A cluster randomized trial of an mHealth integrated model of hypertension, diabetes and antenatal care in primary care settings in India and Nepal

Lead Research Organisation: London School of Hygiene & Tropical Medicine
Department Name: Epidemiology and Population Health

Abstract

Although pregnancy-related deaths and diseases still pose a substantial burden in India and Nepal, there has been a decline in maternal deaths since the 1990s, due to a decrease of common causes of mortality such as bleeding. At the same time, there has been an increase in deaths and ill health from other causes such as pregnancy-induced hypertension (PIH) and gestational diabetes (GDM). These two conditions are very frequent in the region where we are planning to conduct the study. Good quality antenatal care (ANC) can prevent, detect and treat these conditions effectively, but unfortunately there is good evidence that these recommended interventions are not being routinely implemented in the study settings.

Our research project aims to address this critical gap and enhance ANC, by using a tablet-based electronic decision support system (EDSS). This tablet (a) prompts frontline health workers to provide evidence-based routine ANC, (b) enhances detection and management of PIH and GDM, (c) facilitates record-keeping and reporting, and (d) links across various levels of care providers.
We are particularly interested in rural pregnant women using public-sector health services. The research questions are:

1) Does an mHealth EDSS, provided to frontline health workers, enhance ANC by improving adherence to national ANC guidelines, and improve the screening, detection, referral and management of GDM and PIH, compared with usual care in primary healthcare settings?

2) What are the socio-economic, health-system and political factors affecting the implementation of the enhanced ANC?

3) What is the cost of the enhanced ANC intervention, the change in resource use, and the costs of the intervention relative to the value of the improved health outcomes achieved?

The project has four components: 1. Formative research using qualitative methods to understand the context, intervention development to develop the technology and how to deliver it, and a pilot test, 2. Cluster randomized controlled trial (cRCT) to randomly pick primary health centres to implement and evaluate the intervention and compare them to other centres who give usual care 3. Ongoing evaluation, using qualitative methods to understand the processes of implementation and 4. Economic analysis to see what the intervention costs and how cost effective it is.

Our project will take place India (Telangana) and Nepal (Kathmandu) and will last 36 months. It will include a multi-disciplinary team of investigators coordinated by the Public Health Foundation of India, India, with support from three regional co-ordinating centres in (a) Delhi, India, (b) Kathmandu, Nepal and (c) London, UK.

Technical Summary

Pregnancy-related deaths and diseases pose a substantial burden to India and Nepal. In India, during 2015, nearly 1.2 million perinatal deaths occurred; in Nepal, with its much smaller population, there were 24,000 deaths. Most of these deaths are preventable with better antenatal care (ANC), but unfortunately there is good evidence that recommended interventions are not routinely implemented in the study settings.

This project attempts to address this critical gap. The ultimate aim of the project is to enhance antenatal care (ANC), by using a tablet-based electronic decision support system (EDSS) that prompts frontline health workers (FHWs) to provide evidence-based routine ANC, enhances detection and management of two increasingly important conditions impacting pregnancy, namely pregnancy-induced hypertension (PIH) and gestational diabetes (GDM), facilitates record-keeping and reporting, and links across levels of care providers.

The research questions are:
-Does an mHealth EDSS, provided to FHWs, enhance ANC by improving adherence to national ANC guidelines, and improve the screening, detection, referral and management of GDM and PIH, compared with usual care in primary healthcare settings?
-What are the socio-economic, health-system and political factors affecting the implementation of the enhanced ANC?
-What is the cost of the enhanced ANC intervention, the change in resource use, and the costs of the intervention relative to the value of the improved health outcomes achieved?

The project, taking place in India (Telangana) and Nepal (Kathmandu),will last 36 months. It includes formative research and process evaluation using qualitative methods, and a cluster randomized trial of 88 primary health centres (and those reporting to them). It has a multi-disciplinary team of investigators, coordinated by the Public Health Foundation of India, India, with support from three regional co-ordinating centres in (a) Delhi, (b) Kathmandu and (c) London

Planned Impact

The ultimate aim of this project is to enhance antenatal care (ANC), to address the changing disease burden affecting pregnant women in India and Nepal. The enhancement includes using a tablet-based electronic decision support system (EDSS) tool that prompts frontline health workers (FHWs) to provide evidence-based routine ANC, enhances the detection and management of two increasingly important conditions, namely pregnancy-induced hypertension (PIH) and gestational diabetes (GDM), facilitates efficient record-keeping and reporting, and links across various levels of care providers in the public-sector health services, that are used by most rural women.

