Commentary: Replication of influential trial helps international policy Multicenter study of the Lactational Amenorrhea Method (LAM): I. Efficacy, duration, and implications for clinical application. Evaluating a streamlined clinical tool and educational outreach intervention for health care workers in Malawi: the PALM PLUS case study Economic evaluation of participatory learning and action with women’s groups facilitated by Accredited Social Health Activists to improve birth outcomes in rural eastern India [Evaluation of the effect of the health education intervention project "Healthy School"]. General practitioners’ views on the acceptability and applicability of a web-based intervention to reduce antibiotic prescribing for acute cough in multiple European countries: a qualitative study prior to a randomised trial Evaluation of the Safe Care, Saving Lives (SCSL) quality improvement collaborative for neonatal health in Telangana and Andhra Pradesh, India: a study protocol The impact of leadership hubs on the uptake of evidence-informed nursing practices and workplace policies for HIV care: a quasi-experimental study in Jamaica, Kenya, Uganda and South Africa The impact of cash transfers on social determinants of health and health inequalities in Sub-Saharan Africa: a systematic review protocol A Systematic Review of The Impact of Improved Housing Interventions on Health In Low And Middle Income Tropical Settings. Cluster-randomised controlled trials of individual and combined water, sanitation, hygiene and nutritional interventions in rural Bangladesh and Kenya: the WASH Benefits study design and rationale The effect of Self-Help Groups on access to maternal health services: evidence from rural India Economic evaluation of a task-shifting intervention for common mental disorders in India. Institutional delivery in rural India: the relative importance of accessibility and economic status Eliciting public preference for health-care resource allocation in South Korea. Improving access to services and interactions with clients in Guatemala: the value of distance learning Monetary incentives in primary health care and effects on use and coverage of preventive health care interventions in rural Honduras: cluster randomised trial
The World Bank , the Gates Foundation and the World Health Organization promote national child deworming programmes in developing countries.1 They assert these programmes will improve nutritional status , health and school performance , and hence contribute to economic growth . Indeed , the World Health Organization states that deworming contributed to Japan ’s economic boom in the 1950s,2 and Nobel Laureates meeting in Copenhagen ranked deworming as the fourth most important intervention to solve the health problems of the whole world.3 Surprisingly , the evidence base for these cl aims from controlled studies is limited . Critically , according to the Cochrane review which two of us author , there is quite good evidence of no effect for the main biomedical outcomes in deworming , making the broader societal benefits on economic development barely credible ( Figure 1).4 Nevertheless , the advocates increasingly rely on a single large quasi-r and omized trial carried out in Kenya , published in 2004 in Econometrica,5 which reports school attendance . Figure 1 . Conceptual framework used to underpin the effects of deworming programmes on economic growth  in developing countries . Contemporary evidence questions this model , as there is now quite good contemporary evidence , summarized in the Cochrane review , that ... This study has been highly influential . The International Initiative for Impact Evaluation commissioned the London School of Hygiene and Tropical Medicine ( LSHTM ) to replicate the analysis , as the original analysis is ‘ based on econometric approaches and used a language and format that would be unfamiliar to many health care research ers’.6 The replication aim ed to provide detail of the methods and reporting in line with the CONSORT statement . The team are internationally recognized , independent and meticulous in their approach . They agreed a protocol , carefully checked and corrected the raw data , and then re-ran their prespecified analysis .6 Their first paper is a pure replication,7 exactly repeating the authors ’ original analysis . This paper clarifies some method ological details not provided in the original paper , but it also uncovers a series of important coding and analysis errors . Some of the corrected results are consistent with the original findings , but others are quite different . Most notably , the much quoted ‘ positive externalities’—where the benefits of treating children in one school ‘ spill over ’ to benefit children in adjacent schools — vanish in their corrected analysis . Their second paper uses approaches more familiar to epidemiologists , and allows a more thorough exploration of the data .8 There are substantial amounts of missing information , and some unexpected patterns that are difficult to explain . For example , there is a correlation between the number of observations in each school and the reported attendance , with more observations associated with lower attendance reported — except in some of the intervention groups , where more frequent observation is associated with better attendance . This raises the possibility that the process of observation influenced outcome reporting and this was different in control and intervention groups . The second paper confirms an association with higher attendance in the deworming schools when stratified by year , but found the combined estimate across years was much larger , and the authors caution the validity of the combined year estimate : this may be due to the stepped-wedge design where the combined year estimate includes a before and after comparison ; or it may be due to the problems with secular and group effects of the number of observations of school attendance varying . To further complicate matters , there was also a concurrent ‘ School Assistance Program ’ ( SAP ) evaluating five other interventions in 27/75 of the study