State of newborn care in South Sudan’s displacement camps: A descriptive study of facility-based deliveries

Reproductive Health, Volume 14, No. 1, Year 2017

Ukuhunyushwa

Background: Approximately 2.7 million neonatal deaths occur annually, with highest rates of neonatal mortality in countries that have recently experienced conflict. Constant instability in South Sudan further strains a weakened health system and poses public health challenges during the neonatal period. We aimed to describe the state of newborn facility-level care in displaced person camps across Juba, Malakal, and Maban. Methods: We conducted clinical observations of the labor and delivery period, exit interviews with recently delivered mothers, health facility assessments, and direct observations of midwife time-use. Study participants were mother-newborn pairs who sought services and birth attendants who provided delivery services between April and June 2016 in five health facilities. Results: Facilities were found to be lacking the recommended medical supplies for essential newborn care. Two of the five facilities had skilled midwives working during all operating hours, with 6.2% of their time spent on postnatal care. Selected components of thermal care (62.5%), infection prevention (74.8%), and feeding support (63.6%) were commonly practiced, but postnatal monitoring (27.7%) was less consistently observed. Differences were found when comparing the primary care level to the hospital (thermal: relative risk [RR] 0.48 [95% CI] 0.40-0.58; infection: RR 1.28 [1.11-1.47]; feeding: RR 0.49 [0.40-0.58]; postnatal: RR 3.17 [2.01-5.00]). In the primary care level, relative to newborns delivered by traditional birth attendants, those delivered by skilled attendants were more likely to receive postnatal monitoring (RR 1.59 [1.09-2.32]), but other practices were not statistically different. Mothers’ knowledge of danger signs was poor, with fever as the highest reported (44.8%) followed by not feeding well (41.0%), difficulty breathing (28.9%), reduced activity (27.7%), feeling cold (18.0%) and convulsions (11.2%). Conclusions: Addressing health service delivery in contexts affected by conflict is vital to reducing the global newborn mortality rate and reaching the Sustainable Development Goals. Gaps in intrapartum and postnatal care, particularly skilled care at birth, suggest a critical need to build the capacity of the existing health workforce while increasing access to skilled deliveries. A cross-sectional descriptive design was employed using health facility assessments, direct observation of midwife time-use, clinical observation of the labor and delivery period, and exit interviews with recently delivered mothers. The study population consisted of mother-newborn pairs who sought services and birth attendants who provided delivery services between April and June 2016 in five health facilities operated by International Medical Corps (IMC) in displacement camps located in South Sudan: Maban (Gendrassa and Kaya), Juba, and Malakal. Maban hosts refugee camps, whereas Juba and Malakal have internally displaced person (IDP) camps. One hospital and four PHCCs that conduct the majority of deliveries in the camps agreed to participate in the study. The hospital, located in Juba, operated 24/7 with skilled attendants, an in-patient department and comprehensive emergency obstetric care, while the PHCCs have midwives and traditional birth attendants (TBA) conducting deliveries. Health facilities in the camps were selected based on: (1) provision of delivery care, (2) delivery of at least 20 births per month, and (3) management by IMC. The sample size for these current analyses of baseline data was based on power calculations conducted to ensure that the planned pre-post evaluation would be sufficiently powered to detect changes as a result of the intervention components. Male and female midwives, aged 18 and older, who were working a daytime shift on the date of data collection at one of the study facilities were eligible for time-use observation. A midwife was observed every ten minutes over an eight-hour shift for a four-day period at each facility to reach the necessary sample size. We estimated that midwives spend about 40 min of an eight-hour working day on postnatal care. To detect a 5% difference post-intervention in the proportion of time spent on postnatal care (e.g. 8% to 13%) with an alpha of 0.05, 0.8 power and 5% non-response rate, we required a total sample size of 620 observations at baseline and end line. Women, aged 15 and older, arriving at a study facility for delivery during the 9-week enrollment period were eligible for recruitment for observation of the labour and delivery period and an exit interview. Similarly, the sample size calculated to see a change in baseline was 185 deliveries based on a two-sample comparison of the primary outcome—proportion of newborns that receive the components of essential newborn care (Table 1). This assumed a 50% baseline prevalence of the primary outcome, a conservative estimate due to a lack of data from similar settings, and a 15% detectable difference with an alpha of 0.05 and power of 0.8. The sample size accounted for a non-response rate of 8% based on a 3% stillbirth rate and 5% referral for complications. The sample was doubled to allow for analyses stratified by facility type: hospital and PHCC. Women delivering a stillbirth were subsequently excluded from analysis of observation data. Recently delivered mothers who participated in a clinical observation and did not have a stillbirth or neonatal death were asked to participate in an exit interview. Components of essential newborn care measured in the clinical observations Locally-based non-clinicians were hired as research assistants and trained jointly to standardize data collection procedures across the health facilities. The three research teams consisted of three to five research assistants and one site supervisor. A ten-day training was conducted by study co-investigators to orient the teams to newborn clinical practices, research ethics