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Open access Protocol BMJ Open: first published as 10.1136/bmjopen-2020-045163 on 2 March 2021. Downloaded from Digital health literacy intervention to support maternal, child and family health in primary healthcare settings of Pakistan during the age of coronavirus: study protocol for a randomised controlled trial Sara Rizvi Jafree,1 Nadia Bukhari,2 Anam Muzamill,3 Faiza Tasneem,4 Florian Fischer 5,6 To cite: Jafree SR, Bukhari N, ABSTRACT Strengths and limitations of this study Muzamill A, et al. Digital health Introduction There is a need to continue primary literacy intervention to support healthcare services through digital communication for ► This is the first randomised controlled trial in maternal, child and family disadvantaged women living in underdeveloped areas health in primary healthcare Pakistan investigating the effects of a digital health of Pakistan, especially in the age of the coronavirus settings of Pakistan during literacy intervention for hygiene and sanitation, and pandemic, social distancing and lockdown of communities. the age of coronavirus: study coronavirus awareness and prevention, tailored to This project will be the first of its kind in aiming to protocol for a randomised the needs of disadvantaged women of reproductive implement a digital health literacy intervention, using controlled trial. BMJ Open years. 2021;11:e045163. doi:10.1136/ smartphone and internet, to disadvantaged women ► We aim to use a two-step approach to pretesting bmjopen-2020-045163 through female community healthcare workers. Improved and then establishing an intervention; the findings health literacy in women of reproductive years is known to ► Prepublication history and will be relevant for digital health literacy interven- promote maternal, child and family health overall. additional material for this paper tions in general, but particularly in times of the coro- is available online. To view these Methods and analysis The study will include a baseline navirus pandemic, where social distancing hinders http://bmjopen.bmj.com/ survey, a pre- and post- test survey and a 3- month files, please visit the journal the provision of health services to women depen- lasting intervention on (1) hygiene and prevention and online (http:// dx. doi. org/ 10. dent on primary health services in their community. 1136/ bmjopen- 2020- 045163). (2) coronavirus awareness and prevention. Women of ► The study will be an important contribution to the reproductive years will be sampled from disadvantaged knowledge about efficacy of digital health literacy Received 25 September 2020 areas across the four provinces of Pakistan (Baluchistan, interventions to support sustainable development Revised 15 February 2021 Khyber Pakhtunkhwa, Punjab and Sindh), and the selection Accepted 23 February 2021 goals for maternal and child health. criteria will be poor, semiliterate or illiterate, belonging ► We anticipate cultural barriers in gaining permission to underdeveloped neighbourhoods devoid of universal for women’s participation in the study and the en- healthcare coverage and dependent on free primary gagement with smartphones and internet, especially on September 28, 2021 by guest. Protected copyright. health services. A target of 1000 women will comprise in more conservative and inaccessible regions. the sample, with 500 women each assigned randomly to ► There are limitations to generalisability due to poten- the intervention and control groups. Analysis of variance tial bias from including women who gave consent to and multivariate analysis will be used for analysing the participate in the study and also because outcomes intervention’s effects compared with the control group. will be measured based on subjective perceptions Ethics and dissemination Ethics approval for this study of respondents. has been received from the Internal Review Board of the Forman Christian College University (reference number: IRB-252/06-2020). Results will be published in academic © Author(s) (or their journals of repute and dissemination to the international has estimated that 1 in 10 South Asians face employer(s)) 2021. Re- use health challenges, multimorbidity and risk permitted under CC BY-NC. No scientific community and stakeholders will also be planned commercial re- use. See rights through workshops. of infectious disease; with each additional 1 2 and permissions. Published by Trial registration number NCT04603092. morbidity carrying greater risk of mortality. BMJ. Pakistan’s healthcare sector is known to be For numbered affiliations see under- resourced and inefficient, with health end of article. INTRODUCTION budget allocation standing at less than 1.5% 3 Correspondence to South Asia is home to 25% of the world of gross domestic product. Primary health- Dr