schools , which was not part of the r and omized intervention . Attendance patterns differed on the basis of involvement in the SAP , which the authors suggest could well lead to bias.8 One of the critical points the LSHTM papers make is that the administration of the deworming drugs was part of a ‘ complex health education and drug treatment intervention’.8 The intervention schools also received regular public health lectures , wall charts and teacher training on worm prevention . Interestingly , the pure replication shows very similar impacts of the intervention on children in the intervention schools irrespective of whether they took the deworming medicine or not.7 For Miguel and colleagues , they term this as ‘ indirect within-school effects ’ of deworming , but equally the effects could be due to the non-specific effects of the health promotion interventions in the intervention schools . So where does this take us ? There is a small effect on school attendance for sure , but this should not be over-interpreted , as the LSHTM authors say , given the concerns raised regarding the risk of bias , and the independent effects on school attendance of the programme of health promotion . In addition , the study shows that allocation to the deworming group does not influence student progress , as the re- analysis shows clearly no evidence of a difference in examination performance between deworming and control groups.7,8 In the context of the global evidence base , there is only one other study that has examined school attendance with no obvious effect shown.4 Given all these uncertainties , we simply do n’t know if there is truly an effect on school attendance from the data , in taking all these factors into account formally in a GRADE analysis .4 But what weakens the case of deworming still further is that there is now quite good evidence of no effect for most of the main outcomes ( Figure 1 ) , including nutritional status , haemoglobin , cognition and school performance . This is important because without these effects it seems implausible that deworming itself would have an independent effect on school attendance or economic development . Obviously children infected with worms should be treated . Trials from over 20 years ago in an area of Kenya where all the children were heavily infected showed benefit . Another trial in India showed benefit , but subsequent trials in the same area failed to show an effect.4,9 So deworming may have helped in these exceptional , heavily infected , untreated population s from another decade , but this is scarcely a solid base for contemporary policy : public health nutrition has changed , worm burden has declined and this probably accounts for the lack of effect on biomedical outcomes in contemporary studies .10 We have been perplexed by the un question ing belief behind deworming in the advocates , and have found it is deep rooted in American history . The Rockefeller Sanitary Commission in 1909 sought to eradicate hookworm in the Southern USA population , where it was seen as a cause of ‘ some of the proverbial laziness of the poorer classes ’ and to improve worker productivity ; these were extended with the Rockefeller International Health Commission established in 1913.11 The beliefs and assumptions appear to continue , with ‘ Deworm the World ’ aim ing to deworm 220 million children in India during 2015.12 What have we learned from this ? Certainly that replication is a valuable process , not least for errors that have the potential to mislead , but also to provide a much better interpretation of the potential biases in studies . In terms of policies in deworming , it suggests donors and Nobel Prize winners need to be aware of their prior assumptions , and base decisions on the all the evidence from reliable studies within a systematic review , not just select a single study . They need to look at all relevant outcomes , not just one . They need to consider bias and confounding . Our view is that current promotion of community deworming is certainly a panacea : a single solution to multiple problems in low- and middle-income countries , and that the belief that deworming will impact substantially on economic development seems delusional when you look at the results of reliable controlled trials . This is a view , based on over 15 years of engagement with critically appraising the literature in this field.13 We recommend anyone responsible for public or philanthropic money going to large scale deworming to read these replication studies , the original publication , the authors ’ responses to the replication and the 2015 version of the Cochrane review that includes corrections from these replications plus data from five further studies , including the recently published DEVTA study of 2 million children.4,14 Then make up your own mind . Conflict of interest : PG and DTR are authors of a Cochrane review of community deworming programmes . PG is funded by the Department for International Development to provide reliable independent systematic review s for the benefit of developing countries ; PG receives salary support from Countdown , a DFID-supported research grant in programmatic implementation of neglected tropical disease programmes A multicenter study of the Lactational Amenorrhea Method ( LAM )  was carried out to test the acceptability and efficacy of the method . Additionally , the data are used to test new constructs for improvement of method criteria . A protocol was design ed at the Institute for Reproductive Health ( IRH ) , Department of Obstetrics and Gynecology , Georgetown University Medical Center , a World Health Organization ( WHO ) Collaborating Center , and was review ed and modified in collaboration with the co-sponsors , the World Health Organization and the South to South Cooperation for Reproductive Health , and the principal investigators from each site . Data were gathered prospect ively on  LAM acceptors at 11 sites . Data were entered and cleaned on-site and further cleaned and analyzed at IRH , using country-level and pooled data to produce descriptive statistics and life tables . The 