We anticipate impact at different levels and among different groups: at the health system level, among pregnant women, among healthcare providers and policymakers.

Health system: The intervention will enhance and improve the quality of ANC services and provide continuity of care by integration of routine ANC with the screening, detection, referral and management of GDM and PIH in the most efficient manner. It will also ease the work flow in the primary care settings and likely increase cost-efficiency.

Pregnant women: The enhanced quality of ANC will lead to improved health outcomes for both mothers and their babies in the near term as well as subsequently during their lifecourse by reducing the risk of hypertension, diabetes and adverse cardiovascular health outcomes. It will also increase women's satisfaction with public sector's health services and boost confidence in the health system and providers.

Healthcare providers: The project offers a unique opportunity for their professional upskilling and delivery of integrated evidence based high quality ANC services, through improved record keeping, reporting, timely prompts, and easier work flow. This will lead to improved outcomes for the women, reduce costs, enhance health system performance and responsiveness to community needs.

Policymakers: They will recieve much needed evidence for implementing better approaches to enhance existing ANC services for improving women's health.

Publications

10 25 50
publication icon
Mohan S (2023) A cluster randomized controlled trial of an electronic decision-support system to enhance antenatal care services in pregnancy at primary healthcare level in Telangana, India: trial protocol. in BMC pregnancy and childbirth

publication icon
Radovich E (2022) Additional file 1 of Measuring the quality of antenatal care in a context of high utilisation: evidence from Telangana, India

publication icon
Radovich E (2023) Assessing the potential of two electronic decision support systems to improve the quality of antenatal care in primary care facilities in Nepal: study protocol

publication icon
Radovich E (2022) Measuring the quality of antenatal care in a context of high utilisation: evidence from Telangana, India. in BMC pregnancy and childbirth

publication icon
Radovich E (2023) Assessing the potential of two electronic decision support systems to improve the quality of antenatal care in primary care facilities in Nepal: study protocol

publication icon
Radovich E (2023) Assessing the potential of two electronic decision support systems to improve the quality of antenatal care in primary care facilities in Nepal: study protocol

publication icon
Radovich E (2023) Assessing the potential of two electronic decision support systems to improve the quality of antenatal care in primary care facilities in Nepal: study protocol

publication icon
Radovich E (2024) A realist approach to implementation fidelity in a mixed-method evaluation of electronic decision support systems to improve the quality of antenatal care in Nepal

 
Description Guided by our Theory of Change and mixed-methods approach, we evaluated the implementation of two electronic decision support systems (EDSS), aiming to generate evidence relevant for interpreting changes in ANC quality before and after implementation of two EDSS applications (mIRA and WHO EDSS) in Nepal and for further understanding the theories underpinning EDSS quality improvements. We implemented both EDSS in 19 primary-level ANC facilities using a mix of qualitative and quantitative methods. The key findings came under nine themes that deepened our understanding of how the EDSS was used and highlighted the complexities and challenges to achieving the desired ANC quality improvements.
1. Essential stakeholders were insufficiently engaged, and 2. facilities had mixed levels of readiness to employ the EDSS recommendations. 3. ANC staff trained in EDSS use were not necessarily confident in using it. 4. ANC staff did not always use the EDSS, or use it as intended. 5. There was mixed evidence that ANC staff believed that the EDSS benefited their work, and 6. evidence of inadequate integration of EDSS with existing health systems. 7. The inflexibility of EDSS design did not reflect how ANC staff made decisions about pregnant women's needs, and ANC staff did not substantially change their approach to ANC provision.

