine, University of Cape Town, School of Public Health and Family Medicine, Cape Town, South Africa
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Adam M, Johnston J, Job N, Dronavalli M, Le Roux I, Mbewu N, Mkunqwana N, Tomlinson M, McMahon SA, LeFevre AE, Vandormael A, Kuhnert KL, Suri P, Gates J, Mabaso B, Porwal A, Prober C, Bärnighausen T. Evaluation of a community-based mobile video breastfeeding intervention in Khayelitsha, South Africa: The Philani MOVIE cluster-randomized controlled trial. PLoS Med 2021; 18:e1003744. [PMID: 34582438 PMCID: PMC8478218 DOI: 10.1371/journal.pmed.1003744] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 07/28/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In South Africa, breastfeeding promotion is a national health priority. Regular perinatal home visits by community health workers (CHWs) have helped promote exclusive breastfeeding (EBF) in underresourced settings. Innovative, digital approaches including mobile video content have also shown promise, especially as access to mobile technology increases among CHWs. We measured the effects of an animated, mobile video series, the Philani MObile Video Intervention for Exclusive breastfeeding (MOVIE), delivered by a cadre of CHWs ("mentor mothers"). METHODS AND FINDINGS We conducted a stratified, cluster-randomized controlled trial from November 2018 to March 2020 in Khayelitsha, South Africa. The trial was conducted in collaboration with the Philani Maternal Child Health and Nutrition Trust, a nongovernmental community health organization. We quantified the effect of the MOVIE intervention on EBF at 1 and 5 months (primary outcomes), and on other infant feeding practices and maternal knowledge (secondary outcomes). We randomized 1,502 pregnant women in 84 clusters 1:1 to 2 study arms. Participants' median age was 26 years, 36.9% had completed secondary school, and 18.3% were employed. Mentor mothers in the video intervention arm provided standard-of-care counseling plus the MOVIE intervention; mentor mothers in the control arm provided standard of care only. Within the causal impact evaluation, we nested a mixed-methods performance evaluation measuring mentor mothers' time use and eliciting their subjective experiences through in-depth interviews. At both points of follow-up, we observed no statistically significant differences between the video intervention and the control arm with regard to EBF rates and other infant feeding practices [EBF in the last 24 hours at 1 month: RR 0.93 (95% CI 0.86 to 1.01, P = 0.091); EBF in the last 24 hours at 5 months: RR 0.90 (95% CI 0.77 to 1.04, P = 0.152)]. We observed a small, but significant improvement in maternal knowledge at the 1-month follow-up, but not at the 5-month follow-up. The interpretation of the results from this causal impact evaluation changes when we consider the results of the nested mixed-methods performance evaluation. The mean time spent per home visit was similar across study arms, but the intervention group spent approximately 40% of their visit time viewing videos. The absence of difference in effects on primary and secondary endpoints implies that, for the same time investment, the video intervention was as effective as face-to-face counseling with a mentor mother. The videos were also highly valued by mentor mothers and participants. Study limitations include a high loss to follow-up at 5 months after premature termination of the trial due to the COVID-19 pandemic and changes in mentor mother service demarcations. CONCLUSIONS This trial measured the effect of a video-based, mobile health (mHealth) intervention, delivered by CHWs during home visits in an underresourced setting. The videos replaced about two-fifths of CHWs' direct engagement time with participants in the intervention arm. The similar outcomes in the 2 study arms thus suggest that the videos were as effective as face-to-face counselling, when CHWs used them to replace a portion of that counselling. Where CHWs are scarce, mHealth video interventions could be a feasible and practical solution, supporting the delivery and scaling of community health promotion services. TRIAL REGISTRATION The study and its outcomes were registered at clinicaltrials.gov (#NCT03688217) on September 27, 2018.
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Affiliation(s)
- Maya Adam
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States of America
- Heidelberg University Institute of Global Health, Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
- * E-mail:
| | - Jamie Johnston
- Stanford Center for Health Education, Stanford, California, United States of America
| | - Nophiwe Job
- Stanford Center for Health Education, Stanford, California, United States of America
- Digital Medic, Stanford Center for Health Education, Cape Town, South Africa
| | | | - Ingrid Le Roux
- The Philani Maternal Child Health and Nutrition Trust, Khayelitsha, South Africa
| | - Nokwanele Mbewu
- The Philani Maternal Child Health and Nutrition Trust, Khayelitsha, South Africa
| | - Neliswa Mkunqwana
- Digital Medic, Stanford Center for Health Education, Cape Town, South Africa
| | - Mark Tomlinson
- Institute for Life Course Health Research, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
- School of Nursing and Midwifery, Queens University, Belfast, United Kingdom
| | - Shannon A. McMahon
- Heidelberg University Institute of Global Health, Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Amnesty E. LeFevre
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- University of Cape Town, School of Public Health and Family Medicine, Cape Town, South Africa
| | - Alain Vandormael
- Heidelberg University Institute of Global Health, Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
| | - Kira-Leigh Kuhnert
- Stanford Center for Health Education, Stanford, California, United States of America
- Digital Medic, Stanford Center for Health Education, Cape Town, South Africa
| | - Pooja Suri
- Stanford Center for Health Education, Stanford, California, United States of America
- Berkeley School of Public Health, Berkeley, California, United States of America
| | - Jennifer Gates
- Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Bongekile Mabaso
- School of Management Studies, University of Cape Town, Cape Town, South Africa
| | - Aarti Porwal
- Stanford Center for Health Education, Stanford, California, United States of America
- Digital Medic, Stanford Center for Health Education, Cape Town, South Africa
| | - Charles Prober
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States of America
