Evidence of a causal link between health outcomes, insurance coverage, and a policy to expand access: experimental data from children in the Philippines. A Systematic Review of The Impact of Improved Housing Interventions on Health In Low And Middle Income Tropical Settings. mHealth Interventions in Low and Middle-Income Countries: A Systematic Review Conducting experimental research in marginalised populations: clinical and methodological implications from a mixed-methods randomised controlled trial in Kenya Effectiveness and spillover of an after-school health promotion program for Hispanic elementary school children. The impact of cash transfers on social determinants of health and health inequalities in Sub-Saharan Africa: a systematic review protocol Improving access to services and interactions with clients in Guatemala: the value of distance learning Evaluating a Large-Scale Community-Based Intervention to Improve Pregnancy and Newborn Health Among the Rural Poor in India. Systematic reviews of health effects of social interventions: 2. Best available evidence: how low should you go? Improving the reporting of public health intervention research: advancing TREND and CONSORT. Effect of Removing Direct Payment for Health Care on Utilisation and Health Outcomes in Ghanaian Children: A Randomised Controlled Trial The effects of improving hospital physicians working conditions on patient care: a prospective, controlled intervention study Evaluating a streamlined clinical tool and educational outreach intervention for health care workers in Malawi: the PALM PLUS case study A systematic review of online interventions for mental health in low and middle income countries: a neglected field Evaluating the health effects of social interventions Improving rural cancer patients' outcomes: a group-randomized trial. Assessing the incremental effects of combining economic and health interventions: the IMAGE study in South Africa.
In this paper , we present evidence on the health effects of a health insurance intervention targeted to poor children using data from a r and omized policy experiment known as the Quality Improvement Demonstration Study . Among study participants , using a difference-in-difference regression model , we estimated a 9 - 12 and 4 - 9 percentage point reduction in the likelihood of wasting and having an infection , respectively , as measured by a common biomarker C-reactive Protein . Interestingly , these benefits were not apparent at the time of discharge ; the beneficial health effects were manifest several weeks after release from the hospital 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 The purpose of this review was to determine whether mHealth interventions were effective in low- and middle-income countries in order to create a baseline for the evidence to support mHealth in developing countries . Studies were identified by search ing Medline on 02 October 2014 for articles published in the English language between January 2000 and September 2014 . Inclusion criteria were : 1 ) written in English , 2 ) completion of an mHealth intervention in a low or middle-income country , 3 ) measurement of patient outcomes , and 4 ) participants 18 years of age or older . 7,920 titles were review ed and 7 were determined eligible based on inclusion criteria . Interventions included a cluster r and omized trial , mixed methods study , retrospective comparison of an opt-in text message program , a two-arm proof of concept , single arm trial , a r and omized trial , and a single subject design . Five out of seven of the studies showed significant difference between the control and intervention . Currently there is little evidence on mHealth interventions in developing countries , and existing studies are very diverse ; however initial studies show changes in clinical outcomes , adherence , and health communication , including improved communication with providers , decrease in travel time , ability to receive expert advice , changes in clinical outcomes , and new forms of cost-effective education . While this initial review is promising , more evidence is needed to support and direct system-level re source investment ABSTRACT Experimental studies to test interventions for people living with HIV in low- and middle-income countries are essential to ensure appropriate and effective clinical care . The implication s of study participation on outcome data in such population s have been discussed theoretically , but rarely empirically examined . We aim ed to explore the effects of participating in a r and omised controlled trial conducted in an HIV clinic in Mombasa , Kenya . We report qualitative data from the Treatment Outcomes in Palliative Care trial , which evaluated the impact of a nurse-led palliative care intervention for HIV positive adults on antiretroviral therapy compared to st and ard care . Participants in both arms attended five monthly quantitative data collection appointments . Post-trial exit , 10 control and 20 intervention patients participated in semi-structured qualitative interviews , analysed using thematic analysis . We found benefit attributed to the compassion of the research team , social support , communication , completion of patient reported outcome measures ( PROMs ) and material support ( transport reimbursement ) . Being treated with compassion and receiving social support enabled participants to build positive relationships with the research team , which improved mental health and well-being . Open and non-judgmental communication made participants feel accepted . Participants described how repeated completion of the PROMs was a prompt for reflection , through which they began to help themselves and self-care . Participant reimbursements relieved financial hardship and enabled them to fulfil their social responsibilities , enhancing self-worth . These findings emphasise the importance of compassion , support and effective communication in the clinical encounter , particularly in stigmatised and isolated population s , and the potential of the integration of simple PROMs to improve patient outcomes . Participation in research has unexpected positive