How Should Home-Based Maternal and Child Health Records Be Implemented? A Global Framework Analysis

Inequalities in ownership and availability of home-based vaccination records in 82 low- and middle-income countries

INTRODUCTION

Home-based records (HBRs) are widely used for recording health information including child immunisations. We studied levels and inequalities in HBR ownership in low-income and middle-income countries (LMICs) using data from national surveys conducted since 2010.

METHODS

We used data from national household surveys (Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS)) from 82 LMICs. 465 060 children aged 6-35 months were classified into four categories: HBR seen by the interviewer; mother/caregiver never had an HBR; mother/caregiver had an HBR that was lost; and reportedly have an HBR that was not seen by the interviewer. Inequalities according to age, sex, household wealth, maternal education, antenatal care and giving birth in an institutional setting were studied, as were associations between HBR ownership and vaccine coverage. Pooled analyses were carried out using country weights based on child populations.

RESULTS

An HBR was seen for 67.8% (95% CI 67.4% to 68.2%) of the children, 9.2% (95% CI 9.0% to 9.4%) no longer had an HBR, 12.8% (95% CI 12.5% to 13.0%) reportedly had an HBR that was not seen and 10.2% (95% CI 9.9% to 10.5%) had never received one. The lowest percentages of HBRs seen were in Kiribati (22.1%), the Democratic Republic of Congo (24.5%), Central African Republic (24.7%), Chad (27.9%) and Mauritania (35.5%). The proportions of HBRs seen declined with age and were inversely associated with household wealth and maternal schooling. Antenatal care and giving birth in an institutional setting were positively associated with ownership. There were no differences between boys and girls. When an HBR was seen, higher immunisation coverage and lower vaccine dropout rates were observed, but the direction of this association remains unclear.

INTERPRETATION

HBR coverage levels were remarkably low in many LMICs, particularly among children from the poorest families and those whose mothers had low schooling. Contact with antenatal and delivery care was associated with higher HBR coverage. Interventions are urgently needed to ensure that all children are issued HBRs, and to promote proper storage of such cards by families.

Travelling numbers and broken loops: A qualitative systematic review on collecting and reporting maternal and neonatal health data in low-and lower-middle income countries

Data and indicator estimates are considered vital to document persisting challenges in maternal and newborn health and track progress towards global goals. However, prioritization of standardised, comparable quantitative data can preclude the collection of locally relevant information and pose overwhelming burdens in low-resource settings, with negative effects on the provision of quality of care. A growing body of qualitative studies aims to provide a place-based understanding of the complex processes and human experiences behind the generation and use of maternal and neonatal health data. We conducted a qualitative systematic review exploring how national or international requirements to collect and report data on maternal and neonatal health indicators are perceived and experienced at the sub-national and country level in low-income and lower-middle income countries. We systematically searched six electronic databases for qualitative and mixed-methods studies published between January 2000 and March 2023. Following screening of 4084 records by four reviewers, 47 publications were included in the review. Data were analysed thematically and synthesised from a Complex Adaptive Systems (CAS) theoretical perspective. Our findings show maternal and neonatal health data and indicators are not fixed, neutral entities, but rather outcomes of complex processes. Their collection and uptake is influenced by a multitude of system hardware elements (human resources, relevancy and adequacy of tools, infrastructure, and interoperability) and software elements (incentive systems, supervision and feedback, power and social relations, and accountability). When these components are aligned and sufficiently supportive, data and indicators can be used for positive system adaptivity through performance evaluation, prioritization, learning, and advocacy. Yet shortcomings and broken loops between system components can lead to unforeseen emergent behaviors such as blame, fear, and data manipulation. This review highlights the importance of measurement approaches that prioritize local relevance and feasibility, necessitating participatory approaches to define context-specific measurement objectives and strategies.

