Almost Random: Evaluating a Large-Scale Randomized Nutrition Program in the Presence of Crossover

Large-scale randomized interventions have the potential to uncover the causal effect of programs applying to a large population, thereby improving on the insights gained from currently dominant smaller randomized studies. However, the external validity gained through larger interventions typically implies less supervision and often comes at the cost of some deviation from the randomization plan. This paper investigates the impact of the Nutrition Enhancement Program, which aims to improve child nutrition in Senegal based on a large-scale randomized community intervention. The analysis explicitly deals with deviation from the planned treatment and suggests approaches for combining ex-post adjustments such as propensity score matching with the randomized treatment plan. The authors do not detect a strong overall program impact on the outcome measure of weight-for-age based on planned treatment status, but do find an impact on the youngest children. Moreover, the project impact is clearer when the analysis considers treatment crossover using alternative estimators of two-stage least-squares and propensity score matching. The findings underscore the importance of addressing the shortcomings of large-scale randomization interventions in a systematic manner in order to understand the selection process that can guide further implementation of such projects, as well as to expose the true, causal effect of such programs.Nutrition; Impact evaluation

Evaluation of the Population and Poverty Research Initiative (PopPov)

Since 2005, the William and Flora Hewlett Foundation, with collaboration and co-funding from research councils in the United Kingdom, the Netherlands, France, and Norway and from the World Bank, has invested in a portfolio of social science research on the relationship between population dynamics and micro- and macroeconomic outcomes. It is known as the Population and Poverty Research Initiative (PopPov), and its geographic focus is on subSaharan Africa (SSA). The starting premises that led to the development of PopPov were that evidence showing that population dynamics could affect economic outcomes might increase the interest of ministers of finance in funding population policies and that they might be most convinced by rigorous research done by respected economists. The core aim of the program has been to build (or, in some cases, rebuild) and advance the field of economic demography, orienting the work toward research that would be relevant for policy and would increase recognition by economic policymakers of the value of lowering the rate of population growth and investing in family planning (FP). The program also aimed to strengthen the capacity of researchers in SSA. The PopPov initiative tried to achieve these aims through four main components: (1) grants to support research on PopPov core topics of interest, (2) fellowships to support graduate students preparing their doctoral dissertations, (3) conferences and workshops to support the development of networking opportunities, and (4) other dissemination activities. PopPov has funded 56 doctoral fellows and, together with its partners, has supported 61 research projects. Seven international conferences and additional workshops have been held, and there have been several other dissemination activities. The Population Reference Bureau (PRB) and the Center for Global Development (CGD) have been the secretariats for PopPov. Since 2008, the Institute of International Education (IIE) has administered the fellowship program.In November 2012, to help guide its decisions about both the substance and means of future investments, the foundation issued a request for proposals (RFP) for an evaluation of PopPov. The RAND Corporation was selected to conduct the evaluation

Social Interactions and Fertility in Developing Countries

There is strong evidence that, in addition to individual and household characteristics, social interactions are important in determining fertility rates. Social interactions can lead to a multiplier effect where an individual’s ideas, and fertility choice, can affect the fertility decisions of others. We merge all available Demographic and Health Surveys to investigate the factors that influence both individual and average group fertility. We find that in the early phase of the fertility transition the impact of a woman’s education and experience of child death on her group’s average fertility are more than three times as large as their direct effect on her own fertility decision.demography, growth, age structure, population, economy.

Identifying Opportunities for Collaboration Across the Social Sciences to Reach the 10-10-10: A Multilevel Approach.

BACKGROUND:The national and global strategy to combat HIV, often referred to as the "90-90-90," aims to diagnose 90% of people living with HIV, get 90% of those diagnosed onto antiretroviral treatment (ART), and achieve viral suppression in 90% of those on ART. The remaining 10-10-10 who will be undiagnosed, not on ART, or not virally suppressed, include vulnerable persons and populations most affected by social determinants of health. Given their foci on the social determinants of health at the individual, social, and structural levels, social scientists are in a prime position to help reach the 10-10-10. A potentially effective way for social scientists to achieve this goal is to examine the issues that affect the 10-10-10 using a multilevel framework, to understand at what levels their own approaches fit within such a multilevel framework, and to seek intentional collaborations with other social scientists who may work at different levels but whose approaches may complement their own within multilevel collaborations. APPROACH:The present article describes how a multilevel framework can guide collaboration across disciplines within the social sciences toward the common goal of reaching the 10-10-10. CONCLUSIONS:Within a multilevel framework, social scientists can work collaboratively to address the needs of individuals among the 10-10-10 within the social and structural contexts (eg, social norms, stigma, poverty, and barriers to care) that affect their health. Such an approach draws on the unique strengths and approaches of different social-science disciplines while also building capacity for individuals most affected by social determinants of health

