Integration of antenatal care services with health programmes in low- and middle-income countries: systematic review.

BACKGROUND: Antenatal care (ANC) presents a potentially valuable platform for integrated delivery of additional health services for pregnant women-services that are vital to reduce the persistently high rates of maternal and neonatal mortality in low- and middle-income countries (LMICs). However, there is limited evidence on the impact of integrating health services with ANC to guide policy. This review assesses the impact of integration of postnatal and other health services with ANC on health services uptake and utilisation, health outcomes and user experience of care in LMICs. METHODS: Cochrane Library, MEDLINE, Embase, CINAHL Plus, POPLINE and Global Health were searched for studies that compared integrated models for delivery of postnatal and other health services with ANC to non-integrated models. Risk of bias of included studies was assessed using the Cochrane Effective Practice and Organisation of Care (EPOC) criteria and the Newcastle-Ottawa Scale, depending on the study design. Due to high heterogeneity no meta-analysis could be conducted. Results are presented narratively. FINDINGS: 12 studies were included in the review. Limited evidence, with moderate- to high-risk of bias, suggests that integrated service delivery results in improved uptake of essential health services for women, earlier initiation of treatment, and better health outcomes. Women also reported improved satisfaction with integrated services. CONCLUSIONS: The reported evidence is largely based on non-randomised studies with poor generalizability, and therefore offers very limited policy guidance. More rigorously conducted and geographically diverse studies are needed to better ascertain and quantify the health and economic benefits of integrating health services with ANC

The ethics of New Development Economics: is the Experimental Approach to Development Economics morally wrong?

ArticleThe 2000s have witnessed the arrival and growing popularity of randomized controlled experiments (RCTs) in Development Economics. Whilst this new way of conducting research on development has unfolded important insights, the ethical challenge it provokes has not yet been systematically examined. The present article aims at filling this gap by providing the first ad hoc discussion of the moral issues that accompany the use of RCTs in Development Economics. Claiming that this new research agenda needs its own, specific set of ethical guidelines, we expose the six ethical problems that these experiments potentially provoke and that should therefore be carefully assessed by ethics committees before an RCT is launched and by scholarly journals before its results are published