and procedures, and the study instruments. Researchers practiced the interview aloud in both Arabic and Nuer languages to ensure the translation was standard between researchers. To improve reliability, a two-day pilot session was held to standardize observations between researchers, with one day in the classroom observing videos as a group and one day in a facility observing live births with researchers from the same site. Site supervisors received additional training to conduct the health facility assessment. Data collection occurred at the five study facilities, starting with a health facility assessment. In April 2016, study health facilities were assessed for readiness to provide intrapartum and postnatal services using a structured questionnaire and checklist on the mobile device. The site supervisor interviewed the midwife in-charge about the availability of skilled birth attendants, running water, and electricity over the past month. Medical equipment, supplies and drugs for intrapartum and postnatal care were observed for availability in the delivery and postnatal care wards, and in relevant cases for functionality or expiration. The checklist for medical commodities was based on the recommended newborn supplies outlined in the Newborn Health in Humanitarian Settings Field Guide. Following the assessment, we conducted the time-use observations. At each facility, for a four-day period, one midwife was randomly selected each day for time-use observation. Every ten minutes over an eight-hour period, the researcher recorded the main activity in which the midwife was engaged using a structured checklist; activities were categorized into eighteen general tasks for midwives such as postnatal care, intrapartum care, antenatal care (ANC), documentation, supervision, cleaning, and other tasks. Patient census data in the maternity unit was noted on every observation day. Informed consent was attained from each midwife. For clinical observations, one researcher was assigned per shift to ensure continuous coverage during facility operating hours. Data collectors rotated every eight to twelve-hour shift, depending on the security guidance in each site. Each mother-newborn pair was observed for at least one and no more than 6 h before starting a new observation. The observation was documented using a structured checklist, based on the Maternal and Child Health Integrated Program (MCHIP) Quality of Care Surveys [15]. We observed the following clinical practices: (i) partograph use, (ii) preparation for delivery, (iii) immediate postnatal care, (iv) bag and mask resuscitation for non-breathing babies, and (v) kangaroo mother care (KMC) for low birth weight babies. Additional information on the outcome of the mother and newborn, gravidity, parity and birth weight was extracted from clinical records. Following observation and before the mother was discharged, researchers administered an exit interview using a structured questionnaire (in either Arabic or Nuer, according to the mother’s preference). Information was gathered on the mother’s demographic characteristics and her knowledge of six newborn danger signs without prompting response options. Verbal consent was obtained for both clinical observations and exit interviews from all participating mothers. Data were entered on Android tablets using Magpi mobile data software (DataDyne Group LLC, Version 3.2.2). Data were monitored daily for quality checks and uploaded to an online server by site supervisors, reviewed for consistency, and exported to Stata (StataCorp LP, Version 13.1) for analysis. Descriptive analyses were performed to explore frequencies, means and interval estimation. Missing and “don’t know” responses were analyzed as missing and excluded from analysis. The activities measured in the time-use observations were classified into three categories: contact time for newborn care (by antenatal, delivery and postnatal care), non-contact productive time (i.e. documentation, meetings, training, supervision and cleaning) and non-productive time (i.e. waiting for patients, break time and socializing). Proportion of the total amount of observed time spent on each activity was estimated and a regression analysis was conducted to estimate associations with facility type. In the clinical observations, we conducted descriptive analyses of up to 65 practices for partograph use, delivery preparation, immediate postnatal care, neonatal resuscitation, and KMC. The primary outcome was defined by the proportion of newborns who received the essential components of immediate postnatal care: (i) thermal care, (ii) infection prevention, (iii) feeding support, and (iv) postnatal monitoring; individual sub-items contributing to these composite components are shown in Table 1. Partograph use was not analyzed among women who were admitted immediately to the labor room because they were assumed to be in the second stage of labour. For the exit interviews, the pre-defined response options for knowledge of newborn danger signs were entered as a binary (yes/no) variable. One point was assigned for each answer that was coded as ‘yes’, giving a maximum score of six. The overall knowledge score was categorized as ‘poor’ (zero to one danger signs), ‘moderate’ (two to three), and ‘adequate’ (four to six). Mother’s age, parity and years living in the camp were measured as a continuous variable and categorized as a binary variable for analysis. A chi-squared statistic was used to examine differences in newborn care practices by type of health worker and facility. Multiple logistic regression, in a stepwise backward manner with a 0.05 cutoff, was used to identify factors associated with newborn practices and maternal knowledge including maternal, newborn and health worker characteristics. In each step, variables that are least significant are removed until all variables in the regression model have a p-value of less than or equal to 0.05. Associations were examined by relative risks (RR), using a modified Poisson approach with a robust variance estimator, and 95% confidence intervals [16].

