Does exposure to health information through mobile phones increase immunisation knowledge, completeness and timeliness in rural India?

BMJ Global Health, Volume 6, Year 2021

Interpretation

Introduction Immunisation plays a vital role in reducing child mortality and morbidity against preventable diseases. As part of a randomised controlled trial in rural Madhya Pradesh, India to assess the impact of Kilkari, a maternal messaging programme, we explored determinants of parental immunisation knowledge and immunisation practice (completeness and timeliness) for children 0-12 months of age from four districts in Madhya Pradesh. Methods Data were drawn from a cross-sectional survey of women (n=4423) with access to a mobile phone and their spouses (n=3781). Parental knowledge about immunisation and their child’s receipt of vaccines, including timeliness and completeness, was assessed using self-reports and vaccination cards. Ordered logistic regressions were used to analyse the factors associated with parental immunisation knowledge. A Heckman two-stage probit model was used to analyse completeness and timeliness of immunisation after correcting for selection bias from being able to produce the immunisation card. Results One-third (33%) of women and men knew the timing for the start of vaccinations, diseases linked to immunisations and the benefits of Vitamin-A. Less than half of children had received the basic package of 8 vaccines (47%) and the comprehensive package of 19 vaccines (44%). Wealth was the most significant determinant of men’s knowledge and of the child receiving complete and timely immunisation for both basic and comprehensive packages. Exposure to Kilkari content on immunisation was significantly associated with an increase in men’s knowledge (but not women’s) about child immunisation (OR: 1.23, 95% CI 1.02 to1.48) and an increase in the timeliness of the child receiving vaccination at birth (Probit coefficient: 0.08, 95% CI 0.08 to 0.24). Conclusion Gaps in complete and timely immunisation for infants persist in rural India. Mobile messaging programmes, supported by mass media messages, may provide one important source for bolstering awareness, uptake and timeliness of immunisation services. Trial registration number NCT03576157. The study was conducted in rural MP, a state in central India with one of the lowest per capita state domestic products.23 There remains a significant gender gap in women’s literacy and access to mobile phones within and across MP and throughout much of India. Findings from the 2015–2016 National Family Health Survey (NFHS) suggest that across MP, literacy rates were 59% and 82% for women and men, respectively.24 The gender gap in women versus household access to mobile phones is estimated to be 60% in rural areas and 44% in urban areas in 2015.24 MP falls below national averages for most health indicators, including immunisations. Among children 12–23 months of age, 54% were fully immunised (Bacille Calmette-Guerin (BCG), measles and three doses each of polio and DPT) in MP as compared with 62% nationally.24 Study findings draw from data captured as part of the RCT in four districts (Rewa, Hoshangabad, Mandsaur and Rajgarh) of MP, described in detail elsewhere.22 In brief, women 4–7 months pregnant (5095) with access to mobile phones were randomised to either a comparison arm of no calls or an intervention arm where they were eligible to receive Kilkari calls from the 18th week of pregnancy up until the child’s first birthday. The RCT assessed the impact of Kilkari on various reproductive maternal newborn and child health (RMNCH) behaviours including full and timely immunisations among children 0–12 months of age.22 The present analysis used the postpartum survey data from 4423 postpartum women (87%, out of 5095 total enrolled in Kilkari) with a live birth during the index pregnancy and their husbands (3781 men). Data could not be collected from 642 husbands primarily due to migration for work. The interviews were conducted face-to-face in Hindi and included questions on socioeconomic and demographic factors, access to mobile phones and parental knowledge about immunisation. Information on what vaccines the child received from birth to the time of postpartum survey (approximately 12 months after birth) was recorded from the government-issued vaccination card called the Mother and Child Protection (MCP) card. After adjusting for twins and number of children born since the baseline, information was available for 3891 children, for whom interviews of both the parents could be conducted. Out of these 3891 children, the MCP card was available for 3230 children. Posthoc power analysis indicated that the final sample of 3230 children was powered to detect a change of up to 4% in immunisation coverage for children 0–12 months old, with a power of 80% and a type-I error of 0.05. During the postpartum survey, women (mothers) and their husbands (fathers) were asked 11 questions to assess their knowledge about childhood immunisation. Questions covered timing of first vaccination, diseases against which a child needs to be vaccinated within the first year of their birth and benefits of Vitamin-A. A score of 1 was assigned for each correct response and 0 otherwise, with equal weights assigned to each response, resulting in a composite knowledge score for each respondent ranging from 0 to 11. Full immunisation (comprehensive) was if the child received all 19 vaccines listed in online supplemental Annexure-2 (following the guidelines of India’s National Immunisation Guideline25), to which a score of 1 was assigned, else they were assigned 0. Full immunisation (basic) was if the child received all eight basic vaccines: BCG, three doses of DPT, three doses of Polio and measles, to which a score of 1 was