Step-wedge cluster-randomised community-based trials: An application to the study of the impact of community health insurance

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.BACKGROUND: We describe a step-wedge cluster-randomised community-based trial which has been conducted since 2003 to accompany the implementation of a community health insurance (CHI) scheme in West Africa. The trial aims at overcoming the paucity of evidence-based information on the impact of CHI. Impact is defined in terms of changes in health service utilisation and household protection against the cost of illness. Our exclusive focus on the description and discussion of the methods is justified by the fact that the study relies on a methodology previously applied in the field of disease control, but never in the field of health financing. METHODS: First, we clarify how clusters were defined both in respect of statistical considerations and of local geographical and socio-cultural concerns. Second, we illustrate how households within clusters were sampled. Third, we expound the data collection process and the survey instruments. Finally, we outline the statistical tools to be applied to estimate the impact of CHI. CONCLUSION: We discuss all design choices both in relation to methodological considerations and to specific ethical and organisational concerns faced in the field. On the basis of the appraisal of our experience, we postulate that conducting relatively sophisticated trials (such as our step-wedge cluster-randomised community-based trial) aimed at generating sound public health evidence, is both feasible and valuable also in low income settings. Our work shows that if accurately designed in conjunction with local health authorities, such trials have the potential to generate sound scientific evidence and do not hinder, but at times even facilitate, the implementation of complex health interventions such as CHI

PCR Based Genotyping of Lulu Cattle of Nepal for A1, A2 Type Beta-caseins

Lulu is an indigenous breed of cattle (Bos taurus) found in high altitude regions of western Nepal. Population of Lulu cattle has been declining due to introgression with other exotic breeds to increase milk productivity. Here we aimed at finding potential approach for conserving Lulu cattle and its assets by studying the milk contents and investigating which variant of beta-casein protein is present in this breed. Beta caseins are an abundant protein in cow milk with A1 and A2 being the most common genetic variants of this protein. Consumption of A1 type of milk has numerous health-related complications whereas A2 type of milk has numerous human health promoting factors. We used restriction fragment length polymorphism (RFLP) for determining the A1 and A2 variant of beta casein in Lulu cattle. For performing DNA extraction, we collected (n = 18) blood samples of Lulu from Mustang and (n=17) Nepal Agriculture research council farm. The amplified fragments in 3% agarose at 251bp and 213bp respectively confirmed the presence of both A1 and A2 gene in Lulu; however, A2 was of greater abundance. Our study indicated that Lulu has A2 variant of beta-casein predominantly. The gene frequency of A1A1 is 0, A1A2 is 0.06 and A2A2 is 0.94. We further found that the allele frequency of A1 and A2 is 0.03 and 0.97 respectively. We designed special primer for sequencing CSN2 genes since A2 type beta casein gene was predominantly seen on Lulu. The sequencing result further supports our RFLP result as most of our samples have “C” nucleotide SNP in amplified CSN2 gene sequence. The Chi-square value of the current study is 0.04 which supports Hardy-Weinberg equilibrium inferring that Lulu cattle are still in the pure state, where there is no genetic introgression with the exotic breed for the sake of improvement of productivity

Prevalence of cardiovascular risk factors among chronic kidney disease patients undergoing hemodialysis in a tertiary care center, Kathmandu, Nepal

The risk of cardiovascular disease is higher in chronic kidney disease patients compared to the general population and its impact is higher in developing countries compared to the developed countries. With this background in mind, we aimed to evaluate the prevalence of different cardiovascular risk factors in patients on maintenance hemodialysis in a tertiary care center. Chronic kidney disease patients aged 18 years and above who were under maintenance hemodialysis in the hemodialysis unit of Nepal Medical College were included in the study. Pre-dialysis venous blood samples from the participants were collected and analyzed for serum calcium, phosphorus, total protein, albumin and hemoglobin. Calcium phosphate product was calculated. Out of 100 study participants, 52% were male and 48% were female. Age-wise distribution showed 38% of the participants were below 40 years. The mean age of the participants was 45.86 ± 14.4 years. Ninety-three percent had hypertension and 29% had diabetes mellitus. Hypocalcemia was present in 80%, hyperphosphatemia was seen among 81% and high calcium phosphate product was present in 33% of the participants. Low hemoglobin (< 10gm/dL) was found in 86%. The cardiovascular risk trend in the Nepalese chronic kidney disease population is fairly different compared to the western population. Participants were younger. Prevalence of hypertension and diabetes was high. The high prevalence of anemia might be due to unaffordability of the participants for regular erythropoietin therapy. Inadequately managed hyperphosphatemia despite the widespread use of phosphorus binders, is still a major clinical challenge in patients on hemodialysis