Time Preferences Predict Mortality among HIV-Infected Adults Receiving Antiretroviral Therapy in Kenya

Background: Identifying characteristics of HIV-infected adults likely to have poor treatment outcomes can be useful for targeting interventions efficiently. Research in economics and psychology suggests that individuals’ intertemporal time preferences, which indicate the extent to which they trade-off immediate vs. future cost and benefits, can influence various health behaviors. While there is empirical support for the association between time preferences and various non-HIV health behaviors and outcomes, the extent to which time preferences predict outcomes of those receiving antiretroviral therapy (ART) has not been examined previously. Methods: HIV-infected adults initiating ART were enrolled at a health facility in Kenya. Participants’ time preferences were measured at enrollment and used to classify them as having either a low or high discount rate for future benefits. At 48 weeks, we assessed mortality and ART adherence, as measured by Medication Event Monitoring System (MEMS). Logistic regression models adjusting for socio-economic characteristics and risk factors were used to determine the association between time preferences and mortality as well as MEMS adherence ≥90%. Results: Overall, 44% (96/220) of participants were classified as having high discount rates. Participants with high discount rates had significantly higher 48-week mortality than participants with low discount rates (9.3% vs. 3.1%; adjusted odds ratio 3.84; 95% CI 1.03, 14.50). MEMS adherence ≥90% was similar for participants with high vs. low discount rates (42.3% vs. 49.6%, AOR 0.70; 95% CI 0.40, 1.25). Conclusion: High discount rates were associated with significantly higher risk of mortality among HIV-infected patients initiating ART. Greater use of time preference measures may improve identification of patients at risk of poor clinical outcomes. More research is needed to further identify mechanisms of action and also to build upon and test the generalizability of this finding

Let\u27s talk about antibiotics: A randomised trial of two interventions to reduce antibiotic misuse

BACKGROUND: Children with acute respiratory tract infections (ARTIs) receive ≈11.4 million unnecessary antibiotic prescriptions annually. A noted contributor is inadequate parent-clinician communication, however, efforts to reduce overprescribing have only indirectly targeted communication or been impractical. OBJECTIVES: Compare two feasible (higher vs lower intensity) interventions for enhancing parent-clinician communication on the rate of inappropriate antibiotic prescribing. DESIGN: Multisite, parallel group, cluster randomised comparative effectiveness trial. Data collected between March 2017 and March 2019. SETTING: Academic and private practice outpatient clinics. PARTICIPANTS: Clinicians (n=41, 85% of eligible approached) and 1599 parent-child dyads (ages 1-5 years with ARTI symptoms, 71% of eligible approached). INTERVENTIONS: All clinicians received 20 min ARTI diagnosis and treatment education. Higher intensity clinicians received an additional 50 min communication skills training. All parents viewed a 90 second antibiotic education video. MAIN OUTCOMES AND MEASURES: Inappropriate antibiotic treatment was assessed via blinded medical record review by study clinicians and a priori defined as prescriptions for the wrong diagnosis or use of the wrong agent. Secondary outcomes were revisits, adverse drug reactions (both assessed 2 weeks after the visit) and parent ratings of provider communication, shared decision-making and visit satisfaction (assessed at end of the visit on Likert-type scales). RESULTS: Most clinicians completed the study (n=38, 93%), were doctors (n=25, 66%), female (n=30, 78%) and averaged 8 years in practice. All parent-child dyad provided data for the main outcome (n=855 (54%) male, n=1043 (53%) CONCLUSIONS AND RELEVANCE: Rate of inappropriate prescribing was low in both arms. Clinician education coupled with parent education may be sufficient to yield low inappropriate antibiotic prescribing rates. The absence of a significant difference between groups indicates that communication principles previously thought to drive inappropriate prescribing may need to be re-examined or may not have as much of an impact in practices where prescribing has improved in recent years. TRIAL REGISTRATION NUMBER: NCT03037112

