WHO guidelines for home-based records were just recently released - WHO recommendations on home-based records for maternal, newborn and child health. Geneva: World Health Organization; 2018.
The recommendations, rationale and remarks below are abstracted from the document, which has been uploaded to the TechNet-21 Resource Library (TRL) here. The document is also available online here: http://www.who.int/maternal_child_adolescent/documents/home-based-records-guidelines/en/.
Readers of the HBR recommendations will find that published evidence demonstrating benefits of HBRs is limited. Many of us on the Guideline Development Group (GDG) knew this to be the case before the guideline development work began. As a professional who believes in evidence-based approaches to public health, some may question why I (and many others) remain resolute ambassadors for home-based records and their role as a key component of immunization service delivery. First and foremost, I believe that every parent has a right to a documented record of what interventions have been taken with their child by healthcare professionals, vaccination included. I also beleive very strongly in the importance of informed decisions by healthcare workers, and I recognize home-based records serve as a tool designed to provide frontline health workers with a standardized patient history that is convenient, comprehensive and vital to making such informed decisions about the need for care and immunization services. Without a doubt, gaps in our collective knowledge of the benefits of home-based records exists and these gaps need to be filled. But let's not lose the momentum that has been built over the past several years to re-energize the functional importance of home-based records within immunization service delivery.
Recommendations. Two primary recommendations resulted from the Guideline Development Group (GDG) consultations. These include:
- The use of home-based records, as a complement to facility-based records, is recommended for the care of pregnant women, mothers, newborns and children, to improve care-seeking behaviours, male involvement and support in the household, maternal and child home care practices, infant and child feeding, and communication between health providers and women/caregivers. (Low-certainty evidence)
- There was insufficient evidence available to determine if any specific type, format or design of home-based records is more effective. Policy-makers should involve stakeholders to discuss the important considerations with respect to type, content and implementation of home-based records.
Rationale. The rationale for these recommendations was as follows.
The GDG considered the evidence presented and judged that, overall, the certainty of evidence of the effectiveness of home-based records was low. They recognized that the existing evidence base has limitations, including: the small number of studies found, half of which were conducted in high-income countries; the age of these, with some conducted before 2000; and the variety in the studies, which looked at different types of home-based records and measured a broad array of outcomes.
The impact varied by outcome. Some studies showed a positive effect on maternal health immunization care-seeking, outcomes related to a supportive home environment for maternal and child health (MCH) care, improved infant feeding and other child health care practices, improved child growth and development, improved continuity of care across MCH, and improved communication with health providers. However, there was also no significant effect reported on many maternal, newborn and child care-seeking and care practice outcomes. For many outcomes, no studies were found.
Although the evidence base has its limitations, the GDG determined that the desirable effects outweigh any undesirable effects, and also considered in their judgements the fact that home-based records have a long history and are implemented in at least 163 countries. Furthermore, they considered the qualitative evidence that reports women, caregivers and providers from a variety of settings value different forms of home-based records. The GDG also noted that home-based records contribute to a larger objective of ensuring the right to access to information and are in line with global efforts for people-centred care, which WHO embraces.
Remarks. Further remarks around these recommendations included the following.
- In remote and fragile settings, where health systems are weak or where health information systems are absent or poor, and in locations where caregivers may use multiple health facilities, home-based records may be of greater value than in more developed settings and health systems.
- Concerns about the privacy of online or electronic records were reported in studies. The GDG highlighted the potential sensitivity of information in home-based records on HIV testing, status or treatment. Careful consideration should be given as to what personal information is necessary to include in home-based records, to avoid stigma and discrimination.
- Countries currently using home-based records should consider appropriate use, design and content, as well as sustainable financing to maximize their use and impact.
- Additional research is needed on the benefits of using home-based records for recording information on single aspects of care, versus home-based records that include wider MNCH aspects for health education purposes. Evidence was not available at this time to inform this priority question for countries.