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PEER REVIEW HISTORY
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are provided with free text boxes to elaborate on their assessment. These free text comments are
reproduced below.
ARTICLE DETAILS
TITLE (PROVISIONAL)
AUTHORS
Exploiting Social Influence to Magnify Population-Level Behavior
Change in Maternal and Child Health: Study Protocol for a
Randomized Controlled Trial of Network Targeting Algorithms in
Rural Honduras
Shakya, H; Stafford, Derek; Hughes, D.; Keegan, Thomas; Negron,
Rennie; Broome, Jai; McKnight, Mark; Nicoll, Liza; Nelson, Jennifer;
Iriarte, Emma; Ferrera, Maria; Airoldi, Edo; Fowler, James;
Christakis, Nicholas
VERSION 1 - REVIEW
REVIEWER
REVIEW RETURNED
GENERAL COMMENTS
David A. Shoham
Department of Public Health Sciences, Loyola University Chicago
Stritch School of Medicine, Maywood, IL, USA
18-Aug-2016
This is an intriguing study protocol that will test various levels of
recruitment to a reproductive, maternal, neonatal, and child health
intervention in Honduras that employ social network principles. The
rationale for the trial, which will randomize 176 villages (with a total
of 30k individuals) to various network-based treatment
implementations and with eight proportions of the population
targeted in an 8x2 factorial design. The proposal is extremely
ambitious but resources commensurate with the effort required
appear to be in place. Ultimately, the researchers hope to find
treatment thresholds and demonstrate that partial network data
collection (eg, targeting friends of randomly selected individuals) will
have similar impact as more cumbersome whole-network
(sociometric or socioeconomic) network designs. This is a novel
approach: while members of the research team have demonstrated
effectiveness of this approach for H1N1, it has not, to my
knowledge, been applied to a health behavioral intervention
I do have some questions about the statistical models to be used.
First, the authors focus on analyses at the individual and the
ecological (village) level which will ignore the richness of the data
nested withing villages.
Second, the influence process is modeled as a regression of the
ego's behavior on their alters' treatment status (equation 1, SA page
8). They plan to stratify based on number of friends named and
combine in a meta-analytic fashion. But this seems like an overly
simplistic approach that may obscure important spillover effects. It is
encouraging to see that alternative models for alter influence (eg,
average alter, model 1b) will be assessed.
Third, there is no proposed analysis of the network structure itself
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apart from centrality measures and density. The standard approach
for sociometric network data is an exponential random graph model,
which will test whether certain ties are more or less likely to be
present. There could be heterogeneity of ties across villages, which
could impact delivery. I realize the network selection approach, not
network structure, is the focus of this protocol, but it seems like a
missed opportunity nevertheless. This doesn't impact the basic idea
here, as such analyses could be conducted with the type of data
they propose collecting.
Fourth, there is an assumption that more central nodes will have a
greater effect in the diffusion of behavior change. This is true,
conditional on the central nodes receiving the treatment or taking on
the behavior change. But there is a long literature documenting the
resistance of central nodes to novel behaviors. This creates a
tension between receptiveness to change and network reach (or the
ability to influence others) which might be a wash in the proposed
work.
Finally, the treatments themselves are only briefly described on p.7.
I realize that the network is the focus of the "treatment" here (not the
intervention itself) but still the intervention deserves more attention.
I look forward to seeing the results of this trial. I believe it will be an
important contribution to both public health and network science.
REVIEWER
REVIEW RETURNED
GENERAL COMMENTS
Allison Doub Hepworth
Penn State University, United States
06-Sep-2016
This protocol describes an ambitious and important study that aims
to test how social network targeting could be used to promote the
broad uptake of positive reproductive, maternal, neonatal, and child
health behaviors and attitudes in rural Honduras. This large-scale,
resource-intensive project is expected to yield results that could
inform the design of other health behavior change interventions,
particularly in developing countries. As written, the manuscript
excels in providing an overview of the projects‟ mission and analytic
aims. The supplementary materials provide extensive additional
information about the statistical techniques that will be used to test
the research questions and the network data collection tool.
My main concern is that the manuscript does not contain sufficient
detail about the intervention. Without information about the efficacy
or effectiveness of the intervention, it is difficult for a reader to feel
confident that this study will yield the expected results. As a reader, I
need to know more about how intervention design and delivery
effects (e.g., implementation fidelity, skill-level of the counselor,
intervention dosage) will the accounted for when making inferences
about what promotes the uptake of the targeted RMNCH attitudes
and behaviors. My comments are outlined by page and line number
as they appeared in the PDF for review.
Abstract
Page 2 Lines 5-7
Revise first two sentences to make a more specific statement about
the state of reproductive, maternal, neonatal, and child health in
developing countries and what interventions can do to help.
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Recommend removing ambiguous words such as “lag” and “demand
side” that are not clear to outside readers.
Strengths and limitations
Page 2 Line 43 Sample or samples?
Background
Page 3 Lines 29-32 Revise to be less conversational; recommend
something like: “To promote improvements in key RMNCH
behaviors, change is needed in the provision of services and in
community-level demand for services and practices within
communities.”
Background
Page 4 Line 14 Remove parentheses and offset with commas;
Change “whereby” to “wherein” or “in which”
This Study
Page 4 Line 35 Remove “here”
Page 4 Lines 41-44 Revise to better describe the role of algorithms.
