Publications

2018
Garg, CC, et al. 2018. “Costing of three feeding regimens for home-based management of children with uncomplicated severe acute malnutrition from a randomised trial in India”. BMJ Global Health 3 (e000702). Publisher's VersionAbstract

Trial design Three feeding regimens—centrally produced ready-to-use therapeutic food, locally produced readyto-use therapeutic food, and augmented, energy-dense, home-prepared food—were provided in a community setting for children with severe acute malnutrition (SAM) in the age group of 6–59 months in an individually randomised multicentre trial that enrolled 906 children. Foods, counselling, feeding support and treatment for mild illnesses were provided until recovery or 16 weeks.

Methods Costs were estimated for 371 children enrolled in Delhi in a semiurban location after active survey and identification, enrolment, diagnosis and treatment for mild illnesses, and finally treatment with one of the three regimens, both under the research and government setting. Direct costs were estimated for human resources using a price times quantity approach, based on their salaries and average time taken for each activity. The cost per week per child for food, medicines and other consumables was estimated based on the total expenditure over the period and children covered. Indirect costs for programme management including training, transport, non-consumables, infrastructure and equipment were estimated per week per child based on total expenditures for research study and making suitable adjustments for estimations under government setting.

Results No significant difference in costs was found across the three regimens per covered or per treated child. The average cost per treated child in the government setting was estimated at US$56 (<3500 rupees).

Conclusion Home-based management of SAM with a locally produced ready-to-use therapeutic food is feasible, acceptable, affordable and very cost-effective in terms of the disability-adjusted life years saved and gross national income per capita of the country. The treatment of SAM at home needs serious attention and integration into the existing health system, along with actions to prevent SAM.

Trial registration number NCT01705769; Pre-results.

Mazumder, S, et al. 2018. “Kangaroo mother care: using formative research to design an acceptable community intervention”. BMC Public Health 18 (307). Publisher's VersionAbstract

Background: Low and middle income countries (LMICs), including India, contribute to a major proportion of low birth weight (LBW) infants globally. These infants require special care. Kangaroo Mother Care (KMC) in hospitals is a cost effective and efficacious intervention. In institutional deliveries, the duration of facility stay is often short. In LMICs, a substantial proportion of deliveries still occur at home and access to health care services is limited. In these circumstances, a pragmatic choice may be to initiate KMC at home for LBW babies. However, evidence is lacking on benefits of community-initiated KMC (cKMC). Promoting KMC at home without an understanding of its acceptability may lead to limited success.

Methods: We conducted formative research to assess the feasibility, acceptability and adoption of cKMC with the aim of designing an intervention package for a randomised controlled trial in LBW infants in Haryana, India. Qualitative methods included 40 in-depth interviews with recently delivered women and 6 focus group discussions, two each with fathers and grandfathers, grandmothers, and community health workers. A prototype intervention package to promote cKMC was developed and tested in 28 mother-infant pairs (of them, one mother had twins), using Household (HH) trials.

Results: We found that most mothers in the community recognized that babies born small required special care. In spite of not being aware of the practice of KMC, respondents felt that creating awareness of KMC benefits will promote practice. They expressed concerns about doing KMC for long periods because mothers needed rest after delivery. However, the cultural practice of recently delivered women not expected to be doing household chores and availability of other family members were identified as enablers. HH trials provided an opportunity to test the intervention package and showed high acceptability for KMC. Most mothers perceived benefits such as weight gain and increased activity in the infant.

Conclusions: Community-initiated KMC is acceptable by mothers and adoption rates are high. Formative research is essential for developing a strategy for delivery of an intervention.

Trial registration: Trial registration number CTRI/2015/10/006267. Name of Registry: Clinical Trials Registry - India. URL of Registry: http://ctri.nic.in/Clinicaltrials/login.php Date of Registration: 15/10/2015. Date of enrolment of the first participant to the trial: 18/04/2015.

Keywords: Kangaroo mother care, Household trials, Formative research

Moyo, N, et al. 2018. “Access factors linked to maternal deaths in Lundazi district, Eastern Province of Zambia: a case control study analysing maternal death reviews”. BMC Pregnancy and Childbirth 18 (101). Publisher's VersionAbstract

Background: Access factors associated with maternal death are important to understand because they are considered to be an essential measure of women’s health and indicative of the performance of health care systems in any community globally. This study aimed to analyse the access risk factors linked to maternal deaths in Lundazi district of the Eastern Province of Zambia using secondary data obtained from maternal death reviews and delivery registers.

Methods: This was a case-control study with cases being recorded maternal deaths for Lundazi district (n = 100) while controls were randomly selected Lundazi District Hospital deliveries (n = 300) for the period 2010 to 2015. STATA™ (Stata Corporation, Texas, TX, USA) version 12.0 was used to analyse data. Odds ratio and 95% confidence intervals with associated p-values were used to analyse disparities between cases and controls while bivariate and multivariate regression analyses were done to show associations.

