Gambian Mothers Lack Obstetric Danger Sign Knowledge, But Educational Intervention Shows Promise.

Background: The Gambia has the 12th highest maternal mortality rate in the world, with 80% of deaths resulting from avoidable causes. Unawareness of pregnancy danger signs (DS) has been shown to be a barrier to seeking obstetric care, while app-based education intervention has shown promise. Objective: We aim to assess patient awareness of DS, identify barriers to awareness, and evaluate potential for implementing smartphone-based technologies for education. Methods: A cross-sectional semi-structured survey was administered to Gambian women (n = 100) across five hospitals/health centers. Data and informed consent were collected via an online survey portal. Analysis included bivariate analysis and descriptive statistics with p < 0.05 significance level. Recall of 0-2 DS per category was classified as "low" knowledge, 3-5 as "moderate" knowledge, and 6+ as "sufficient" knowledge. Cross-category recall was quantified for overall awareness level (0-6 = "low", 7-12 = "moderate", 13+ = "sufficient". N = 28 total DS). Findings: Although 75% of participants (n = 100) self-perceived "sufficient" knowledge of DS, the average recall was only two (SD = 2, n = 11) pregnancy DS, one labor and delivery DS (SD = 1, n = 8), and one postpartum DS (SD = 1, n = 9). Twenty-one women were unable to recall any danger signs. "Low" awareness was identified in 77% of women, while 23%, and 0% of women showed "moderate" and "sufficient" overall awareness, respectively. Education level was significantly correlated with overall danger sign recall (ρ(98) = .243, p = .015) and awareness level (ρ(98) = .265, p = .008). Monthly income was significantly correlated with awareness level (ρ(97) = .311, p = .002). Smartphone ownership was reported by 76% of women, and 97% expressed interest in using app-based video (94%) or provider (93%) teaching. Conclusions: Women had low knowledge of obstetric danger signs, and true awareness of danger signs was remarkably lower than self-perceived knowledge. However, patients exhibited proper healthcare-seeking behavior when danger signs arose. Findings suggest that video- or messaging-based education from local healthcare providers may be effective DS educational interventions.

Considering Risks to Researchers and Staff in Low-Resource Settings during Public Health Crises: A Proposed Conceptual Model.

Human subjects research protections have historically focused on mitigating risk of harm and promoting benefits for research participants. In many low-resource settings (LRS), complex and often severe challenges in daily living, poverty, geopolitical uprisings, sociopolitical, economic, and climate crises increase the burdens of even minimal risk research. While there has been important work to explore the scope of ethical responsibilities of researchers and research teams to respond to these wider challenges and hidden burdens in global health research, less attention has been given to the ethical dilemmas and risk experienced by frontline researcher staff as they perform research-related activities in LRS. Risks such as job insecurity, moral distress, infection, or physical harm can be exacerbated during public health crises, as recently highlighted by the COVID-19 pandemic. We highlight the layers of risk research staff face in LRS and present a conceptual model to characterize drivers of this risk, with particular attention to public health crises. A framework by which funders, institutions, principal investigators, and/or research team leaders can systematically consider these additional layers of risk to researchers and frontline staff is an important and needed addition to routine research proposals and protocol review.