Antiretroviral therapy in Sub-Saharan Africa: Evaluation of adverse effects

Objective of the study was to evaluate the prevalence and risk factors of ART-associated hepatotoxicity and anemia under d4T- and AZT-based regimens. The study was a multicenter retrospective observational study using pooled data from four AIDS-treatment sites in Mozambique and three in Malawi from 01.01.2006 to 31.08.2012. Computerized records of 10,567 HIV-infected, ART-naïve, non-pregnant adults, who started ART and had at least 12 months of follow-up after initiation of ART, were reviewed. Initial first-line ART regimens consisted of d4T- and AZT-based combinations; 95% of the patients received NVP as NNRTI. CD4 cell count, plasma HIV RNA (viral load, VL), body mass index (BMI), GOT and hemoglobin (HB) were measured before starting ART. GOT as indicator for hepatotoxicity and HB as indicator for anemia was measured after month 1, 2, 3, 6, 9 and 12. Prevalence of hepatotoxicity grade 1+2 and 3+4 and anemia grade 1+2 and 3+4 in d4T-based and AZT-based regimens during the 12-months follow-up were analyzed. The possible risk factors for prevalence increase “type of ART combination”, “CD4 count before ART”, “VL before ART”, “nutritional status before ART (BMI)”, sex and “malaria events after the start of ART” were identified by univariate and/or multivariate regression technique. Results The cohort of 10,567 patients was dichotomized in a “d4T-based arm”(n= 8231, 77.9%) and an “AZT-based arm” (n= 2306, 21.8%). Prevalence of hepatotoxicity 1+2 and 3+4 before starting ART was 18.1% and 0.5%. Prevalence of ART-associated hepatotoxicity 1+2 declined until month 3, and of hepatotoxicity 3+4 until month 6 of follow-up. In the “d4T-based arm”, prevalence of ART-associated hepatotoxicity 1+2 was during the follow-up higher than in the “AZT-based arm”. Prevalence of anemia 1+2 and 3+4 before starting ART was 28.5% and 6.7%. The prevalence of ART-associated anemia declined constantly during follow-up. The prevalence of ART-associated anemia 1+2 and 3+4 was during the complete follow-up (anemia 3+4 not in month 1) higher in the “AZT-based” than in the “d4T-based arm”. Evaluation of risk factors for increased hepatotoxicity prevalence In the univariate analysis, a d4T-based combination was during the complete follow-up a statistically significant risk factor for higher prevalence of hepatotoxicity grade 1+2 compared to AZT-based combinations, and never for higher prevalence of hepatotoxicity grade 3+4. In the multivariate analysis, a d4T-based combination was statistically significant associated at month 1, 2, 3, 6 and 9, and female sex at month 1, 2, 3, 6 and 12 with increased hepatotoxicity 1+2 prevalence. A pre-ART BMI>18.5 was a statistically significant protection factor against increased hepatotoxicity 1+2 prevalence in the first three months of ART. Pre-ART CD4 count and pre-ART VL were never statistically significant associated with increased hepatotoxicity prevalence. Evaluation of risk factors for increased anemia prevalence In the univariate analysis an AZT-based combination was a statistically significant risk factor for higher prevalence of anemia grade 1+2 during the complete follow-up, and for higher prevalence of anemia grade 3+4 at month 2, 3 and 6, compared to d4T-based combinations. In the multivariate analysis cumulative malaria was a statistically significant risk factor for an increased prevalence of anemia 1+2 in all months of the follow-up, and of anemia 3+4 in month 2 and 6. AZT-based combination was only in month 1statistically significant associated with increased anemia 1+2 prevalence, and with increased anemia 3+4 prevalence in month 2, 3 and 6. A pre-ART BMI>18.5 was a statistically significant protection factor against anemia 1+2 in month 1 and 2, and against anemia 3+4 in month 2. Pre-ART CD4 count was never and pre-ART VL only in month 1 statistically significant associated with increased anemia 1+2. An indirect comparison of overall, not only ART-associated hepatotoxicity and anemia prevalence in the d4T- and AZT- based arm during 12 months identified as most frequent statistically significant factors pre-ART VL>100,000 c/ml (risk factor) and pre-ART BMI>18.5 (protection factor). Pre-ART anemia was never and a high pre-ART CD4 count only once statistically significant associated with an increased hepatotoxicity and anemia prevalence. 19 of 22 statistically significant factors were identified in the first 3 months of ART. 17 of 22 statistically significant factors were identified in the “d4T-based arm”. In the “AZT-based arm” all 5 identified statistically significant factors were associated with anemia prevalence in the first 3 months of ART. Conclusion Hepatotoxicity prevalence: In sub-Saharan settings, a d4T-based combination and female sex are the most frequent statistically significant and independent risk factors for increased prevalence of ART-associated hepatotoxicity 1+2. A good nutritional status (pre-ART BMI>18.5) protects statistically significant against an increase of hepatotoxicity 1+2. In an indirect comparison of overall hepatotoxicity prevalence a pre-ART VL>100,000 c/ml was a statistically significant risk factor for hepatotoxicity 1+2 in the first 3 months of d4T-based ART. Anemia prevalence: In sub-Saharan settings, cumulative malaria increased significantly and independently the risk for anemia 1+2 during 12 months after the start of ART, and for anemia 3+4 at months 2 and 6. An AZT-based combination is only at month 1 a significant, independent risk factor for anemia 1+2, but until month 6 for anemia 3+4. A pre-ART BMI>18.5 was a significant and independent protective factor against anemia in the first two months of ART. In the indirect comparison of overall anemia prevalence a pre-ART VL>100,000 c/ml was a frequent statistically significant risk factor for anemia 1+2 and 3+4, mainly in the “d4T-based arm“. Less toxic first-line drugs than d4T, AZT and NVP must be introduced in sub-Sahara Africa. Also BMI and VL must be measured and considered when the start of ART and the initial first-line combination is decided