Interventions to promote adherence to antiretroviral therapy in Africa: a network meta-analysis

Background: Adherence to antiretroviral therapy (ART) is necessary for the improvement of the health of patients and for public health. We sought to determine the comparative effectiveness of different interventions for improving ART adherence in HIV-infected people living in Africa. Methods: We searched for randomised trials of interventions to promote antiretroviral adherence within adults in Africa. We searched AMED, CINAHL, Embase, Medline (via PubMed), and ClinicalTrials.gov from inception to Oct 31, 2014, with the terms “HIV”, “ART”, “adherence”, and “Africa”. We created a network of the interventions by pooling the published and individual patients\u27 data for comparable treatments and comparing them across the individual interventions with Bayesian network meta-analyses. The primary outcome was adherence defined as the proportion of patients meeting trial defined criteria; the secondary endpoint was viral suppression. Findings: We obtained data for 14 randomised controlled trials, with 7110 patients. Interventions included daily and weekly short message service (SMS; text message) messaging, calendars, peer supporters, alarms, counselling, and basic and enhanced standard of care (SOC). Compared with SOC, we found distinguishable improvement in self-reported adherence with enhanced SOC (odds ratio [OR] 1·46, 95% credibility interval [CrI] 1·06–1·98), weekly SMS messages (1·65, 1·25–2·18), counselling and SMS combined (2·07, 1·22–3·53), and treatment supporters (1·83, 1·36–2·45). We found no compelling evidence for the remaining interventions. Results were similar when using viral suppression as an outcome, although the network contained less evidence than that for adherence. Treatment supporters with enhanced SOC (1·46, 1·09–1·97) and weekly SMS messages (1·55, 1·01–2·38) were significantly better than basic SOC. Interpretation: Several recommendations for improving adherence are unsupported by the available evidence. These findings can inform future intervention choices for improving ART adherence in low-income settings. Funding: None

Short Message Service (SMS)-Based Intervention to Improve Treatment Adherence among HIV-Positive Youth in Uganda: Focus Group Findings

This paper presents one of the first qualitative studies to discuss programmatic barriers to SMS-based interventions for HIV-positive youth and discusses pathways through which youth perceive them to work. We conducted six focus groups with 20 male and 19 female HIV-positive youths in two clinics in Kampala, Uganda. We find that youth commonly use SMS as over 90% of this study’s youths knew how to read, write and send messages and almost three-fourths of them had phones. Youth strongly felt that the success of this intervention hinged on ensuring confidentiality about their HIV-positive status. Key programmatic challenges discussed where restrictions on phone use and phone sharing that could exclude some youth. Participants felt that the intervention would improve their adherence by providing them with needed reminders and social support. Youths’ suggestions about intervention logistics related to content, frequency, timing and two-way messages will be helpful to practitioners in the field

Consumption Smoothing and HIV/AIDS: The Case of Two Communities in South Africa

HIV/AIDS threatens to overstretch the already frail informal safety nets in countries heavily affected by the epidemic, potentially making it difficult for households with HIV-positive members to keep up appropriate consumption levels when experiencing shocks. These households may, in addition, face exclusion from informal insurance networks because of widespread stigmatization. Surprisingly, the resilience of informal networks to HIV-related shocks and their uncertain worth for afflicted households in particular have not been empirically tested to date. Using 3 years of a novel panel data set from two poor South African communities experiencing HIV-related illnesses and deaths, we investigate the ability of households to insure their consumption. We find little evidence that affected households show an extra propensity to consume out of income changes, which indicates that these households can rely on informal insurance to the same degree as their nonaffected peers. However, on the basis of the result that affected as well as nonaffected households adjust their expenditures in reaction to income changes, the benchmark hypothesis of full insurance is rejected for both types of households. This result indicates that informal insurance mechanisms are of limited value in the sample, potentially because they have been eroded by repeated stresses brought about by the HIV epidemic. (c) 2010 by The University of Chicago. All rights reserved..