benefits for participants , which should be taken into account when design ing research in similar population s. Research ers should be aware of the effects of financial reimbursement and contact with research ers in isolated and impoverished communities OBJECTIVES We evaluated the effectiveness and spillover of an after-school health education and physical activity program among Hispanic elementary school children . METHODS In fall 2008 , students in third through fifth grade s in 6 schools in El Paso , Texas ( n = 901 ) , were r and omized to intervention ( n = 292 participants ) or control ( n = 354 ) classrooms ( 4 unknown ) . Intervention classrooms also contained a spillover group ( n = 251 ) that did not join the after-school program but that completed measurements and surveys . The intervention was a 12-week culturally tailored after-school program meeting twice a week . Four-month outcomes were body mass index , aerobic capacity , and dietary intentions and knowledge . We calculated intervention exposure as the proportion of after-school participants per classroom . RESULTS Intervention exposure predicted lower body mass index ( P = .045 ) , higher aerobic capacity ( P = .012 ) , and greater intentions to eat healthy ( P = .046 ) for the classroom at follow-up . Intervention effectiveness increased with increasing proportions of intervention participants in a classroom . Non participants who had classroom contact with program participants experienced health improvements that could reduce their risk of obesity . CONCLUSIONS Spillover of beneficial intervention effects to non participants is a valuable public health benefit and should be part of program impact assessment 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 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 Objectives . We evaluated the effectiveness of the Sure Start project , which was implemented in 7 districts of Uttar Pradesh , India , to improve maternal and newborn health . Methods . Interventions were implemented at 2 r and omly assigned levels of intensity . Forty percent of the areas received a more intense intervention , including community-level meetings with expectant mothers . A baseline survey consisted of 12 000 women who completed pregnancy in 2007 ; a follow-up survey was conducted for women in 2010 in the same villages . Our quantitative analyses provide an account of the project 's impact . Results . We observed significant health improvements in both intervention areas over time ; in the more intensive intervention areas , we found greater improvements in care-seeking and healthy behaviors . The more intensive intervention areas did not experience a significantly greater decline in neonatal mortality . Conclusions . This study demonstrates that community-based efforts , especially mothers ' group meetings design ed to increase care-seeking and healthy behaviors , are effective and can be implemented at large scale Study objective : There is little guidance on how to select the best available evidence of health effects of social interventions . The aim of this paper was to assess the implication s of setting particular inclusion criteria for evidence synthesis . Design : Analysis of all relevant studies for one systematic review , followed by sensitivity analysis of the effects of selecting studies based on a two dimensional hierarchy of study design and study population . Setting : Case study of a systematic review of the effectiveness of interventions in promoting a population shift from using cars towards walking and cycling .  Main results : The distribution of available evidence was skewed . Population level interventions were less likely than individual level interventions to have been studied using the most rigorous study design s ; nearly all of the population level evidence would have been missed if only r and omised controlled trials had been included . Examining the studies that were excluded did not change the overall conclusions about effectiveness , but did identify additional categories of intervention such as health walks and parking charges that merit further research , and provided evidence to challenge assumptions about the actual effects of progressive urban transport policies . Conclusions : Unthinking adherence to a hierarchy of study design as a means of selecting studies may reduce the value of evidence synthesis and reinforce an “ inverse evidence law ” whereby the least is known about the effects of interventions most likely to influence whole population s. Producing generalisable estimates of effect sizes is only one possible objective of evidence synthesis . Mapping the available evidence and uncertainty about effects may also be important BACKGROUND Evidence -based public health decision-making depends on high quality and transparent accounts of what interventions are effective , for whom , how and at what cost . Improving the quality of reporting of r and omized and non-r and omized study design s through the CONSORT and TREND statements has had a marked impact on the quality of study design s. However , public health users of systematic review s have been concerned with the paucity of synthesized information on context , development and rationale , implementation processes and sustainability factors . METHODS This paper examines the existing reporting frameworks for research against information sought by users of systematic review s of public health interventions and suggests additional items that should be considered in future recommendations on the reporting of public health interventions . RESULTS Intervention model , theoretical and ethical considerations , study design choice , integrity of intervention/process evaluation , context , differential effects and inequalities and sustainability are often overlooked in reports of public health interventions . CONCLUSION Population health policy makers need synthesized , detailed and high quality a priori accounts of effective interventions in order to make better progress in tackling population morbidities and inequalities . Adding simple criteria to reporting st and ards will significantly improve the quality and