Changing Gender and Social Norms, Attitudes and Behaviours

Social norms are informal rules and shared social expectations that shape individual attitudes and behaviour (Arias, 2015; Marcus and Harper, 2015). Gender norms are social norms that relate specifically to gender differences. A common gender norm, for example, is that women and girls will and should do the majority of domestic work (Marcus and Harper, 2015). This helpdesk report presents studies of programmes that aim to bring about changes in gender and social norms; and changes in wider attitudinal and behaviour. Much of the literature and some programme designs recognise the need to change social norms in order to change behaviours, such as HIV/AIDs prevention and better sanitation and hygiene. The report looks at interventions targeting individual and inter-relational levels (e.g. workshops); community levels (e.g. community dialogue, community mobilisation and youth initiatives); and wider societal levels (mass media and edutainment). It highlights the effects of such interventions, focusing on rigorous evaluations

Non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in low- and middle-income countries.

BACKGROUND: Many people with mental, neurological and substance-use disorders (MNS) do not receive health care. Non-specialist health workers (NSHWs) and other professionals with health roles (OPHRs) are a key strategy for closing the treatment gap. OBJECTIVES: To assess the effect of NSHWs and OPHRs delivering MNS interventions in primary and community health care in low- and middle-income countries. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register) (searched 21 June 2012); MEDLINE, OvidSP; MEDLINE In Process & Other Non-Indexed Citations, OvidSP; EMBASE, OvidSP (searched 15 June 2012); CINAHL, EBSCOhost; PsycINFO, OvidSP (searched 18 and 19 June 2012); World Health Organization (WHO) Global Health Library (searched 29 June 2012); LILACS; the International Clinical Trials Registry Platform (WHO); OpenGrey; the metaRegister of Controlled Trials (searched 8 and 9 August 2012); Science Citation Index and Social Sciences Citation Index (ISI Web of Knowledge) (searched 2 October 2012) and reference lists, without language or date restrictions. We contacted authors for additional studies. SELECTION CRITERIA: Randomised and non-randomised controlled trials, controlled before-and-after studies and interrupted-time-series studies of NSHWs/OPHR-delivered interventions in primary/community health care in low- and middle-income countries, and intended to improve outcomes in people with MNS disorders and in their carers. We defined an NSHW as any professional health worker (e.g. doctors, nurses and social workers) or lay health worker without specialised training in MNS disorders. OPHRs included people outside the health sector (only teachers in this review). DATA COLLECTION AND ANALYSIS: Review authors double screened, double data-extracted and assessed risk of bias using standard formats. We grouped studies with similar interventions together. Where feasible, we combined data to obtain an overall estimate of effect. MAIN RESULTS: The 38 included studies were from seven low- and 15 middle-income countries. Twenty-two studies used lay health workers, and most addressed depression or post-traumatic stress disorder (PTSD). The review shows that the use of NSHWs, compared with usual healthcare services: 1. may increase the number of adults who recover from depression or anxiety, or both, two to six months after treatment (prevalence of depression: risk ratio (RR) 0.30, 95% confidence interval (CI) 0.14 to 0.64; low-quality evidence); 2. may slightly reduce symptoms for mothers with perinatal depression (severity of depressive symptoms: standardised mean difference (SMD) -0.42, 95% CI -0.58 to -0.26; low-quality evidence); 3. may slightly reduce the symptoms of adults with PTSD (severity of PTSD symptoms: SMD -0.36, 95% CI -0.67 to -0.05; low-quality evidence); 4. probably slightly improves the symptoms of people with dementia (severity of behavioural symptoms: SMD -0.26, 95% CI -0.60 to 0.08; moderate-quality evidence); 5. probably improves/slightly improves the mental well-being, burden and distress of carers of people with dementia (carer burden: SMD -0.50, 95% CI -0.84 to -0.15; moderate-quality evidence); 6. may decrease the amount of alcohol consumed by people with alcohol-use disorders (drinks/drinking day in last 7 to 30 days: mean difference -1.68, 95% CI -2.79 to -0.57); low-quality evidence).It is uncertain whether lay health workers or teachers reduce PTSD symptoms among children. There were insufficient data to draw conclusions about the cost-effectiveness of using NSHWs or teachers, or about their impact on people with other MNS conditions. In addition, very few studies measured adverse effects of NSHW-led care - such effects could impact on the appropriateness and quality of care. AUTHORS' CONCLUSIONS: Overall, NSHWs and teachers have some promising benefits in improving people's outcomes for general and perinatal depression, PTSD and alcohol-use disorders, and patient- and carer-outcomes for dementia. However, this evidence is mostly low or very low quality, and for some issues no evidence is available. Therefore, we cannot make conclusions about which specific NSHW-led interventions are more effective

