The SUMMIT 10-Year Follow-up Study (S10Y)

This study is a continuation of the Supplementation with Multiple Micronutrients Intervention Trial (SUMMIT), which was implemented by the Summit Institute of Development from 2001-2004. The SUMMIT 10-year follow-up (S10Y) assesses the long term impact of Maternal Multiple Micronutrient (MMN) supplementation on child cognition, socio-emotional and physical capability, at 9-12 years of age in children whose mothers had consumed MMN supplements, as compared to iron and folic acid (IFA), during pregnancy and 3-months postpartum in Lombok, Indonesia. Evidence of long-term benefits of MMN on child development are intended to inform policy change, and current investments in community-based maternal and infant health programs that would provide for deployment of maternal MMN supplementation in low-resource settings.

The design of our follow-up study is based on two lines of evidence from the SUMMIT and existing literature. First, micronutrients in addition to IFA are important for brain development during pregnancy and lactation, which are crucial periods for the brain development of the infant. Second, the benefit of MMN is greater for certain groups of women. In the SUMMIT, we found benefits of MMN over IFA on motor and cognitive ability at age 3.5 years in children of undernourished (low arm circumference) and anaemic mothers.

The field phase of the study was conducted from June 2012 to October 2014. In Phase 1, we tracked all women who had been enrolled in SUMMIT between 2001-2004 and re-enrolled them and the child from that pregnancy. In Phase 2, we are selecting a cohort of over 3,000 children and collected data on cognition, socio-emotional, physical activity, motor function, child health, hemoglobin and nutritional status. In Phase 3, we gathered information from the childrens schools regarding their school performance, and other factors such as teacher qualification and facilities.

The scientists leading this work are Husni Muadz (University of Mataram), Anuraj Shankar (Harvard University), Elizabeth Prado (UC Davis), Susy Sebayang, Mandri Apriatni and Ben Harefa (Summit Institute of Development), Michael Ullman (Georgetown University), Jarred Lum (Deakin University), and Katie Alcock (Lancaster University).
Higher Education Network Ring Initiative (HENRI)

Summit Institute of Development and University of Mataram is collaborating with Harvard T.H. School of Public Health, SEAMEO RECFON, University of Andalas and Helen Keller International for the Higher Education Network Ring Initiatve (HENRI). HENRI is aimed at training a cadre of Indonesian scientists and public health professionals in the analysis and use of country level data for decision-making by:

Establishing an active educational data repository and access portal
Developing and implementing a curriculum for training of integrated and applied data analysis with the focus on obtaining results for policy making, program planning, and impact evaluation
Enhancing the capacity of universities and institutions in Indonesia to provide higher education and training in research on maternal and newborn health and nutrition by providing scholarships and fellowships for researchers and government officials to study in Indonesia and abroad with HENRI partners, providing funds to analyze and publish findings, and build mentoring networks.
The activity is funded by the United States Agency for International Development-Indonesia through the Harvard T.H. School of Public Health.

The Supplementation with Multiple Micronutrients Intervention Trial (SUMMIT)

The SUMMIT was a large scale cluster randomized controlled trial. The trial was conducted in Lombok, West Nusa Tenggara, Indonesia from 2001-2004 with the goal to reduce maternal and infant death in the context of routine prenatal care. The study enrolled nearly 42,000 pregnant women and employed around 500 field staff. The results of the trial showed that providing multiple micronutrient (MMN) supplement to pregnant women could reduce the risk of infant mortality by nearly 20% compared to providing iron-folic acid (IFA) only (see publication). This protective effect was nearly double in anemic women whose children experienced a 38% reduction in mortality. Multiple micronutrient impact on mortality was even more prominent when the quality of antenatal care was also enhanced (Shankar, 2009). This indicated that health can be improved by enhancing routine prenatal care with participatory approaches and evidence-based decisions. MMN supplements also reduced the risk of low birthweight especially in better nourished women (Sebayang, 2011) and anemic women (Supplementation with Multiple Micronutrients Intervention Trial (SUMMIT) Study Group, 2008). When the children were 3 years old, we saw cognitive improvements when their mothers were given MMN supplements during pregnancy (Prado, 2012).

The SUMMIT was supported by funds from the Turner Foundation, the United Nations International Childrens Emergency Fund, the Centre for Health and Human Development and the United States Agency for International Development-Indonesia through Helen Keller International-Indonesia. For downloadable documents please go to Publications.

OpenSRP / Thrive Indonesia
Frontline health workers (FLHWs) are the first and often the only point of contact for health care access for millions of people. Especially in resource-constrained environments which have a shortage of trained physicians and nurses, FLHWs form the backbone of the health system. However, FLHWs are often inadequately trained, and have poor access to health information, tools and guidance. The isolation and rudimentary training of this cadre of workers has often limited their capacity to provide little more than the most basic care, with little continuity of care for the clients being served. To this end, mHealth strategies have been developed for data collection, to provide continued skills development and training for FLHWs, increase the range of task-shifted health activities, and improving communication between different levels of the health care system, improve emergency health referrals, and overall motivation of the FLHW. The Indonesian health care system employs thousands of women frontline health workers, relying on paper-based health registers which present strategic challenges for communication, coordination, and resource sharing across all levels of this decentralized health system. There is a clear and urgent need for an integrated health information system to generate quality data, reduce the workload of frontline health workers, and provide data in real time for program managers and policy makers to guide strategy and improve health outcomes.

This project aims to adapt and trail an electronic information system, Open Smart Register Platform (OpenSRP), to provide an integrated health platform to improve frontline workforce efficiencies, data quality, and timeliness of RMNCH interventions to enhance maternal and neonatal health outcomes. The OpenSRP is an electronic register-based mHealth platform that covers the entire RMNCH continuum of care and related core interventions, such as antenatal care, birth planning, and vaccination. It combines data collection, client management, and reporting workflows into one linked mobile interface. OpenSRP is currently being implemented in India among one cadre of frontline health workers in a form that is localized to the Karnataka State ANMs: with content specific to their roles, responsibilities, intervention types and schedules. OpenSRP has not yet been made into a generic tool for adapted use among different cadres of health workers across countries.

The study hypothesizes that the OpenSRP improves frontline workforce efficiencies, data quality, and timeliness of RMNCH interventions, compared to use of current paper-based information-system approaches. ‘THRIVE Phase 1’ is a multisite study to be conducted in Bangladesh, Indonesia, and Pakistan. It consists of qualitative formative research to adapt the OpenSRP, followed by a quasi-experimental field-testing to assess the deployment and will be conducted over a 24-month period. This research study comprises three stages and four interlinked objectives with the overall goal being to determine the adaptation requirements, implementation components, and effect of an electronic information system as an intervention on the performance of health workers delivering RMNCH interventions. The findings of this research will be used to inform a second phase of research, entitled “THRIVE Phase 2”, which will include a robust multi-site randomized controlled trial which will aims to measure coverage, quality of implementation, cost-effectiveness of health system gains, and resulting impact on clients employing the Open Smart Register Platform (OpenSRP) across different cadres focused on delivering RMNCH interventions.