I-AI Digest

Study Justification:

– Approximately 2.7 million neonatal deaths occur annually, with the highest rates in countries that have experienced conflict.
– South Sudan’s constant instability strains the health system and poses challenges for newborn care.
– Describing the state of newborn facility-level care in displacement camps can help address public health challenges and reduce neonatal mortality.

Study Highlights:

– Facilities in the displacement camps lack recommended medical supplies for essential newborn care.
– Only two out of five facilities have skilled midwives working during all operating hours, with limited time spent on postnatal care.
– Some components of thermal care, infection prevention, and feeding support are commonly practiced, but postnatal monitoring is less consistently observed.
– Differences exist between primary care level and hospital in terms of newborn care practices.
– Mothers’ knowledge of danger signs is poor, with fever being the most commonly reported sign.

Study Recommendations:

– Build the capacity of the existing health workforce to provide skilled care at birth.
– Increase access to skilled deliveries in displacement camps.
– Improve availability of medical supplies for essential newborn care.
– Strengthen postnatal monitoring practices.
– Enhance maternal knowledge of newborn danger signs.

Key Role Players:

– Health facility staff (midwives, doctors, nurses)
– International Medical Corps (IMC)
– Research assistants
– Site supervisors

Cost Items for Planning Recommendations:

– Training programs for health facility staff to build their capacity
– Procurement of medical supplies for essential newborn care
– Hiring and training of research assistants and site supervisors
– Data collection and analysis tools (Android tablets, data software)
– Monitoring and quality control measures

Amandla Obufakazi

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a descriptive study using multiple methods, including clinical observations, exit interviews, and health facility assessments. The study population consisted of mother-newborn pairs and birth attendants in five health facilities in South Sudan’s displacement camps. The study provides valuable insights into the state of newborn facility-level care in these camps. However, the evidence could be strengthened by including a larger sample size and conducting a more comprehensive analysis of the data. Additionally, the study could benefit from a comparison group to better understand the impact of the interventions. To improve the evidence, future studies could consider increasing the sample size, conducting a randomized controlled trial, and including a control group for comparison.