For example, “We will use theoretically derived (?) algorithms to
choose a subset of structurally influential individuals from within the
population receiving an intervention. Throughout this protocol the
term “treatment” refers only to the algorithms used to choose
individuals, while the term “intervention” refers only to the program
designed to promote positive RMNCH behaviors and attitudes.
Page 4 Line 44-45 Intervention adoption to some people means
willingness to deliver the intervention within a community OR the
likelihood that someone participates in the intervention when it is
offered; If you are measuring whether people are utilizing the
behaviors that are promoted in the intervention I would recommend
using the term “uptake” although that too can be ambiguous.
Recommend revising to be explicit here in this early introductory
paragraph with something like: “We will assess whether differential
network targeting results in differential uptake (i.e. practice or
implementation) of the RMNCH behaviors and attitudes promoted in
the intervention.”
Methods/Study Design
Preliminary Work
Page 5 Line 27 Give some examples of such RMNCH outcomes to
remind readers (it has been a while since the introductory
paragraphs).
Page 5 Line 55 – Briefly define 8 x 2 design or say that it is
described in detail in aim 2
Page 6 Line 2-3 Are there any differences between those who have
declined to participate in the study and those who consented?
Network data collection
Page 6 Line 14 You already said in Page 6 Line 1 that the
photographic census is complete…
Measurement
Page 6 Give some timeline estimates for when these surveys will be
administered – particularly for “baseline” and “final outcome”
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surveys. I see you have this in Figure 4 but it is currently not very
clear from this bulleted list. Unless there is a page limit requirement,
I recommend adding in some of the text from the supplement about
the network level and individual level centrality measures you will be
calculating in the “baseline social network survey” and “final
outcome survey”. You may think about how to make that more clear
in the text that you‟re measuring the whole network twice.
Behavioral Health Intervention
Page 7 Line 8 I would like to see a reference for “elements that
successfully promote RMNCH behaviors” or please make it clear
that components are based on theoretical success.
In general, I feel the description of the intervention is lacking
sufficient details to allow replication. Is there a manual for this
intervention? Will there be fidelity checks?
I see you have a reference for the counseling method but I do not
see a lot of detail about whether this intervention has been piloted or
evaluated for efficacy. If the intervention is still in development or if
its development and evaluation has been described elsewhere,
please make that more clear in the manuscript and/or direct the
reader to such resources.
It seems to me that knowing your intervention should work for those
who receive it is important and I do not see much discussion of that
in the current manuscript. As a reader, I am left wondering questions
like: “What ability will they have to detect differences in social
diffusion if the intervention is ineffective?” and “How will they be able
to parse out the differences in uptake related to provider effects
(e.g., a particularly skilled and invested counselor) from those
associated with social diffusion.”
If the intervention is new and has not yet been described in detail in
a peer reviewed publication, I recommend referring to a text such as,
Specifying and reporting complex behaviour change interventions:
the need for a scientific method (Michie, Fixsen, Grimshaw & Eccles,
2009; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2717906/) and
following the guidelines outlined there.
Page 9 line 27 – Revise – too conversational. Recommend
something like:
“This is a central and overarching study objective.”
Supplementary material
Page 11 line 30
I was surprised by the mention of “wave 2” data collection here,
likely because the measurement section currently lacks a clear
timeline in the text. Please be sure to revise that.
Limitations
Page 12 – Please discuss how you plan to handle missing data and
what influence that might have on your results. Discuss both missing
data that occurs during the consent process and attrition between
Wave 1 and Wave 2. How will you handle new people moving in?
People moving out or passing away? (Perhaps that is uncommon
but please mention it). Consider discussing limitations related to the
intervention in both its lack of demonstrated efficacy (if that is true –
if not true please add in a reference or narrative demonstrating it
already is efficacious) and what that might mean for your results.
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Supplementary material A
Individual-level measures
Page 22 Line 46 Please revise to be more clear about what
measures of centrality you will calculate in this study and what you
might expect to find, as you did with the network-level measures
section. As written, the section on centrality is too general. There are
also a few places where citations are missing as indicated by
[REF(S)]. I would remove the term “first-order metric” and use a less
field specific term or explain in more detail what you mean by this.
The information and examples are helpful to readers unfamiliar with
network analysis but please tie it back to your study, as you did with
network-level measures.
Extra space between given “a unique” code
Page 28 Paragraph on randomization showing some odd bolding.
Page 28 Line 48 Abbreviation “IDB” is used without defining in
supplementary material
Page 28 Line 52 I am not clear on what you mean by “However,
while we will not explicitly reveal which villages are receiving what
dosage, this could be inferred from observing approximately what
percent of households are receiving the intervention.” Are you
referring the village residents? What would be observed, as these
are individual households in counseling sessions? What impact
might this have on the study outcomes if participants figure out the
dosage? Consider adding this discussion to the limitations section.
I hope the authors make these revisions so that the protocol could
be considered for review again. Thank you for your time on this very
interesting and potentially transformative work.