With respect to improvements in clinical-care we found: 8. use of the EDSS during the consultation increased use of some tests. The EDSS was intended to prompt ANC staff to perform tests for pregnant women. Observations of ANC before and after implementation suggested the average number of the four primary ANC components (composite of measurement and recording of blood pressure and the performance of blood glucose, urinary dipstick and hemoglobin tests) improved from 1.11 before to 1.56 after implementation (p=0.09). Performance of components also improved: urinary dipstick test (7.9% to 23.5%, p=0.07), hemoglobin test (7.9% to 17.7 %, p=0.21), and blood glucose test (2.6% to 20.6%, p=0.02).
9. The EDSS did not guarantee timely ANC tests. The EDSS asked for more frequent tests as per Nepali/ WHO guidelines, but these were not part of staffs' usual practice. Evidence from the longitudinal case study, in-depth interviews, monitoring visits, and validation workshops showed auxiliary nurse midwives generally tested during the first ANC visit but not repeat tests unless they observed abnormal results or were advised by doctors to repeat tests. ANC staff explained they limited tests out of concern for women's finances. We observed five instances where ANC staff had not performed a test where the EDSS reminder led them to perform the test. Also, ANC staff were trained to administer oral-glucose tolerance tests to detect gestational diabetes using test kits we provided. The longitudinal study and monitoring visits showed that ANC staff initiated and performed the test for most clients. Among ANC observations where patients reported experiencing vomiting, vaginal bleeding, severe headache, decreased or absent fetal movement, severe abdominal pain or blurred vision), the proportion of providers who took the appropriate action in response improved from 0.0% (0/7) before EDSS implementation to 100% (5/5) afterwards.
Exploitation Route We used the findings from the formative phase and evaluation phases to share with the Ministry of Health in Nepal and have also fed back to WHO. OM and OC prepared a funding proposal to the MRC to continue the trial work ("A cluster randomised controlled trial of an electronic decision support system for antenatal care providers in Nepal"), but this was not selected for funding. We will continue to engage with the Nepal Ministry of Health as they plan their digital platforms for health.
Sectors Digital/Communication/Information Technologies (including Software)

Healthcare
 
Description Our work has influenced how the WHO is thinking about ANC apps in settings where there are many providers providing care within a specific ANC visit. The Nepal team has successfully developed a Nepali version the WHO's digital ANC module - an ANC electronic decision support system. We changed the focus of the Nepal project to implementation research, where we aimed to evaluate the implementation of both the mIRA and WHO EDSS. This change in focus in Nepal enabled the project to respond to questions raised by Nepali policy makers in the formative phase, and to allow us to better understand the Nepal-specific implementation facilitators and barriers. We hope this research contributes to the WHO's understanding about the use of their EDSS in different contexts and helps the Government implement electronic health records and digital interventions in antenatal care and in primary care more generally. The research offers evidence to the Government to choose between the two EDSS. Officials have a clearer understanding of the differences between the two apps, with an expressed preference for using the modified WHO ANC App for integration within their move to digital platforms. We have also influenced the Telengana state officials in how they may look at quality and continuity of ANC care, and think about routine data collection. We have also communicated formative findings to the Nepal government on health care providers views on use of Apps.
Sector Digital/Communication/Information Technologies (including Software),Healthcare
Impact Types Policy & public services
 
Description (India) Meeting with health officials at Commissionerate of Health and Family Welfare (CHFW)
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Contribution to a national consultation/review
 
Description (India) Meeting with the Commissioner, Commissionerate of Health and Family Welfare (CHFW)
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Contribution to a national consultation/review
 
Description (India) Meeting with the Commissionerate of Health and Family Welfare (CHFW)
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Contribution to a national consultation/review
 
Description Contribution to a national consultation/reviewon results of mIRA implementation research
Geographic Reach Asia 
Policy Influence Type Contribution to a national consultation/review
 
Description Presenation of formative research to the Telengana Ministry of Health
Geographic Reach Asia 
Policy Influence Type Contribution to a national consultation/review
 
Description Presenation of formative to Nepal Ministry of health stakeholders
Geographic Reach Asia 
Policy Influence Type Contribution to a national consultation/review
 
Description LSHTM 2019-20 Doctoral Project Travelling Scholarship
Amount £3,950 (GBP)
Funding ID 1402301 
Organisation London School of Hygiene and Tropical Medicine (LSHTM) 
Sector Academic/University
Country United Kingdom
Start 07/2020 
End 07/2021
 
Description LSHTM Health and Hygiene Seed Grant
Amount £49,865 (GBP)
Organisation Reckitt Benckiser 
Sector Private
Country United Kingdom
Start 07/2023 
End 07/2024
 
Description LSHTM UKRI COVID-19 Grant Extension Application
Amount £178,058 (GBP)
Organisation London School of Hygiene and Tropical Medicine (LSHTM) 
Sector Academic/University
Country United Kingdom
Start 08/2020 
End 09/2021
 
Title Nepal and India: Facility survey dataset 
Description These data sets capture information from a facility survey in the study areas in Nepal (N=10) and India (N=23). This include information on the infrastructure of the facility (e.g. electricity availability and internet access), components of ANC provided and whether they have the drugs/equipment to provide these services. We gained ethical approval for this data collection, and have said that the anonymised Nepal dataset can be shared with other researchers upon request, once data cleaning is finalized. The India Dataset is the property of PHFI 
Type Of Material Database/Collection of data 
Year Produced 2020 
Provided To Others? No  
Impact These data have been of critical importance for informing our team about readiness of facilities to incorporate an electronic decision support system. For example, in Nepal, all facilities surveyed had access to reliable electricity and internet access for at least two hours a day. Higher-level facilities provided more components of ANC than lower-level facilities. We have used this information to suggest primary adn secondary outcomes for the trial. 
 