Impact of Maternal Human Immunodeficiency Virus Infection on Birth Outcomes and Infant Survival in Rural Mozambique

Sub-Saharan Africa harbors more than two-thirds of the world’s 33.2 million persons infected with human immunodeficiency virus (HIV) and 80% of the world’s HIV-infected women. In parts of southern Africa, more than 30% of pregnant women attending antenatal clinics are infected with HIV, thus making HIV infection one of the most common complications of pregnancy in sub-Saharan Africa. With successful interventions, mother-to-child transmission (MTCT) of HIV has been reduced to less than 2% in developed countries. However, in untreated populations, MTCT of HIV during pregnancy, delivery, and breastfeeding still occurs at an approximate overall rate of 25–40%, and accounts for almost 420,000 new HIV infections in children and 270,000–320,000 pediatric deaths annually. Until 2004, single-dose intrapartum and neonatal nevirapine (sd-NVP) was the recommended regimen by the World Health Organization to prevent MTCT of HIV among women without access to antiretroviral therapy. Preventive MTCT programs with an sd-NVP have been shown to decrease perinatal HIV transmission to 8% in controlled clinical trial settings. However, there is great concern about the rapid development of resistance. In addition, in predominantly breastfeeding populations of sub- Saharan Africa, most MTCT of HIV still occurs during the postnatal period. Currently, MTCT prevention programs in sub-Saharan African countries include zidovudine and lamivudine during the final weeks of pregnancy and sd-NVP at delivery. In addition, the newborn receives sd-NVP at birth and zidovudine for seven days. Nevertheless, effectiveness of these strategies relies on the great challenge of availability of the drugs and compliance with them, given that these preventive regimens are prolonged and unsupervised. Several studies from the Africa have reported that HIVinfected pregnant women are at increased risk of adverse pregnancy outcomes such as spontaneous abortion, stillbirths, and preterm labor. However, this analysis is complicated by many factors associated with HIV infection and poor pregnancy outcomes such as malnutrition, anemia, and other frequent infections such as syphilis or malaria. These factors may contribute to the observation that the association between HIV infection and adverse pregnancy outcomes is stronger in women from developing countries. Maternal HIV infection has also been associated with an increased risk of infant death. It is well documented that up to 35% of HIV-infected infants may die before the first year of age, but HIV-negative children born to HIV-infected mothers are also at high risk of mortality. There have been few studies characterizing the impact of HIV infection during pregnancy on the mother and her infant and even fewer from rural African settings. The main aim of this study was to assess the impact of HIV infection on birth outcomes and infant survival in a rural area of southern Mozambique. Furthermore, the study also evaluated the effect of unsupervised sd-NVP administration for prevention of MTCT of HIV on HIV RNA viral load at delivery and the prevalence of NVP resistance mutations

Review of effectiveness and cost effectiveness: Increasing the uptake of HIV testing to reduce undiagnosed infection and prevent transmission among black African communities living in England

Globally, the HIV epidemic continues to have an impact on the lives of millions of people. In 2008, there were an estimated 83,000 people living with HIV (both diagnosed and undiagnosed), equivalent to 1.3 per 1000 population in the UK. In that same year, 7,798 people were newly diagnosed with HIV. The global epidemic is reflected in the UK; around 38% (2,790) of these newly diagnosed infections were among black Africans who acquired their HIV through heterosexual contact. It is thought that most (87%) of these infections among black Africans in the UK were acquired abroad, mainly in sub-Saharan Africa Health Protection Agency 2009). Late diagnosis of HIV is defined as diagnosis taking place after anti-retroviral treatment would normally have begun, or when the person has an illness which defines them as having AIDS. It is the most important factor associated with HIVrelated disease and death in the UK and is a particular problem among black Africans. In 2007, over 40% of new diagnoses among black Africans were classified as ‘late’. HIV testing can help reduce transmission of the virus. People who find out they have HIV may change their sexual behaviour as a result of the diagnosis. A negative HIV test provides an opportunity for preventive education and advice and may also lead to changes in behaviour. Increasing the frequency of testing may result in earlier detection of HIV following infection - when it is most virulent - providing greater opportunity to reduce transmission