98+% efficacy of LAM is confirmed in a wide variety of setting s. In addition , the results yield insight on the possibility of continued use beyond 6 months . LAM is found to be highly effective as an introductory postpartum method when offered in a variety of cultures , health care setting s , socio-economic strata , and industrial and developing country locales . In addition , LAM  acceptance complements breastfeeding behaviors without ongoing breastfeeding support services . The parameters studied yield high efficacy and method continuation . Therefore , the basic tenets of the 1995 Bellagio consensus on LAM is reconfirmed and it is recommended that LAM be reconfirmed and it is recommended that LAM be incorporated into hospital , maternity , family planning , maternal and child health , and other primary health care setting Background Nearly 3 million people in re source -poor countries receive antiretrovirals for the treatment of HIV/AIDS , yet millions more require treatment . Key barriers to treatment scale up are shortages of trained health care workers , and challenges integrating HIV/AIDS care with primary care . The research PALM PLUS ( Practical Approach to Lung Health and HIV/AIDS in Malawi ) is an intervention design ed to simplify and integrate existing Malawian national guidelines into a single , simple , user-friendly guideline for mid-level health care workers . Training utilizes a peer-to-peer educational outreach approach . Research is being undertaken to evaluate this intervention to generate evidence that will guide future decision-making for consideration of roll out in Malawi . The research consists of a cluster r and omized trial in 30 public health centres in Zomba District that measures the effect of the intervention on staff satisfaction and retention , quality of patient care , and costs through quantitative , qualitative and health economics methods . Results and outcomes In the first phase of qualitative inquiry respondents from intervention sites demonstrated in-depth knowledge of PALM PLUS compared to those from control sites . Participants in intervention sites felt that the PALM PLUS tool empowered them to provide better health services to patients . Interim staff retention data shows that there were , on average , 3 to 4 staff departing from the control and intervention sites per month . Additional qualitative , quantitative and economic analyses are planned . The partnershipDignitas International and the Knowledge Translation Unit at the University of Cape Town Lung Institute have led the adaptation and development of the PALM PLUS intervention , using experience gained through the implementation of the South African precursor , PALSA PLUS . The Malawian partners , REACH Trust and the Research Unit at the Ministry of Health , have led the qualitative and economic evaluations . Dignitas and Ministry of Health have facilitated interaction with implementers and policy-makers . Challenges and successesThis initiative is an example of South-South knowledge translation between South Africa and Malawi , mediated by a Canadian academic-NGO hybrid . Our success in developing and rolling out PALM PLUS in Malawi suggests that it is possible to adapt and implement this intervention for use in other re source -limited setting Background Neonatal mortality remains unacceptably high in many low and middle-income countries , including India . A community mobilisation intervention using participatory learning and action with women ’s groups facilitated by Accredited Social Health Activists ( ASHAs ) was conducted to improve maternal and newborn health . The intervention was evaluated through a cluster-r and omised controlled trial conducted in Jharkh and and Odisha , eastern India . This aims to assess the cost-effectiveness this intervention . Methods Costs were estimated from the provider ’s perspective and calculated separately for the women ’s group intervention and for activities to strengthen Village Health Sanitation and Nutrition Committees ( VHNSC ) conducted in all trial areas . Costs were estimated at 2017 prices and converted to US dollar ( USD ) . The incremental cost-effectiveness ratio ( ICER ) was calculated with respect to a do-nothing alternative and compared with the WHO thresholds for cost-effective interventions . ICERs were calculated for cases of neonatal mortality and disability-adjusted life years ( DALYs ) averted . Results The incremental cost of the intervention was USD 83 per averted DALY ( USD 99 inclusive of VHSNC strengthening costs ) , and the incremental cost per newborn death averted was USD 2545 ( USD 3046 inclusive of VHSNC strengthening costs ) . The intervention was highly cost-effective according to WHO threshold , as the cost per life year saved or DALY averted was less than India ’s Gross Domestic Product ( GDP ) per capita . The robustness of the findings to assumptions was tested using a series of one-way sensitivity analyses . The sensitivity analysis does not change the conclusion that the intervention is highly cost-effective . Conclusion Participatory learning and action with women ’s groups facilitated by ASHAs was highly cost-effective to reduce  neonatal mortality in rural setting s with low literacy levels and high neonatal mortality rates . This approach could effectively complement facility-based care in India and can be scaled up in comparable high mortality setting UNLABELLED Contemporary health-education intervention programs are increasingly used as a tool for improving health of school children  [ 1 - 4 ] . Since 1992 a Network of 13 elementary Health Promoting Schools established in Yugoslavia ( though not yet admitted to the European Network ) has been operational . The Project was approved by the Ministries of Health , Education and Ecology from the very beginning , and financially supported by the Government of Serbia since 1995 . The team of up to 40 health professionals , school principals and school project managers worked together for four years to change the working conditions in schools knowledge , attitudes and behaviour of school children and staff in order to improve