assigned, else they were assigned 0 (following the NFHS24). Timely immunisation (comprehensive) was assessed by comparing the expected vaccination date to the actual vaccination date. Each vaccine’s recommended vaccination date was estimated by calculating when the vaccine should have been administered based on the child’s date of birth as listed in their MCP card and according to Government of India vaccine schedule guidelines.25 The actual vaccination date was recorded from the child’s MCP card. For each vaccine, we assigned 1 if it was administered within 28 days of the date the vaccine becomes due and a 0 if not. Each child thus had a total timely immunisation score that varied from 0 to 19. Timely immunisation (basic) was defined as the administration of BCG, three doses of DPT, three doses of polio and the measles vaccine at the 6–10 weeks, 10–14 weeks, 14–18 weeks and 9–10 months, respectively. For each vaccine, a score of 1 was assigned if it was administered within time (as described for the comprehensive package above), else 0, with a total score varied from 0 to 8. Frequencies and proportions were used to understand the characteristics of the sample, exposure to Kilkari immunisation calls, parental knowledge on immunisation and immunisation status among the children. We used ordered logistic regression, separately for mothers and fathers, to assess the factors associated with parental knowledge of immunisation. To assess the correlates of parent’s immunisation knowledge, the following model specification was used: I-KNOW=f(KILKARI, SES, M-INDIV, M-ACCESS, IMMU-INFO, DIST) (1), where I-KNOW is the immunisation knowledge score, on a scale varying from 0 to 11. KILKARI is a binary variable, where 1 indicates if the cumulative time of content listening under the Kilkari programme was ≥50% (at least 441 econd of total 881 second of cumulative content on immunisation were played), 0 otherwise. The information was collected from the call records data. SES is a vector of socioeconomic characteristics of the mother which includes dummies for caste (other backward class (OBC), scheduled caste/scheduled tribe (SC/ST) and others) and wealth quintiles (computed by principal component analysis based on various assets ownership and availability of amenities in household). M-INDIV represents a mother’s total years of completed formal education, number of children she has, dummy variables to represent her employment status (1 if employed), and if she plays any role in taking decision of daily purchases of the household and her pregnancy. A mother’s mobile phone access is proxied by M-ACCESS which comprises dummies representing whether she owns a personal mobile phone, if she has access to the mobile phone for more than 12 hours a day and if the phone is often at zero balance. Sources of immunisation information are represented by the vector IMMU-INFO which includes dummies on whether the mother has asked for immunisation information from any health worker, whether she has received the same from any health worker and if she reported to receive information from (i) television or (ii) print (poster/newspaper/handout). Finally, vector DIST represents district dummies. For the analysis of factors associated with father’s immunisation knowledge, the explanatory variables remain the same as equation (1) (KILKARI, SES, father’s individual characteristics, father’s access to mobile phone and district dummies) except the vector on sources of immunisation information (asked and received information from health worker, received information from television or print media), which was not collected and is not part of the analysis. Out of the total sample of 3891 children, the MCP card was available for 3230 (83% of sample) children. There could be systemic differences between mothers who could produce the MCP card and those who could not. To address this, we applied Heckman two-stage sample selection model to correct for selection bias.26 In the first step, the model estimates the probability of having the MCP card, which can be expressed as: Prob (MCP=1 | Z)=f(Z (KILKARI, SES, M-INDIV, M-ACCESS, IMMU-INFO, ASHA, DIST)) (2), where MCP=1 if the mother could produce the MCP card, 0 otherwise; Z is a vector of explanatory variables representing a mother’s characteristics explained in equation (1) and the caste of ASHA, the frontline worker playing a crucial role in RMNCH related issues, as a proxy to capture the capability of her. In the second stage, after incorporating the predicted probability of having the MCP card as an explanatory variable, the model to predict the practice of immunisation can be represented as: P-IMMU* = β*X + ε (3), where P-IMMU, probability of child to be immunised, is not observed if the mother could not produce the MCP card. The conditional expectation of immunisation practice can be expressed as: E(P-IMMU | X, MCP=1) = β*X+E(ε|X, MCP=1) (4), where X is a vector of characteristics expressed in equation (1), additionally including (i) parental immunisation knowledge scores, (ii) child’s gender (to assess any gender-based bias) and (iii) if the child received most vaccines at the Anganwadi centre, the nutrition and childcare centre at the village and a common place for immunisation. The analysis of determinants of full immunisation and timely immunisation of basic and comprehensive package, vaccination at birth, at 6–10 weeks, 10–14 weeks, 14–18 weeks and 9–10 months were done using Heckman probit model. Ethical clearance for this study was obtained from the Independent Ethics Review Boards of Johns Hopkins School of Public Health Institution in Baltimore, Maryland and Sigma Research in India. Verbal informed consent was obtained from the study participants, for participation in the RCT and in the baseline and postpartum survey.