Abstract

A cross-sectional descriptive design was employed using health facility assessments, direct observation of midwife time-use, clinical observation of the labor and delivery period, and exit interviews with recently delivered mothers. The study population consisted of mother-newborn pairs who sought services and birth attendants who provided delivery services between April and June 2016 in five health facilities operated by International Medical Corps (IMC) in displacement camps located in South Sudan: Maban (Gendrassa and Kaya), Juba, and Malakal. Maban hosts refugee camps, whereas Juba and Malakal have internally displaced person (IDP) camps. One hospital and four PHCCs that conduct the majority of deliveries in the camps agreed to participate in the study. The hospital, located in Juba, operated 24/7 with skilled attendants, an in-patient department and comprehensive emergency obstetric care, while the PHCCs have midwives and traditional birth attendants (TBA) conducting deliveries. Health facilities in the camps were selected based on: (1) provision of delivery care, (2) delivery of at least 20 births per month, and (3) management by IMC. The sample size for these current analyses of baseline data was based on power calculations conducted to ensure that the planned pre-post evaluation would be sufficiently powered to detect changes as a result of the intervention components. Male and female midwives, aged 18 and older, who were working a daytime shift on the date of data collection at one of the study facilities were eligible for time-use observation. A midwife was observed every ten minutes over an eight-hour shift for a four-day period at each facility to reach the necessary sample size. We estimated that midwives spend about 40 min of an eight-hour working day on postnatal care. To detect a 5% difference post-intervention in the proportion of time spent on postnatal care (e.g. 8% to 13%) with an alpha of 0.05, 0.8 power and 5% non-response rate, we required a total sample size of 620 observations at baseline and end line. Women, aged 15 and older, arriving at a study facility for delivery during the 9-week enrollment period were eligible for recruitment for observation of the labour and delivery period and an exit interview. Similarly, the sample size calculated to see a change in baseline was 185 deliveries based on a two-sample comparison of the primary outcome—proportion of newborns that receive the components of essential newborn care (Table 1). This assumed a 50% baseline prevalence of the primary outcome, a conservative estimate due to a lack of data from similar settings, and a 15% detectable difference with an alpha of 0.05 and power of 0.8. The sample size accounted for a non-response rate of 8% based on a 3% stillbirth rate and 5% referral for complications. The sample was doubled to allow for analyses stratified by facility type: hospital and PHCC. Women delivering a stillbirth were subsequently excluded from analysis of observation data. Recently delivered mothers who participated in a clinical observation and did not have a stillbirth or neonatal death were asked to participate in an exit interview. Components of essential newborn care measured in the clinical observations Locally-based non-clinicians were hired as research assistants and trained jointly to standardize data collection procedures across the health facilities. The three research teams consisted of three to five research assistants and one site supervisor. A ten-day training was conducted by study co-investigators to orient the teams to newborn clinical practices, research ethics and procedures, and the study instruments. Researchers practiced the interview aloud in both Arabic and Nuer languages to ensure the translation was standard between researchers. To improve reliability, a two-day pilot session was held to standardize observations between researchers, with one day in the classroom observing videos as a group and one day in a facility observing live births with researchers from the same site. Site supervisors received additional training to conduct the health facility assessment. Data collection occurred at the five study facilities, starting with a health facility assessment. In April 2016, study health facilities were assessed for readiness to provide intrapartum and postnatal services using a structured questionnaire and checklist on the mobile device. The site supervisor interviewed the midwife in-charge about the availability of skilled birth attendants, running water, and electricity over the past month. Medical equipment, supplies and drugs for intrapartum and postnatal care were observed for availability in the delivery and postnatal care wards, and in relevant cases for functionality or expiration. The checklist for medical commodities was based on the recommended newborn supplies outlined in the Newborn Health in Humanitarian Settings Field Guide. Following the assessment, we conducted the time-use observations. At each facility, for a four-day period, one midwife was randomly selected each day for time-use observation. Every ten minutes over an eight-hour period, the researcher recorded the main activity in which the midwife was engaged using a structured checklist; activities were categorized into eighteen general tasks for midwives such as postnatal care, intrapartum care, antenatal care (ANC), documentation, supervision, cleaning, and other tasks. Patient census data in the maternity unit was noted on every observation day. Informed consent was attained from each midwife. For clinical observations, one researcher was assigned per shift to ensure continuous coverage during facility operating hours. Data collectors rotated every eight to twelve-hour shift, depending on the security guidance in each site. Each mother-newborn pair was observed for at least one and no more than 6 h before starting a new observation. The observation was documented using a structured checklist, based on the Maternal and Child Health Integrated Program (MCHIP) Quality of Care Surveys [15]. We observed the following clinical practices: (i) partograph use, (ii) preparation for delivery, (iii) immediate postnatal care, (iv) bag and mask resuscitation for non-breathing babies, and (v) kangaroo mother care (KMC) for low birth weight babies. Additional information on the outcome of the mother and newborn, gravidity, parity and birth weight was extracted from clinical records. Following observation and before the mother was discharged, researchers administered an exit interview using a structured questionnaire (in either Arabic or Nuer, according to the mother’s preference). Information was gathered on the mother’s demographic characteristics and her knowledge of six newborn danger signs without prompting response options. Verbal consent was obtained for both clinical observations and exit interviews from all participating mothers. Data were entered on Android tablets using Magpi mobile data software (DataDyne Group LLC, Version 3.2.2). Data were monitored daily for quality checks and uploaded to an online server by site supervisors, reviewed for consistency, and exported to Stata (StataCorp LP, Version 13.1) for analysis. Descriptive analyses were performed to explore frequencies, means and interval estimation. Missing and “don’t know” responses were analyzed as missing and excluded from analysis. The activities measured in the time-use observations were classified into three categories: contact time for newborn care (by antenatal, delivery and postnatal care), non-contact productive time (i.e. documentation, meetings, training, supervision and cleaning) and non-productive time (i.e. waiting for patients, break time and socializing). Proportion of the total amount of observed time spent on each activity was estimated and a regression analysis was conducted to estimate associations with facility type. In the clinical observations, we conducted descriptive analyses of up to 65 practices for partograph use, delivery preparation, immediate postnatal care, neonatal resuscitation, and KMC. The primary outcome was defined by the proportion of newborns who received the essential components of immediate postnatal care: (i) thermal care, (ii) infection prevention, (iii) feeding support, and (iv) postnatal monitoring; individual sub-items contributing to these composite components are shown in Table 1. Partograph use was not analyzed among women who were admitted immediately to the labor room because they were assumed to be in the second stage of labour. For the exit interviews, the pre-defined response options for knowledge of newborn danger signs were entered as a binary (yes/no) variable. One point was assigned for each answer that was coded as ‘yes’, giving a maximum score of six. The overall knowledge score was categorized as ‘poor’ (zero to one danger signs), ‘moderate’ (two to three), and ‘adequate’ (four to six). Mother’s age, parity and years living in the camp were measured as a continuous variable and categorized as a binary variable for analysis. A chi-squared statistic was used to examine differences in newborn care practices by type of health worker and facility. Multiple logistic regression, in a stepwise backward manner with a 0.05 cutoff, was used to identify factors associated with newborn practices and maternal knowledge including maternal, newborn and health worker characteristics. In each step, variables that are least significant are removed until all variables in the regression model have a p-value of less than or equal to 0.05. Associations were examined by relative risks (RR), using a modified Poisson approach with a robust variance estimator, and 95% confidence intervals [16].