Results: The likelihood of experiencing maternal death was 94% less among women who completed their scheduled antenatal care visits than those who did not (OR 0.06, 95% CI = 0.01–0.27, p = < 0.001). Delayed referral associated with maternal deaths and complications were 30% (30) for cases, 12% (37) for controls and 17% (67) for both cases and controls. Long distances, unskilled deliveries were 3%, (15) for both cases and controls with 13% (13) for cases and 1% (2) for controls only.

Conclusion: Antenatal care is important in screening for pre-existing risk conditions as well as complications in early stages of pregnancy that could impact adversely during pregnancy and childbirth. Delay in seeking health care during pregnancy could be minimised if health services are brought closer to the communities to reduce on distances covered by pregnant women in Lundazi. Maternal education appears to influence antenatal health care utilisation because greater knowledge and understanding of the importance of antenatal care might increase the ability to select most appropriate service. Therefore, there is need for Lundazi District Health Office to scale up interventions that motivate women to make at least four scheduled antenatal care visits during pregnancy as recommended by the World Health Organization.

Tumwine, JK, et al. 2018. “Exclusive breastfeeding promotion and neuropsychological outcomes in 5-8 year old children from Uganda and Burkina Faso: Results from the PROMISE EBF cluster randomized trial”. Plos One 13 (2) : e0191001. Publisher's VersionAbstract

Background

The beneficial effects from exclusive breastfeeding (EBF) have been widely acknowledged. We assessed the effect of exclusive breastfeeding promotion by peer counsellors in Uganda and Burkina Faso, on cognitive abilities, social emotional development, school performance and linear growth among 5–8 years old children.

Methods

Children in the PROMISE EBF trial (2006–2008) were re-enrolled in the follow-up PROMISE Saving Brains (SB) study (2013–2015). Caretaker interviews captured sociodemographic characteristics and social emotional development using the parent version of the Strengths and Difficulties Questionnaire (SDQ). Overall cognition and working memory were assessed using the Kaufman Assessment Battery for Children, second edition (KABC2), cognitive flexibility was measured with the Child Category Test (CCT), and attention with the Test of Variables of Attention (T.O.V.A), while school performance was measured by a standardized test on arithmetic and reading. Country-pooled, age adjusted z-scores from each of the above outcomes were entered into a linear regression model controlling for confounders.

Results

The number of children re-enrolled in the intervention and control arms were: 274/396 (69.2%) and 256/369 (69.4%) in Uganda and 265/392 (67.6%) and 288/402 (71.6%) in Burkina Faso. Assessment of cognitive ability showed small and no significant differences, of which general cognition (z-scores, 95% CI) showed the largest mean difference: -0.17 (-0.40; 0.05). Social emotional symptoms were similar across arms. There were no differences in school performance or linear growth for age detected.

Conclusion

Peer promotion for exclusive breastfeeding in Burkina Faso and Uganda was not associated with differences at 5–8 years of age in a range of measures of child development: cognitive abilities, emotion-behaviour-social symptoms or linear growth. This study from sub Saharan Africa did not reconfirm findings elsewhere that have shown an association between exclusive breastfeeding and cognitive performance. This might be due to a number of methodological limitations inherent in the current study. For example since the majority of the children were breastfed, the benefits of the intervention could have been diluted. Other factors such as the mental and HIV status of the mothers (which were not assessed in the current study) could have affected our results. Hence regarding the effect of exclusive breastfeeding on measures of child neurocognitive development in sub Saharan Africa, the jury is still out.

Venkateswaran, Mahima, et al. 2018. “eRegQual—an electronic health registry with interactive checklists and clinical decision support for improving quality of antenatal care: study protocol for a cluster randomized trial”. Trials 19 (54). Publisher's VersionAbstract

Background

Health worker compliance with established best-practice clinical and public health guidelines may be enhanced by customized checklists of care and clinical decision support driven by point-of-care data entry into an electronic health registry. The public health system of Palestine is currently implementing a national electronic registry (eRegistry) for maternal and child health. This trial is embedded in the national implementation and aims to assess the effectiveness of the eRegistry’s interactive checklists and clinical decision support, compared with the existing paper based records, on improving the quality of care for pregnant women.

Methods

This two-arm cluster randomized controlled trial is conducted in the West Bank, Palestine, and includes 120 clusters (primary healthcare clinics) with an average annual enrollment of 60 pregnancies. The intervention tool is the eRegistry’s interactive checklists and clinical decision support implemented within the District Health Information System 2 (DHIS2) Tracker software, developed and customized for the Palestinian context. The primary outcomes reflect the processes of essential interventions, namely timely and appropriate screening and management of: 1) anemia in pregnancy; 2) hypertension in pregnancy; 3) abnormal fetal growth; 4) and diabetes mellitus in pregnancy. The composite primary health outcome encompasses five conditions representing risk for the mother or baby that could have been detected or prevented by high-quality antenatal care: moderate or severe anemia at admission for labor; severe hypertension at admission for labor; malpresentation at delivery undetected during pregnancy; small for gestational age baby at delivery undetected during pregnancy; and large for gestational age baby at delivery. Primary analysis at the individual level taking the design effect of the clustering into account will be performed as intention-to-treat.