Title Nepal: ANC clinical observation dataset 
Description We observed 38 ANC visits pre-EDSS implementation and 34 post-EDSS implementation to evaluate the effect of the EDSS on the quality of ANC. We compared ANC quality scores pre- and post-implementation of the EDSS in intervention facilities. 
Type Of Material Database/Collection of data 
Year Produced 2023 
Provided To Others? No  
Impact Observations of ANC before and after implementation suggested the mean number of the four primary ANC components (measurement and recording of blood pressure and the performance of blood glucose, urinary dipstick and hemoglobin tests) improved, but this could have been due to chance. 
 
Title Nepal: ANC observation dataset 
Description This data set captures information from observations of antenatal care (ANC) consultations in the study areas in Nepal (N=10). This include information on the socio-demographics of women accessing ANC, a checklist of components of ANC undertaken during the consultation and the type of healthcare worker which did this, and the record keeping undertaken during the consultation. We gained ethical approval for this data collection, and have said that the anonymised data set can be shared with other researchers upon request. 
Type Of Material Database/Collection of data 
Year Produced 2020 
Provided To Others? No  
Impact These data have been of critical importance for informing our team about the delivery of ANC in our study settings, and therefore informing the development of our intervention. For example, it is clear in India that ANC care is quite fragmented with women seeing multiple different types of healthcare workers in a visit. In Nepal, ANC is generally delivered by the auxiliary nurse midwife. 
 
Title Nepal: Health facilities survey dataset 
Description This survey includes data on the availability and functioning of equipment and medicines in the 19 implementation facilities. 
Type Of Material Database/Collection of data 
Year Produced 2023 
Provided To Others? No  
Impact Facilities had mixed levels of readiness to employ the ANC recommendations made by the EDSS 
 
Title Nepal: Monitoring visit dataset 
Description This dataset consists of monthly in-person monitoring visit data plus data from the backend of the EDSS. 
Type Of Material Database/Collection of data 
Year Produced 2023 
Provided To Others? No  
Impact The monitoring visits revealed techinical issues with the implementation of the EDSS, which provides valuable information regarding the tablet and app specification for future implementation. 
 
Title Nepal: Time-motion observation dataset 
Description Dataset of continuous observations made of nine auxiliary nurse midwives at two primary care facilities in Nepal. Observations consist of two rounds of data collection and include timestamped activities related to clinical care and record-keeping taking place during facility open hours. 
Type Of Material Database/Collection of data 
Year Produced 2023 
Provided To Others? No  
Impact First time, to our knowledge, that time-motion methods have been used in Nepal to describe the work of auxiliary nurse midwives, the dataset offers a detailed account of the day-to-day activities of auxiliary nurse midwives. The dataset is currently being analysed for a forthcoming publication. 
 
Title Nepal: audit of records dataset 
Description Dataset consists of extracted information from two paper-based records (the antenatal card and antenatal register) and one electronic record (the electronic decision support system software [EDSS]) in 19 primary health facilities. The dataset includes pregnant women's records before (n=136) and after (n=138) EDSS implementation. 
Type Of Material Database/Collection of data 
Year Produced 2023 
Provided To Others? No  
Impact The dataset enabled the team to estimate the percentage completeness (any value recorded) and agreement (whether values matched) before and after electronic decision support system (EDSS) implementation of antenatal care (ANC) paper-based records to look at potential unintended effects of the intervention. Notably, the intervention did not negatively impact on paper-based ANC recordkeeping, and EDSS implementation resulted in general improvements in completeness and agreement of paper-based ANC records. 
 