Florian Fischer; population, the majority of who are poor and care services in Pakistan are not adequate or florian. fischer1@ charite. de without universal health coverage. Research well planned, contributing to the infectious Jafree SR, et al. BMJ Open 2021;11:e045163. doi:10.1136/bmjopen-2020-045163 1 Open access BMJ Open: first published as 10.1136/bmjopen-2020-045163 on 2 March 2021. Downloaded from disease burden in the country and unfavourable indi- Aim of the study cators for maternal and child health.4 There is critical The study’s aim is to develop and implement a digital need for more integrated and innovative planning for health literacy intervention to disadvantaged women in primary health services, where identification of diseases, the areas of (1) hygiene and sanitation and (2) corona- treatment referrals and prevention is possible. According virus awareness and prevention. The study includes a base- to its number of inhabitants, Pakistan is the sixth largest line survey and a pre- and post- test survey. The 3- month country worldwide,5 with more than a 100 million women lasting digital health literacy intervention, using a smart- living there. Local research has confirmed that women phone and internet, will include four components of (A) in the country are suffering from a quadruple disease video tutorials, (B) one- on- one training for improving burden of (1) communicable/infectious diseases, (2) awareness and practices, (C) group training, and (D) non- communicable diseases, (3) accidents, injuries and one- on- one training for a self- management chart. The violence, and (4) multimorbidity.6 7 Additionally, women data will be collected by community healthcare workers from lower and middle-income countries (LMIC) may and the participants of this study will be disadvantaged suffer from health challenges and infection risk more women, defined as poor, semiliterate or illiterate and than men.1 It has also been estimated that women from belonging to underdeveloped neighbourhoods devoid unfavourable sociodemographic backgrounds and living of universal healthcare coverage and dependent on free in deprived areas experience health challenges and primary health services. multimorbidity 15 years earlier than people from more affluent backgrounds.8 An additional and important consideration is that METHODS women from Pakistan suffer from regressive cultural Study design norms and community neglect. This is why most women A randomised controlled trial (RCT) will be conducted 9 in Pakistan are unemployed, illiterate or semiliterate, providing a digital health literacy intervention for (1) 6 crippled by poverty and thus increasingly vulnerable to hygiene and sanitation and (2) coronavirus awareness multiple health burdens. Several sociocultural burdens and prevention. A summary of the proposed steps and adversely influence the health of women of reproductive the timeline is provided in table 1. We expect to conclude years in Pakistan, including low health literacy, under- the study within 5 months, with a cushion of 15 days. The nutrition, early marriage, lack of birth spacing and a study follows three consecutive steps. At the first step, culture that prevents health-seeking behaviour. Though baseline data will be collected about the health challenges it is assumed that health challenges affect people at faced by women living in disadvantaged communities. more advanced years, pregnant women in LMICs are At the second step, a pretest survey will be administered at an increased risk of health burdens and infectious to both the control and intervention groups assessing http://bmjopen.bmj.com/ 1 2 10 diseases. Pregnant women are not merely at risk of their health literacy. A health literacy booklet will be mortality themselves, but there is concern that their child provided to both the control and intervention groups 11 is also at heightened risk. after the pretest. In addition, the intervention group will The greatest concern for LMICs and Pakistan is that receive an intervention using digital means, smartphone women of reproductive years who are illiterate and semi- and internet, through a 3-month period for promoting literate are not able to manage health, or adopt protec- health literacy related to: (1) hygiene and sanitation and tive behaviour, due to lack of awareness and education, (2) coronavirus awareness and prevention. At third and and difficulty in understanding instructions by physicians final step, both the control and intervention groups will on September 28, 2021 by guest. Protected copyright. or public health experts. Research suggests that health be delivered a post- test to assess the differences between services provided to women of reproductive years in intervention and non- intervention
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