Browsing by Author "Noguchi, Lisa"

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    Behavioral design for antenatal and postnatal care in Malawi
    (Kamuzu University of Health Sciences, 2020-08-25) Mbilizi, Yamikani; Noguchi, Lisa; James, Carlyn
    Type of study: Behavioral formative research ii. Problem: According to USAID’s 2019 statistics, Malawi has one of the highest maternal mortality rates in Africa and globally, with 439 maternal deaths per 100,000 live births. Recently, the government adopted the new WHO guidelines that recommend 8 antenatal contacts during pregnancy. The 2015- 2016 Demographic and Health Survey (DHS) found that 95% of women accessed ANC. Yet, only 51% of women completed (the previously recommended) 4 visits. Only 24% of women seek ANC during the first trimester. At a global level, UNICEF’s 2019 data reports that at least 85% of women access antenatal care with up to 65% receiving 4 antenatal visits. In comparison, only 46% of Malawian mothers meet the previously recommended 4 ANC sessions. In Malawi, women often attend ANC late. JHPIEGO will conduct implementation research (IR) for antenatal and postnatal service delivery models and tools in Malawi (and Ethiopia and Mali). This IR will generate evidence on how best to strengthen antenatal and postnatal platforms—not only to deliver equitable, high quality services, but also robust and resilient enough to test interventions and transition to scale. JHPIEGO’s study design will employ human-centered design to explicitly reflect actual conditions and incorporate considerations necessary to understand and inform scale up and sustainability. The project will use human-centered and behavioral design (HCD) to develop context-specific program implementation strategies, approaches, and models of antenatal and postnatal care for pregnant and postpartum women in Malawi. In the first phase (empathy) of the HCD approach that will be used end users are engaged to better understand the barriers and drivers to antenatal and postnatal care, and to solicit their suggestions for interventions that better meet the needs of the population. For this activity, interviews and group discussions will be conducted with women, aged 18-49 who live in Blantyre (Malawi) to understand their realities and how they facilitate or hinder access to and use of antenatal and postnatal care services. In addition, interviews will be conducted with related individuals and community groups identified by the women, to understand their perspectives and the way in which they influence women’s decisions. All of these participants shall advise and subsequently validate ideas generated through the inquiry period. The ideas generated through this workshop will then be narrowed down and prioritized for further testing after approval from local authorities. The intent of this study is to work with women, related individuals, and community groups using the HCD methodology to gather information in order to design, develop and implement an intervention. The results are not designed to be generalizable. They would be applicable to women in Malawi only. Ideas will be generated during the design workshop but after prioritization and selection of the ideas, separate studies that will be designed from these activities will examine the feasibility and acceptability for the intervention(s) designed as a result of HCD. These protocols will be developed and submitted in the future since they will be human subjects research. Objectives of the study Broad objective: To develop approaches for promoting earlier entry into care, improving continuity of care, and improving quality of care during the antenatal and postnatal periods in Malawi. Specific objectives; To conceptualize new service delivery models or tools / products for antenatal and postnatal care that lead to: a) Earlier entry into care: ensuring that pregnant women are seeking ANC during the first trimester of pregnancy b) Continuity of care: ensuring that mothers are accessing 4-8 ANC visits and delivering in the presence of a skilled provider c) Quality care: ensuring that women receive comprehensive ANC services as outlined in the WHO recommendations. d) Make it desirable for pregnant women to begin ANC within the first 12 weeks of pregnancy e) Enable key influencers at interpersonal and community levels to support pregnant women to begin early and continue with ANC f) Empower women to undertake self-care. According to the WHO, selfcare is the ability of families and communities to promote, maintain and cope with health-related issues with or without the help of a healthcare provider g) Enable formal and informal healthcare workers to understand the need and own the delivery of quality ANC services h) Leverage positive examples of access to care and use these to advise the community to rethink antenatal and postnatal care services Methodology Study Place: The study will take place in rural Blantyre in Mpemba and Mdekha townships. We believe these two locations have few and remotely located health facilities where communities are challenged by limited accessibility to antenatal and postnatal care. We have chosen Limbe and Zingwangwa as peri-urban locations within Blantyre with a diverse community and health facilities that are more accessible, however challenges with antenatal care are present that need exploration and understanding. The interviews, group discussions, and observations will take place in the community at participants’ homes, workplaces, schools and at health facilities. The human centered design workshops