Title Nepal: longitudinal qualitative case studies and in-depth interview transcripts 
Description Longitudinal case studies conducted in four primary care level facilities in Nepal, two each implementing the mIRA and WHO electronic decision support system (EDSS) resulted in a rich dataset of semi-structured observation notes and detailed research reflections and field notes. The observations were conducted a four different time points throughout the intervention implementation period. The observation notes and field notes are complemented by transcripts from in-depth interviews with healthcare providers involved in the intervention, including facility managers and auxiliary nurse midwives. 
Type Of Material Database/Collection of data 
Year Produced 2022 
Provided To Others? No  
Impact The dataset enabled detailed understanding of the implementation process and contextual factors shaping the intervention. The dataset has been analysed for two forthcoming publications: firstly an overall results paper describing and explaining the outcome of the intervention, and secondly a methodological paper reflecting on the strengths of ethnographic inquiry to understanding health facility contexts and processes. 
 
Description Collaboration with Ona Systems Inc, a social enterprise in Kenya and USA, to modify an app prepared for the World Health Organization 
Organisation Ona Systems Inc.
Country United States 
Sector Private 
PI Contribution We collaborated with Ona Systems to develop a Nepali version of the World Health Organzation (WHO) ANC app module. We shared desirable features we had identified, and fed back on problems arising during use of app.
Collaborator Contribution Ona Systems Inc is a social enterprise. https://ona.io/home/case-study/customizing-tools-and-services-for-global-needs/ One of their projects consisted of developing and testing an app for WHO. As part of our project Ona Systems Inc modified the WHO ANC app for use in Nepal. They delivered training and technical support to the Nepali team to develop the and adapt the ANC module for the Nepal context, including Nepali years.
Impact A Nepali version of the app developed for the World Health Organzation ANC module. The evidence base for the application is https://anc-pnc.srhr.org/
Start Year 2021
 
Description Collaboration with WHO on creating an electronic decision support tool for antenatal care 
Organisation World Health Organization (WHO)
Country Global 
Sector Public 
PI Contribution This mutually beneficial partnership between our study group and the World Health Organization (WHO) arose from a shared interest in using Electronic Decision Support Systems (EDSS) to improve the quality of routine antenatal care (ANC). We worked closely with the team at WHO to critically review the EDSS tool they developed for use in routine antenatal care. We shared our formative research on the current ANC set ups in India and Nepal, and the stakeholder interviews on the acceptability and desirability of having an app to support ANC. We also adapted a version of their ANC module application for use in the Nepal context as one of the two apps we studies (alongside the mIRA app). We shared our findings with WHO. We attended a panel presentation of the WHO results for use of the app, at the FIGO conference in Paris in Dec 2023.
Collaborator Contribution The WHO were happy for their tool to form the basis of our intervention, and worked with us to adapt it for use in the local contexts and to add on more detailed components for treatment of high-risk women. They shared the App prototype and linked us with their technical team. The evidence base for the application is https://anc-pnc.srhr.org/ WHO (Ozge Tuncalp lead) were also willing to partner with us in a subsequent proposal we put in for an MRC trial (which was not funded). WHO also prepared https://www.who.int/publications/i/item/9789240020306, a Digital Adaptation Kit for Antenatal Care: Operational requirements for implementing WHO recommendations in digital systems
Impact We shared results from our formative phase research with the WHO team to give them a sense of the opportunities and challenges for EDSS use in the areas of Nepal and India in which out trial is being conducted, and they have shared the WHO ANC reference app. This represents a multi-disciplinary collaboration, bringing together IT specialists, clinicians, qualitative researchers and epidemiologists.
Start Year 2019
 
Description Commissionerate of Health and Family Welfare, Government of Telangana collaboration to permit trial, and to increase likelihood of subsequent uptake and scale up 
Organisation Government of Telangana
Department Commissionerate of Health and Family Welfare
Country India 
Sector Public 
PI Contribution We worked in partnership with the Commissionerate of Health and Family Welfare (CHFW) in Telangana, under the lead of PHFI. We prepared briefings for the the CHFW and shared research findings. We reviewed the ongoing routine KCR data collection and provided detailed feedback on data quality and suggested improvements. We contributed to analyses and presentations prepared for the Commissionerate. The main liaison was with the Public Health Foundation of India which was our Indian Partner, funded by DBT
Collaborator Contribution The CHFW have been supportive in facilitating our work in the State, and provided work space within their offices for two researchers employed on our project to facilitate collaborative working between our groups. They have supported our ongoing formative phase research by working closely with our team to assess the current quality of ANC care in the State and to review the current system in which frontline healthcare workers enter data from routine data.
Impact The main outputs to stem from this collaboration thus far are a detailed report from our team to the CHFW including recommendations on they can improve quality and utilisation of the data routinely collected in the State.
Start Year 2019
 