Discussion

This trial, embedded in the national implementation of the eRegistry in Palestine, allows the assessment of process and health outcomes in a large-scale pragmatic setting. Findings will inform the use of interactive checklists and clinical decision support driven by point-of-care data entry into an eRegistry as a health systems-strengthening approach.

Trial registration

ISRCTN trial registration number, ISRCTN18008445. Registered on 6 April 2017.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2386-5) contains supplementary material, which is available to authorized users.

Keywords: Interactive checklists, Clinical decision support, Quality of care, Antenatal care, Maternal and newborn health, eHealth, Electronic registry, eRegistries, Health systems, Health surveillance

2017
Chandyo, RK, et al. 2017. “The effects of vitamin B12 supplementation in pregnancy and postpartum on growth and neurodevelopment in early childhood: Study Protocol for a Randomized Placebo Controlled Trial”. BMJ Open 7. Publisher's VersionAbstract
Introduction Vitamin B12 is crucial for normal cell division
and differentiation, and necessary for the development
and myelination of the central nervous system. Pregnant
mothers in resource poor settings are at risk for poor
vitamin B12 status. Poor vitamin B12 status in infancy
is linked to poor growth and neurodevelopment. Brain
development starts from conception, and pregnancy is a
period of rapid growth and development for the brain.
Methods and analysis The study is an individually
randomised double-blind placebo controlled trial in 800
pregnant Nepalese women randomised in a 1:1 ratio. A daily
dose of 50 μg of vitamin B12 or placebo is given to women
from early pregnancy, not later than week 15, until 6 months
after birth. Weekly visits are conducted in order to record
compliance, growth and morbidity. The primary outcomes are
scores on the cognitive, language and motor subscales of the
Bayley Scales of Infant and Toddler Development, Third Edition,
measured at 6 and 12 months of age, and growth (length and
weight) measured at 6 and 12 months of age.
Ethics and dissemination National Health and Research
Council, Nepal (NHRC 253/2016) and Regional Committee
for Medical and Health Research Ethics of Western
Norway (2016/1620/REK vest) have approved the study.
Investigators who have contributed to the conceptualising,
conducting, as well as being involved in the data analyses
and manuscript writing will be eligible for authorship
and be responsible to share outcomes with different
stakeholders through publications and workshops.
The results from this study may support new dietary
guidelines for Nepalese and possibly South Asian pregnant
women that can lead to improved pregnancy outcomes,
neurodevelopment and cognitive functioning in children.
Trial registration number Universal Trial Number:
U1111-1183-4093. Trial registration: clinicaltrials. gov:
NCT03071666. Protocol date: version 1.2, 1 June 2017.
Mori, AT, et al. 2017. “Cost-benefit and extended cost-effectiveness analysis of a comprehensive adolescent pregnancy prevention program in Zambia: study protocol for a cluster randomized controlled trial”. Trials 18 (604). Publisher's VersionAbstract

Background: Early marriages, pregnancies and births are the major cause of school drop-out among adolescent

girls in sub-Saharan Africa. Birth complications are also one of the leading causes of death among adolescent girls.

This paper outlines a protocol for a cost-benefit analysis (CBA) and an extended cost-effectiveness analysis (ECEA) of

a comprehensive adolescent pregnancy prevention program in Zambia. It aims to estimate the expected costs,

monetary and non-monetary benefits associated with health-related and non-health outcomes, as well as their

distribution across populations with different standards of living.

Methods: The study will be conducted alongside a cluster-randomized controlled trial, which is testing the hypothesis

that economic support with or without community dialogue is an effective strategy for reducing adolescent childbearing

rates. The CBA will estimate net benefits by comparing total costs with monetary benefits of health-related and

non-health outcomes for each intervention package. The ECEA will estimate the costs of the intervention

packages per unit health and non-health gain stratified by the standards of living. Cost data include program

implementation costs, healthcare costs (i.e. costs associated with adolescent pregnancy and birth complications

such as low birth weight, pre-term birth, eclampsia, medical abortion procedures and post-abortion complications) and

costs of education and participation in community and youth club meetings. Monetary benefits are returns to education

and averted healthcare costs. For the ECEA, health gains include reduced rate of adolescent childbirths and non-health

gains include averted out-of-pocket expenditure and financial risk protection. The economic evaluations will

be conducted from program and societal perspectives.

Discussion: While the planned intervention is both comprehensive and expensive, it has the potential to produce

substantial short-term and long-term health and non-health benefits. These benefits should be considered seriously

when evaluating whether such a program can justify the required investments in a setting with scarce resources. The

economic evaluations outlined in this paper will generate valuable information that can be used to guide large-scale

implementation of programs to address the problem of the high prevalence of adolescent childbirth and school

drop-outs in similar settings.