usefulness of published evidence and increase its impact on public health program planning Background Delays in accessing care for malaria and other diseases can lead to disease progression , and user fees are a known barrier to accessing health care . Governments are introducing free health care to improve health outcomes . Free health care affects treatment seeking , and it is therefore assumed to lead to improved health outcomes , but there is no direct trial evidence of the impact of removing out-of-pocket payments on health outcomes in developing countries . This trial was design ed to test the impact of free health care on health outcomes directly . Methods and Findings 2,194 households containing 2,592 Ghanaian children under 5 y old were r and omised into a prepayment scheme allowing free primary care including drugs , or to a control group whose families paid user fees for health care ( normal practice ) ; 165 children whose families had previously paid to enrol in the prepayment scheme formed an observational arm . The primary outcome was moderate anaemia ( haemoglobin [ Hb ] < 8 g/dl ) ; major secondary outcomes were health care utilisation , severe anaemia , and mortality . At baseline the r and omised groups were similar . Introducing free primary health care altered the health care seeking behaviour of households ; those r and omised to the intervention arm used formal health care more and nonformal care less than the control group . Introducing free primary health care did not lead to any measurable difference in any health outcome . The primary outcome of moderate anaemia was detected in 37 ( 3.1 % ) children in the control and 36 children ( 3.2 % ) in the intervention arm ( adjusted odds ratio 1.05 , 95 % confidence interval 0.66–1.67 ) . There were four deaths in the control and five in the intervention group . Mean Hb concentration , severe anaemia , parasite prevalence , and anthropometric measurements were similar in each group . Families who previously self-enrolled in the prepayment scheme were significantly less poor , had better health measures , and used services more frequently than those in the r and omised group . Conclusions In the study setting , removing out-of-pocket payments for health care had an impact on health care-seeking behaviour but not on the health outcomes measured . Trial registration : Clinical Trials.gov ( # NCT00146692 ) Background Physicians , particularly in hospitals , suffer from adverse working conditions . There is a close link between physicians ’ psychosocial work environment and the quality of the work they deliver . Our study aim ed to explore whether a participatory work- design intervention involving hospital physicians is effective in improving working conditions and quality of patient care . Methods A prospect i ve , controlled intervention study was conducted in two surgical and two internal departments . Participants were 57 hospital physicians and 1581 in patients . The intervention was a structured , participatory intervention based on continuous group meetings . Physicians actively analyzed problematic working conditions , developed solutions , and initiated their implementation . Physicians ’ working conditions and patients ’ perceived quality of care were outcome criteria . These variables were assessed by st and ardized question naires . Additional data on implementation status were gathered through interviews . Results Over the course of ten months , several work-related problems were identified , categorized , and ten solutions were implemented . Post-intervention , physicians in the intervention departments reported substantially less conflicting dem and s and enhanced quality of cooperation with patients ’ relatives , compared to control group physicians . Moreover , positive changes in enhanced colleague support could be attributed to the intervention . Regarding patient reports of care quality of care , patient ratings of physicians organization of care improved for physicians in the intervention group . Five interviews with involved physicians confirm the plausibility of obtained results , provide information on implementation status and sustainability of the solutions , and highlight process-related factors for re- design interventions to improve hospital physicians work . Conclusions This study demonstrates that participatory work design for hospital physicians is a promising intervention for improving working conditions and promoting patient quality of care 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 . Low and middle income countries ( LMICs ) are facing an increase of the impact of mental health problems while confronted with limited re sources and limited access to mental health care , known as the ‘ mental health gap ’ . One strategy to reduce the mental health gap would be to utilize the internet to provide more widely-distributed and low cost mental health care . We undertook this systematic review to investigate the effectiveness and efficacy of online interventions in LMICs . Methods . We systematic ally search ed the data -bases PubMed , PsycINFO , JMIR , and additional sources . MeSH terms , Thesaurus , and free text keywords were used . We included all r and omized controlled trials ( RCTs ) of online interventions in LMICs . Results . We found only three articles reported results of RCTs on  online interventions for mental health conditions in LMICs , but none of these interventions was compared with an active control condition . Also , the mental health conditions were diverse across the three studies . Conclusions . There is a dearth of studies examining the effect of online interventions  in LMICs , so we can not draw a firm conclusion on its effectiveness . However , given the effectiveness of  online interventions in high income countries and sharp increase of internet access in LMICs , online interventions may offer a potential to help reduce the ‘ mental health gap ’ . More studies are urgently needed in LMICs Is no evidence better than any evidence when controlled studies are unethical ? Rigorous evidence on the health effects of social interventions is scarce1 2 despite calls for