VERSION 1 – AUTHOR RESPONSE
Reviewer: 1
Reviewer Name: David A. Shoham
Institution and Country: Department of Public Health Sciences, Loyola University Chicago Stritch
School of Medicine, Maywood, IL, USA
Please state any competing interests or state „None declared‟: None declared
Please leave your comments for the authors below
This is an intriguing study protocol that will test various levels of recruitment to a reproductive,
maternal, neonatal, and child health intervention in Honduras that employ social network
principles. The rationale for the trial, which will randomize 176 villages (with a total of 30k individuals)
to various network-based treatment implementations and with eight proportions of the population
targeted in an 8x2 factorial design. The proposal is extremely ambitious but resources commensurate
with the effort required appear to be in place. Ultimately, the researchers hope to find treatment
thresholds and demonstrate that partial network data collection (eg, targeting friends of randomly
selected individuals) will have similar impact as more cumbersome whole-network (sociometric or
socioeconomic) network designs. This is a novel approach: while members of the research team
have demonstrated effectiveness of this approach for H1N1, it has not, to my knowledge, been
applied to a health behavioral intervention
I do have some questions about the statistical models to be used. First, the authors focus on
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analyses at the individual and the ecological (village) level which will ignore the richness of the data
nested withing villages.
We appreciate the reviewers concern. We do in fact plan to do subgroup analyses, which we mention
in the appendix under Aim 4:
“Subgroups such as cliques, components, and communities will be identified within these village
networks (in particular, using state-of-the-art community detection algorithms that have recently been
invented 13). These subgroups will be identified in two different ways. We will identify subgroups
based solely on network properties, independent of any covariate properties; and we will also identify
subgroups based upon correlated values of covariates, such as education, income, or gender norms.”
Second, the influence process is modeled as a regression of the ego's behavior on their alters'
treatment status (equation 1, SA page 8). They plan to stratify based on number of friends named
and combine in a meta-analytic fashion. But this seems like an overly simplistic approach that may
obscure important spillover effects. It is encouraging to see that alternative models for alter influence
(eg, average alter, model 1b) will be assessed.
Thank you for your thoughts on this. There are of course many ways of modeling this type of dynamic,
which is why we have proposed some alternative models.
Third, there is no proposed analysis of the network structure itself apart from centrality measures and
density. The standard approach for sociometric network data is an exponential random graph model,
which will test whether certain ties are more or less likely to be present. There could be heterogeneity
of ties across villages, which could impact delivery. I realize the network selection approach, not
network structure, is the focus of this protocol, but it seems like a missed opportunity nevertheless.
This doesn't impact the basic idea here, as such analyses could be conducted with the type of data
they propose collecting.
We appreciate your comment. While we certainly intend to use ERGM models to test our hypotheses,
for the sake of space, and due to the complexity of the analyses already, we have simply opted not to
mention all possible analytic approaches that we will use with this data.
Fourth, there is an assumption that more central nodes will have a greater effect in the diffusion of
behavior change. This is true, conditional on the central nodes receiving the treatment or taking on
the behavior change. But there is a long literature documenting the resistance of central nodes to
novel behaviors. This creates a tension between receptiveness to change and network reach (or the
ability to influence others) which might be a wash in the proposed work.
We agree that cross-cutting effects are possible. However, our earlier work in Honduras (Kim et al.
2015) leads us to believe that, on balance, network targeting will have a positive effect on the number
of individuals reached. Of course, this is why we have proposed to do a trial, since it is uncertain
whether we will find what we think we will. We believe it will also be helpful to report a null result if, as
the reviewer worries, the effects of centrality are washed out by the difficulty of getting central nodes
to change their behavior.
Finally, the treatments themselves are only briefly described on p.7. I realize that the network is the
focus of the "treatment" here (not the intervention itself) but still the intervention deserves more
attention.
Thank you for your important comments. We have added more information regarding the intervention
on page 7 and in the supplementary appendix.
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In the manuscript:
“The implementing partner in this project, the Inter-American Development Bank (IDB) through the
Salud Mesoamerica Initiative (SMI), is responsible for designing and implementing an integral
intervention to promote RMNCH behavior change in Honduras. To work within the constraints of this
study, the intervention had to meet specific requirements including: 1) alignment with priorities of the
Ministry of Health (MOH) of Honduras, the Bill & Melinda Gates Foundation (BMGF), and the needs of
the population; 2) contain new messages for the targeted population to allow for detection of changes
in knowledge, attitudes and practices; 3) include tracers or identifiers which could be detected during
follow-up surveys; 4) not use mass-media communication techniques, including radio spots, flyers,
posters, as these would contaminate the network effects of the study; 5) have a strong monitoring
component; and 6) in order to test the spread of behavior from person to person, have a
demonstrated effectiveness in similar settings. The intervention would also have to adopt the targeting
strategy provided by YINS, focusing on network position, as opposed to targeting households with
primary audiences for the behavior change of interest. For example, the targeting algorithm could
hypothetically identify a household with two grandfathers, and therefore select it to receive the
intervention. This household would usually not be selected for an intervention on prenatal care or
neonatal practices, given that there are no pregnant women living there.