Trial registration: ClinicalTrials.gov, NCT02709967. Registered on 2 March 2016. ISRCTN, ISRCTN12727868.

Registered on 4 March 2016.

Keywords: Adolescent pregnancy, Early marriage, School drop-out, Cost-benefit analysis, Extended cost-effectiveness

analysis, Cash transfer, Catastrophic health expenditure, Cluster randomized controlled trial.

Munhoz, TN, et al. 2017. “Effect of childhood nutrition counselling onintelligence in adolescence: a 15-year follow-up of a cluster-randomised trial”. Public Health Nutr 20 (11) : 2034-2041. Publisher's VersionAbstract

The present study aimed to assess the effects of an early childhood nutrition counselling intervention on intelligence (as measured by the intelligence quotient (IQ)) at age 15–16 years.

A single-blind, cluster-randomised trial.

In 1998, in Southern Brazil, mothers of children aged 18 months or younger were enrolled in a nutrition counselling intervention (n 424). Counselling included encouragement and promotion of exclusive breast-feeding until 6 months of age and continued breast-feeding supplemented by protein-, lipid- and carbohydrate-rich foods after age 6 months up to age 2 years. The control group received routine feeding advice. In 2013, the fourth round of follow-up of these individuals, at the age of 15–16 years, was undertaken. IQ was assessed using the short form of the Wechsler Adult Intelligence Scale (WAIS-III). Mental disorders (evaluated using the Development and Well-Being Assessment (DAWBA)) and self-reported school failure, smoking and alcohol use were also investigated. Adjusted analyses were conducted using a multilevel model in accordance with the sampling process.

Adolescents, mean (sd) age of 15·4 (0·5) years (n 339).

Mean (sd) total IQ score was lower in the intervention group than the control group (93·4 (11·4) and 95·8 (11·2), respectively) but the association did not persist after adjustment. The prevalence of any mental disorders was similar between intervention and control groups (23·1 and 23·5 %, respectively). There were no differences between groups regarding school failure, smoking and alcohol use.

Nutrition counselling intervention in early childhood had no effect on intelligence measured during adolescence.

Upadhyay, RP, et al. 2017. “Immunization practices in low birth weightinfants from rural Haryana, India: Findings fromsecondary data analysis”. Journal of Global Health 7 (2). Publisher's VersionAbstract

Background

Low birth weight (LBW) infants constitute a vulnerable subset of infants with impaired immunity in early life. In India, there is scarcity of studies that focus on immunization practices in such infants. This analysis aimed to examine immunization practices in LBW infants with the intention to identify areas requiring intervention.

Methods
Data on immunization status of LBW infants enrolled in an 
individually randomized, double–masked, placebo–controlled trial of
neonatal vitamin A supplementation were analysed. Study outcomes
were full immunization by one year of age and delayed vaccination
with DPT1 and DPT3. Multivariable logistic regression was performed
to identify factors associated with the outcome(s).

Findings

Out of 10 644 LBW infants enrolled in trial, immunization data were available for 10 517 (98.8%). Less than one–third (29.7%) were fully immunized by one year of age. Lowest wealth quintile (adjusted odds ratio (AOR) 0.39, 95% confidence interval (CI) 0.32–0.47), Muslim religion (AOR 0.41, 95% CI 0.35–0.48) and age of mother <20 years (AOR 0.62, 95% CI 0.52–0.73) were associated with decreased odds of full immunization. Proportion of infants with delayed vaccination for DPT1 and DPT3 were 52% and 81% respectively. Lowest wealth quintiles (AOR 1.51, 95% CI 1.25–1.82), Muslim religion (AOR 1.41, 95% CI 1.21–1.65), mother aged <20 years (AOR 1.31, 95% CI 1.11–1.53) and birth weight <2000 g (AOR 1.20, 95% CI 1.03–1.40) were associated with higher odds of delayed vaccination for DPT–1. Maternal education (≥12 years of schooling) was associated with high odds of full immunization (AOR 2.39, 95% CI 1.97–2.91) and low odds of delayed vaccination for both DPT–1 (AOR 0.59, 95% CI 0.49–0.73) and DPT–3 (AOR 0.57, 95% CI 0.43–0.76)

Conclusion
In this population, LBW infants are at a risk of delayed and incomplete immunization and therefore need attention. The risks
are even higher in identified subgroups that should specifically be targeted.

Sinah, B, et al. 2017. “Integrated Interventions Delivered in Health Systems, Home, and Community Havethe Highest Impact on Breastfeeding Outcomes in Low- and Middle-Income Countries.”. J Nutr. 147 (11) : 2179S-2187S. Publisher's VersionAbstract

Background: Improving breastfeeding rates is critical. In low- and middle-income countries (LMICs), only subtle improvements in breastfeeding rates have been observed over the past decade, which highlights the need for accelerating breastfeeding promotion interventions.