their health [ 5 ] . The goal of this paper is to present results of health education intervention in changing of hygienic conditions in schools , as well as some of the attitudes , behaviour and knowledge of pupils and their parents . METHOD The study took place before and after the intervention -- at two points in time -- during 1993 and 1996 . The tri-angular approach including ( 1 ) pupils , ( 2 ) schools ( teachers , school environment ) , and ( 3 ) parents , was used . A r and om pretest and post-test study design with control group ( 12 experimental and two control schools ) has been implemented . The multiphase cluster sample was employed in order to represent all of the country typical regions . Six types of especially design ed question naires were used to provide comparable variables in the sample of pupils , their parents and teachers . Exception were 1st- grade rs and 4th- grade rs for whom information were gathered by means of a " draw- and -write " investigation technique [ 6 ] . The response rate was 88.70 % before and 98.28 % after intervention . Data were analyzed by descriptive and inferential statistics using SPSS/PC software . RESULTS Schools are somewhat less overcrowded , much cleaner and better maintained after the four-year intervention . Toilets are in a better condition , but there is still much more to be done . The 1st- and 4th- grade rs , surveyed by the draw- and -write method , mentioned numerous ways of keeping and improving health , which were summarized as fifteen health-improvement measures ( Graph 1 ) . The most frequently mentioned measures were nutrition , physical activity , general hygiene , oral and dental hygiene , sleeping and fresh air . Each of these measures was mentioned by over 20 % of the surveyed pupils . Eleven of 15 variables showed significant increase in frequencies ( at the level of at least p < 0.01 ) after the intervention . As an indicator of a nutrition behaviour , the regularity of main meals is analyzed ( Graph 2 ) . The majority of children eat regularly and the difference before and after intervention is significant only for the school meal ( c2 = 30.715 , p < 0.001 ) . Although over 70 % of children learn that general hygiene is good for health in junior grade rs , only about little more than 30 % of senior grade rs have a bath or shower every day , while others only once or twice a week . The differences are significant before and after the intervention ( c2 = 10.648 , p < 0.05 ) only for everyday practice . More than 90 % of senior- grade pupils brush their teeth at least once or several times a day . Over 60 % of children in our survey go in for sport , whereas about 20 % never do so . It seems that the intervention contributed symbolically to this practice important for health , though before-after difference is significant ( c2 = 6.673 , p < 0.05 ) . However , in the control group schools children have much less physical activity in 1996 , and this difference is significant ( c2 = 14.070 , p < 0.010 ) . The psycho-emotional status of Yugoslav young people is strongly influenced by the situation in the country the war , the economic disaster and the impact of international sanctions . Consequently , more than one-fourth of the children complained of frequent exhaustion and concentration problems , which their parents also noticed . ( ABSTRACT TRUNCATED Background Interventions to promote prudent antibiotic prescribing by general practitioners ( GPs ) have often only been developed for use in one country . We aim ed to develop an intervention which would be appropriate to implement in multiple European countries in order to offer greater benefit to practice whilst using fewer re sources . The INTRO ( INternet TRaining for antibiOtic use ) intervention needed to deliver training to GPs in the use of C-Reactive Protein ( CRP ) near patient tests to help diagnose acute cough and in communication skills to help explain prescribing decisions to patients . We explored GPs ’ views on the initial version of INTRO to test acceptability and potentially increase applicability for use in multiple countries before the start of a r and omised trial . Method 30 GPs from five countries ( Belgium , Engl and , the Netherl and s , Pol and and Spain ) , were interviewed using a “ think aloud ” approach . GPs were asked to work through the intervention and discuss their views on the content and format in relation to following the intervention in their own practice . GPs viewed the same intervention but versions were created in five language s. Data were coded using thematic analysis . Results GPs in all five countries reported the view that the intervention addressed an important topic , was broadly acceptable and feasible to use , and would be a useful tool to help improve clinical practice . However , GPs in the different countries identified aspects of the intervention that did not reflect their national culture or healthcare system . These included perceived differences in communication style used in the consultation , consultation length and the stage of illness at which patient typically presented . Conclusion An online intervention to support evidence -based use of antibiotics is acceptable and feasible to implement amongst GPs in multiple countries . However , tailoring of the intervention to suit national context s was necessary by adding local information and placing more emphasis on the fact that GPs could select the communication skills they wished to use in practice . Using think aloud methods to complement the development of interventions is a powerful method to identify regional context ual barriers to intervention implementation ABSTRACT Background : The collaborative quality improvement approach proposed by the Institute for Healthcare Improvement has the potential to improve coverage of evidence -based maternal and newborn health practice s. The Safe Care , Saving Lives initiative supported the implementation of 20 evidence -based maternal and newborn care practice s , targeting labour wards and neonatal care units in 85 public and private hospitals in Telangana and And hra Pradesh , India . Objective : We present a protocol for the evaluation of this programme which aims to ( a ) estimate the effect of the initiative on evidence -based care practice s and mortality ; ( b ) evaluate the mechanisms leading to changes in adherence to evidence -based practice s , and their relationship with context ual factors ; ( c ) explore the feasibility of scaling-up the approach . Methods : The mixed- method evaluation is based on a plausibility design nested within a phased implementation . The 29 non-r and omly selected hospitals comprising wave II of the programme were compared to the 31 remaining hospitals where the quality improvement approach started later . We assessed mortality and adherence to evidence -based practice s at baseline and endline using abstract ion of registers , checklists , observations and interviews in intervention and comparison hospitals . We also explored the mechanisms and drivers of change in adherence to evidence -based practice s. Qualitative methods investigated the mechanisms of change in purpose fully selected case study hospitals . A readiness assessment complemented the analysis of what works and why . We used a difference-in-difference approach to estimate the effects of the intervention on mortality and coverage . Thematic analysis was used for the qualitative data . Discussion : This is the first quality improvement collaborative targeting neonatal health in secondary and tertiary hospitals in a middle-income country linked to a government health insurance scheme . Our process evaluation is theory driven and will refine hypotheses about how this quality improvement approach contributes to institutionalization of evidence -based practice Background The enormous impact of HIV on communities and health services in Sub-Saharan Africa and the Caribbean has especially affected nurses , who comprise the largest proportion of the health workforce in low- and middle-income countries ( LMICs ) . Strengthening action-based leadership for and by nurses is a means to improve the uptake of evidence -informed practice s for HIV care . Methods A prospect i ve quasi-experimental study in Jamaica , Kenya , Ug and a and South Africa examined the impact of establishing multi-stakeholder leadership hubs on evidence -informed HIV care practice s. Hub members were engaged through a participatory action research ( PAR ) approach . Three intervention districts were purpose fully selected in each country , and three control districts were chosen in Jamaica , Kenya and Ug and a. WHO level 3 , 4 and 5 health care institutions and their employed nurses were r and omly sample d. Self-administered , vali date d instruments measured clinical practice s ( reports of self and peers ) , quality assurance , work place policies and stigma at baseline and follow-up . St and ardised average scores ranging from 0 to 1 were computed for clinical practice s , quality assurance and work place policies . Stigma scores were summarised as 0 ( no reports ) versus 1 ( one or more reports ) . Pre-post differences in outcomes between intervention and control groups were compared using the Mantel Haenszel chi-square for dichotomised stigma scores , and independent t tests for other measures . For South Africa , which had no control group , pre-post differences were compared using a Pearson chi-square and independent t test . Multivariate analysis was completed for Jamaica and Kenya . Hub members in all countries self-assessed changes in their capacity at follow-up ; these were examined using a paired t test . Results Response  rates among health care institutions were 90.2 and 80.4 % at baseline and follow-up , respectively . Results were mixed . There were small but statistically significant pre-post , intervention versus control district improvements in workplace policies and quality assurance in Jamaica , but these were primarily due to a decline in scores in the control group . There were modest improvements in clinical practice s , workplace policies and quality assurance in South Africa ( pre-post ) ( clinical practice s of self — pre 0.67 ( 95 % CI , 0.62 , 0.72 ) versus post 0.78 ( 95 % CI , 0.73–0.82 ) , p = 0.002 ; workplace policies — pre 0.82 ( 95 % CI , 0.70 , 0.85 ) versus post 0.87 ( 95 % CI , 0.84 , 0.90 ) , p = 0.001 ; quality assurance — pre 0.72 ( 95 % CI , 0.67 , 0.77 ) versus post 0.84 ( 95 % CI , 0.80 , 0.88 ) ) . There were statistically significant improvements in scores for nurses stigmatising patients  ( Jamaica reports of not stigmatising — pre-post intervention 33.9 versus 62.4 % , pre-post control 54.7 versus 64.4 % , p = 0.002— and Kenya pre-post intervention 35 versus 51.6 % , pre-post control 34.2 versus 47.8 % , p = 0.006 ) and for nurses being stigmatised ( Kenya reports of no stigmatisation — pre-post intervention 23 versus 37.3 % , pre-post control 15.4 versus 27 % , p = 0.004 ) . Multivariate results for Kenya and Jamaica were non-significant . Twelve hubs were established ; 11 were active at follow-up . Hub members ( n = 34 ) reported significant improvements in their capacity to address care gaps . Conclusions Leadership hubs , comprising nurses and other stakeholders committed to change and provided with capacity building can collectively identify issues and act on strategies that may improve practice and policy . Overall , hubs did not provide the necessary force to improve the uptake of evidence -informed HIV care in their districts . If hubs are to succeed , they must be integrated within district health authorities and become part of formal , legal organisations that can regularise and sustain them Background There is increasing pressure to address the social determinants of health ( SDoH ) and health inequities through the implementation of culturally acceptable interventions particularly in Sub-Saharan Africa ( SSA ) where health outcomes are generally poor . Available evaluation research on cash transfers ( CTs ) suggests that the programs may influence the wider determinants of health in SSA ; yet , there has been no attempt to synthesize the evidence regarding their contribution to tackling the SDoH and