Given these requirements, an educational package using the Timed and Targeted Counseling
methodology complemented with alternative methods of face-to-face communication including songs,
rhymes, and riddles, was designed with World Vision and Child Fund Honduras. The social and
behavior change communication strategy for the intervention was designed using the “P-Process”, a
tool developed by Johns Hopkins Center for Communication Programs, and used for more than 30
years for planning strategic, evidence-based health communication programs. This intervention will be
delivered by trained community health workers for 24 months on a monthly basis to the households
selected for the study. Timed and Targeted Counseling (ttC), has been implemented in 20 countries
worldwide by World Vision.45 It is targeted in time (when it is needed), in space (by visiting in the
home), and in individualized approaches (messages and barriers focus on the circumstances of a
specific family). This methodology uses narrative and negotiation in a 1-2 hour visit with families to
discuss positive and negative scenarios and create a list of agreements with families to try out new
practices. It should be noted that ttC is normally implemented in households with pregnant women
and/or children under two, and counseling is provided to all family members based on stage of the
pregnancy or age of the child.
This methodology was adjusted to include messages for topics of interest to the study based on
findings from formative research conducted for intervention design (Annex X) and evidence-based,
cost-effective practices related to study outcomes.
Study outcomes include: 1) use of folic acid in women of reproductive age to prevent birth defects; 2)
receiving prenatal care in the first trimester; 3) having a birth preparation plan for seeking timely
prenatal care, institutional birth, post-partum care and emergencies; 4) exclusive breastfeeding for
infants under 6 months; 5) immediate breastfeeding after birth; 6) proper thermal and cord care for
newborn infants; 7) proper treatment of diarrhea in children, including the use of zinc (which is a new
component of the SMI program, here); 8) paternal involvement in child care, particularly for newborns;
9) use of modern family planning methods; and10) delaying pregnancy until 18 years of age.
While only very specific households will be targeted according to our randomization methods,
participants from target households will not be discouraged from inviting others, and a careful record
of attendees will be kept. CHWs have a team of supervisors for intervention quality control and ensure
that CHWs are visiting the correct houses. The IDB/SMI team has also incorporated the use of
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mHealth tools to aid in intervention delivery (for example, all stories are available in an animated
video format), data quality and timeliness. The IDB is also currently working on supply-side
interventions with the Government of Honduras through SMI and other complementary programs, to
ensure community members seeking services receive quality care.
As part of the intervention protocol, we will keep careful track of which CHWs have visited which
households in order to allow us to adjust for possible provider effects that could impact the study
outcomes.”
In the appendix
“Intervention implementation details:
14 visit topics have been created for the intervention. Based on the household diagnosis, the CHW
selects where to start and how to advance through the program and visits can be repeated depending
on reported behaviors. Topics and order are modified as the family situation changes. The materials
for the CWH created for the household intervention include:
1. 4 Counseling Books
2. 3 sets of illustrated cards with information about proper diet and nutrition during pregnancy, danger
signs for pregnant, birth, postpartum and postnatal periods
3. 25 stories of 3 to 5 minutes each in a 2D audio-visual format, including sound, music, and the story
read aloud.
Materials are also provided to the families who partake in the intervention to reinforce key messages
and motivate the practices discussed. These materials include:
1. Book of messages and agreements for the family
2. Pictures related to the messages discussed and crayons for coloring
3. House Identifier
4. Calendar with key messages for household
5. Unisex cardboard box with printed lined bearing the logo and slogan of the project.
6. Picture to hang on the wall portraying a sense of maternity lived by the whole family
The home visit is divided into four main parts 1) validation of the house; 2) introduction; 3)
development; and 4) closing, and contain the following steps:
1. Validation: Per study requirements, the CHW records their GPS location, verifies that the people in
the house match the list of people provided by YINS, and record any additional meeting attendees.
2. Introduction: Greeting and check in with the family to determine current situation, and introduction
to the theme of the visit. As the family gathers, the CHW will play the song for the intervention, record
all members present and conduct a quick survey to determine level of knowledge, attitudes and
practices related to the topic. This CHW will also explain the activities to be conducted during the visit.
3. Development: The CHW begins by checking if the family has a priority issue they would like to
discuss during the session. After discussing these issues, the CHW begins telling the “problem” story
or playing the story animation on the tablet, ensuring that all family members carefully listen, look at
the pictures, and answer any questions the family may have. The CHW will then tell the “positive”
story, and uses the “guide” questions that accompany the story to have a dialogue about the story
and negotiate behavior changes with the family. The CHW will then use complementary tools such as
songs, riddles or visual aids to review main ideas with the family.
4. Closing: The CHW will summarize the discussion and write the agreement in the family counseling
book regarding what the family wishes to practice and alternative solutions to the potential barriers
identified during the visit. As a reaffirmation of the messages of the story, the last activity is to provide
coloring book sheets to the family to color pictures of the key messages discussed. Additionally, the
date of the next visit will be agreed and included on the family‟s calendar. The CHW will play the
intervention song again and thank the family again for their time before leaving.”
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I look forward to seeing the results of this trial. I believe it will be an important contribution to both
public health and network science.
Reviewer: 2
Reviewer Name: Allison Doub Hepworth
Institution and Country: Penn State University, United States
Please state any competing interests or state „None declared‟: None declared
Please leave your comments for the authors below
This protocol describes an ambitious and important study that aims to test how social network
targeting could be used to promote the broad uptake of positive reproductive, maternal, neonatal, and
child health behaviors and attitudes in rural Honduras. This large-scale, resource-intensive project is
expected to yield results that could inform the design of other health behavior change interventions,
particularly in developing countries. As written, the manuscript excels in providing an overview of the
projects‟ mission and analytic aims. The supplementary materials provide extensive additional
information about the statistical techniques that will be used to test the research questions and the
network data collection tool.