Objective: The objective of this article is to update evidence on the effect of interventions on early initiation of and exclusive (<1 and 1–5 mo) and continued (6–23 mo) breastfeeding rates in LMICs when delivered in health systems, in the home or in community environments, or in a combination of settings.

Methods: A systematic literature search was conducted in PubMed, Cochrane, and CABI databases to identify new articles relevant to our current review, which were published after the search date of our earlier meta-analysis (October 2014). Nine new articles were found to be relevant and were included, in addition to the other 52 studies that were identified in our earlier meta-analysis. We reported the pooled ORs and corresponding 95% CIs as our outcome estimates. In cases of high heterogeneity, random-effects models were used and causes were explored by subgroup analysis and meta-regression.

Results: Early initiation of and exclusive (<1 and 1–5 mo) and continued (6–23 mo) breastfeeding rates in LMICs improved significantly as a result of interventions delivered in health systems, in the home or community, or a combination of these. Interventions delivered concurrently in a combination of settings were found to show the largest improvements in desired breastfeeding outcomes. Counseling provided in any setting and baby-friendly support in health systems appear to be the most effective interventions to improve breastfeeding.

Conclusions: Improvements in breastfeeding practices are possible in LMICs with judicious use of tested interventions, particularly when delivered in a combination of settings concurrently. The findings can be considered for inclusion in the Lives Saved Tool model.

Sinha, B, et al. 2017. “Low-birthweight infants born to short-staturemothers are at additional risk of stunting and poor growth velocity: Evidencefrom secondary data analyses”. Matern Child Nutr 14 (1). Publisher's VersionAbstract

Low-birthweight (LBW) infants are at an increased risk of stunting and poor linear growth. The risk might be additionally higher in these infants when born to short mothers. However, this hypothesis has been less explored. The objective of this secondary data analysis was to determine the risk of linear growth faltering and difference in linear growth velocity in LBW infants born to short mothers (<150 cm) compared to those born to mothers with height ≥150 cm during the first year of life. This analysis uses data from a community-based randomized controlled trial of 2,052 hospital-born term infants with birthweight ≤2,500g from urban low–middle socioeconomic neighbourhoods in Delhi, India. Data on maternal height and infant birth length were available from 1,858 (90.5%) of the infants. Infant anthropometry outcomes were measured at birth, 3, 6, 9, and 12 months of age. We found that infants born to short mothers had around twofold higher odds of stunting and lower attained length-for-age Z scores compared to infants of mothers with height ≥150 cm, at all ages of assessment. Linear growth velocity was significantly lower in infants of short mothers particularly in the first 6 months of life. We conclude that LBW infants born to short mothers are at a higher risk of stunting and have slower postnatal growth velocity resulting in lower attained length-for-age Z scores in infancy. Evidence-based strategies need to be tested to optimize growth velocity in LBW infants especially those born to short mothers.

Welch, VA, et al. 2017. “CONSORT-Equity 2017 extension and elaboration for better reporting of health equity in randomised trials”. BMJ. Publisher's VersionAbstract

We outline CONSORT-Equity 2017 reporting standards, an extension to the CONSORT (Consolidated Standards of Reporting Trials) statement that aims to improve the reporting of intervention effects in randomised trials where health equity is relevant. Health inequities are unfair differences in health that can be avoided by reasonable action. We defined a randomised trial where health equity is relevant as one that assesses effects on health equity by evaluating an intervention focused on people experiencing social disadvantage or by exploring the difference in the effect of the intervention between two groups (or as a gradient across more than two groups) experiencing different levels of social disadvantage, or both. We held a consensus meeting with diverse potential users from high, middle, and low income countries, including knowledge users such as patients and methodologists. We discussed evidence for each proposed extension item from empirical studies, reviews, key informant interviews, and an online survey, aiming to improve clarity of reporting without imposing undue burden on authors. The new guidance contains equity extensions to 16 items from CONSORT 2010 plus one new item on research ethics reporting, with examples of good practice and a brief explanation and elaboration for each. Widespread uptake of this guidance for the reporting of trials where health equity is relevant will make it easier for decision makers to find and use evidence from randomised trials to reduce unfair inequalities in health.

Onarheim, KH, et al. 2017. “What if the baby doesn't survive? Health-care decision making for ill newborns in Ethiopia”. Social Science & Medicine. Publisher's VersionAbstract

