Victoria Ward

All Publications

• Overview of the Global and US Burden of Preterm Birth. Clinics in perinatology Ward, V. C., Lee, A. C., Hawken, S., Otieno, N. A., Mujuru, H. A., Chimhini, G., Wilson, K., Darmstadt, G. L. 2024; 51 (2): 301-311

  Abstract

  Preterm birth (PTB) is the leading cause of morbidity and mortality in children globally, yet its prevalence has been difficult to accurately estimate due to unreliable methods of gestational age dating, heterogeneity in counting, and insufficient data. The estimated global PTB rate in 2020 was 9.9% (95% confidence interval: 9.1, 11.2), which reflects no significant change from 2010, and 81% of prematurity-related deaths occurred in Africa and Asia. PTB prevalence in the United States in 2021 was 10.5%, yet with concerning racial disparities. Few effective solutions for prematurity prevention have been identified, highlighting the importance of further research.

  View details for DOI 10.1016/j.clp.2024.02.015

  View details for PubMedID 38705642

• Estimating Gestational Age and Prediction of Preterm Birth Using Metabolomics Biomarkers. Clinics in perinatology Ward, V. C., Hawken, S., Chakraborty, P., Darmstadt, G. L., Wilson, K. 2024; 51 (2): 411-424

  Abstract

  Preterm birth (PTB) is a leading cause of morbidity and mortality in children aged under 5 years globally, especially in low-resource settings. It remains a challenge in many low-income and middle-income countries to accurately measure the true burden of PTB due to limited availability of accurate measures of gestational age (GA), first trimester ultrasound dating being the gold standard. Metabolomics biomarkers are a promising area of research that could provide tools for both early identification of high-risk pregnancies and for the estimation of GA and preterm status of newborns postnatally.

  View details for DOI 10.1016/j.clp.2024.02.012

  View details for PubMedID 38705649

• Community health worker perspectives on advocacy: design-based research to develop a digital advocacy training course. Frontiers in public health Job, N., Johnston, J. S., Westgate, C., Skinner, N. A., Ward, V., Ballard, M. 2024; 12: 1334279

  Abstract

  While community health workers (CHWs) are well-positioned as health advocates, they frequently lack support and feel undervalued. Advocacy training may prepare CHWs to support communities better.This study uses a design-based research approach to (1) explore how participation in curriculum-development workshops for a digital advocacy course influenced CHWs' (n = 25) perceptions of advocacy and (2) describe how CHW involvement shaped course development. Data were collected via five discussion groups and seven surveys over six months.Initially, the CHWs perceived themselves as community-advocates but not as self-advocates. They increasingly reflected on the merits of advocating for better working conditions and aspired to greater involvement in decision-making. CHWs reflected positively on their advisory role in shaping the course to improve content acceptability and validity.Training efforts to engage CHWs in advocacy must overcome systemic barriers and norms internalized by CHWs that deter them from reaching their full potential as advocates.

  View details for DOI 10.3389/fpubh.2024.1334279

  View details for PubMedID 38660355

  View details for PubMedCentralID PMC11039831

• Exploring the role of community health organizations in promoting public health during a health crisis: a qualitative study of COVID-19 responses in South Africa and Zambia. Global health promotion Johnston, J. S., Zhang Aluri, K., Job, N., Kuhnert, K. L., Prober, C., Ward, V., Skinner, N. A. 2023: 17579759231205854

  Abstract

  While the COVID-19 pandemic amplified the need for accurate and actionable health information, uncertainty and the proliferation of misinformation have contributed to significant mistrust in public health messages, especially among marginalized communities. Community health organizations can play an important role in creating trust and providing targeted health information to vulnerable groups. This qualitative study, which is focused on community health organizations supporting vulnerable populations in South Africa and Zambia, finds that during the pandemic, community health organizations expanded their roles and leveraged their established access and trust to support the communities they serve with health education and services. However, the reliance on external support limits the organizations' ability to respond in an effective and efficient manner during health crises.

  View details for DOI 10.1177/17579759231205854

  View details for PubMedID 37909401

• Use of open-source online course content for training in public health emergencies: Evidence from COVID-19 education for health professionals. JMIR medical education Skinner, N. A., Job, N., Krause, J., Frankel, A., Ward, V., Johnston, J. 2023

  Abstract

  BACKGROUND: The onset of the COVID-19 pandemic generated an urgent need for credible and actionable information to guide public health responses. The massive open-source online course (MOOC) format may be a valuable path for disseminating timely and widely accessible training for health professionals during public health crises; however, the reach and effectiveness of health-worker directed online courses during the pandemic remains largely unexplored.OBJECTIVE: This study investigates the use of an open-source online course series designed to provide critical COVID-19 knowledge to frontline health workers and public health professionals globally. The study investigates how open-source online educational content can be optimized to support knowledge sharing among health professionals in public health emergencies, particularly in resource-limited contexts.METHODS: The study examines global course enrollment patterns (N=2,185) and in-depth interviews with a purposive sub-sample of health professionals enrolled in the course series (N=12) selected to investigate the sharing of online content in pandemic responses. Interviewed learners were from Ethiopia, India, Kenya, Liberia, Malawi, Rwanda, Thailand, Uganda, the United Arab Emirates, and the United States. Inductive analysis and constant comparative methods were used to systematically code data and identify key themes emerging from interview data.RESULTS: Analysis revealed that the online course content helped fill a critical gap in trustworthy COVID-19 information for pandemic responses and was shared through health worker professional and personal networks. Enrollment patterns and qualitative data illustrate how health professionals shared information within their professional networks. While learners shared knowledge they gained from the course, they expressed a need for contextualized information to more effectively educate others in their networks and in their communities. Due to technological and logistical barriers, participants did not attempt to adapt content to share with others.CONCLUSIONS: This study illustrates that health professional networks can facilitate the sharing of online open-source health education content, yet to fully leverage potential benefits, additional support is required to facilitate the adaptation of course content to more effectively reach communities globally.CLINICALTRIAL:

  View details for DOI 10.2196/42412

  View details for PubMedID 36735834

• Real world external validation of metabolic gestational age assessment in Kenya. PLOS global public health Hawken, S., Ward, V., Bota, A. B., Lamoureux, M., Ducharme, R., Wilson, L. A., Otieno, N., Munga, S., Nyawanda, B. O., Atito, R., Stevenson, D. K., Chakraborty, P., Darmstadt, G. L., Wilson, K. 2022; 2 (11): e0000652

  Abstract

  Using data from Ontario Canada, we previously developed machine learning-based algorithms incorporating newborn screening metabolites to estimate gestational age (GA). The objective of this study was to evaluate the use of these algorithms in a population of infants born in Siaya county, Kenya. Cord and heel prick samples were collected from newborns in Kenya and metabolic analysis was carried out by Newborn Screening Ontario in Ottawa, Canada. Postnatal GA estimation models were developed with data from Ontario with multivariable linear regression using ELASTIC NET regularization. Model performance was evaluated by applying the models to the data collected from Kenya and comparing model-derived estimates of GA to reference estimates from early pregnancy ultrasound. Heel prick samples were collected from 1,039 newborns from Kenya. Of these, 8.9% were born preterm and 8.5% were small for GA. Cord blood samples were also collected from 1,012 newborns. In data from heel prick samples, our best-performing model estimated GA within 9.5 days overall of reference GA [mean absolute error (MAE) 1.35 (95% CI 1.27, 1.43)]. In preterm infants and those small for GA, MAE was 2.62 (2.28, 2.99) and 1.81 (1.57, 2.07) weeks, respectively. In data from cord blood, model accuracy slightly decreased overall (MAE 1.44 (95% CI 1.36, 1.53)). Accuracy was not impacted by maternal HIV status and improved when the dating ultrasound occurred between 9 and 13 weeks of gestation, in both heel prick and cord blood data (overall MAE 1.04 (95% CI 0.87, 1.22) and 1.08 (95% CI 0.90, 1.27), respectively). The accuracy of metabolic model based GA estimates in the Kenya cohort was lower compared to our previously published validation studies, however inconsistency in the timing of reference dating ultrasounds appears to have been a contributing factor to diminished model performance.

  View details for DOI 10.1371/journal.pgph.0000652

  View details for PubMedID 36962760

  View details for PubMedCentralID PMC10021775

• Improving the precision of maternal, newborn, and child health impact through geospatial analysis of the association of contextual and programmatic factors with health trends in Bihar, India. Journal of global health Abdalla, S., Pair, E., Mehta, K., Ward, V., Mahapatra, T., Darmstadt, G. L. 2022; 12: 04064

  Abstract

  Background: There is a scarcity of research that comprehensively examines programme impact from a context-specific perspective. We aimed to determine the conditions under which the Bihar Technical Support Programme led to more favourable outcomes for maternal and child health in Bihar.Methods: We obtained block-level data on maternal and child health indicators during the state-wide scale-up of the pilot Ananya programme and data on health facility readiness, along with geographical and sociodemographic variables. We examined the associations of these factors with increases in the levels of indicators using multilevel logistic regression, and the associations with rates of change in the indicators using Bayesian Hierarchical modelling.Results: Frontline worker (FLW) visits between 2014-2017 were more likely to increase in blocks with better night lighting (odds ratio (OR)=1.23, 95% confidence interval (CI)=1.01-1.51). Birth preparedness increased in blocks with increasing FLW visits (OR=3.43, 95% CI=1.15-10.21), while dry cord care practice increased in blocks where satisfaction with FLW visits was increasing (OR=1.52, 95% CI=1.10-2.11). Age-appropriate frequency of complementary feeding increased in blocks with higher development index (OR=1.55, 95% CI=1.16-2.06) and a higher percentage of scheduled caste or tribe (OR=3.21, 95% CI=1.13-9.09). An increase in most outcomes was more likely in areas with lower baseline levels.Conclusions: Contextual factors (eg, night lighting and development) not targeted by the programme and FLW visits were associated with favourable programme outcomes. Intervention design, including intervention selection for a particular geography, should be modified to fit the local context in the short term. Expanding collaborations beyond the health sector to influence modifiable contextual factors in the long term can result in a higher magnitude and more sustainable impact.Registration: ClinicalTrials.gov: NCT02726230.

  View details for DOI 10.7189/jogh.12.04064

  View details for PubMedID 36412069

• Unlocking the global health potential of dried blood spot cards. Journal of global health Bota, B., Ward, V., Lamoureux, M., Santander, E., Ducharme, R., Hawken, S., Potter, B. K., Atito, R., Nyamanda, B., Munga, S., Otieno, N., Chakraborty, S., Saha, S., Stringer, J. S., Mwape, H., Price, J. T., Mujuru, H. A., Chimhini, G., Magwali, T., Chakraborty, P., Darmstadt, G. L., Wilson, K. 2022; 12: 03027

  View details for DOI 10.7189/jogh.12.03027

  View details for PubMedID 35841606

• Digital Education for Health Professionals: An Evidence Map, Conceptual Framework, and Research Agenda. Journal of medical Internet research Tudor Car, L., Poon, S., Kyaw, B. M., Cook, D. A., Ward, V., Atun, R., Majeed, A., Johnston, J., van der Kleij, R. M., Molokhia, M., V Wangenheim, F., Lupton, M., Chavannes, N., Ajuebor, O., Prober, C. G., Car, J. 2022; 24 (3): e31977