My main concern is that the manuscript does not contain sufficient detail about the intervention.
Without information about the efficacy or effectiveness of the intervention, it is difficult for a reader to
feel confident that this study will yield the expected results. As a reader, I need to know more about
how intervention design and delivery effects (e.g., implementation fidelity, skill-level of the counselor,
intervention dosage) will the accounted for when making inferences about what promotes the uptake
of the targeted RMNCH attitudes and behaviors.
Thank you for your important comments. Please see the additions on page 7 of the manuscript which
provide greater detail on the intervention.
My comments are outlined by page and line number as they appeared in the PDF for review.
Abstract
Page 2 Lines 5-7
Revise first two sentences to make a more specific statement about the state of reproductive,
maternal, neonatal, and child health in developing countries and what interventions can do to help.
Recommend removing ambiguous words such as “lag” and “demand side” that are not clear to
outside readers.
We appreciate the reviewers suggestion and have revised the abstract to read:
“Despite global progress on many measures of child health, rates of neonatal mortality remain high in
the developing world. Evidence suggests that substantial improvements can be achieved with simple,
low-cost interventions within family and community settings, particularly those that are designed to
change knowledge and behavior at the community level.”
Strengths and limitations
Page 2 Line 43 Sample or samples?
We have corrected the sentence to read sample.
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Background
Page 3 Lines 29-32 Revise to be less conversational; recommend something like: “To promote
improvements in key RMNCH behaviors, change is needed in the provision of services and in
community-level demand for services and practices within communities.”
We have revised the sentence accordingly.
Background
Page 4 Line 14 Remove parentheses and offset with commas; Change “whereby” to “wherein” or “in
which”
We have revised the sentence accordingly.
This Study
Page 4 Line 35 Remove “here”
We have revised the sentence accordingly.
Page 4 Lines 41-44 Revise to better describe the role of algorithms. For example, “We will use
theoretically derived (?) algorithms to choose a subset of structurally influential individuals from within
the population receiving an intervention. Throughout this protocol the term “treatment” refers only to
the algorithms used to choose individuals, while the term “intervention” refers only to the program
designed to promote positive RMNCH behaviors and attitudes.
We appreciate that suggestion and have revised the sentence according to the reviewer‟s
recommendation.
Page 4 Line 44-45 Intervention adoption to some people means willingness to deliver the intervention
within a community OR the likelihood that someone participates in the intervention when it is offered;
If you are measuring whether people are utilizing the behaviors that are promoted in the intervention I
would recommend using the term “uptake” although that too can be ambiguous. Recommend revising
to be explicit here in this early introductory paragraph with something like: “We will assess whether
differential network targeting results in differential uptake (i.e. practice or implementation) of the
RMNCH behaviors and attitudes promoted in the intervention.”
We have included this revision in the manuscript.
Methods/Study Design
Preliminary Work
Page 5 Line 27 Give some examples of such RMNCH outcomes to remind readers (it has been a
while since the introductory paragraphs).
We appreciate the reviewers suggestions and have revised the document to read:
“We developed an extensive survey instrument to capture the various outcomes that will be
addressed through the household-level interventions that will be implemented by IDB/SMI, including
use of folic acid, prenatal care utilization, birth plan preparation, immediate breastfeeding after birth,
exclusive breastfeeding for infants up to 6 months old, proper thermal and cord care for newborns,
proper treatment of diarrhea in children, and paternal involvement in child care.”
Page 5 Line 55 – Briefly define 8 x 2 design or say that it is described in detail in aim 2
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We have instructed readers to look at Aim 2 for details on the 8x2 design.
Page 6 Line 2-3 Are there any differences between those who have declined to participate in the
study and those who consented?
We do not know that information. We have a count of the total population over the age of 12 in those
areas, but no breakdown of the demographics.
Network data collection
Page 6 Line 14 You already said in Page 6 Line 1 that the photographic census is complete…
We thank the reviewer for catching that detail. We have changed the text to read:
“As the photographic census is complete, we will next use bespoke software we have prepared and
made publicly available (http://humannaturelab.net/resources/software/trellis/), named Trellis (see
Appendix 2), to undertake the main survey, which includes a battery of “name generator” questions to
capture social relationships”
Measurement
Page 6 Give some timeline estimates for when these surveys will be administered – particularly for
“baseline” and “final outcome” surveys. I see you have this in Figure 4 but it is currently not very clear
from this bulleted list. Unless there is a page limit requirement, I recommend adding in some of the
text from the supplement about the network level and individual level centrality measures you will be
calculating in the “baseline social network survey” and “final outcome survey”. You may think about
how to make that more clear in the text that you‟re measuring the whole network twice.
We thank the reviewer for these suggestions. We have included dates for each survey wave, and
have also added in text to clarify the calculation of network measures from the network data at each
wave.