Parental developmental screening with CARE: A pilot hybrid assessment and intervention with vulnerable families in Colombia

Poverty and scarcity of resources make children in low-and-middle-income countries at risk of not reaching their developmental potential. Despite a near-universal interest in risk reduction, effective interventions like enhancing reading skills in parents to diminish developmental delay remain elusive for the great majority of vulnerable families. We undertook a efficacy study for parental use of a booklet called CARE for developmental screening of children between 36 to 60 months old (M = 44.0, SD = 7.5). All participants (N = 50), lived in vulnerable, low-income neighborhoods in Colombia. The study followed a pilot Quasi-Randomised Control Trial design (i.e., control group participants assigned based on non-random criteria) of parent training with a CARE intervention group compared to a control group. Data was analyzed using two-way ANCOVA for sociodemographic variables' interaction with follow-up results and one-way ANCOVA to evaluate the relations between the intervention and post-measurement of developmental delays and cautions and other language related-skills outcomes, while controlling for pre-measurements. These analyses indicated that the CARE booklet intervention enhanced children's developmental status and narrative skills (developmental screening delay items, F(1, 47) = 10.45, p = .002, partial η2 = .182; narrative devices scores, F(1, 17) = 4.87, p = .041, partial η2 = .223). Several limitations (e.g., sample size) and possible implications for the analysis of children's developmental potential are discussed and considered for future research, along with the effects of the COVID-19 pandemic on the closure of preschools and community care centers.

R. L, S. S, Panniyammakal J, Lavis A. Patients', carers' and healthcare providers' views of patient-held health records in Kerala, India: A qualitative exploratory study

INTRODUCTION

Poor medical information transfer across healthcare visits and providers poses a potential threat to patient safety. Patient-held health records (PHRs) may be used to facilitate informational continuity, handover communication and patient self-management. However, there are conflicting opinions on the effectiveness of PHRs, other than in maternal and child care. Moreover, the experiences of users of PHRs in low- and middle-income countries are critical in policy decisions but have rarely been researched.

AIM

This study aimed to explore similarities and differences in the perspectives of patients, carers and healthcare providers (HCPs) on the current PHRs for diabetes and hypertension in Kerala.

METHODS

A qualitative design was used comprising semistructured interviews with patients with diabetes/hypertension (n = 20), carers (n = 15) and HCPs (n = 17) in Kerala, India. Data were analysed using thematic analysis.

RESULTS

Themes generated regarding the experiences with PHRs from each user group were compared and contrasted. The themes that arose were organized under three headings: use of PHRs in everyday practice; the perceived value of PHR and where practice and value conflict. We found that in the use of PHRs in everyday practice, multiple PHRs posed challenges for patients carrying records and for HCPs locating relevant information. Most carers carried all patients' past PHRs, while patients made decisions on which PHR to take along based on the purpose of the healthcare visit. HCPs appreciated having PHRs but documented limited details in them. The perceived value of PHRs by each group for themselves was different. While HCPs placed value on PHRs for enabling better clinical decision-making, preventing errors and patient safety, patients perceived them as transactional tools for diabetes and hypertension medications; carers highlighted their value during emergencies.

CONCLUSION

Our findings suggest that users find a variety of values for PHRs. However, these perceived values are different for each user group, suggesting minimal functioning of PHRs for informational continuity, handover communication and self-management.

PATIENT AND PUBLIC INVOLVEMENT

Patients and carers were involved during the pilot testing of topic guides, consent and study information sheets. Patients and carers gave their feedback on the materials to ensure clarity and appropriateness within the context.

The RE-AIM framework-based evaluation of the implementation of the Maternal and Child Health Handbook program in Angola: a mixed methods study

Background

The World Health Organization recommends the Maternal and Child Health Handbook (MCH-HB) to promote health service utilization from pregnancy to early childhood. Although many countries have adopted it as a national health policy, there is a paucity of research in MCH-HB’s implementation. Thus, this study aimed to evaluate the MCH-HB’s implementation status based on the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, Maintenance), and identify facilitators of, and barriers to its implementation in Angola to understand effective implementation strategies.

Methods

A cross-sectional survey was conducted targeting all health facilities which implemented MCH-HB, subsamples of health workers, and officers responsible for the MCH-HB at the municipality health office. Using the 14 indicators based on the RE-AIM framework, health facilities’ overall implementation statuses were assessed. This categorized health facilities into optimal-implementation and suboptimal-implementation groups. To identify barriers to and facilitators of MCH-HB implementation, semi-structured interviews were conducted among health workers and municipality health officers responsible for MCH-HB. The data were analyzed via content analysis.