  Abstract

  Health professions education has undergone major changes with the advent and adoption of digital technologies worldwide.This study aims to map the existing evidence and identify gaps and research priorities to enable robust and relevant research in digital health professions education.We searched for systematic reviews on the digital education of practicing and student health care professionals. We searched MEDLINE, Embase, Cochrane Library, Educational Research Information Center, CINAHL, and gray literature sources from January 2014 to July 2020. A total of 2 authors independently screened the studies, extracted the data, and synthesized the findings. We outlined the key characteristics of the included reviews, the quality of the evidence they synthesized, and recommendations for future research. We mapped the empirical findings and research recommendations against the newly developed conceptual framework.We identified 77 eligible systematic reviews. All of them included experimental studies and evaluated the effectiveness of digital education interventions in different health care disciplines or different digital education modalities. Most reviews included studies on various digital education modalities (22/77, 29%), virtual reality (19/77, 25%), and online education (10/77, 13%). Most reviews focused on health professions education in general (36/77, 47%), surgery (13/77, 17%), and nursing (11/77, 14%). The reviews mainly assessed participants' skills (51/77, 66%) and knowledge (49/77, 64%) and included data from high-income countries (53/77, 69%). Our novel conceptual framework of digital health professions education comprises 6 key domains (context, infrastructure, education, learners, research, and quality improvement) and 16 subdomains. Finally, we identified 61 unique questions for future research in these reviews; these mapped to framework domains of education (29/61, 47% recommendations), context (17/61, 28% recommendations), infrastructure (9/61, 15% recommendations), learners (3/61, 5% recommendations), and research (3/61, 5% recommendations).We identified a large number of research questions regarding digital education, which collectively reflect a diverse and comprehensive research agenda. Our conceptual framework will help educators and researchers plan, develop, and study digital education. More evidence from low- and middle-income countries is needed.

  View details for DOI 10.2196/31977

  View details for PubMedID 35297767

• Implementing health communication tools at scale: mobile audio messaging and paper-based job aids for front-line workers providing community health education to mothers in Bihar, India. BMJ global health Ward, V., Abdalla, S., Raheel, H., Weng, Y., Godfrey, A., Dutt, P., Mitra, R., Sastry, P., Chamberlain, S., Shannon, M., Mehta, K., Bentley, J., Darmstadt Md, G. L., Ananya Study Group, Atmavilas, Y., Bentley, J., Bhattacharya, D., Borkum, E., Carmichael, S. L., Chaudhuri, I., Creanga, A., Darmstadt, G. L., Dutt, P., Irani, L., Krishnan, S., Mahapatra, T., Mehta, K. M., Mitra, R., Munar, W., Nanda, P., Pepper, K., Raheel, H., Rangarajan, A., Saggurti, N., Sastry, P., Schooley, J., Shah, H., Srikantiah, S., Tarigopula, U. K., Ward, V., Walker, D., Weng, Y., Wilhelm, J. 2021; 6 (Suppl 5)

  Abstract

  INTRODUCTION: As part of an investment by the Bill & Melinda Gates Foundation to support the Government of Bihar to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) statewide, BBC Media Action implemented multiple communication tools to support front-line worker (FLW) outreach. We analyse the impacts of a package of mHealth audio messaging and paper-based job aids used by FLWs during government-sponsored village health, sanitation and nutrition days (VHSNDs) on knowledge and practices of childbearing women across the RMNCHN continuum of care.METHODS: Data from two surveys collected between July and September 2016 were analysed using logistic regression to compare health-related knowledge and behaviours between women who had been exposed at VHSNDs to the mHealth GupShup Potli (GSP) audio recordings or interpersonal communication (IPC) tools versus those who were unexposed.RESULTS: Exposure to GSP recordings (n=2608) was associated with improved knowledge across all continuum-of-care domains, as well as improved health-related behaviours in some domains. The odds of having taken iron-folic acid (IFA) tablets were significantly higher in exposed women (OR 1.5, 95% CI 1.1 to 2.2), as was contraceptive use (OR 2.0, 95% CI 1.2 to 3.2). There were no differences in birth preparedness or complementary feeding practices between groups. Exposure to IPC paper-based tools (n=2002) was associated with a twofold increased odds of IFA consumption (OR 2.3, 95% CI 1.7 to 3.2) and contraceptive use (OR 1.8, 95% CI 1.2 to 2.8). Women exposed to both tools were generally at least twice as likely to subsequently discuss the messages with others.CONCLUSION: BBC Media Action's mHealth audio messaging job aids and paper-based IPC tools were associated with improved knowledge and practices of women who were exposed to them across multiple domains, suggesting their important potential for improving health outcomes for beneficiaries at scale in low-resource settings.TRIAL REGISTRATION NUMBER: NCT02726230.