Continual Professional Development (CPD): Improving Quality of Nursing Care in Nepal

The notion that health professionals should be accountable to people and the society they serve is not a new concept (1). Globally, health professionals are being nudged to demonstrate their commitment with continuing professional development (CPD) in order to maintain competence in light of evidence-based practice and ever changing technology in health service provision. CPD provides an important strategy to improve the knowledge and skills of health practitioners as well as the quality of service (2). The World Health Organization also stresses the need to capacity enhancement of nurses and midwives through education, training and career development in Southeast Asia (3). The member states in the Region have agreed on a Decade for Strengthening Human Resources for Health in South-East Asia, 2015–2024, and country action plans have been developed to strengthen physicians, nurses and midwives with the focus on transforming education and retention (4). This editorial highlights the importance of CPD and existing lack of such provision in the field of nursing in Nepal

Effective Biosorption of Phosphate from Water Using Fe(III)-Loaded Pomegranate Peel

Removal of phosphate from wastewater is necessary for the safety of public health and environmental protection. The present study used an easily available and affordable biosorbent obtained from the pomegranate peel for the excision of phosphate from water. The biosorption behavior of raw pomegranate peel powder (RPGPP) was found negligible. The RPGPP was further saponified with Ca(OH)2 followed by Fe(III) loading to obtain Fe(III)-loaded pomegranate peels (Fe(III)-PGPP), which was then employed for the phosphate uptake. Fourier transform infrared spectroscopy (FTIR), energy dispersive X-ray (EDX) spectroscopy, scanning electron microscopy (SEM), and X-ray diffraction (XRD) were used to characterize the biosorbent. The batch adsorption test was used to evaluate the adsorption viability of biosorbents for removing phosphate from aqueous solution. Fe(III)-PGPP was determined to have a pHPZC of 5.40. The experimental data were best explained by the Langmuir isotherm and pseudo-second-order kinetic model. Fe(III)-PGPP had the largest phosphate biosorption capacity of 99.30 mg g–1 at the optimum pH of 3.0 and 2.5 hours of contact time. From the results obtained, Fe(III)-PGPP adsorbent can be regarded as an effective and cost-efficient material for the treatment of phosphate-anion-contaminated water

The demand for sports and exercise: Results from an illustrative survey

Funding from the Department of Health policy research programme was used in this study.There is a paucity of empirical evidence on the extent to which price and perceived benefits affect the level of participation in sports and exercise. Using an illustrative sample of 60 adults at Brunel University, West London, we investigate the determinants of demand for sports and exercise. The data were collected through face-to-face interviews that covered indicators of sports and exercise behaviour; money/time price and perceived benefits of participation; and socio- economic/demographic details. Count, linear and probit regression models were fitted as appropriate. Seventy eight per cent of the sample participated in sports and exercise and spent an average of £27 per month and an average of 20 min travelling per occasion of sports and exercise. The demand for sport and exercise was negatively associated with time (travel or access time) and ‘variable’ price and positively correlated with ‘fixed’ price. Demand was price inelastic, except in the case of meeting the UK government’s recommended level of participation, which is time price elastic (elasticity = −2.2). The implications of data from a larger nationally representative sample as well as the role of economic incentives in influencing uptake of sports and exercise are discussed.This article is available through the Brunel Open Access Publishing Fund

Smoking and health-related quality of life in English general population: Implications for economic evaluations