A formative and outcome evaluation of a community based antiretroviral therapy adherence programme : the case of Sizophila, Cape Town, South Africa

This dissertation is informed by a formative and outcome evaluation of the Sizophila programme, a community based antiretroviral therapy (ART) programme. The programme is administered by the Desmond Tutu HIV Foundation, a non-profit organization. The aim of the programme is to enhance ART health outcomes and promote individual wellbeing among people accessing human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) related services in the Hannan-Crusaid Centre. The goal of the evaluation was to assess the Sizophila programme implementation and to determine the impact of the home visit intervention on the medium-term outcomes of HIV viral load suppression and loss to follow-up. The evaluation was primarily for the programme staff. An implicit Sizophila programme theory was explicated from the programme staff and the evaluator reviewed relevant programme documentation to formulate an explicit programme theory. To assess the plausibility of this theory, social science perspectives based on reviews of empirical evidence of previous research were solicited. The initial Sizophila programme theory was simplistic in assuming a simple cause-effect relationship. The final programme theory recognised that programme interventions function through certain moderators and mediators that can either strengthen or weaken the intervention-outcome effect

Three Essays in Development Economics

This dissertation consists of three chapters. They study two topics in the context of a developing economy: how households make health-related decisions and how firms make use of political connections. Chapter One aims to understand the role of social stigma in the HIV epidemic. Public health experts have seen the stigma as a leading barrier affecting the delivery of HIV-related health care. This chapter uses a field experiment in Mozambique to tackle this issue. To obtain local measures of the HIV stigma environment in the study sites, I conducted a baseline survey one year before the experiment. Experiment participants with excessive concerns, defined as overestimating the stigma in their communities, were randomly assigned an intervention to relieve stigma concerns. The intervention, which drew upon findings from the baseline survey, was designed to reveal the correct degree of stigma that a participant had overestimated. Analyses show that this intervention raised the HIV test uptake rate by 7.7 percentage points (or by 37 percent) from 20.7 percent under the control condition. To quantify the intervention effect, I introduced testing coupons of different values to estimate the demand curve for an HIV test. The concern-relieving intervention raised an individual’s willingness-to-pay for an HIV test by $1.30 or more than half of the daily cost-of-living in the study population. Chapter Two evaluates a prominent effort to help families cope with HIV/AIDS: a U.S. government program in Mozambique, “Strengthening Communities and Children” (or Portuguese abbreviation, FCC), that implements home visits alongside a set of complementary interventions. This chapter focuses on the primary outcome of HIV testing, and two key mechanisms: improvements in HIV-related knowledge, and reductions in HIV-related stigmatizing attitudes. Causal identification exploits multiple levels of random assignment, most prominently of entire communities to FCC program receipt or to a control group. We find that the FCC program has positive but small effects on HIV testing. Treatment effects are only one-fifth the magnitude of, and statistically significantly smaller than, the average of expert predictions elicited in advance. Likely mechanisms behind these modest effects are that the program worsened some aspects of households’ HIV-related knowledge, and also worsened HIV-related stigmatizing attitudes. Additional treatments randomly assigned at the household level during our follow-up survey further highlight the role of these mechanisms: treatments improving knowledge and alleviating stigma concerns raise the impact of the FCC program on HIV testing. Chapter Three focuses on a new context and studies the value of pollical connections in China. Inviting a government official to sit on the board is a commonly used strategy for firms seeking to become politically connected. This chapter estimates the value of this type of political connection with a nationwide, targeted policy shock in China. In October 2013, the central government announced a new policy that restricted government officials from working in firms. Firms with government-official outside directors were affected. I find that government-official outside directors do add to firm value: The stock return of affected firms is, on average, eight percentage points lower than that of the control firms in the 12 months following the policy change. The variation in treatment effects across firms suggests that firms rely on this type of political connection to different degrees. Several potential working mechanisms are explored.PHDEconomicsUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/163143/1/hangyu_1.pd