Results

A total of 88 health facilities and 216 health workers were surveyed to evaluate the implementation status, and 155 interviews were conducted among health workers to assess the barriers to and facilitators of the implementation. The overall implementation target was achieved in 50 health facilities (56.8%). The target was achieved by more health facilities in urban than rural areas (urban 68.4%, rural 53.6%) and by more health facilities of higher facility types (hospital 83.3%, health center 59.3%, health post 52.7%). Through the interview data’s analysis, facilitators of and barriers to MCH-HB were comprehensively demonstrated. MCH-HB’s content advantage was the most widely recognized facilitator and inadequate training for health workers was the most widely recognized barrier.

Conclusions

Strengthening education for health workers, supervision by municipality health officers, and community sensitization were potential implementation strategies. These strategies must be intensified in rural and lower-level health facilities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08454-9.

Effects of the maternal and child health handbook and other home-based records on mothers' non-health outcomes: a systematic review

OBJECTIVE

This review aimed to investigate the effects of the maternal and child health (MCH) handbook and other home-based records on mothers' non-health outcomes.

DESIGN

Systematic review.

DATA SOURCES

PubMed, Web of Science, CINAHL, Academic Search Complete, PsycArticles, PsycINFO, SocINDEX, CENTRAL, NHS EED, HTA, DARE, Ichuushi and J-STAGE through 26 March 2022.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Original research articles examining home-based records and mothers' non-health outcomes published in English or Japanese across various study designs.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted relevant data and assessed the risk of bias. We assessed the certainty of evidence for each study using the Grading of Recommendations Assessment, Development, and Evaluation approach. Due to the heterogeneity of the included studies, we conducted a narrative synthesis of their findings.

RESULTS

Of the 4199 articles identified, we included 47 articles (20 in Japanese) in the review. Among the different types of home-based records, only the MCH handbook provided essential information about the mother-child relationship, and its use facilitated the mother-child bonding process. Mothers reported generally feeling satisfied with the use of home-based records; although their satisfaction with health services was influenced by healthcare providers' level of commitment to using these records. While home-based records positively affected communication within the household, we observed mixed effects on communication between mothers/caregivers and healthcare providers. Barriers to effective communication included a lack of satisfactory explanations regarding the use of home-based records and personalised guidance from healthcare providers. These records were also inconsistently used across different health facilities and professionals.

CONCLUSIONS

The MCH handbook fostered the mother-child bond. Mothers were generally satisfied with the use of home-based records, but their engagement depended on how these records were communicated and used by healthcare providers. Additional measures are necessary to ensure the implementation and effective use of home-based records.

PROSPERO REGISTRATION NUMBER

CRD42020166545.

Agreement and Reliability of Parental Reports and Direct Screening of Developmental Outcomes in Toddlers at Risk

Developmental screening is a practice that directly benefits vulnerable and low-income families and children when it is regular and frequently applied. A developmental screening tool administered by parents called CARE is tested. CARE contains a compilation of activities to report and enhance development at home. Hundred and fifty-seven families in Bogotá (Colombia) initially responded to a call to participate in developmental screening tools' validation and reliability study. All children (Average: 42.7 months old; SD: 9.4; Min: 24, Max: 58) were screened directly by trained applicants using a Spanish version of the Denver Developmental Screening test [i.e., the Haizea-Llevant (HLL) screening table]. After a first screening, 61 dyads were positive for follow-up and received a second HLL screening. Fifty-two out of 61 dyads use and returned CARE booklet after 1-month screening at home. The comparative analysis for parent reports using CARE and direct screening observation included (a) the effects of demographic variables on overall and agreement, (b) agreement and congruence between the CARE report classification and direct screening classification ("At risk" or "Not at risk"), (c) receiver operating characteristic analysis, (d) item-Level agreement for specific developmental domains, and (e) acceptability and feasibility analysis. Results and conclusions show the parental report using the CARE booklet as a reliable screening tool that has the potential to activate alerts for an early cognitive delay that reassure clinicians and families to further specialized and controlled developmental evaluations and act as a screen for the presence of such delay in four developmental dimensions.