Description Public Health Foundation of India: Initial partner for work on cRCT of the mIRA EDSS 
Organisation Public Health Foundation of India
Country India 
Sector Public 
PI Contribution Beginning in 2017 we worked with Public Health Foundation India (PHFI) to develop the proposal and conduct the research. We contributed formative research, a theory of change, and support to the development of the mIRA EDSS. 9, researchers at Dhulikhel Hospital, Kathmandu University Hospital and the London School of Hygiene and Tropical Medicine have collaborated on a project, funded by the United Kingdom Medical Research Council (UK MRC). The project initially partnered with the Public Health Foundation India, working in Telengana State, with funds from the India DBT, but funding for activities in India were delayed and subsequently suspended.
Collaborator Contribution PHFI introduced us to Dhulikhel Hospital, Kathmandu University Hospital, Nepal. They held the study launch meting and were responsible for developing guidelines the comissioning othe mIRA app with funds from the India DBT. We amicably seperated the studies when timelines were out of sync but funding for activities in India were delayed and the cRCT was subsequently suspended.
Impact Outputs included: ANC guidelines, the mIRA app, formative research, and the published trial protocol.
Start Year 2018
 
Title Nepali version of the WHO digital ANC module 
Description Working with the WHO and their tech partner Ona Systems Inc, the Nepali team has created a Nepali version of the WHO digital ANC module, which, alongside the mIRA EDSS, was evaluated during the implementation research phase. The WHO EDSS focusses on facilitating the adoption and adaption of WHO ANC guidelines for routine care. 
Type Management of Diseases and Conditions
Current Stage Of Development Early clinical assessment
Year Development Stage Completed 2022
Development Status Closed
Impact Final version implemented. Nepali government considering scale-up 
 
Title mIRA: an electronic decision support system for frontline health workers to provide quality ANC 
Description The tool was developed by PHFI, the India DBT partners within this current Newton Fund MRC grant. We also received inputs from the WHO, who have separate funding to develop a similar tool. Our partnership shares lessons, avoids duplication of effort, and strengthens the potential for scale-up. The tool is an electronic decision support system (EDSS) for ANC, to support the management of pregnant women during ANC. It includes prompts for health workers to ensure they provide all elements of evidence based care, and has algorithms to recommend preventive measures, treatment, or referral. 
Type Management of Diseases and Conditions
Current Stage Of Development Early clinical assessment
Year Development Stage Completed 2022
Development Status Actively seeking support
Impact None yet. Final version ready for implementation but DBT funds withdrawn. 
 
Title Nepal versions of World Health Organziation ANC Module App and of mIRA application 
Description We adapted a version of mIRA EDSS app and the WHO ANC module app to suit hte Nepali context 
Type Of Technology Webtool/Application 
Year Produced 2022 
Impact We were able to use the apps in our implementation research and to present findings to the Nepali Government to help inform their decisions on future digital platforms 
 
Description "Please tell them no more apps mam". Formative research for a possible mHealth intervention in Telangana State, India. Poster presenation at Global Health Services Research Conference. Presenter Radha Krishnam 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact "Please tell them no more apps mam". Formative research for a possible mHealth intervention in Telangana State, India. Poster presentation at the Sixth Global Symposium on Health Systems Research, Virtual symposium November 10 - 12, 2020.
Year(s) Of Engagement Activity 2020
 
Description (India) In-person training sessions 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Other audiences
Results and Impact The training of the field workers consisted of the following items:

Study Design, Deliverables for Health Workers, and Timeline
Indian Primary Healthcare System
Routine ANC Guidelines
Record keeping methods (MCP Card in detail)
Study Tools (Facility survey and Audit of record-keeping in detail)
Electronic Decision Support System (EDSS)
Year(s) Of Engagement Activity 2022
 
Description (India) Introduction and orientation of the health workers for the study 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact On the 22nd of Feb 2022, the India team held a virtual meeting to introduce and orient the health workers to the study.
Year(s) Of Engagement Activity 2022
 
Description (India) Virtual practice sessions with Health Workers 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact Online sessions were run from the 28 of Feb to the 1st of March with Helath Workers to present specific case scenarios in relation to the mIRA EDSS.
Year(s) Of Engagement Activity 2022
 
Description (Nepal) Local stakeholder meeting 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Other audiences
Results and Impact This meeting with Stakeholders, including governement officials, was on 21st February, 2022 at Dhulikhel Hospital.