Copyright @ 2012 Vogl et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.This article has been made available through the Brunel Open Access Publishing Fund.Background: Little is known as to how health-related quality of life (HRQoL) when measured by generic instruments such as EQ-5D differ across smokers, ex-smokers and never-smokers in the general population; whether the overall pattern of this difference remain consistent in each domain of HRQoL; and what implications this variation, if any, would have for economic evaluations of tobacco control interventions. Methods: Using the 2006 round of Health Survey for England data (n = 13,241), this paper aims to examine the impact of smoking status on health-related quality of life in English population. Depending upon the nature of the EQ-5D data (i.e. tariff or domains), linear or logistic regression models were fitted to control for biology, clinical conditions, socio-economic background and lifestyle factors that an individual may have regardless of their smoking status. Age- and gender-specific predicted values according to smoking status are offered as the potential 'utility' values to be used in future economic evaluation models. Results: The observed difference of 0.1100 in EQ-5D scores between never-smokers (0.8839) and heavy-smokers (0.7739) reduced to 0.0516 after adjusting for biological, clinical, lifestyle and socioeconomic conditions. Heavy-smokers, when compared with never-smokers, were significantly more likely to report some/severe problems in all five domains - mobility (67%), self-care (70%), usual activity (42%), pain/discomfort (46%) and anxiety/depression (86%) -. 'Utility' values by age and gender for each category of smoking are provided to be used in the future economic evaluations. Conclusion: Smoking is significantly and negatively associated with health-related quality of life in English general population and the magnitude of this association is determined by the number of cigarettes smoked. The varying degree of this association, captured through instruments such as EQ-5D, may need to be fed into the design of future economic evaluations where the intervention being evaluated affects (e.g. tobacco control) or is affected (e.g. treatment for lung cancer) by individual's (or patients') smoking status

Social sciences research in neglected tropical diseases 2: A bibliographic analysis

The official published version of the article can be found at the link below.Background There are strong arguments for social science and interdisciplinary research in the neglected tropical diseases. These diseases represent a rich and dynamic interplay between vector, host, and pathogen which occurs within social, physical and biological contexts. The overwhelming sense, however, is that neglected tropical diseases research is a biomedical endeavour largely excluding the social sciences. The purpose of this review is to provide a baseline for discussing the quantum and nature of the science that is being conducted, and the extent to which the social sciences are a part of that. Methods A bibliographic analysis was conducted of neglected tropical diseases related research papers published over the past 10 years in biomedical and social sciences. The analysis had textual and bibliometric facets, and focussed on chikungunya, dengue, visceral leishmaniasis, and onchocerciasis. Results There is substantial variation in the number of publications associated with each disease. The proportion of the research that is social science based appears remarkably consistent (<4%). A textual analysis, however, reveals a degree of misclassification by the abstracting service where a surprising proportion of the "social sciences" research was pure clinical research. Much of the social sciences research also tends to be "hand maiden" research focused on the implementation of biomedical solutions. Conclusion There is little evidence that scientists pay any attention to the complex social, cultural, biological, and environmental dynamic involved in human pathogenesis. There is little investigator driven social science and a poor presence of interdisciplinary science. The research needs more sophisticated funders and priority setters who are not beguiled by uncritical biomedical promises

Cost-effectiveness of increasing the reach of smoking cessation interventions in Germany: results from the EQUIPTMOD

Aims: To evaluate costs, effects and cost effectiveness of increased reach of specific smoking cessation interventions in Germany. Design: A Markov-based state transition return on investment model (EQUIPTMOD) was used to evaluate current smoking cessation interventions as well as two prospective investment scenarios. A healthcare perspective (extended to include out-of-pocket payments) with lifetime horizon was considered. A probabilistic analysis was used to assess uncertainty around predicted estimates. Setting: Germany. Participants: Cohort of current smoking population (18+ years) in Germany. Interventions: Interventions included group-based behavioral support, financial incentive programs and varenicline. For Prospective Scenario 1 the reach of group-based behavioral support, financial incentive program and varenicline was increased by 1% of yearly quit attempts (=57,915 quit attempts), while Prospective Scenario 2 represented a higher reach mirroring the levels observed in England. Measurements: EQUIPTMOD considered reach, intervention cost, number of quitters, QALYs gained, cost effectiveness and return on investment. Findings: The highest returns through reduction in smoking-related healthcare costs were seen for the financial incentive program (€2.71 per €1 invested), followed by that of group-based behavioral support (€1.63 per €1 invested), compared with no interventions. Varenicline had lower returns (€1.02 per €1 invested) than the other two interventions. At the population level, Prospective Scenario 1 led to 15,034 QALYs gained and €27 million cost-savings, compared with Current Investment. Intervention effects and reach contributed most to the uncertainty around the return-on-investment estimates. At a hypothetical willingness-to-pay threshold of only €5,000, the probability of being cost effective is around 75% for Prospective Scenario 1. Conclusions Increasing the reach of group-based behavioral support, financial incentives and varenicline for smoking cessation by just 1% of current annual quit attempts provides a strategy to German policy makers that improves the population’s health outcomes and that may be considered cost-effective