health inequalities . To date , nearly all the review s on CTs ' impact on health have predominantly featured evidence from Latin America with limited transferability to the social , cultural , and political environments in SSA . Therefore , the aim of this study is to undertake a systematic review to assess the role of CTs in tackling the wider determinants of health and health inequalities in SSA . Methods / design A systematic review of published and unpublished literature on CTs ’ impact on health and health determinants covering the period 2000–2016 will be undertaken . Studies will be considered for inclusion if they present quantitative or qualitative data , including all relevant study design s. The SDoH conceptual framework will be used to guide the data extraction process . EPPI Review er software will be used for data management and analysis . Studies included in the review will be analyzed by narrative synthesis and /or meta- analysis as appropriate for the nature of the data retrieved . Discussion This review will provide empirical evidence on the impact of CTs on SDoH to inform CT policy , implementation , and research in SSA . The protocol follows the Preferred Reporting Items for Systematic Review and Meta- Analysis Protocol s ( PRISMA -P ) . Systematic review registration This protocol has been registered with the PROSPERO international prospect i ve register of systematic review s , reference CRD42015025015 PHP289 A SyStemAtic Review of tHe imPAct of imPRoved HouSing inteRventionS on HeAltH in low And middle income tRoPicAl Setting S Butt T1 , Von Seidlein L2 1University College London , London , UK , 2Mahidol Oxford Tropical Medicine Research Unit , Bangkok , Thail and Objectives : Housing has a major impact on human health and wellbeing in the developing world directly ( e.g. through household accidents ) and indirectly ( e.g. through mediating contact between occupants and disease vectors ) . The objective of this review was to investigate the impact of improved housing on health in tropical zones of low and middle income countries . MethOds : A systematic review of major health and architecture data bases was conducted in order to identify records reporting the impact of housing features on the health of people living in tropical regions . Information was extracted and reported using a st and ardised form . Results were classified by study characteristics and qualitative trends explored . Results : We identified 120 studies that met the inclusion criteria . Studies covered vector-borne , gastrointestinal and respiratory diseases and household injuries . 76 were observational , 27 were trials ( including 11 r and omised controlled trials ) , 9 were models and 7 were studies considering economic aspects of  housing interventions . Of the economic studies identified , 3 were cost benefit analysis , 3 were cost per disability-adjusted life year ( DALY ) , while 1 measured burden of disease in DALYs . Outcomes were classified as economic ( 7 ) such as DALYs , direct health ( 57 ) such as incidence of diarrhoea , indirect health such as question naires ( 16 ) or surrogate ( 39 ) such as mosquito counts in a house . cOnclusiOns : There have been a considerable number of studies investigating the impact of housing features on health in tropical regions . Most focused on the impact of one or more housing feature on one or more health outcome . A smaller number of studies looked at whole house interventions and there have been few economic evaluations of improved housing interventions . A holistic approach to assessing health in the context of housing and consideration of issues of economics and implementation would be valuable topics for future research Introduction Enteric infections are common during the first years of life in low-income countries and contribute to growth faltering with long-term impairment of health and development . Water quality , sanitation , h and washing and nutritional interventions can independently reduce enteric infections and growth faltering . There is little evidence that directly compares the effects of these individual and combined interventions on diarrhoea and growth when delivered to infants and young children . The objective of the WASH Benefits study is to help fill this knowledge gap . Methods and analysis WASH Benefits includes two cluster-r and omised trials to assess improvements in water quality , sanitation , h and washing and child nutrition — alone and in combination — to rural households with pregnant women in Kenya and Bangladesh . Geographically matched clusters ( groups of household compounds in Bangladesh and villages in Kenya ) will be r and omised to one of six intervention arms or control . Intervention arms include water quality , sanitation , h and washing , nutrition , combined water+sanitation+h and washing ( WSH ) and WSH+nutrition . The studies will enrol newborn children ( N=5760 in Bangladesh and N=8000 in Kenya ) and measure outcomes at 12 and 24 months after intervention delivery . Primary outcomes include child length-for-age Z-scores and caregiver-reported diarrhoea . Secondary outcomes include stunting prevalence , markers of environmental enteropathy and child development scores ( verbal , motor and personal/social ) . We will estimate unadjusted and adjusted intention-to-treat effects using semiparametric estimators and permutation tests . Ethics and dissemination Study protocol s have been review ed and approved by human subjects review boards at the University of California , Berkeley , Stanford University , the International Centre for Diarrheal Disease Research , Bangladesh , the Kenya Medical Research Institute , and Innovations for Poverty Action . Independent data safety monitoring boards in each country oversee the trials . This study is funded by a grant from the Bill & Melinda Gates Foundation to the University of California , Berkeley . Registration Trial registration identifiers ( http://www . clinical trials.gov ) : NCT01590095 ( Bangladesh ) , NCT01704105 ( Kenya ) Introduction The main challenge for achieving universal health coverage in India is ensuring