(1) Baseline social networks: The name generator questions to collect sociocentric data will be
included in the baseline survey. From these measures we will calculate community level and
individual level measures of network connectivity including various measures of centrality (please see
online appendix for more details). 2016
(2) Baseline RMNCH care behavior and norms for all individuals in the villages. Specific maternal
neonatal, and child health behavior questions will be asked only of individuals who have already had
a child. Norms and attitudes questions will be asked of everyone and will include attitudes towards
RMNCH behaviors as well as the role of fathers in prenatal and neonatal health. 2016
(3) Concurrent norms and behavior surveys: one year into the intervention, we will administer surveys
to track changes in norms and behaviors as well as possible sources of intervention spread. For this
survey, we will also monitor the implementation of the intervention by asking questions specific to
receiving intervention activities. 2017
(4) Final outcome survey: a second wave of social networks data collection, RMNCH care behavior,
and norms questions for all individuals in the villages. Again using this second wave of social network
data, we will calculate network connectivity at the individual and community levels. 2018.
Behavioral Health Intervention
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Page 7 Line 8 I would like to see a reference for “elements that successfully promote RMNCH
behaviors” or please make it clear that components are based on theoretical success.
In general, I feel the description of the intervention is lacking sufficient details to allow replication. Is
there a manual for this intervention? Will there be fidelity checks?
I see you have a reference for the counseling method but I do not see a lot of detail about whether
this intervention has been piloted or evaluated for efficacy. If the intervention is still in development or
if its development and evaluation has been described elsewhere, please make that more clear in the
manuscript and/or direct the reader to such resources.
It seems to me that knowing your intervention should work for those who receive it is important and I
do not see much discussion of that in the current manuscript. As a reader, I am left wondering
questions like: “What ability will they have to detect differences in social diffusion if the intervention is
ineffective?” and “How will they be able to parse out the differences in uptake related to provider
effects (e.g., a particularly skilled and invested counselor) from those associated with social diffusion.”
If the intervention is new and has not yet been described in detail in a peer reviewed publication, I
recommend referring to a text such as, Specifying and reporting complex behaviour change
interventions: the need for a scientific method (Michie, Fixsen, Grimshaw & Eccles, 2009;
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2717906/) and following the guidelines outlined there.
Thank you for your important comments. We have added references and more details in the
manuscript and in the appendix as requested by the reviewer.
In the manuscript:
“The implementing partner in this project, the Inter-American Development Bank (IDB) through the
Salud Mesoamerica Initiative (SMI), is responsible for designing and implementing an integral
intervention to promote RMNCH behavior change in Honduras. To work within the constraints of this
study, the intervention had to meet specific requirements including: 1) alignment with priorities of the
Ministry of Health (MOH) of Honduras, the Bill & Melinda Gates Foundation (BMGF), and the needs of
the population; 2) contain new messages for the targeted population to allow for detection of changes
in knowledge, attitudes and practices; 3) include tracers or identifiers which could be detected during
follow-up surveys; 4) not use mass-media communication techniques, including radio spots, flyers,
posters, as these would contaminate the network effects of the study; 5) have a strong monitoring
component; and 6) in order to test the spread of behavior from person to person, have a
demonstrated effectiveness in similar settings. The intervention would also have to adopt the targeting
strategy provided by YINS, focusing on network position, as opposed to targeting households with
primary audiences for the behavior change of interest. For example, the targeting algorithm could
hypothetically identify a household with two grandfathers, and therefore select it to receive the
intervention. This household would usually not be selected for an intervention on prenatal care or
neonatal practices, given that there are no pregnant women living there.
Given these requirements, an educational package using the Timed and Targeted Counseling
methodology complemented with alternative methods of face-to-face communication including songs,
rhymes, and riddles, was designed with World Vision and Child Fund Honduras. The social and
behavior change communication strategy for the intervention was designed using the “P-Process”, a
tool developed by Johns Hopkins Center for Communication Programs, and used for more than 30
years for planning strategic, evidence-based health communication programs. This intervention will be
delivered by trained community health workers for 24 months on a monthly basis to the households
selected for the study. Timed and Targeted Counseling (ttC), has been implemented in 20 countries
worldwide by World Vision.45 It is targeted in time (when it is needed), in space (by visiting in the
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home), and in individualized approaches (messages and barriers focus on the circumstances of a
specific family). This methodology uses narrative and negotiation in a 1-2 hour visit with families to
discuss positive and negative scenarios and create a list of agreements with families to try out new
practices. It should be noted that ttC is normally implemented in households with pregnant women
and/or children under two, and counseling is provided to all family members based on stage of the
pregnancy or age of the child.
This methodology was adjusted to include messages for topics of interest to the study based on
findings from formative research conducted for intervention design (Appendix 3) and evidence-based,
cost-effective practices related to study outcomes.
Study outcomes include: 1) use of folic acid in women of reproductive age to prevent birth defects; 2)
receiving prenatal care in the first trimester; 3) having a birth preparation plan for seeking timely
prenatal care, institutional birth, post-partum care and emergencies; 4) exclusive breastfeeding for
infants under 6 months; 5) immediate breastfeeding after birth; 6) proper thermal and cord care for
newborn infants; 7) proper treatment of diarrhea in children, including the use of zinc (which is a new
component of the SMI program, here); 8) paternal involvement in child care, particularly for newborns;
9) use of modern family planning methods; and10) delaying pregnancy until 18 years of age.