  View details for DOI 10.1136/bmjgh-2021-005538

  View details for PubMedID 34312155

• Design preferences for global scale: a mixed-methods study of "glocalization" of an animated, video-based health communication intervention. BMC public health Adam, M., Chase, R. P., McMahon, S. A., Kuhnert, K., Johnston, J., Ward, V., Prober, C., Barnighausen, T. 2021; 21 (1): 1223

  Abstract

  BACKGROUND: Designing health communication interventions for global scaling promotes health literacy and facilitates rapid global health messaging. Limited literature explores preferences for animation prototypes and other content characteristics across participants in different global regions. Prior research underscores an urgent need for health communication interventions that are compelling and accessible across culturally and geographically diverse audiences. This study presents feedback from global learners on animation design preferences and other key considerations for the development of educational video content intended for global adaptation and scaling.METHODS: We used a mixed-methods, sequential explanatory design, with a qualitative descriptive approach to the analysis of the qualitative data. We recruited participants from an international group of learners enrolled in a massive open online course. Through an online quantitative survey (n=330), we sought preferences from participants in 73 countries for animation design prototypes to be used in video-based health communication interventions. To learn more about these preferences, we conducted in-depth interviews (n=20) with participants selected using maximum variation purposive sampling.RESULTS: Generally, respondents were willing to accept animation prototypes that were free of cultural and ethnic identifiers and believed these to be preferable for globally scalable health communication videos. Diverse representations of age, gender roles, and family structure were also preferred and felt to support inclusive messaging across cultures and global regions. Familiar-sounding voiceovers using local languages, dialects, and accents were preferred for enhancing local resonance. Across global regions, narratives were highlighted as a compelling approach to facilitating engagement and participants preferred short videos with no more than two or three health messages.CONCLUSIONS: Our findings suggest that global learners may be willing to accept simplified visuals, designed for broad cross-cultural acceptability, especially if the content is localized in other ways, such as through the use of locally resonating narratives and voiceovers. Diverse, inclusive portrayals of age, gender roles and family structure were preferred.

  View details for DOI 10.1186/s12889-021-11043-w

  View details for PubMedID 34172016

• Managing Persistent Hypertension and Tachycardia Following Septic Shock, Limb Ischemia, and Amputation: The Role for beta-Blockade. Clinical pediatrics Brewster, R., Lee, J., Nguyen, E., Ward, V. 2021; 60 (4-5): 226–29

  View details for DOI 10.1177/00099228211006704

  View details for PubMedID 33853367

• A novel way of determining gestational age upon the birth of a child. Journal of global health Wilson, K., Ward, V., Chakraborty, P., Darmstadt, G. L. 2021; 11: 03078

  View details for DOI 10.7189/jogh.11.03078

  View details for PubMedID 34552714

• Best practices in global health evaluation: Reflections on learning from an independent program analysis in Bihar, India. Journal of global health Mehta, K. M., Ward, V. C., Darmstadt, G. L. 2020; 10 (2): 020395

  View details for DOI 10.7189/jogh.10.020395

  View details for PubMedID 33403103

• Geospatial variations in trends of reproductive, maternal, newborn and child health and nutrition indicators at block level in Bihar, India, during scale-up of Ananya program interventions. Journal of global health Abdalla, S., Pair, E., Mehta, K. M., Ward, V. C., Darmstadt, G. L. 2020; 10 (2): 021004

  Abstract

  Background: Geographical variations in the levels and trajectory of health indicators at local level can inform the adaptation of interventions and development of targeted approaches for efficient scale-up of intervention impact. We examined the hypothesis that time trends of a set of reproductive, maternal, newborn, and child health and nutrition (RMNCHN) indicators varied at block-level during the statewide scale-up phase of the Ananya program in Bihar, India.Methods: We used data on 22 selected indicators from four rounds of the Community-based Household Survey carried out between 2014 and 2017. Indicator levels at each round were estimated for each block. We used hierarchical Bayesian spatiotemporal modelling to smooth the raw estimates for each block with the estimates from its neighbouring blocks, and to examine space-time interaction models for evidence of variations in trends of indicators across blocks. We expressed the uncertainty around the smoothed levels and the trends with 95% credible intervals.Results: There was evidence of variations in trends at block level in all but three indicators: facility delivery, public facility delivery, and age-appropriate initiation of complementary feeding. Fifteen indicators showed trends in opposite directions (increases in some blocks and declines in others). All blocks had at least 97.5% probability of a rise in immediate breastfeeding, early pregnancy registration, and having at least four antenatal care visits. All blocks had at least 97.5% probability of a decline in seeking care for pregnancy complications.Conclusions: The findings underscore the value of monitoring and evaluation at local level for targeted implementation of RMNCHN interventions. There is a need for identifying systematic factors leading to universal trends, or variable contextual or implementation factors leading to variable trends, in order to optimise primary health care program impact.Study registration: ClinicalTrials.gov number NCT02726230.

  View details for DOI 10.7189/jogh.10.021004

  View details for PubMedID 33425328

• Health layering of self-help groups: impacts on reproductive, maternal, newborn and child health and nutrition in Bihar, India. Journal of global health Mehta, K. M., Irani, L., Chaudhuri, I., Mahapatra, T., Schooley, J., Srikantiah, S., Abdalla, S., Ward, V., Carmichael, S. L., Bentley, J., Creanga, A., Wilhelm, J., Tarigopula, U. K., Bhattacharya, D., Atmavilas, Y., Nanda, P., Weng, Y., Pepper, K. T., Darmstadt, G. L., Ananya Study Group, Atmavilas, Y., Bhattacharya, D., Bentley, J., Borkum, E., Carmichael, S., Chaudhuri, I., Creanga, A., Darmstadt, G. L., Dutt, P., Irani, L., Mahapatra, T., Mehta, K. M., Mitra, R., Munar, W. A., Nanda, P., Pepper, K. T., Raheel, H., Rangarajan, A., Saggurti, N., Sastry, P., Shah, H., Srikantiah, S., Tarigopula, U. K., Ward, V., Weng, Y., Walker, D., Wilhelm, J. 2020; 10 (2): 021007