Despite efforts to improve access to and quality of care for newborns, the first month after birth remains the most dangerous period of life. Given high neonatal mortality in low-income countries, saving newborn lives is a key priority for global and national health policy agendas. However, little is known about how these policies resonate with local understandings, experiences and household priorities. In this qualitative study we examined families' decision making and health-care-seeking in Butajira, Ethiopia. Data were collected through observation in hospital, in-depth interviews (41), and focus group discussions (7) with family members, health-care workers, and community members (October–November 2015). Transcripts and field notes were analyzed inductively using qualitative content analysis. Findings indicate that newborn health was not always the family's priority. Local perceptions of newborns as not yet useful members of the household alongside costly health-care services delayed decision making and care-seeking. While sickness was recognized as dangerous for the ill newborn, seeking health-care could be harmful for the economic survival of the family. In a resource-constrained setting, families' focused on productive assets in order to minimize long-term risks, and waited before seeking newborn health-care services. Until the baby had survived the first vulnerable weeks and months of life, the unknown newborn was not yet seen as a social person by the community. Personhood evolved progressively as the baby became a part of the family. A newborn death was surrounded by silence, and families received minimal support from traditional financial associations, iddirs. Decisions regarding health-care were contingent upon families' understandings of newborns and their resource-constrained circumstances. Improving newborn health involves recognizing why families choose to (not) seek health-care, and their actual opportunities and constraints in making such decisions. The everyday realities of vulnerable newborns must be at the center of global and national policy discussions and local implementation.

Keywords: EthiopiaNewborn healthHealth-care-seekingDecision makingPersonhoodPovertyQualitative research

Katirayi, L, et al. 2017. “Echoes of old HIV paradigms: reassessing the problem of engaging men in HIV testing and treatment through women's perspectives”. Reproductive Health. Article in PumedAbstract

BACKGROUND: With the introduction of 2016 World Health Organization guidelines recommending universal antiretroviral therapy (ART), there has been increased recognition of the lack of men engaging in HIV testing and treatment. Studies in sub-Saharan Africa indicate there have been challenges engaging men in HIV testing and HIV-positive men into treatment.


METHODS:This qualitative study explored women's perspective of their male partner's attitudes towards HIV and ART and how it shapes woman's experience with ART. Data were collected through in-depth interviews and focus group discussions with HIV-positive pregnant and postpartum women on Option B+ and health care workers in Malawi and Zimbabwe. In Malawi, 19 in-depth interviews and 12 focus group discussions were conducted from September-December 2013. In Zimbabwe, 15 in-depth interviews and 21 focus-group discussions were conducted from July 2014-March 2014.


RESULTS:The findings highlighted that many men discourage their partners from initiating or adhering to ART. One of the main findings indicated that despite the many advancements in HIV care and ART regimens, there are still many lingering negative beliefs about HIV and ART from the earlier days of the epidemic. In addition to existing theories explaining men's resistance to/absence in HIV testing and treatment as a threat to their masculinity or because of female-focused health facilities, this paper argues that men's aversion to HIV may be a result of old beliefs about HIV and ART which have not been addressed.


CONCLUSIONS: Due to lack of accurate and up to date information about HIV and ART, many men discourage their female partners from initiating and adhering to ART. The effect of lingering and outdated beliefs about HIV and ART needs to be addressed through strengthened communication about developments in HIV care and treatment. Universal ART offers a unique opportunity to curb the epidemic, but successful implementation of these new guidelines is dependent on ART initiation and adherence by both women and men. Strengthening men's understanding about HIV and ART will greatly enhance women's ability to initiate and adhere to ART and improve men's health.


KEYWORDS: ART initiation; Africa; HIV; Lifelong treatment; Male engagement; PMTCT; Qualitative; Universal treatment

Hailu, A, et al. 2017. “Economic burden of malaria and predictors of cost variability to rural households in south-central Ethiopia”. Plos One. Article in PumedAbstract

BACKGROUND: While recognizing the recent remarkable achievement in the global malaria reduction, the disease remains a challenge to the malaria endemic countries in Africa. Beyond the huge health consequence of malaria, policymakers need to be informed about the economic burden of the disease to the households. However, evidence on the economic burden of malaria in Ethiopia is scanty. The aims of this study were to estimate the economic burden of malaria episode and to identify predictors of cost variability to the rural households.

METHODS:A prospective costing approach from a household perspective was employed. A total of 190 malaria patients were enrolled to the study from three health centers and nine health posts in Adami Tullu district in south-central Ethiopia, in 2015. Primary data were collected on expenditures due to malaria, forgone working days because of illness, socioeconomic and demographic situation, and households' assets. Quantile regression was applied to predict factors associated with the cost variation. Socioeconomic related inequality was measured using concentration index and concentration curve.


RESULTS: The median cost of malaria per episode to the household was USD 5.06 (IQR: 2.98-8.10). The direct cost accounted for 39%, while the indirect counterpart accounted for 61%. The history of malaria in the last six months and the level of the facility visited in the health system predominantly influenced the direct cost. The indirect cost was mainly influenced by the availability of antimalarial drugs in the health facility. The concentration curve and the concentration index for direct cost indicate significant pro-rich inequality. Plasmodium falciparum is significantly more costly for households compared to Plasmodium vivax.


CONCLUSION:The economic burden of malaria to the rural households in Ethiopia was substantial-mainly to the poor-indicating that reducing malaria burden could contribute to the poverty reduction as well.