effective coverage of poor and vulnerable communities in the face of high levels of income and gender inequity in access to health care . Drawing on the social capital generated through women ’s participation in community organizations like SHGs can influence health outcomes . To date , evidence about the impact of SHGs on health outcomes has been derived from pilot-level interventions , some using r and omised controlled trials and other rigorous methods . While the evidence from these studies is convincing , our study is the first to analyse the impact of SHGs at national level . Methods We analyzed the entire data set from the third national District Level Household Survey from 601 districts in India to assess the impact of the presence of SHGs on maternal health service uptake . The primary predictor variable was presence of a SHG in the village . The outcome variables were : institutional delivery ; feeding new-borns colostrum ; knowledge about family planning methods ; and ever used family planning . We controlled for respondent education , wealth , heard or seen health messages , availability of health facilities and the existence of a village health and sanitation committee . Results Stepwise logistic regression shows respondents from villages with a SHG were 19 per cent ( OR : 1.19 , CI : 1.13 - 1.24 ) more likely to have delivered in an institution , 8 per cent ( OR : 1.08 , CI : 1.05 - 1.14 ) more likely to have fed newborns colostrum , have knowledge ( OR : 1.48 , CI 1.39 – 1.57 ) and utilized ( OR : 1.19 , CI 1.11 – 1.27 ) family planning products and services . These results are significant after controlling for individual and village-level heterogeneities and are consistent with existing literature that the social capital generated through women ’s participation in SHGs influences health outcome . Conclusion The study concludes that the presence of SHGs in a village is associated with higher knowledge of family planning and maternal health service uptake in rural India . To achieve the goal of improving public health nationally , there is a need to underst and more fully the benefits of systematic collaboration between the public health community and these grassroots organizations OBJECTIVE To carry out an economic evaluation of a task-shifting intervention for the treatment of depressive and anxiety disorders in primary -care setting s in Goa , India . METHODS Cost-utility and cost-effectiveness analyses based on generalized linear models were performed within a trial set in 24 public and private primary -care facilities . Subjects were r and omly assigned to an intervention or a control arm . Eligible subjects in the intervention arm were given psycho-education , case management , interpersonal psychotherapy and /or antidepressants by lay health workers . Subjects in the control arm were treated by physicians . The use of health-care re sources , the disability of each subject and degree of psychiatric morbidity , as measured by the Revised Clinical Interview Schedule , were determined at 2 , 6 and 12 months . FINDINGS Complete data , from all three follow-ups , were collected from 1243 ( 75.4 % ) and 938 ( 81.7 % ) of the subjects enrolled in the study facilities from the public and private sectors , respectively . Within the public facilities , subjects in the intervention arm showed greater improvement in all the health outcomes investigated than those in the control arm . Time costs were also significantly lower in the intervention arm than in the control arm , whereas health system costs in the two arms were similar . Within the private facilities , however , the effectiveness and costs recorded in the two arms were similar . CONCLUSION Within public primary -care facilities in Goa , the use of lay health workers in the care of subjects with common mental disorders was not only cost-effective but also cost-saving Background Skilled attendance at delivery is an important indicator in monitoring progress towards Millennium Development Goal 5 to reduce the maternal mortality ratio by three quarters between 1990 and 2015 . In addition to professional attention , it is important that mothers deliver their babies in an appropriate setting , where life saving equipment and hygienic conditions can also help reduce the risk of complications that may cause death or illness to mother and child . Over the past decade interest has grown in examining influences on care-seeking behavior and this study investigates the determinants of place of delivery in rural India , with a particular focus on assessing the relative importance of community access and economic status . Methods A descriptive analysis of trends in place of delivery using data from two national representative sample surveys in 1992 and 1998 is followed by a two-level (  child/mother  and  community ) r and om-effects logistical regression model using the second survey to investigate the determinants . Results In this investigation of institutional care seeking for child birth in rural India , economic status emerges as a more crucial determinant than access . Economic status is also the strongest influence on the choice between a private-for-profit or public facility amongst institutional births . Conclusion Greater availability of obstetric services will not alone solve the problem of low institutional delivery rates . This is particularly true for the use of private-for-profit institutions , in which the distance to services does not have a significant adjusted effect . In the light of these findings a focus on increasing dem and for existing services seems the most rational action . In particular , financial constraints need to be addressed , and results support current trials of dem and side financing in India OBJECTIVES To identify the principles the public considers important and the trade-offs between different values in health-care re source allocation practice s. METHODS This study approached the issue in both qualitative and quantitative ways . In a qualitative study , two focus groups discussed the issues of re source allocation in health care . To facilitate the discussion , a simple ranking task and a series of pairwise choice practice s were implemented . A discrete choice experiment survey question naire was also administered to a sample of the general population . Attributes and levels were determined through literature review s and the results from the focus group interview . We used a r and om-effect probit model to assess the effects of each attribute . RESULTS Through the focus group interviews , we found strong public support for the principle of equal opportunity . The participants thought that the severity of disease was the most important criterion when setting priorities . The majority supported the idea that the most disadvantaged should have the highest priority even when their health gains are less than those of others . The discrete choice experiment results showed that the severity of disease , health gains , and patients ' socioeconomic status significantly influence their choices , with each parameter having an expected sign . CONCLUSION The results showed that Koreans support not only health maximization but also equal opportunity , fair re source allocation , and e quality Objective To develop and test a distance-learning programme to improve the quality and efficiency of family planning services in Guatemala . Methods The setting was rural family planning services in Guatemala . The study design was quasi-experimental with one intervention and one control group and with pre- and post-intervention measures . Two staff members from each of 20 r and omly selected health districts were trained as leaders of the training programme . In turn , the 40 trainers trained a total of 240 service providers , under the supervision of four health area facilitators . The results were compared with 20 r and omly selected control health districts . The intervention was a distance-learning programme including 40 in-class hours followed by 120 inservice practice hours spread over a 4-month period . Distinctively , the programme used a cascade approach to training , intensive supervision , and close monitoring and evaluation . Patient flow analysis was used to determine number of contacts , waiting times , and the interaction time between service providers and clients . Consultation observations were used to assess the quality and completeness of reproductive health information and services received by clients . Results The intervention showed a positive impact on reducing the number of contacts before the consultation and client waiting times . More complete services and better quality services were provided at intervention clinics . Some , but not all , of the study objectives were attained . The long-term impact of the intervention is as yet unknown . Conclusion Distance-learning programmes are an effective methodology for training health professionals in rural areas BACKGROUND Scaling-up of effective preventive interventions in child and maternal health is constrained in many developing countries by lack of dem and . In Latin America , some governments have been trying to increase dem and for health interventions by making direct payments to poor households contingent on them keeping up-to- date with preventive health services . We undertook a public health programme effectiveness trial in Honduras to assess this approach , contrasting it with a direct transfer of re sources to local health teams . METHODS 70 municipalities were selected because they had the country 's highest prevalence of malnutrition . They were allocated at r and om to four groups : money to households ; re sources to local health teams combined with a community-based nutrition intervention ; both packages ; and neither . Evaluation surveys of about 5600 households were undertaken at baseline and roughly 2 years later . Pregnant women and mothers of children younger than 3 years old were asked about use of health services ( primary outcome ) and coverage of interventions such as immunisation and growth monitoring  ( secondary outcome ) . Reports were supplemented with data from children 's health cards and government service utilisation data . Analysis was by mixed effects regression , accounting for the municipality-level r and omisation . FINDINGS The household-level intervention had a large impact ( 15 - 20 percentage points ; p<0.01 ) on the reported coverage of antenatal care and well-child check-ups . Childhood immunisation series could thus be started more opportunely , and the coverage of growth monitoring was markedly increased ( 15 - 21 percentage points ; p<0.01 . Measles and tetanus toxoid immunisation were not affected . The transfer of re sources to local health teams could not be implemented properly because of legal complications . INTERPRETATION Conditional payments to households increase the use and coverage of preventive health care interventions
While we found relatively good st and ards of reporting the study ’s question , population , interventions , comparators and conclusions , the overall reporting was poor , and evidence of unfamiliarity with international guidelines was evident ( i.e. absence of incremental analysis , of discounting long-term costs and effects ) .
Analysis or description of place-to-place variability was infrequent .
Use and acceptance of health economic evaluations ( HEEs ) has been much greater in developed than in developing nations .
Nevertheless , while developing countries lag behind in the development of HEE methods , they could benefit from the progress made in other countries and concentrate on ways in which existing methods can be used or would need to be modified to fulfill their specific needs .
HEEs , as context -specific tools , are not easily generalizable from setting to setting .
Existing studies regarding generalizability and transferability of HEEs have primarily been conducted in developed countries .
Therefore , a legitimate question for policy makers in Latin America and the Caribbean region ( LAC ) is to what extent HEEs conducted in industrialized economies and in LAC are generalizable to LAC ( trans-regional ) and to other LAC countries ( intra-regional ) , respectively .