While only very specific households will be targeted according to our randomization methods,
participants from target households will not be discouraged from inviting others, and a careful record
of attendees will be kept. CHWs have a team of supervisors for intervention quality control and ensure
that CHWs are visiting the correct houses. The IDB/SMI team has also incorporated the use of
mHealth tools to aid in intervention delivery (for example, all stories are available in an animated
video format), data quality and timeliness. The IDB is also currently working on supply-side
interventions with the Government of Honduras through SMI and other complementary programs, to
ensure community members seeking services receive quality care.
As part of the intervention protocol, we will keep careful track of which CHWs have visited which
households in order to allow us to adjust for possible provider effects that could impact the study
outcomes.”
In the appendix
“Intervention implementation details:
14 visit topics have been created for the intervention. Based on the household diagnosis, the CHW
selects where to start and how to advance through the program and visits can be repeated depending
on reported behaviors. Topics and order are modified as the family situation changes. The materials
for the CWH created for the household intervention include:
4. 4 Counseling Books
5. 3 sets of illustrated cards with information about proper diet and nutrition during pregnancy, danger
signs for pregnant, birth, postpartum and postnatal periods
6. 25 stories of 3 to 5 minutes each in a 2D audio-visual format, including sound, music, and the story
read aloud.
Materials are also provided to the families who partake in the intervention to reinforce key messages
and motivate the practices discussed. These materials include:
7. Book of messages and agreements for the family
8. Pictures related to the messages discussed and crayons for coloring
9. House Identifier
10. Calendar with key messages for household
11. Unisex cardboard box with printed lined bearing the logo and slogan of the project.
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12. Picture to hang on the wall portraying a sense of maternity lived by the whole family
The home visit is divided into four main parts 1) validation of the house; 2) introduction; 3)
development; and 4) closing, and contain the following steps:
5. Validation: Per study requirements, the CHW records their GPS location, verifies that the people in
the house match the list of people provided by YINS, and record any additional meeting attendees.
6. Introduction: Greeting and check in with the family to determine current situation, and introduction
to the theme of the visit. As the family gathers, the CHW will play the song for the intervention, record
all members present and conduct a quick survey to determine level of knowledge, attitudes and
practices related to the topic. This CHW will also explain the activities to be conducted during the visit.
7. Development: The CHW begins by checking if the family has a priority issue they would like to
discuss during the session. After discussing these issues, the CHW begins telling the “problem” story
or playing the story animation on the tablet, ensuring that all family members carefully listen, look at
the pictures, and answer any questions the family may have. The CHW will then tell the “positive”
story, and uses the “guide” questions that accompany the story to have a dialogue about the story
and negotiate behavior changes with the family. The CHW will then use complementary tools such as
songs, riddles or visual aids to review main ideas with the family.
8. Closing: The CHW will summarize the discussion and write the agreement in the family counseling
book regarding what the family wishes to practice and alternative solutions to the potential barriers
identified during the visit. As a reaffirmation of the messages of the story, the last activity is to provide
coloring book sheets to the family to color pictures of the key messages discussed. Additionally, the
date of the next visit will be agreed and included on the family‟s calendar. The CHW will play the
intervention song again and thank the family again for their time before leaving.”
Page 9 line 27 – Revise – too conversational. Recommend something like:
“This is a central and overarching study objective.”
We have revised the sentence to now read:
“This increased efficiency through the social effect is a central and overarching study objective.”
Supplementary material
Page 11 line 30
I was surprised by the mention of “wave 2” data collection here, likely because the measurement
section currently lacks a clear timeline in the text. Please be sure to revise that.
Thank you for pointing that out. We have tried to make the timeline more clear throughout the
manuscript.
Limitations
Page 12 – Please discuss how you plan to handle missing data and what influence that might have on
your results. Discuss both missing data that occurs during the consent process and attrition between
Wave 1 and Wave 2. How will you handle new people moving in? People moving out or passing
away? (Perhaps that is uncommon but please mention it). Consider discussing limitations related to
the intervention in both its lack of demonstrated efficacy (if that is true – if not true please add in a
reference or narrative demonstrating it already is efficacious) and what that might mean for your
results.
Thank you for your comments. We have added text regarding limitations on pages 2 and 12, and text
on missingness to the Appendix.
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In the appendix
“Participant attrition and missing data:
Over 90% of community residents have agreed to participate in the study, so bias due to failure to
recruit participants is very low. Observations with missing data will be dropped from the analyses,
which will also not create bias in the data as assignment to treatment groups, and therefore
missingness, is random. We will also make our best effort to keep track of study participants who
move from one study village to another, in order to retain them in the study.
”
In the manuscript:
“Our intervention also has limitations. In the ideal scenario, we would use an evidence-based
intervention for community-based neonatal health tested in rural Honduras implemented to
“guarantee” behavior change amongst the initially targeted individuals, the ripples of which would be
studied in the RTC. However, given the restraints of the study, this “ideal intervention” does not exist.