  Abstract

  Background: Self-help group (SHG) interventions have been widely studied in low and middle income countries. However, there is little data on specific impacts of health layering, or adding health education modules upon existing SHGs which were formed primarily for economic empowerment. We examined three SHG interventions from 2012-2017 in Bihar, India to test the hypothesis that health-layering of SHGs would lead to improved health-related behaviours of women in SHGs.Methods: A model for health layering of SHGs - Parivartan - was developed by the non-governmental organisation (NGO), Project Concern International, in 64 blocks of eight districts. Layering included health modules, community events and review mechanisms. The health layering model was adapted for use with government-led SHGs, called JEEViKA+HL, in 37 other blocks of Bihar. Scale-up of government-led SHGs without health layering (JEEViKA) occurred contemporaneously in 433 other blocks, providing a natural comparison group. Using Community-based Household Surveys (CHS, rounds 6-9) by CARE India, 62 reproductive, maternal, newborn and child health and nutrition (RMNCHN) and sanitation indicators were examined for SHGs with health layering (Pavivartan SHGs and JEEViKA+HL SHGs) compared to those without. We calculated mean, standard deviation and odds ratios of indicators using surveymeans and survey logistic regression.Results: In 2014, 64% of indicators were significantly higher in Parivartan members compared to non-members residing in the same blocks. During scale up, from 2015-17, half (50%) of indicators had significantly higher odds in health layered SHG members (Parivartan or JEEViKA+HL) in 101 blocks compared to SHG members without health layering (JEEViKA) in 433 blocks.Conclusions: Health layering of SHGs was demonstrated by an NGO-led model (Parivartan), adapted and scaled up by a government model (JEEViKA+HL), and associated with significant improvements in health compared to non-health-layered SHGs (JEEViKA). These results strengthen the evidence base for further layering of health onto the SHG platform for scale-level health change.Study registration: ClinicalTrials.gov number NCT02726230.

  View details for DOI 10.7189/jogh.10.021007

  View details for PubMedID 33425331

• Health impact of self-help groups scaled-up statewide in Bihar, India. Journal of global health Mehta, K. M., Irani, L., Chaudhuri, I., Mahapatra, T., Schooley, J., Srikantiah, S., Abdalla, S., Ward, V. C., Carmichael, S. L., Bentley, J., Creanga, A., Wilhelm, J., Tarigopula, U. K., Bhattacharya, D., Atmavilas, Y., Nanda, P., Weng, Y., Pepper, K. T., Darmstadt, G. L., Ananya Study Group, Atmavilas, Y., Bhattacharya, D., Bentley, J., Borkum, E., Carmichael, S., Chaudhuri, I., Creanga, A., Darmstadt, G. L., Dutt, P., Irani, L., Mahapatra, T., Mehta, K. M., Mitra, R., Munar, W. A., Nanda, P., Pepper, K. T., Raheel, H., Rangarajan, A., Saggurti, N., Sastry, P., Shah, H., Srikantiah, S., Ward, V., Weng, Y., Walker, D., Wilhelm, J. 2020; 10 (2): 021006

  Abstract

  Background: The objective of this study was to assess the impact of self-help groups (SHGs) and subsequent scale-up on reproductive, maternal, newborn, child health, and nutrition (RMNCHN) and sanitation outcomes among marginalised women in Bihar, India from 2014-2017.Methods: We examined RMNCHN and sanitation behaviors in women who were members of any SHGs compared to non-members, without differentiating between types of SHGs. We analysed annual surveys across 38 districts of Bihar covering 62690 women who had a live birth in the past 12 months. All analyses utilised data from Community-based Household Surveys (CHS) rounds 6-9 collected in 2014-2017 by CARE India as part of the Bihar Technical Support Program funded by the Bill & Melinda Gates Foundation. We examined 66 RMNCHN and sanitation indicators using survey logistic regression; the comparison group in all cases was age-comparable women from the geographic contexts of the SHG members but who did not belong to SHGs. We also examined links between discussion topics in SHGs and changes in relevant behaviours, and stratification of effects by parity and mother's age.Results: SHG members had higher odds compared to non-SHG members for 60% of antenatal care indicators, 22% of delivery indicators, 70% of postnatal care indicators, 50% of nutrition indicators, 100% of family planning and sanitation indicators and no immunisation indicators measured. According to delivery platform, most FLW performance indicators (80%) had increased odds, followed by maternal behaviours (57%) and facility care and outreach service delivery (22%) compared to non-SHG members. Self-report of discussions within SHGs on specific topics was associated with increased related maternal behaviours. Younger SHG members (<25 years) had attenuated health indicators compared to older group members (≥25 years), and women with more children had more positive indicators compared to women with fewer children.Conclusions: SHG membership was associated with improved RMNCHN and sanitation indicators at scale in Bihar, India. Further work is needed to understand the specific impacts of health layering upon SHGs. Working through SHGs is a promising vehicle for improving primary health care.Study registration: ClinicalTrials.gov number NCT02726230.

  View details for DOI 10.7189/jogh.10.021006

  View details for PubMedID 33425330

• Impact of mHealth interventions for reproductive, maternal, newborn and child health and nutrition at scale: BBC Media Action and the Ananya program in Bihar, India. Journal of global health Ward, V. C., Raheel, H., Weng, Y., Mehta, K. M., Dutt, P., Mitra, R., Sastry, P., Godfrey, A., Shannon, M., Chamberlain, S., Kaimal, R., Carmichael, S. L., Bentley, J., Abdalla, S., Pepper, K. T., Mahapatra, T., Srikantiah, S., Borkum, E., Rangarajan, A., Sridharan, S., Rotz, D., Nanda, P., Tarigopula, U. K., Atmavilas, Y., Bhattacharya, D., Darmstadt, G. L., Ananya Study Group, Atmavilas, Y., Bhattacharya, D., Bentley, J., Borkum, E., Carmichael, S., Chaudhuri, I., Creanga, A., Darmstadt, G. L., Dutt, P., Irani, L., Mahapatra, T., Mehta, K. M., Mitra, R., Munar, W. A., Nanda, P., Pepper, K. T., Raheel, H., Rangarajan, A., Saggurti, N., Sastry, P., Shah, H., Srikantiah, S., Tarigopula, U. K., Ward, V., Weng, Y., Walker, D., Wilhelm, J. 2020; 10 (2): 021005