Jull, J, et al. 2017. “When is a randomised controlled trial health equity relevant? Development and validation of a conceptual framework”. BMJ Open. Publisher's VersionAbstract

Background Randomised controlled trials can provide evidence relevant to assessing the equity impact of an intervention, but such information is often poorly reported. We describe a conceptual framework to identify health equity-relevant randomised trials with the aim of improving the design and reporting of such trials.

Methods An interdisciplinary and international research team engaged in an iterative consensus building process to develop and refine the conceptual framework via face-to-face meetings, teleconferences and email correspondence, including findings from a validation exercise whereby two independent reviewers used the emerging framework to classify a sample of randomised trials.

Results A randomised trial can usefully be classified as ‘health equity relevant’ if it assesses the effects of an intervention on the health or its determinants of either individuals or a population who experience ill health due to disadvantage defined across one or more social determinants of health. Health equity-relevant randomised trials can either exclusively focus on a single population or collect data potentially useful for assessing differential effects of the intervention across multiple populations experiencing different levels or types of social disadvantage. Trials that are not classified as ‘health equity relevant’ may nevertheless provide information that is indirectly relevant to assessing equity impact, including information about individual level variation unrelated to social disadvantage and potentially useful in secondary modelling studies.

Conclusion The conceptual framework may be used to design and report randomised trials. The framework could also be used for other study designs to contribute to the evidence base for improved health equity.

  • health
  • equity
  • randomized controlled trials
  • framework

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Chowdhury, R, et al. 2017. “Gender differences in infant survival: A secondary data analysis in rural North India”. BMJ Open 7. Publisher's VersionAbstract

Objective To examine gender differences in infant survival on the first day of life, in the first week of life, and in the neonatal and post-neonatal periods by socio-demographic and economic variables.

Design Secondary data analysis was performed on data from a cluster randomised trial on the effect of implementation of the Integrated Management of Neonatal and Childhood Illness programme, India.

Settings The study setting was Palwal and Faridabad, districts of Haryana, a state in North India.

Measures Multiple logistic regression models taking the cluster design into account were used to estimate gender differences in mortality in different periods of infancy.

Results A total of 60 480 infants were included in these analyses. Of 4060 infant deaths, 2054 were female (7.2% of all females born) and 2006 were male (6.3% of all males born). The death rate was significantly higher in females in the post-neonatal period but not during the neonatal period. The odds of death at 29–180 days and at 181–365 days were 1.4 (95% CI 1.3 to 1.6) and 1.7 (95% CI: 1.4 to 2.0) higher in females compared with males, respectively. This increase was seen across all socio-demographic and economic strata.

Conclusion Gender differences during the post-neonatal period are a major threat to the survival and health of female infants in India. Programmes need to identify measures that can specifically reduce female mortality.

Nankabirwa, V, et al. 2017. “Efficacy of umbilical cord cleansing with a single application of 4% chlorhexidine for the prevention of newborn infections in Uganda: study protocol for a randomized controlled trial.”. Trials. Article in Pubmed Abstract

BACKGROUND: Yearly, nearly all the estimated worldwide 2.7 million neonatal deaths occur in low- and middle-income countries. Infections, including those affecting the umbilical cord (omphalitis), are a significant factor in approximately a third of these deaths. In fact, the odds of all-cause mortality are 46% higher among neonates with omphalitis than in those without. Five large randomized controlled trials in Asia and Sub-Saharan Africa (SSA) have examined the effect of multiple cord stump applications with 4% chlorhexidine (CHX) for at least 7 days on the risk of omphalitis and neonatal death. These studies, all community-based, show that multiple CHX applications reduced the risk of omphalitis. Of these trials, only one study from South Asia (the Bangladeshi study) and none from Africa examined the effect of a single application of CHX as soon as possible after birth. In this Bangladeshi trial, CHX led to a reduction in the risk of mild-moderate omphalitis and neonatal death. It is important, in an African setting, to explore the effect of a single application among health-facility births. A single application is programmatically much simpler to implement than daily applications for 7 days. Therefore, our study compares umbilical cord cleansing with a single application of 4% CHX at birth with dry cord care among Ugandan babies born in health facilities, on the risk of omphalitis and severe neonatal illness.


METHODS: The CHX study is a facility-based, individually randomized controlled trial that will be conducted among 4760 newborns in Uganda. The primary outcomes are severe illness and omphalitis during the neonatal period. Analysis will be by intention-to-treat.

DISCUSSION: This study will provide novel evidence, from a Sub-Saharan African setting, of the effect of umbilical cord cleansing with a single application of 4% CHX at birth and identify modifiable risk factors for omphalitis.

TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT02606565. Registered on 12 November 2015.