AI Digest

Study Justification:

The study aimed to assess the impact of a maternal messaging program called Kilkari on parental immunization knowledge and immunization practice in rural Madhya Pradesh, India. The justification for the study is based on the importance of immunization in reducing child mortality and morbidity from preventable diseases. The study aimed to fill the knowledge gaps and identify factors influencing immunization knowledge and practice in rural India.

Study Highlights:

1. The study found that only one-third of women and men had adequate knowledge about the timing of vaccinations, diseases linked to immunizations, and the benefits of Vitamin-A.
2. Less than half of the children had received the basic package of 8 vaccines and the comprehensive package of 19 vaccines.
3. Wealth was found to be the most significant determinant of men’s knowledge and the child’s receipt of complete and timely immunization.
4. Exposure to Kilkari content on immunization was associated with an increase in men’s knowledge about child immunization and an increase in the timeliness of vaccination at birth.

Study Recommendations:

1. Mobile messaging programs, supported by mass media messages, can play a crucial role in increasing awareness, uptake, and timeliness of immunization services in rural areas.
2. Efforts should be made to improve parental knowledge about immunization, especially among women, through targeted interventions and educational campaigns.
3. Strategies should be implemented to address the wealth disparities that influence immunization knowledge and practice, ensuring equitable access to immunization services.
4. Health workers should be trained to provide accurate and timely immunization information to parents, and efforts should be made to strengthen the role of frontline workers, such as ASHAs, in promoting immunization.

Key Role Players:

1. Health workers: They play a crucial role in providing immunization information and services to parents.
2. Frontline workers (ASHAs): They can contribute to promoting immunization and addressing knowledge gaps in rural communities.
3. Mass media agencies: They can support mobile messaging programs by disseminating immunization-related information through various media channels.
4. Policy makers: They can develop and implement policies that prioritize immunization and address barriers to access and knowledge gaps.

Cost Items for Planning Recommendations:

1. Training and capacity building for health workers and frontline workers.
2. Development and implementation of educational campaigns and mass media messages.
3. Infrastructure and logistics for delivering immunization services in rural areas.
4. Monitoring and evaluation of immunization programs to assess their effectiveness and make necessary adjustments.
5. Research and data collection to inform evidence-based decision making.
6. Collaboration and coordination among stakeholders to ensure efficient and effective implementation of immunization programs.
Please note that the cost items provided are general categories and not actual cost estimates. The actual cost will depend on the specific context and implementation strategies.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study conducted a randomised controlled trial in rural Madhya Pradesh, India, and collected data from a large sample size of women and men with access to mobile phones. The study used ordered logistic regressions and a Heckman two-stage probit model to analyze the factors associated with parental immunization knowledge and the completeness and timeliness of immunization. The findings suggest that exposure to a maternal messaging program on mobile phones was associated with increased knowledge and improved timeliness of immunization. However, the abstract does not provide information on potential limitations of the study or the generalizability of the findings. To improve the strength of the evidence, future research could include a more diverse sample and address potential confounding factors.