  Abstract

  Background: Mobile health (mHealth) tools have potential for improving the reach and quality of health information and services through community health workers in low- and middle-income countries. This study evaluates the impact of an mHealth tool implemented at scale as part of the statewide reproductive,maternal, newborn and child health and nutrition (RMNCHN) program in Bihar, India.Methods: Three survey-based data sets were analysed to compare the health-related knowledge, attitudes and behaviours amongst childbearing women exposed to the Mobile Kunji and Dr. Anita mHealth tools during their visits with frontline workers compared with those who were unexposed.Results: An evaluation by Mathematica (2014) revealed that exposure to Mobile Kunji and Dr. Anita recordings were associated with significantly higher odds of consuming iron-folic acid tablets (odds ratio (OR)=2.3, 95% confidence interval (CI)=1.8-3.1) as well as taking a set of three measures for delivery preparedness (OR=2.8, 95% CI=1.9-4.2) and appropriate infant complementary feeding (OR=1.9, 95% CI=1.0-3.5). CARE India's Community-based Household Surveys (2012-2017) demonstrated significant improvements in early breastfeeding (OR=1.64, 95% CI=1.5-1.78) and exclusive breastfeeding (OR=1.46, 95% CI=1.33-1.62) in addition to birth preparedness practices. BBC Media Action's Usage & Engagement Survey (2014) demonstrated a positive association between exposure to Mobile Kunji and Dr. Anita and exclusive breastfeeding (58% exposed vs 43% unexposed, P<0.01) as well as maternal respondents' trust in their frontline worker.Conclusions: Significant improvements in RMNCHN-related knowledge and behaviours were observed for Bihari women who were exposed to Mobile Kunji and Dr. Anita. This analysis is unique in its rigorous evaluation across multiple data sets of mHealth interventions implemented at scale. These results can help inform global understanding of how best to use mHealth tools, for whom, and in what contexts.Study registration: ClinicalTrials.gov number NCT02726230.

  View details for DOI 10.7189/jogh.10.021005

  View details for PubMedID 33425329

• Evaluation of a large-scale reproductive, maternal, newborn and child health and nutrition program in Bihar, India, through an equity lens. Journal of global health Ward, V. C., Weng, Y., Bentley, J., Carmichael, S. L., Mehta, K. M., Mahmood, W., Pepper, K. T., Abdalla, S., Atmavilas, Y., Mahapatra, T., Srikantiah, S., Borkum, E., Rangarajan, A., Sridharan, S., Rotz, D., Bhattacharya, D., Nanda, P., Tarigopula, U. K., Shah, H., Darmstadt, G. L., Ananya Study Group, Atmavilas, Y., Bhattacharya, D., Bentley, J., Borkum, E., Carmichael, S., Chaudhuri, I., Creanga, A., Darmstadt, G. L., Dutt, P., Irani, L., Mahapatra, T., Mehta, K. M., Mitra, R., Munar, W. A., Nanda, P., Pepper, K. T., Raheel, H., Rangarajan, A., Saggurti, N., Sastry, P., Shah, H., Srikantiah, S., Tarigopula, U. K., Ward, V., Weng, Y., Walker, D., Wilhelm, J. 2020; 10 (2): 021011

  Abstract

  Background: Despite increasing focus on health inequities in low- and middle income countries, significant disparities persist. We analysed impacts of a statewide maternal and child health program among the most compared to the least marginalised women in Bihar, India.Methods: Utilising survey-weighted logistic regression, we estimated programmatic impact using difference-in-difference estimators from Mathematica data collected at the beginning (2012, n=10174) and after two years of program implementation (2014, n=9611). We also examined changes in disparities over time using eight rounds of Community-based Household Surveys (CHS) (2012-2017, n=48349) collected by CARE India.Results: At baseline for the Mathematica data, least marginalised women generally performed desired health-related behaviours more frequently than the most marginalised. After two years, most disparities persisted. Disparities increased for skilled birth attendant identification [+16.2% (most marginalised) vs +32.6% (least marginalized), P<0.01) and skin-to-skin care (+14.8% vs +20.4%, P<0.05), and decreased for immediate breastfeeding (+10.4 vs -4.9, P<0.01). For the CHS data, odds ratios compared the most to the least marginalised women as referent. Results demonstrated that disparities were most significant for indicators reliant on access to care such as delivery in a facility (OR range: 0.15 to 0.48) or by a qualified doctor (OR range: 0.08 to 0.25), and seeking care for complications (OR range: 0.26 to 0.64).Conclusions: Disparities observed at baseline generally persisted throughout program implementation. The most significant disparities were observed amongst behaviours dependent upon access to care. Changes in disparities largely were due to improvements for the least marginalised women without improvements for the most marginalised. Equity-based assessments of programmatic impacts, including those of universal health approaches, must be undertaken to monitor disparities and to ensure equitable and sustainable benefits for all.Study registration: ClinicalTrials.gov number NCT02726230.