more evidence from r and omised studies .3 One reason for the lack of such experimental research on social interventions may be the perception among research ers , policymakers , and others that r and omised design s belong to the biomedical world and that their application to social interventions is both unethical and simplistic.4 Applying experimental design s to social interventions may be problematic but is not always impossible and is a desirable alternative to uncontrolled experimentation.3 However , even when r and omised design s have been used to evaluate social interventions , opportunities to incorporate health measures have often been missed.5 For example , income supplementation is thought to be a key part of reducing health inequalities,6 but rigorous evidence to support this is lacking because most r and omised controlled trials of income supplementation have not included health measures .5 Current moves to increase uptake of benefits offer new opportunities to establish the effects of income supplements on health . In attempting to design such a study , however , we found that r and omised or other controlled trials were difficult to justify ethically , and our eventual design was rejected by funders . # # # # Box 1 Attendance allowance A pilot study carried out by one of us ( RH ) showed substantial health gains  among elderly people after receipt of attendance allowance . We therefore decided to pursue a full scale study of the health effects of income supplementation . CONTEXT Significant barriers exist in the delivery of state-of-the-art cancer care to rural population s. Rural providers ' knowledge and practice s , their rural health care delivery systems , and linkages to cancer specialists are not optimal ; therefore , rural cancer patient outcomes are less than achievable . PURPOSE To test the effects of a strategy targeting rural providers and their practice environment on patient travel for care , satisfaction , economic barriers , and health-related quality of life . METHODS A group-r and omized trial was conducted with 18 rural communities in the north- central United States . Twelve of these communities were included and defined as the unit of analysis for the patient outcomes portion of the study . The intervention targeted rural providers and their practice environment . The subjects were patients with breast , colorectal , lung , and prostate cancers from the rural communities . The main outcomes were patients ' travel to obtain health care , satisfaction with care , perceptions of economic barriers to care , and health-related quality of life . In total , 881 patients were included . RESULTS Group r and omization was balanced . Travel for health care was significantly reduced in the community group exposed to the intervention during months 13 to 24 following cancer diagnosis . The mean miles traveled per patient were 1,326 ( SE = 306 ) for the experimental group and 2,186 ( SE = 347 ) for the control group ( P = 0.03 ) . No significant differences in satisfaction with care , economic barriers to care , or health-related quality of life were found . CONCLUSIONS The intervention significantly reduced  cancer patient travel for health care , which suggests that access to care improved in the experimental group . The results of this study do not allow conclusion that there was no effect on other patient outcomes . The results supported the study 's conceptual framework and many of its hypotheses OBJECTIVE To explore whether adding a gender and HIV training programme to microfinance initiatives can lead to health and social benefits beyond those achieved by microfinance alone . METHODS Cross-sectional data were derived from three r and omly selected matched clusters in rural South Africa : ( i ) four villages with 2-year exposure to the Intervention with Microfinance for AIDS and Gender Equity ( IMAGE ) , a combined microfinance-health training intervention ; ( ii ) four villages with 2-year exposure to microfinance services alone ; and ( iii ) four control villages not targeted by any intervention .  Adjusted risk ratios ( aRRs ) employing village-level summaries compared associations between groups in relation to indicators of economic well-being , empowerment , intimate partner violence ( IPV ) and HIV risk behaviour . The magnitude and consistency of aRRs allowed for an estimate of incremental effects . FINDINGS A total of 1409 participants were enrolled , all female , with a median age of 45 . After 2 years , both the microfinance-only group and the IMAGE group showed economic improvements relative to the control group . However , only the IMAGE group demonstrated consistent associations across all domains with regard to women 's empowerment , intimate partner violence and HIV risk behaviour . CONCLUSION The addition of a training component to group-based microfinance programmes may be critical for achieving broader health benefits . Donor agencies should encourage intersectoral partnerships that can foster synergy and broaden the health and social effects of economic interventions such as microfinance
We identified three primary mechanisms of spillovers : reduced disease transmission , social proximity and substitution of re sources within households .
We found the strongest evidence for spillovers through reduced disease transmission , particularly vaccines and mass drug administration .
In general , the proportion of a population receiving an intervention was associated with improved health .
We found evidence of publication bias for certain spillover estimates but not for total or direct effects .
Conclusions We found the strongest evidence for spillovers from vaccines and mass drug administration to control infectious disease .
There was little high quality evidence of spillovers for other interventions
Background Many interventions delivered to improve health may benefit not only direct recipients but also people in close physical or social proximity .
Our objective was to review all published literature about the spillover effects of interventions on health outcomes in low-middle income countries and to identify methods used in estimating these effects .