Abstract

The study was conducted in rural MP, a state in central India with one of the lowest per capita state domestic products.23 There remains a significant gender gap in women’s literacy and access to mobile phones within and across MP and throughout much of India. Findings from the 2015–2016 National Family Health Survey (NFHS) suggest that across MP, literacy rates were 59% and 82% for women and men, respectively.24 The gender gap in women versus household access to mobile phones is estimated to be 60% in rural areas and 44% in urban areas in 2015.24 MP falls below national averages for most health indicators, including immunisations. Among children 12–23 months of age, 54% were fully immunised (Bacille Calmette-Guerin (BCG), measles and three doses each of polio and DPT) in MP as compared with 62% nationally.24 Study findings draw from data captured as part of the RCT in four districts (Rewa, Hoshangabad, Mandsaur and Rajgarh) of MP, described in detail elsewhere.22 In brief, women 4–7 months pregnant (5095) with access to mobile phones were randomised to either a comparison arm of no calls or an intervention arm where they were eligible to receive Kilkari calls from the 18th week of pregnancy up until the child’s first birthday. The RCT assessed the impact of Kilkari on various reproductive maternal newborn and child health (RMNCH) behaviours including full and timely immunisations among children 0–12 months of age.22 The present analysis used the postpartum survey data from 4423 postpartum women (87%, out of 5095 total enrolled in Kilkari) with a live birth during the index pregnancy and their husbands (3781 men). Data could not be collected from 642 husbands primarily due to migration for work. The interviews were conducted face-to-face in Hindi and included questions on socioeconomic and demographic factors, access to mobile phones and parental knowledge about immunisation. Information on what vaccines the child received from birth to the time of postpartum survey (approximately 12 months after birth) was recorded from the government-issued vaccination card called the Mother and Child Protection (MCP) card. After adjusting for twins and number of children born since the baseline, information was available for 3891 children, for whom interviews of both the parents could be conducted. Out of these 3891 children, the MCP card was available for 3230 children. Posthoc power analysis indicated that the final sample of 3230 children was powered to detect a change of up to 4% in immunisation coverage for children 0–12 months old, with a power of 80% and a type-I error of 0.05. During the postpartum survey, women (mothers) and their husbands (fathers) were asked 11 questions to assess their knowledge about childhood immunisation. Questions covered timing of first vaccination, diseases against which a child needs to be vaccinated within the first year of their birth and benefits of Vitamin-A. A score of 1 was assigned for each correct response and 0 otherwise, with equal weights assigned to each response, resulting in a composite knowledge score for each respondent ranging from 0 to 11. Full immunisation (comprehensive) was if the child received all 19 vaccines listed in online supplemental Annexure-2 (following the guidelines of India’s National Immunisation Guideline25), to which a score of 1 was assigned, else they were assigned 0. Full immunisation (basic) was if the child received all eight basic vaccines: BCG, three doses of DPT, three doses of Polio and measles, to which a score of 1 was assigned, else they were assigned 0 (following the NFHS24). Timely immunisation (comprehensive) was assessed by comparing the expected vaccination date to the actual vaccination date. Each vaccine’s recommended vaccination date was estimated by calculating when the vaccine should have been administered based on the child’s date of birth as listed in their MCP card and according to Government of India vaccine schedule guidelines.25 The actual vaccination date was recorded from the child’s MCP card. For each vaccine, we assigned 1 if it was administered within 28 days of the date the vaccine becomes due and a 0 if not. Each child thus had a total timely immunisation score that varied from 0 to 19. Timely immunisation (basic) was defined as the administration of BCG, three doses of DPT, three doses of polio and the measles vaccine at the 6–10 weeks, 10–14 weeks, 14–18 weeks and 9–10 months, respectively. For each vaccine, a score of 1 was assigned if it was administered within time (as described for the comprehensive package above), else 0, with a total score varied from 0 to 8. Frequencies and proportions were used to understand