- Stanford Center for Health Education, Stanford, California, United States of America
- Digital Medic, Stanford Center for Health Education, Cape Town, South Africa
| | - Till Bärnighausen
- Heidelberg University Institute of Global Health, Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
- Harvard Center for Population and Development Studies, Cambridge, Massachusetts, United States of America
- Wellcome Trust’s Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa
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LeFevre AE, Shah N, Bashingwa JJH, George AS, Mohan D. Does women's mobile phone ownership matter for health? Evidence from 15 countries. BMJ Glob Health 2021; 5:bmjgh-2020-002524. [PMID: 32424014 PMCID: PMC7245424 DOI: 10.1136/bmjgh-2020-002524] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 03/26/2020] [Indexed: 11/03/2022] Open
Abstract
Mobile phones have the potential to increase access to health information, improve patient-provider communication, and influence the content and quality of health services received. Evidence on the gender gap in ownership of mobile phones is limited, and efforts to link phone ownership among women to care-seeking and practices for reproductive maternal newborn and child health (RMNCH) have yet to be made. This analysis aims to assess household and women's access to phones and its effects on RMNCH health outcomes in 15 countries for which Demographic and Health Surveys data on phone ownership are available. Multilevel logistic regression models were used to explore factors associated with women's phone ownership, along with the association of phone ownership to a wide range of RMNCH indicators. Study findings suggest that (1) gender gaps in mobile phone ownership vary, but they can be substantial, with less than half of women owning mobile phones in several countries; (2) the gender gap in phone ownership is larger for rural and poorer women; (3) women's phone ownership is generally associated with better RMNCH indicators; (4) among women phone owners, utilisation of RMNCH care-seeking and practices differs based on their income status; and (5) more could be done to unleash the potential of mobile phones on women's health if data gaps and varied metrics are addressed. Findings reinforce the notion that without addressing the gender gap in phone ownership, digital health programmes may be at risk of worsening existing health inequities.
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Affiliation(s)
- Amnesty E LeFevre
- Faculty of Health Sciences, University of Cape Town, Observatory, Western Cape, South Africa .,International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Neha Shah
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Asha S George
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - Diwakar Mohan
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Shah N, Mohan D, Agarwal S, Scott K, Chamberlain S, Bhatnagar A, Labrique A, Indurkar M, Ved R, LeFevre A. Novel approaches to measuring knowledge among frontline health workers in India: Are phone surveys a reliable option? PLoS One 2020; 15:e0234241. [PMID: 32598348 PMCID: PMC7323989 DOI: 10.1371/journal.pone.0234241] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 05/21/2020] [Indexed: 11/24/2022] Open
Abstract
Background In 2017, India was home to nearly 20% of maternal and child deaths occurring globally. Accredited social health activists (ASHAs) act as the frontline for health services delivery in India, providing a range of reproductive, maternal, newborn, child health, and nutrition (RMNCH&N) services. Empirical evidence on ASHAs’ knowledge is limited, yet is a critical determinant of the quality of health services provided. We assessed the determinants of RMNCH&N knowledge among ASHAs and examined the reliability of alternative modalities of survey delivery, including face-to-face and caller attended telephone interviews (phone surveys) in 4 districts of Madhya Pradesh, India. Methods We carried out face-to-face surveys among a random cross-sectional sample of ASHAs (n = 1,552), and administered a follow-up test-retest survey within 2 weeks of the initial survey to a subsample of ASHAs (n = 173). We interviewed a separate sub-sample of ASHAs 2 weeks of the face-to-face interview over the phone (n = 155). Analyses included bivariate analyses, multivariable linear regression, and prevalence and bias adjusted kappa analyses. Findings The average ASHA knowledge score was 64% and ranged across sub-domains from 71% for essential newborn care, 71% for WASH/ diarrhea, 64% for infant feeding, 61% for family planning, and 60% for maternal health. Leading determinants of knowledge included geographic location, age <30 years of age, education, experience as an ASHA, completion of seven or more client visits weekly, phone ownership and use as a communication tool for work, as well as the ability to navigate interactive voice response prompts (a measure of digital literacy). Efforts to develop a phone survey tool for measuring knowledge suggest that findings on inter-rater and inter-modal reliability were similar. Reliability was higher for shorter, widely known questions, including those about timing of exclusive breastfeeding or number of tetanus shots during pregnancy. Questions with lower reliability included those on sensitive topics such as family planning; questions with multiple response options; or which were difficult for the enumerator to convey. Conclusions Overall results highlight important gaps in the knowledge of ASHAs. Findings on the reliability of phone surveys led to the development of a tool, which can be widely used for the routine, low cost measurement of ASHA RMNCH&N knowledge in India.
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Affiliation(s)
- Neha Shah
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Diwakar Mohan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Smisha Agarwal
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Kerry Scott
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | | | - Alain Labrique
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Meenal Indurkar
- National Health Systems Resource Center, National Institute of Health & Family Welfare, New Delhi, Delhi, India
| | - Rajani Ved
- National Health Systems Resource Center, National Institute of Health & Family Welfare, New Delhi, Delhi, India
| | | | - on behalf of the Kilkari Impact Evaluation team
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Division of Public Health Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- * E-mail:
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