Parent engagement with the New South Wales child health home-based record: A cross-sectional survey and a retrospective chart review

BACKGROUND

In 2018, World Health Organization endorsed universal use of home-based records to improve care for mothers, pregnant women, newborns and children. New South Wales (NSW), Australia has had universal use of a child health home-based record since 1988, with the first major update in 2013. Since the update, limitedbelief is sufficient for constituting evidence has been collected about factors influencing parent use of the record. This study aims to examine parent engagement with the record and whether it is influenced by child's first-born status and Parent Evaluation of Development Status (PEDS) outcome.

METHOD

A survey of 202 parent-child pairs and a review of 20 record books were conducted in NSW, Australia. Odds ratio (OR) at 95% confidence interval (CI) and .05 level of significance, bivariate and multivariate logistic regressions were conducted to examine the influence of first-born status, child's PEDS outcome and other parent-child characteristics on parent engagement with the record.

RESULTS

Parents engaged with the home-based record by taking it for routine checks (80.7%), writing (74.8%) or reading (75.8%) information. Parents of first-born children were more than three times likely to take the record book for routine checks compared with parent of later-born children (adjusted OR [AOR] = 3.70, 95% CI 1.12-12.20). Similarly, parents of children with low PEDS level of risk were significantly less likely to read information in the record book compared with parents of children with high risk (AOR = 0.28, 95% CI 0.08-0.98). Parent record input through direct observation significantly decreased from 85% at 1-month to 60% at 12-month postnatal. Data about at least one vaccination event were recorded in all the record books examined, while 85% had all recommended vaccinations recorded.

CONCLUSION

Parents valued/engaged regularly with a child health home-based record, and the record may be a useful tool for early detection and monitoring of child developmental concerns. Therefore, continued promotion of the use of child health home-based record appears to play an important role in improving child health and development.

Advancing sustainable development goals through immunization: a literature review

BACKGROUND

Immunization directly impacts health (SDG3) and brings a contribution to 14 out of the 17 Sustainable Development Goals (SDGs), such as ending poverty, reducing hunger, and reducing inequalities. Therefore, immunization is recognized to play a central role in reaching the SDGs, especially in low- and middle-income countries (LMICs). Despite continuous interventions to strengthen immunization systems and to adequately respond to emergency immunization during epidemics, the immunization-related indicators for SDG3 lag behind in sub-Saharan Africa. Especially taking into account the current Covid19 pandemic, the current performance on the connected SDGs is both a cause and a result of this.

METHODS

We conduct a literature review through a keyword search strategy complemented with handpicking and snowballing from earlier reviews. After title and abstract screening, we conducted a qualitative analysis of key insights and categorized them according to showing the impact of immunization on SDGs, sustainability challenges, and model-based solutions to these challenges.

RESULTS

We reveal the leveraging mechanisms triggered by immunization and position them vis-à-vis the SDGs, within the framework of Public Health and Planetary Health. Several challenges for sustainable control of vaccine-preventable diseases are identified: access to immunization services, global vaccine availability to LMICs, context-dependent vaccine effectiveness, safe and affordable vaccines, local/regional vaccine production, public-private partnerships, and immunization capacity/capability building. Model-based approaches that support SDG-promoting interventions concerning immunization systems are analyzed in light of the strategic priorities of the Immunization Agenda 2030.

CONCLUSIONS

In general terms, it can be concluded that relevant future research requires (i) design for system resilience, (ii) transdisciplinary modeling, (iii) connecting interventions in immunization with SDG outcomes, (iv) designing interventions and their implementation simultaneously, (v) offering tailored solutions, and (vi) model coordination and integration of services and partnerships. The research and health community is called upon to join forces to activate existing knowledge, generate new insights and develop decision-supporting tools for Low-and Middle-Income Countries' health authorities and communities to leverage immunization in its transformational role toward successfully meeting the SDGs in 2030.