the characteristics of the sample, exposure to Kilkari immunisation calls, parental knowledge on immunisation and immunisation status among the children. We used ordered logistic regression, separately for mothers and fathers, to assess the factors associated with parental knowledge of immunisation. To assess the correlates of parent’s immunisation knowledge, the following model specification was used: I-KNOW=f(KILKARI, SES, M-INDIV, M-ACCESS, IMMU-INFO, DIST) (1), where I-KNOW is the immunisation knowledge score, on a scale varying from 0 to 11. KILKARI is a binary variable, where 1 indicates if the cumulative time of content listening under the Kilkari programme was ≥50% (at least 441 econd of total 881 second of cumulative content on immunisation were played), 0 otherwise. The information was collected from the call records data. SES is a vector of socioeconomic characteristics of the mother which includes dummies for caste (other backward class (OBC), scheduled caste/scheduled tribe (SC/ST) and others) and wealth quintiles (computed by principal component analysis based on various assets ownership and availability of amenities in household). M-INDIV represents a mother’s total years of completed formal education, number of children she has, dummy variables to represent her employment status (1 if employed), and if she plays any role in taking decision of daily purchases of the household and her pregnancy. A mother’s mobile phone access is proxied by M-ACCESS which comprises dummies representing whether she owns a personal mobile phone, if she has access to the mobile phone for more than 12 hours a day and if the phone is often at zero balance. Sources of immunisation information are represented by the vector IMMU-INFO which includes dummies on whether the mother has asked for immunisation information from any health worker, whether she has received the same from any health worker and if she reported to receive information from (i) television or (ii) print (poster/newspaper/handout). Finally, vector DIST represents district dummies. For the analysis of factors associated with father’s immunisation knowledge, the explanatory variables remain the same as equation (1) (KILKARI, SES, father’s individual characteristics, father’s access to mobile phone and district dummies) except the vector on sources of immunisation information (asked and received information from health worker, received information from television or print media), which was not collected and is not part of the analysis. Out of the total sample of 3891 children, the MCP card was available for 3230 (83% of sample) children. There could be systemic differences between mothers who could produce the MCP card and those who could not. To address this, we applied Heckman two-stage sample selection model to correct for selection bias.26 In the first step, the model estimates the probability of having the MCP card, which can be expressed as: Prob (MCP=1 | Z)=f(Z (KILKARI, SES, M-INDIV, M-ACCESS, IMMU-INFO, ASHA, DIST)) (2), where MCP=1 if the mother could produce the MCP card, 0 otherwise; Z is a vector of explanatory variables representing a mother’s characteristics explained in equation (1) and the caste of ASHA, the frontline worker playing a crucial role in RMNCH related issues, as a proxy to capture the capability of her. In the second stage, after incorporating the predicted probability of having the MCP card as an explanatory variable, the model to predict the practice of immunisation can be represented as: P-IMMU* = β*X + ε (3), where P-IMMU, probability of child to be immunised, is not observed if the mother could not produce the MCP card. The conditional expectation of immunisation practice can be expressed as: E(P-IMMU | X, MCP=1) = β*X+E(ε|X, MCP=1) (4), where X is a vector of characteristics expressed in equation (1), additionally including (i) parental immunisation knowledge scores, (ii) child’s gender (to assess any gender-based bias) and (iii) if the child received most vaccines at the Anganwadi centre, the nutrition and childcare centre at the village and a common place for immunisation. The analysis of determinants of full immunisation and timely immunisation of basic and comprehensive package, vaccination at birth, at 6–10 weeks, 10–14 weeks, 14–18 weeks and 9–10 months were done using Heckman probit model. Ethical clearance for this study was obtained from the Independent Ethics Review Boards of Johns Hopkins School of Public Health Institution in Baltimore, Maryland and Sigma Research in India. Verbal informed consent was obtained from the study participants, for participation in the RCT and in the baseline and postpartum survey.