  View details for DOI 10.7189/jogh.10.021011

  View details for PubMedID 33425335

• Impact of the Ananya program on reproductive, maternal, newborn and child health and nutrition in Bihar, India: early results from a quasi-experimental study. Journal of global health Darmstadt, G. L., Weng, Y., Pepper, K. T., Ward, V. C., Mehta, K. M., Borkum, E., Bentley, J., Raheel, H., Rangarajan, A., Bhattacharya, D., Tarigopula, U. K., Nanda, P., Sridharan, S., Rotz, D., Carmichael, S. L., Abdalla, S., Munar, W., Ananya Study Group, Atmavilas, Y., Bhattacharya, D., Bentley, J., Borkum, E., Carmichael, S., Chaudhuri, I., Creanga, A., Darmstadt, G. L., Dutt, P., Irani, L., Mahapatra, T., Mehta, K. M., Mitra, R., Munar, W. A., Nanda, P., Pepper, K. T., Raheel, H., Rangarajan, A., Saggurti, N., Sastry, P., Delhi, N., Shah, H., Srikantiah, S., Tarigopula, U. K., Ward, V., Weng, Y., Walker, D., Wilhelm, J. 2020; 10 (2): 021002

  Abstract

  Background: The Government of Bihar (GoB) in India, the Bill and Melinda Gates Foundation and several non-governmental organisations launched the Ananya program aimed to support the GoB to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) statewide. Here we summarise changes in indicators attained during the initial two-year pilot phase (2012-2013) of implementation in eight focus districts of approximately 28 million population, aimed to inform subsequent scale-up.Methods: The quasi-experimental impact evaluation included statewide household surveys at two time points during the pilot phase: January-April 2012 ("baseline") including an initial cohort of beneficiaries and January-April 2014 ("midline") with a new cohort. The two arms were: 1) eight intervention districts, and 2) a comparison arm comprised of the remaining 30 districts in Bihar where Ananya interventions were not implemented. We analysed changes in indicators across the RMNCHN continuum of care from baseline to midline in intervention and comparison districts using a difference-in-difference analysis.Results: Indicators in the two arms were similar at baseline. Overall, 40% of indicators (20 of 51) changed significantly from baseline to midline in the comparison districts unrelated to Ananya; two-thirds (n=13) of secular indicator changes were in a direction expected to promote health. Statistically significant impact attributable to the Ananya program was found for 10% (five of 51) of RMNCHN indicators. Positive impacts were most prominent for mother's behaviours in contraceptive utilisation.Conclusions: The Ananya program had limited impact in improving health-related outcomes during the first two-year period covered by this evaluation. The program's theories of change and action were not powered to observe statistically significant differences in RMNCHN indicators within two years, but rather aimed to help inform program improvements and scale-up. Evaluation of large-scale programs such as Ananya using theory-informed, equity-sensitive (including gender), mixed-methods approaches can help elucidate causality and better explain pathways through which supply- and demand-side interventions contribute to changes in behaviour among the actors involved in the production of population-level health outcomes. Evidence from Bihar indicates that deep structural constraints in health system organisation and delivery of interventions pose substantial limitations on behaviour change among health care providers and beneficiaries.Study registration: ClinicalTrials.gov number NCT02726230.

  View details for DOI 10.7189/jogh.10.021002

  View details for PubMedID 33427822

• Trends in reproductive, maternal, newborn and child health and nutrition indicators during five years of piloting and scaling-up of Ananya interventions in Bihar, India. Journal of global health Abdalla, S., Weng, Y., Mehta, K. M., Mahapatra, T., Srikantiah, S., Shah, H., Ward, V. C., Pepper, K. T., Bentley, J., Carmichael, S. L., Creanga, A., Wilhelm, J., Tarigopula, U. K., Nanda, P., Bhattacharya, D., Atmavilas, Y., Darmstadt, G. L., Ananya Study Group, Atmavilas, Y., Bentley, J., Bhattacharya, D., Borkum, E., Carmichael, S. L., Chaudhuri, I., Creanga, A., Darmstadt, G. L., Dutt, P., Delhi, N., Irani, L., Delhi, N., Krishnan, S., Mahapatra, T., Mehta, K. M., Francisco, S., Mitra, R., Munar, W., Nanda, P., Pepper, K. T., Raheel, H., Rangarajan, A., Saggurti, N., Sastry, P., Schooley, J., Shah, H., Srikantiah, S., Tarigopula, U. K., Ward, V. C., Walker, D., Weng, Y., Wilhelm, J. 2020; 10 (2): 021003

  Abstract

  Background: The Ananya program in Bihar implemented household and community-level interventions to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) in two phases: a first phase of intensive ancillary support to governmental implementation and innovation testing by non-government organisation (NGO) partners in eight focus districts (2012-2014), followed by a second phase of state-wide government-led implementation with techno-managerial assistance from NGOs (2014 onwards). This paper examines trends in RMNCHN indicators in the program's implementation districts from 2012-2017.Methods: Eight consecutive rounds of cross-sectional Community-based Household Surveys conducted by CARE India in 2012-2017 provided comparable data on a large number of indicators of frontline worker (FLW) performance, mothers' behaviours, and facility-based care and outreach service delivery across the continuum of maternal and child care. Logistic regression, considering the complex survey design and sample weights generated by that design, was used to estimate trends using survey rounds 2-5 for the first phase in the eight focus districts and rounds 6-9 for the second phase in all 38 districts statewide, as well as the overall change from round 2-9 in focus districts. To aid in contextualising the results, indicators were also compared amongst the formerly focus and the non-focus districts at the beginning of the second phase.Results: In the first phase, the levels of 34 out of 52 indicators increased significantly in the focus districts, including almost all indicators of FLW performance in antenatal and postnatal care, along with mother's birth preparedness, some breastfeeding practices, and immunisations. Between the two phases, 33 of 52 indicators declined significantly. In the second phase, the formerly focus districts experienced a rise in the levels of 14 of 50 indicators and a decline in the levels of 14 other indicators. There was a rise in the levels of 22 out of 50 indicators in the non-focus districts in the second phase, with a decline in the levels of 13 other indicators.Conclusions: Improvements in indicators were conditional on implementation support to program activities at a level of intensity that was higher than what could be achieved at scale so far. Successes during the pilot phase of intensive support suggests that RMNCHN can be improved statewide in Bihar with sufficient investments in systems performance improvements.Study registration: ClinicalTrials.gov number NCT02726230.