Objectives of the meeting were:
• To provide an overview of the mIRA project
• To disseminate findings from formative phase
• To demonstrate mIRA application and WHO application
• To discuss on problems for implementing project and potential strategies for intervention.
• To gather valuable feedback and suggestions for implementing project.
Year(s) Of Engagement Activity 2022
 
Description (Nepal) National stakeholder meeting 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact On May 20 2021, the Nepal team held a virtual National Stakeholder meeting, which included government officials.
Year(s) Of Engagement Activity 2021
 
Description (Nepal) mIRA EDSS training with Auxiliary Nurse Midwives 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact The Nepali team conducted training on the mIRA EDSS training with 10 Auxiliary Nurse Midwives 13-15 March 2022.
Year(s) Of Engagement Activity 2022
 
Description (Nepal) mIRA EDSS training with Field Workers 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Other audiences
Results and Impact The Nepali team conducted training on the mIRA EDSS training with 10 Field Workers 6-8th March 2022.
Year(s) Of Engagement Activity 2022
 
Description Conference poster presentation at 16th European Public Health Conference 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Rajani Shakya gave two poster presentations: 1) "A novel approach to assessing the potential of electronic decision support systems( EDSS) to improve the quality of antenatal care in Nepal" and 2) "The impact of digital antenatal care intervention on paper-based recordkeeping: results from an audit of antenatal records in primary health care facilities in Nepal" at the 16th European Public Health Conference in Dublin, Ireland, 9-11 November 2023.
Year(s) Of Engagement Activity 2023
 
Description Conference poster presentation at ECTMIH 2023 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Sulata Karki gave a poster presentation: "Implementation realities of a digital antenatal care improvement intervention in Nepal" to the European Congress on Global Health (ECTMIH 2023) in Utrecht, Netherlands, 20-23 November 2023
Year(s) Of Engagement Activity 2023
 
Description Digital health seminar at Dhulikel Hospital Nepal. Rajani Shakya presented on the mIRA trial. 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Presenation of trial to clinical colleagues adn to academic researchers. Sparked questions adn discussion.
Year(s) Of Engagement Activity 2021
 
Description From new to routine: how an electronic decision support system changes the quality and process of antenatal care in India and Nepal. 22 June 2020 LSHTM online. Presenter Emma Radovich 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact Purpose was to share plans for the process evaluation to a wider group and receive critical feedback. The mIRA cluster randomised trial seeks to test the effectiveness of a tablet-based electronic decision support system to improve the quality of ANC in primary-level health facilities in India and Nepal. The process evaluation of the trial aims to provide insight into how an electronic decision support system contributes to changes in healthcare provider behaviour and the provision of ANC in health facilities.

Many digital health interventions insufficiently interrogate how the technology becomes integrated into systems of health service provision. Drawing from implementation theory and systems thinking, this project will try to better understand the process of implementation, including how a technology becomes part of routine ANC practice, and how a digital health intervention to improve quality of care works (or doesn't work) and why. Multiple statistical approaches will be used in the analysis of primary and secondary trial data to investigate contextual factors and the process of implementation and to explore mechanisms of change.
The main focus of comments was if possible, to think about creating generalizable knowledge: using theory to delineate what hypotheses the theories imply and then use data collection to test hypotheses. The aim is to build bridges by n theory testing and commenting on relevant were the theories. Discussions set up with Carl May afterwards
Year(s) Of Engagement Activity 2020
 
Description National Stakeholder meeting in Nepal 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact The mIRA Nepal National Stakeholder meeting brought together 33 participants including the mIRA research team from Nepal, and individuals the National Planning Commission (NPC), Department of Health Services - Family Welfare Division (FWD), National Health Training Centre (NHTC), Epidemiology and Disease Control Division (EDCD), Integrated Health Information Management Section (IHIMS), Health Insurance Board (HIB), Diabetes Endocrinology Association Nepal (DEAN), Nepal Society of Obstetrics and Gynaecology (NeSOG), Kathmandu Medical College Public Limited (KMC), Maternal and Infant Research Activities (MIRA), Nepal Health Research Council (NHRC), Nepal Chemist and Druggist Association (NCDA), Karuna Foundation, Medic Mobile, Wiseyak, patients with gestational diabetes and Gestational Hypertension along with visitor and Female Community Health Volunteers.
The main objectives of the meeting were:
1. To Inform the meeting participants about the mIRA study
2. Actively involve relevant stakeholders
3. Issues in introduction of Electronic Decision Support System for Antenatal Care
4. Way forward to work collaboratively in future (Public Private Partnership)

