Assessing the reactivity to mobile phones and repeated surveys on reported care-seeking for common childhood illnesses in rural India

Defining and evaluating the Hawthorne effect in primary care, a systematic review and meta-analysis

In 2015, we conducted a randomized controlled trial (RCT) in primary care to evaluate if posters and pamphlets dispensed in general practice waiting rooms enhanced vaccination uptake for seasonal influenza. Unexpectedly, vaccination uptake rose in both arms of the RCT whereas public health data indicated a decrease. We wondered if the design of the trial had led to a Hawthorne effect (HE). Searching the literature, we noticed that the definition of the HE was unclear if stated. Our objectives were to refine a definition of the HE for primary care, to evaluate its size, and to draw consequences for primary care research. We designed a Preferred Reporting Items for Systematic reviews and Meta-Analyses review and meta-analysis between January 2012 and March 2022. We included original reports defining the HE and reports measuring it without setting limitations. Definitions of the HE were collected and summarized. Main published outcomes were extracted and measures were analyzed to evaluate odds ratios (ORs) in primary care. The search led to 180 records, reduced on review to 74 for definition and 15 for quantification. Our definition of HE is "an aware or unconscious complex behavior change in a study environment, related to the complex interaction of four biases affecting the study subjects and investigators: selection bias, commitment and congruence bias, conformity and social desirability bias and observation and measurement bias." Its size varies in time and depends on the education and professional position of the investigators and subjects, the study environment, and the outcome. There are overlap areas between the HE, placebo effect, and regression to the mean. In binary outcomes, the overall OR of the HE computed in primary care was 1.41 (95% CI: [1.13; 1.75]; I 2 = 97%), but the significance of the HE disappears in well-designed studies. We conclude that the HE results from a complex system of interacting phenomena and appears to some degree in all experimental research, but its size can considerably be reduced by refining study designs.

Assessing the reliability of phone surveys to measure reproductive, maternal and child health knowledge among pregnant women in rural India: a feasibility study

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.

Determinants and patterns of care-seeking for childhood illness in rural Pune District, India

BACKGROUND

An estimated 1.2 million children under five years of age die each year in India, with pneumonia and diarrhea among the leading causes. Increasing care-seeking is important to reduce mortality and morbidity from these causes. This paper explores the determinants and patterns of care-seeking for childhood illness in rural Pune district, India.

METHODS

Mothers having at least one child <5 years from the study area of the Vadu Health and Demographic Surveillance System were enrolled in a prospective cohort study. Household sociodemographic information was collected through a baseline questionnaire administered at enrollment. Participants were visited up to six times between July 2015 and February 2016 to collect information on recent childhood acute illness and associated care-seeking behavior. Multivariate logistic regression explored the associations between care-seeking and child, participant, and household characteristics.

RESULTS

We enrolled 743 mothers with 1066 eligible children, completing 2585 follow-up interviews (90% completion). Overall acute illness prevalence in children was 26% with care sought from a health facility during 71% of episodes. Multivariable logistic regression showed care-seeking was associated with the number of reported symptoms (Odds ratio (OR) = 2.4, 95% confidence interval (CI) = 1.5-3.9) and household insurance coverage (OR = 2.2, 95% CI = 1.1-4.3). We observed an interaction between the associations of illness severity and maternal employment on care-seeking. Somewhat-to-very severe illness was associated with increased care-seeking among both employed (OR = 5.0, 95% CI = 2.2-11.1) and currently unemployed mothers (OR = 7.0, 95% CI = 3.9-12.6). Maternal employment was associated with reduced care-seeking for non-severe illness (OR = 0.3, 95% CI = 0.1-0.7), but not associated with care-seeking for somewhat-to-very severe illness. Child sex was not associated with care-seeking.

CONCLUSIONS

This study demonstrates the importance of illness characteristics in determining facility-based care-seeking while also suggesting that maternal employment resulted in decreased care-seeking among non-severe illness episodes. The nature of the association between maternal employment and care-seeking is unclear and should be explored through additional studies. Similarly, the absence of male bias in care-seeking should be examined to assess for potential bias at other stages in the management of childhood illness.

Validating a GPS-based approach to detect health facility visits against maternal response to prompted recall survey

Introduction

Common approaches to measure health behaviors rely on participant responses and are subject to bias. Technology-based alternatives, particularly using GPS, address these biases while opening new channels for research. This study describes the development and implementation of a GPS-based approach to detect health facility visits in rural Pune district, India.

Methods

Participants were mothers of under-five year old children within the Vadu Demographic Surveillance area. Participants received GPS-enabled smartphones pre-installed with a location-aware application to continuously record and transmit participant location data to a central server. Data were analyzed to identify health facility visits according to a parameter-based approach, optimal thresholds of which were calibrated through a simulation exercise. Lists of GPS-detected health facility visits were generated at each of six follow-up home visits and reviewed with participants through prompted recall survey, confirming visits which were correctly identified. Detected visits were analyzed using logistic regression to explore factors associated with the identification of false positive GPS-detected visits.

Results

We enrolled 200 participants and completed 1098 follow-up visits over the six-month study period. Prompted recall surveys were completed for 694 follow-up visits with one or more GPS-detected health facility visits. While the approach performed well during calibration (positive predictive value (PPV) 78%), performance was poor when applied to participant data. Only 440 of 22 251 detected visits were confirmed (PPV 2%). False positives increased as participants spent more time in areas of high health facility density (odds ratio (OR) = 2.29, 95% confidence interval (CI) = 1.62-3.25). Visits detected at facilities other than hospitals and clinics were also more likely to be false positives (OR = 2.78, 95% CI = 1.65-4.67) as were visits detected to facilities nearby participant homes, with the likelihood decreasing as distance increased (OR = 0.89, 95% CI = 0.82-0.97). Visit duration was not associated with confirmation status.

Conclusions

The optimal parameter combination for health facility visits simulated by field workers substantially overestimated health visits from participant GPS data. This study provides useful insights into the challenges in detecting health facility visits where providers are numerous, highly clustered within urban centers and located near residential areas of the population which they serve.