will happen at a venue that is convenient for the participants and is appropriate for conducting such activities, such as a community meeting ground, or in a health facility setting. Study Population: Participants will be recruited from among key stakeholders of ANC and PNC services (but not limited to women aged 18-49) and their partners, their parents, community members (including religious and community leaders), teachers, health care workers, and staff of local NGOs.Exclusion Criteria Any individuals who do not meet the inclusion criteria above. Recruitment strategy Three weeks before commencement of data collection, we will work with community mobilisers to approach the local authorities to inform them of the upcoming formative research and the intention to reach out to the various study populations. With the help of community influencers, the mobilisers will thereafter begin to recruit the community members as per the demographic variables described in the inclusion criteria above. The community health workers will provide information on the research purpose and activity and invite them to participate, agreeing on a convenient time and place for individual activities or by sharing details of any group activities. While we have planned to engage potential participants in advance, as above, we will also employ snowball sampling, asking participants who have completed an activity if they could refer us to other community members that may be useful for the formative research On the day of the formative research, the study team will administer the consent forms (availed in Appendix A-C) prior to commencement of the engagement. If the participant agrees to participate in the study, they will indicate by signing the consent form. Recruitment of Formal Antenatal and Postnatal Service Providers Three weeks before commencement of the study, the community mobilisers will inform the formal service providers’ supervisors about this study, so that they can help to identify people within their teams who often provide ANC services, to participate in the study. The selected people will receive a verbal invitation from the community mobiliser, inviting them to participate in the study. They will be given consent documents for one week so that they can have enough time to familiarize with the study objectives and procedures. Before they sign the consent document, they will also have an opportunity to speak to the researchers in order to ask any further questions. Sample Size We will recruit a total of 68 participants to for the study, as detailed in the table below. The justification for engaging these participants is described in the general inclusion criteria above. Data Collection: Through immersive research, we will engage research participants using three main methods which are one on one interactions, group interactive activities and observation. These three methods will employ different techniques which include visual aids, storytelling activities, debates, short dramas and observation guides in addition to the interview guides for each of the three methods. These techniques are aimed at placing the user at the centre of the research process, which ensures that we dig deep into the drivers of current behaviours as well as identify opportunity areas to develop behavioural design interventions. Data Management and Analysis g. Data Management Data collection tools have been developed by ThinkPlace in conjunction with the protocol team. Quality control queries will be routinely generated for study staff resolution. Audio files generated by the in-depth interviews will be transcribed and translated into English by the interviewers at College of Medicine Johns Hopkins Project (COM-JHP). Once the transcripts are cleaned and final, both the transcripts and the interview summaries will be electronically transferred to the central study team at ThinkPlace in Kenya, using a secure file transfer site, where they will be uploaded and managed using a qualitative software package. Video recordings will also be saved on an external hard drive and uploaded and managed using a qualitative software package. The qualitative data from the IDI transcripts, videos and the summary sheets detailing major points of interest from the storytelling and debates will be used to develop prototypes. h. Data Analysis The team will design, prototype and test strategies that build upon the validated hypotheses and address the framed behaviors and decision-making processes. The focus will be to prioritize solutions and develop 3-5-page concept notes for the highest priority solution in each country. The output will be a visual product designed to clearly capture the output and communicate the recommendations in a comprehensive way. The output will be presented in a manner that will give stakeholders the opportunity to get an in-depth understanding of the prototype evolution process. Expected findings We anticipate identifying the most feasible and acceptable interventions for ANC and PNC based on the discussion and interactions with the community participants and identify the most efficient and desirable approach to deliver these interventions. Dissemination plan When study results are available for dissemination COMREC and other relevant stakeholders (Blantyre DHO, representatives from QECH OBGYN department, Community Advisory Board, community gate keepers, health center staff and participants) will be invited to results dissemination sessions at the site. The site will submit an end of study report to COMREC before closing out the study.