After presenting an overview of the study to the participants, there was time for questions and discussions. There was extensive discussion on the challenges, opportunities and a number of recommendations on the intervention from these stakeholders.
Year(s) Of Engagement Activity 2019
 
Description Presentation at 9th National Summit for the Nepal Health Research Council. 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact Sulata Karki gave an oral presentation on "The implementation realities of a digital antenatal care improvement intervention in Nepal: Auxiliary nurse midwives as street-level bureaucrats" at the Ninth National Summit of Health and Population Scientists in Nepal, Nepal Health Research Council (NHRC) annual conference in Kathmandu, Nepal, 13 April 2023
Year(s) Of Engagement Activity 2023
 
Description Presentation to Nepal Society of Obstetricians 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Rajani Shakya gave oral presentation: "Oral Glucose Tolerance Test (OGTT) for universal screening for Gestational Diabetes Mellitus: How feasible is it in primary healthcare settings of Nepal" at the Conference of the Nepal Society of Obstetricians and Gynecologists (NESOG) in Kathmandu, Nepal, 31 March-1 April 2023.
Year(s) Of Engagement Activity 2023
 
Description Seminar at Public Health Foundation of India 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Study participants or study members
Results and Impact During a collaborative visit for the development of the full proposal for this grant, Oona Campbell delivered a seminar to staff members at the Public Health Foundation of India. This seminar covered a general overview of maternal health, with particular attention to the transition from the Millennium Development Goals to the Sustainable Development Goals. This sparked interesting discussion on the current challenges to improving maternal health in India, and potential solutions including electronic decision support systems.
Year(s) Of Engagement Activity 2018
 
Description Seminar for Maternal and Neonatal Health Group at the London School of Hygiene and Tropical Medicine 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Postgraduate students
Results and Impact Emma Radovich and Oona Campbell gave a presentation on some of the preliminary results from our formative phase research on the quality of antenatal care to a group of students and academics with expertise in the maternal and neonatal health field. This activity was designed to share some of the methods we have used in this study to try and gain a much deeper understanding on the quality of ANC in the settings in which this study is taking place and identify creative ways of measuring trial outcomes. It generated much discussion on the challenges of measuring quality ANC, and indicators for measuring quality. We got interesting insights from the audience on what they think the most important markers of good quality ANC are. We also gained shared learning, with our team providing an overview of tools that other studies can use and the audience providing valuable input that has been incorporated into our trial design.
Year(s) Of Engagement Activity 2020
 
Description Seminar presentation for the LSHTM Maternal & Newborn Health Group on a realist assessment of implementation fidelity in Nepal 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other audiences
Results and Impact Approximately 20 international colleagues, including academic researchers, medical professionals and postgraduate students, attended a hybrid (in-person and online) seminar on conceptual innovations and empirical findings from an assessment of implementation fidelity for the electronic decision support system in Nepal. Research partners from Dhulikhel Hospital - Nepal and Public Health Foundation of India attended. The presentation sparked a robust discussion afterwards on approaches to fidelity assessment and the role of evaluation in other projects and raised questions about and suggestions for improving the design of other digital health interventions. Several attendees mentioned a desire to incorporate some of the reflections raised into their future work.
Year(s) Of Engagement Activity 2023
 
Description Training to Dhulikhel Hospital and School of Public Health staff, Kathmandu University on qualititive research methods by Loveday Penn-Kekana (LSHTM) 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact 35 researchers attended a workshop on use of qualitative analysis methods to understand how auxiliary nurse midwives provide care, and how tablets can be used to improve quality.
Year(s) Of Engagement Activity 2019
 
Description Visit to LSHTM by Rajeev Shrestra, head of the Research and Development Division of the Dhulikhel Hospital to discuss a memorandum of understanding & support for capacity building 
Form Of Engagement Activity Participation in an open day or visit at my research institution
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Arranged meetings with Prof Anne Mills (Deputy Director & Provost of LSHTM) ; with Patrick Ng (Research Contracts Office); with mIRA team members (Sylvia Marinova, Clara Calvert, Loveday-Penn Kekana, Oona Campbell); with Anna Kramer (Strategic Research Coordinator/Partnerships)
Year(s) Of Engagement Activity 2019