Izinto zokwakha

N/A

Emisha

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

1. Strengthening the health workforce: There is a critical need to build the capacity of the existing health workforce, particularly in terms of skilled care at birth. This could involve training and equipping midwives and birth attendants with the necessary skills and resources to provide quality maternal and newborn care.

2. Improving availability of medical supplies: Facilities were found to be lacking the recommended medical supplies for essential newborn care. Ensuring a consistent and adequate supply of medical equipment, supplies, and drugs for intrapartum and postnatal care is essential to improve access to maternal health services.

3. Enhancing postnatal care: Postnatal monitoring was found to be less consistently observed. Increasing the focus on postnatal care, including regular check-ups and monitoring of both mothers and newborns, can help identify and address any potential complications or health issues.

4. Increasing knowledge of danger signs: Mothers’ knowledge of danger signs was poor, with fever being the highest reported. Providing education and awareness programs for mothers on the importance of recognizing and seeking care for danger signs during pregnancy, childbirth, and the postnatal period can help improve maternal and newborn health outcomes.

5. Strengthening referral systems: Given the limited resources and capacity in the displacement camps, establishing effective referral systems between primary care facilities and hospitals can ensure that women and newborns receive timely and appropriate care when complications arise.

6. Leveraging technology for telemedicine: In areas with limited access to skilled birth attendants, utilizing telemedicine and mobile health technologies can help connect healthcare providers with pregnant women, allowing for remote consultations, monitoring, and guidance during pregnancy, childbirth, and the postnatal period.

These innovations, if implemented effectively, can contribute to improving access to maternal health services and reducing maternal and neonatal mortality rates in the displacement camps.

AI Innovations Description

Based on the description provided, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Strengthening Health Service Delivery: There is a critical need to build the capacity of the existing health workforce while increasing access to skilled deliveries. This can be achieved by providing comprehensive training programs for midwives and birth attendants, focusing on essential newborn care, infection prevention, and postnatal monitoring. Additionally, efforts should be made to ensure that health facilities have the necessary medical supplies and equipment for safe deliveries.