  View details for DOI 10.7189/jogh.10.021003

  View details for PubMedID 33427818

• Improving primary health care delivery in Bihar, India: Learning from piloting and statewide scale-up of Ananya. Journal of global health Darmstadt, G. L., Pepper, K. T., Ward, V. C., Srikantiah, S. n., Mahapatra, T. n., Tarigopula, U. K., Bhattacharya, D. n., Irani, L. n., Schooley, J. n., Chaudhuri, I. n., Dutt, P. n., Sastry, P. n., Mitra, R. n., Chamberlain, S. n., Monaghan, S. n., Nanda, P. n., Atmavilas, Y. n., Saggurti, N. n., Borkum, E. n., Rangarajan, A. n., Mehta, K. M., Abdalla, S. n., Wilhelm, J. n., Weng, Y. n., Carmichael, S. L., Raheel, H. n., Bentley, J. n., Munar, W. A., Creanga, A. n., Trehan, S. n., Walker, D. n., Shah, H. n. 2020; 10 (2): 021001

  Abstract

  In 2010, the Bill and Melinda Gates Foundation (BMGF) partnered with the Government of Bihar (GoB), India to launch the Ananya program to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) outcomes. The program sought to address supply- and demand-side barriers to the adoption, coverage, quality, equity and health impact of select RMNCHN interventions. Approaches included strengthening frontline worker service delivery; social and behavior change communications; layering of health, nutrition and sanitation into women's self-help groups (SHGs); and quality improvement in maternal and newborn care at primary health care facilities. Ananya program interventions were piloted in approximately 28 million population in eight innovation districts from 2011-2013, and then beginning in 2014, were scaled up by the GoB across the rest of the state's population of 104 million. A Bihar Technical Support Program provided techno-managerial support to governmental Health as well as Integrated Child Development Services, and the JEEViKA Technical Support Program supported health layering and scale-up of the GoB's SHG program. The level of support at the block level during statewide scale-up in 2014 onwards was approximately one-fourth that provided in the pilot phase of Ananya in 2011-2013. This paper - the first manuscript in an 11-manuscript and 2-viewpoint collection on Learning from Ananya: Lessons for primary health care performance improvement - seeks to provide a broad description of Ananya and subsequent statewide adaptation and scale-up, and capture the background and context, key objectives, interventions, delivery approaches and evaluation methods of this expansive program. Subsequent papers in this collection focus on specific intervention delivery platforms. For the analyses in this series, Stanford University held key informant interviews and worked with the technical support and evaluation grantees of the Ananya program, as well as leadership from the India Country Office of the BMGF, to analyse and synthesise data from multiple sources. Capturing lessons from the Ananya pilot program and statewide scale-up will assist program managers and policymakers to more effectively design and implement RMNCHN programs at scale through technical assistance to governments.

  View details for DOI 10.7189/jogh.10.021001

  View details for PubMedID 33414906

  View details for PubMedCentralID PMC7757841

• Metabolic gestational age assessment in low resource settings: a validation protocol. Gates open research Bota, A. B., Ward, V., Hawken, S., Wilson, L. A., Lamoureux, M., Ducharme, R., Murphy, M. S., Denize, K. M., Henderson, M., Saha, S. K., Akther, S., Otieno, N. A., Munga, S., Atito, R. O., Stringer, J. S., Mwape, H., Price, J. T., Mujuru, H. A., Chimhini, G., Magwali, T., Mudawarima, L., Chakraborty, P., Darmstadt, G. L., Wilson, K. 2020; 4: 150

  Abstract

  Preterm birth is the leading global cause of neonatal morbidity and mortality. Reliable gestational age estimates are useful for quantifying population burdens of preterm birth and informing allocation of resources to address the problem. However, evaluating gestational age in low-resource settings can be challenging, particularly in places where access to ultrasound is limited. Our group has developed an algorithm using newborn screening analyte values derived from dried blood spots from newborns born in Ontario, Canada for estimating gestational age within one to two weeks. The primary objective of this study is to validate a program that derives gestational age estimates from dried blood spot samples (heel-prick or cord blood) collected from health and demographic surveillance sites and population representative health facilities in low-resource settings in Zambia, Kenya, Bangladesh and Zimbabwe. We will also pilot the use of an algorithm to identify birth percentiles based on gestational age estimates and weight to identify small for gestational age infants. Once collected from local sites, samples will be tested by the Newborn Screening Ontario laboratory at the Children's Hospital of Eastern Ontario (CHEO) in Ottawa, Canada. Analyte values will be obtained through laboratory analysis for estimation of gestational age as well as screening for other diseases routinely conducted at Ontario's newborn screening program. For select conditions, abnormal screening results will be reported back to the sites in real time to facilitate counseling and future clinical management. We will determine the accuracy of our existing algorithm for estimation of gestational age in these newborn samples. Results from this research hold the potential to create a feasible method to assess gestational age at birth in low- and middle-income countries where reliable estimation may be otherwise unavailable.

  View details for DOI 10.12688/gatesopenres.13155.1

  View details for PubMedID 33501414

• Factors and Behaviors Related to the Promotion of Pediatric Hospital Medicine Fellow Autonomy: A Qualitative Study of Faculty ACADEMIC PEDIATRICS Maniscalco, J., Davis, E., Gay, A., Ward, V., Truckenbrod, J., Denniston, S. F., Rassbach, C. E. 2019; 19 (6): 703–11

  View details for Web of Science ID 000481567900018