KEYWORDS: Chlorhexidine; Neonatal; Newborn; Omphalitis; Severe illness; Trial

Mazumder, S, et al. 2017. “Impact of community-initiated Kangaroo Mother Care on survival of low birth weight infants: study protocol for a randomized controlled trial.”. Trials. Article in Pubmed Abstract

BACKGROUND: Around 70% neonatal deaths occur in low birth weight (LBW) babies. Globally, 15% of babies are born with LBW. Kangaroo Mother Care (KMC) appears to be an effective way to reduce mortality and morbidity among LBW babies. KMC comprises of early and continuous skin-to-skin contact between mother and baby as well as exclusive breastfeeding. Evidence derived from hospital-based studies shows that KMC results in a 40% relative reduction in mortality, a 58% relative reduction in the risk of nosocomial infections or sepsis, shorter hospital stay, and a lower risk of lower respiratory tract infections in babies with birth weight <2000 g. There has been considerable interest in KMC initiated outside health facilities for LBW babies born at home or discharged early. Currently, there is insufficient evidence to support initiation of KMC in the community (cKMC). Formative research in our study setting, where 24% of babies are born with LBW, demonstrated that KMC is feasible and acceptable when initiated at home for LBW babies. The aim of this trial is to determine the impact of cKMC on the survival of these babies.


METHODS/DESIGN: This randomized controlled trial is being undertaken in the Palwal and Faridabad districts in the State of Haryana, India. Neonates weighing 1500-2250 g identified within 3 days of birth and their mothers are being enrolled. Other inclusion criteria are that the family is likely to be available in the study area over the next 6 months, that KMC was not initiated in the delivery facility, and that the infant does not have an illness requiring hospitalization. Eligible neonates are randomized into intervention and control groups. The intervention is delivered through home visits during the first month of life by study workers with a background and education similar to that of workers in the government health system. An independent study team collects mortality and morbidity data as well as anthropometric measurements during periodic home visits. The primary outcomes of the study are postenrollment neonatal mortality and mortality between enrollment and 6 months of age. The secondary outcomes are breastfeeding practices; prevalence of illnesses and care-seeking practices for the same; hospitalizations; weight and length gain; and, in a subsample, neurodevelopment.


DISCUSSION: This efficacy trial will answer the question whether the benefits of KMC observed in hospital settings can also be observed when KMC is started in the community. The formative research used for intervention development suggests that the necessary high level of KMC adoption can be reached in the community, addressing a problem that seriously constrained conclusions in the only other trial in which researchers examined the benefits of cKMC.

TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02653534. Registered on 26 December 2015 (retrospectively registered).

KEYWORDS: Community-initiated Kangaroo Mother Care; Low birth weight babies; Mortality

Sanou, AS, et al. 2017. “Maternal alcohol consumption during pregnancy and child's cognitive performance at 6-8 years of age in rural Burkina Faso: an observational study”. Peer J. Article in Pubmed Abstract

BACKGROUND: In Burkina Faso, it is not uncommon for mothers to drink alcohol, even during pregnancy. We aimed to study the association between maternal alcohol consumption during pregnancy and the child's cognitive performance using the Kaufman Assessment Battery for Children, 2nd edition (KABC-II) and the Children's Category Test Level 1 (CCT-1) in rural Burkina Faso.


METHODS:We conducted a follow-up study of a community cluster-randomised Exclusive breastfeeding trial, and re-enrolled the children in rural Burkina Faso. A total of 518 children (268 boys and 250 girls) aged 6-8 years were assessed using the KABC-II and the CCT-1. We examined the effect size difference using Cohen's d and conducted a linear regression analysis to examine the association.


RESULTS: Self-reported alcohol consumption during pregnancy was 18.5% (96/518). Children whose mothers reported alcohol consumption during pregnancy performed significantly poorly for memory and spatial abilities tests from small effect size difference for 'Atlantis' (0.27) and 'Triangle' (0.29) to moderate effect size difference for 'Number recall' (0.72) compared to children whose mothers did not consume alcohol during pregnancy; the exposed children scored significantly higher errors with a small effect size (0.37) at problem solving (CCT-1) test compared to unexposed children. At unstandardized and standardized multivariable analysis, children whose mothers reported alcohol consumption during pregnancy performed significantly poorer for memory-'Atlantis' (p = 0.03) and 'Number recall' (p = 0.0001), and spatial ability tests-'Triangle' (p = 0.03); they scored significantly higher errors at problem solving CCT-1 test (p = 0.002); all the results were adjusted for age, sex, schooling, stunting, father's education, mother's employment and the promotion of exclusive breastfeeding. No statistical association was found for visual abilities-'Conceptual Thinking', 'Face recognition', 'Story completion', and reasoning tests-'Rover', 'Block counting', and 'Pattern Reasoning'.


CONCLUSION: Maternal alcohol consumption during pregnancy is associated with poorer cognitive performance for memory, spatial ability, and problem solving tests in the offspring in rural Burkina Faso. Futures studies needs to assess in more detail the maternal alcohol consumption patterns in Burkina Faso and possible preventive strategies.


KEYWORDS: Africa; Burkina Faso; CCT-1; Child development; Children; Cognitive test; KABC-II; Maternal alcohol consumption; Pregnancy

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