2. Improving Knowledge and Awareness: Mothers’ knowledge of danger signs during the postnatal period was found to be poor. To address this, innovative approaches can be developed to improve maternal knowledge and awareness of newborn danger signs. This can include the use of mobile health (mHealth) applications, community-based education programs, and targeted messaging campaigns to reach mothers in displacement camps.

3. Enhancing Collaboration and Coordination: Given the constant instability in South Sudan, it is important to strengthen collaboration and coordination between different stakeholders involved in maternal health. This can be achieved through the establishment of multi-sectoral partnerships, involving government agencies, non-governmental organizations, and international organizations. These partnerships can work together to address the challenges faced in providing maternal health services in displacement camps.

4. Leveraging Technology: Technology can play a crucial role in improving access to maternal health services. Innovations such as telemedicine and mobile clinics can be utilized to reach remote areas and provide essential maternal health services. Additionally, the use of electronic health records and data analytics can help in monitoring and evaluating the quality of care provided, identifying gaps, and making informed decisions for improvement.

5. Empowering Women and Communities: Empowering women and communities is essential for improving access to maternal health. This can be done through community engagement programs that involve women in decision-making processes, promote women’s rights, and provide education on maternal health. Additionally, efforts should be made to address cultural and social barriers that may hinder access to maternal health services.

By implementing these recommendations and developing innovative solutions, access to maternal health can be improved in displacement camps, leading to a reduction in neonatal mortality rates and progress towards achieving the Sustainable Development Goals.

AI Innovations Methodology

Based on the provided description, here are some potential recommendations to improve access to maternal health:

1. Strengthen the health workforce: Increase the number of skilled birth attendants and midwives in health facilities to ensure that there is adequate coverage and availability of skilled care during labor and delivery.

2. Improve availability of medical supplies: Ensure that health facilities have the necessary medical supplies for essential newborn care, including thermal care, infection prevention, feeding support, and postnatal monitoring.

3. Enhance postnatal care: Increase the focus on postnatal care, including monitoring the health of both the mother and newborn after delivery. This can help identify and address any complications or health issues early on.

4. Increase awareness and education: Implement programs to improve knowledge and awareness among mothers about newborn danger signs and the importance of seeking timely medical care. This can help mothers recognize when their newborns require medical attention.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define indicators: Identify specific indicators that can measure the impact of the recommendations, such as the proportion of births attended by skilled birth attendants, availability of essential medical supplies, percentage of mothers receiving postnatal care, and knowledge of newborn danger signs among mothers.

2. Data collection: Collect baseline data on the identified indicators before implementing the recommendations. This can be done through surveys, interviews, and observations in health facilities and among mothers.

3. Implement recommendations: Introduce the recommended interventions, such as increasing the number of skilled birth attendants, improving the availability of medical supplies, and conducting awareness campaigns.

4. Monitor and evaluate: Continuously monitor the implementation of the recommendations and collect data on the indicators identified in step 1. This can be done through regular assessments, surveys, and observations.

5. Analyze data: Analyze the collected data to assess the impact of the recommendations on the identified indicators. Compare the baseline data with the data collected after the implementation of the interventions to determine any changes and improvements.

6. Interpret results: Interpret the results of the analysis to understand the effectiveness of the recommendations in improving access to maternal health. Identify any gaps or areas that require further attention.

7. Adjust interventions: Based on the findings, make any necessary adjustments to the interventions to further improve access to maternal health. This could involve scaling up successful interventions or addressing any challenges or barriers identified during the evaluation.

By following this methodology, it would be possible to simulate the impact of the recommendations on improving access to maternal health and make informed decisions on how to best allocate resources and implement interventions.

Umbhali

Dima Health

Statistics:

Citations: 16

Identifiers:

DOI: 10.1186/s12978-017-0417-z

Research Areas:

Community Interventions, Environmental, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants, Workforce

Study Countries:

Multi-Countries, South Sudan, Sudan

Study Design:

Cross Sectional Study, Grounded Theory, randomised-control-trial

Study Approach:

Quantitative

Participants Gender:

Male & Female

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