For example, in the ideal gold-standard BCC intervention, the person or group whose behavior
change is sought receives the intervention messages as many times as possible. In the typical
community based intervention, in addition to face-to-face counseling, community members would be
exposed to radio messages, banners, flyers, mass text messages, and other media based
communication methods to reinforce messaging. Given that the study relies on information passing
through the social network, mass media communication methods cannot be used by the intervention.
Even some targeted methods, such as sending text messages only to study participants, cannot be
used, because cellphones are distributed unequally throughout the population, affecting its
homogeneity. The intervention team has been creative in adding tools to the intervention, and has
been mindful of including a variety of behavioral changes along the continuum of pregnancy,
childbirth, postnatal care, and child health in order to maximize the possibility that one or more
intervention components are adopted.
Intervention targeting is also affected. Normally in an intervention targeted at changing behaviors in
maternal and neonatal health, households would be selected depending on where pregnant women
live. We could not take these criteria into consideration, given that the targeting mechanism is based
on position in the network, rather than whether or not a woman in the household is pregnant.
Finally, not all aspects of the desired behavior change rely on adequate knowledge, attitudes and
practices at the household level. A clear example is how the conditions in health centers and hospitals
affect behaviors of the population. Although messaging is provided to families regarding the
importance of male involvement in birth, if the hospital or health centers does not have adequate
infrastructure to have private birthing rooms (the norm in Central America), men cannot be in the
room during the birth if another women is also in labor. Although SMI works closing with the MOH to
improve supply-side conditions, some aspects are out of the scope of the program. The study team is
aware of these limitations and is documenting them to have a clear picture of these external factors
which also impact the success of the community-based behavior change intervention.”
Supplementary material A
Individual-level measures
Page 22 Line 46 Please revise to be more clear about what measures of centrality you will calculate
in this study and what you might expect to find, as you did with the network-level measures section.
As written, the section on centrality is too general. There are also a few places where citations are
missing as indicated by [REF(S)]. I would remove the term “first-order metric” and use a less field
specific term or explain in more detail what you mean by this. The information and examples are
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helpful to readers unfamiliar with network analysis but please tie it back to your study, as you did with
network-level measures.
We appreciate the reviewers concerns and have moved the list of specific types of questions that can
be answered using individual network measures from the analytic section further down in the
document, to the section in which we introduce centrality measures.
“The most frequently measured individual-level network metric is centrality- which is relatively intuitive
in concept and is a measure of how “central” an individual is within any given network. In these
analyses we will be able to investigate to what degree individual network centrality can impact the
adoption of the intervention components by any individual within the population. (1) Do participants
with higher centrality adopt the new intervention more readily than those with lower centrality? (2) Do
individuals connected to high centrality social contacts adopt the new intervention more readily? (3)
Are socially isolated individuals less likely to adopt the new intervention? (4) Is the relationship
between intervention adoption and education moderated by network characteristics (e.g., will
educated women who are less socially connected adopt the intervention less readily than educated
women who are well connected)?”
Extra space between given “a unique” code
We fixed that, thank you.
Page 28 Paragraph on randomization showing some odd bolding.
We fixed that, thank you.
Page 28 Line 48 Abbreviation “IDB” is used without defining in supplementary material
We fixed that, thank you.
Page 28 Line 52 I am not clear on what you mean by “However, while we will not explicitly reveal
which villages are receiving what dosage, this could be inferred from observing approximately what
percent of households are receiving the intervention.” Are you referring the village residents? What
would be observed, as these are individual households in counseling sessions? What impact might
this have on the study outcomes if participants figure out the dosage? Consider adding this discussion
to the limitations section.
We thank the reviewer for this questions. We have modified the text to make it clear that we mean the
implementing partner:
“However, while we will not explicitly reveal which villages are receiving what dosage, this could be
inferred by implantation partner from observing approximately what percent of households are
receiving the intervention.”
I hope the authors make these revisions so that the protocol could be considered for review again.
Thank you for your time on this very interesting and potentially transformative work.
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VERSION 2 – REVIEW
REVIEWER
REVIEW RETURNED
GENERAL COMMENTS
Allison Doub Hepworth
Penn State University, USA
17-Nov-2016
Thank you to the authors for taking the time to respond in depth to
each of my prior comments, and to those of the other reviewer.
Combined with the supplementary material, this manuscript is a
thorough protocol description. I do not have any substantive
concerns; there is a lot of information for readers to wade through,
but this is a complex study so I think it is all necessary. In my opinion
the manuscript stands sufficiently on its own and interested readers
can look further to the supplementary material for more detail. You
have presented a transparent look into your research plan, which is
a terrific step forward in the behavioral and health sciences. Best
wishes with this important work.
One very minor revision
P7 line 42 – indicate which online appendix you are referring to
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Exploiting social influence to magnify
population-level behaviour change in
maternal and child health: study protocol for
a randomised controlled trial of network
targeting algorithms in rural Honduras
Holly B Shakya, Derek Stafford, D Alex Hughes, Thomas Keegan, Rennie
Negron, Jai Broome, Mark McKnight, Liza Nicoll, Jennifer Nelson, Emma
Iriarte, Maria Ordonez, Edo Airoldi, James H Fowler and Nicholas A
Christakis
BMJ Open 2017 7:
doi: 10.1136/bmjopen-2016-012996
Updated information and services can be found at:
http://bmjopen.bmj.com/content/7/3/e012996
These include:
References
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