Materials

N/A

Innovations

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Mobile Messaging Programs: The study mentioned the use of Kilkari, a maternal messaging program, to increase awareness and knowledge about immunization. Similar mobile messaging programs can be developed and implemented to provide information and reminders about maternal health, including prenatal care, nutrition, and postpartum care.

2. Telemedicine: Telemedicine can be utilized to provide remote access to healthcare professionals for prenatal and postpartum consultations. This can be especially beneficial for women in rural areas who may have limited access to healthcare facilities.

3. Mobile Applications: Developing mobile applications that provide information and resources related to maternal health can help women access information at their convenience. These applications can include features such as appointment reminders, nutrition tracking, and educational resources.

4. Community Health Workers: Training and deploying community health workers who can provide education, support, and referrals for maternal health services can help bridge the gap between healthcare facilities and women in rural areas.

5. Mobile Clinics: Mobile clinics equipped with basic maternal health services can travel to remote areas, providing essential care to pregnant women and new mothers who may not have easy access to healthcare facilities.

6. Public-Private Partnerships: Collaborations between government agencies, non-profit organizations, and private companies can help improve access to maternal health services. These partnerships can leverage resources, expertise, and technology to reach underserved populations.

It is important to note that the implementation of these innovations should consider the specific context and needs of the target population to ensure effectiveness and sustainability.

AI Innovations Description

The study conducted in rural Madhya Pradesh, India aimed to assess the impact of a maternal messaging program called Kilkari on parental immunization knowledge and immunization practice for children aged 0-12 months. The study found that there were gaps in complete and timely immunization for infants in rural India. Less than half of the children had received the basic package of 8 vaccines, and the comprehensive package of 19 vaccines. The most significant determinant of men’s knowledge and the child’s immunization status was wealth.

Exposure to Kilkari content on immunization was associated with an increase in men’s knowledge about child immunization and an increase in the timeliness of the child receiving vaccination at birth. The study suggests that mobile messaging programs, supported by mass media messages, may be an important source for improving awareness, uptake, and timeliness of immunization services.

The study was conducted in rural Madhya Pradesh, a state in central India with low literacy rates and limited access to mobile phones, particularly for women. The state falls below national averages for most health indicators, including immunizations. The study used data from a randomized controlled trial in four districts of Madhya Pradesh, involving women with access to mobile phones who were eligible to receive Kilkari calls from the 18th week of pregnancy until the child’s first birthday.

The study collected data through face-to-face interviews in Hindi, assessing parental knowledge about immunization and recording information on the vaccines the child received from birth to approximately 12 months. The study used ordered logistic regression to analyze factors associated with parental immunization knowledge and a Heckman two-stage probit model to analyze completeness and timeliness of immunization, correcting for selection bias.

In conclusion, the study highlights the potential of mobile messaging programs like Kilkari to improve access to maternal health by increasing immunization knowledge and timeliness. The findings suggest that such programs, supported by mass media messages, can play a crucial role in bolstering awareness, uptake, and timeliness of immunization services in rural areas.

AI Innovations Methodology

The study mentioned in the description explores the impact of Kilkari, a maternal messaging program, on parental immunization knowledge and immunization practice in rural Madhya Pradesh, India. The goal is to improve access to maternal health by increasing immunization knowledge, completeness, and timeliness.

To simulate the impact of recommendations on improving access to maternal health, a methodology was used in the study. Here is a brief description of the methodology:

1. Study Design: The study utilized a randomized controlled trial (RCT) design. Women with access to mobile phones were randomly assigned to either a comparison arm (no calls) or an intervention arm (eligible to receive Kilkari calls).

2. Data Collection: Data were collected through a cross-sectional survey of women and their spouses. The survey included questions on socioeconomic and demographic factors, access to mobile phones, and parental knowledge about immunization. Information on the vaccines received by the child was recorded from the government-issued vaccination card.

3. Analysis: The data were analyzed using various statistical techniques. Ordered logistic regressions were used to analyze the factors associated with parental immunization knowledge. A Heckman two-stage probit model was used to analyze the completeness and timeliness of immunization, correcting for selection bias.

4. Variables: Several variables were considered in the analysis, including exposure to Kilkari content, socioeconomic characteristics, individual characteristics, access to mobile phones, sources of immunization information, and district dummies.

5. Outcomes: The outcomes of interest included parental immunization knowledge scores, full immunization (comprehensive and basic packages), and timely immunization at different stages.

6. Power Analysis: A posthoc power analysis was conducted to determine the sample size needed to detect changes in immunization coverage. The final sample included 3,230 children.

7. Ethical Considerations: Ethical clearance was obtained from relevant ethics review boards, and verbal informed consent was obtained from study participants.

By using this methodology, the study was able to assess the impact of Kilkari on immunization knowledge, completeness, and timeliness. The findings suggest that mobile messaging programs, supported by mass media messages, can be an important source for improving awareness, uptake, and timeliness of immunization services in rural India.

Please note that this is a summary of the methodology used in the study. For more detailed information, it is recommended to refer to the original research article.

Author

Dima Health

Statistics:

Citations: 2

Identifiers:

DOI: 10.1136/bmjgh-2021-005489

Research Areas:

Community Interventions, Food Security, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Design:

Cross Sectional Study, randomised-control-trial

Study Approach:

Quantitative

Participants Gender:

Male & Female