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  • 1. Batura, Neha
    et al.
    Hill, Zelee
    Haghparast-Bidgoli, Hassan
    Lingam, Raghu
    Colbourn, Timothy
    Kim, Sungwook
    Sikander, Siham
    Pulkki-Brännström, Anni-Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Institute for Global Health, University College London.
    Rahman, Atif
    Kirkwood, Betty
    Skordis-Worrall, Jolene
    Highlighting the evidence gap: how cost-effective are interventions to improve early childhood nutrition and development?2015Inngår i: Health Policy and Planning, ISSN 0268-1080, E-ISSN 1460-2237, Vol. 30, nr 6, s. 813-821Artikkel, forskningsoversikt (Fagfellevurdert)
    Abstract [en]

    There is growing evidence of the effectiveness of early childhood interventions to improve the growth and development of children. Although, historically, nutrition and stimulation interventions may have been delivered separately, they are increasingly being tested as a package of early childhood interventions that synergistically improve outcomes over the life course. However, implementation at scale is seldom possible without first considering the relative cost and cost-effectiveness of these interventions. An evidence gap in this area may deter large-scale implementation, particularly in low- and middle-income countries. We conduct a literature review to establish what is known about the cost-effectiveness of early childhood nutrition and development interventions. A set of predefined search terms and exclusion criteria standardized the search across five databases. The search identified 15 relevant articles. Of these, nine were from studies set in high-income countries and six in low- and middle-income countries. The articles either calculated the cost-effectiveness of nutrition-specific interventions (n = 8) aimed at improving child growth, or parenting interventions (stimulation) to improve early childhood development (n = 7). No articles estimated the cost-effectiveness of combined interventions. Comparing results within nutrition or stimulation interventions, or between nutrition and stimulation interventions was largely prevented by the variety of outcome measures used in these analyses. This article highlights the need for further evidence relevant to low- and middle-income countries. To facilitate comparison of cost-effectiveness between studies, and between contexts where appropriate, a move towards a common outcome measure such as the cost per disability-adjusted life years averted is advocated. Finally, given the increasing number of combined nutrition and stimulation interventions being tested, there is a significant need for evidence of cost-effectiveness for combined programmes. This too would be facilitated by the use of a common outcome measure able to pool the impact of both nutrition and stimulation activities.

  • 2. Batura, Neha
    et al.
    Pulkki-Brännström, Anni-Maria
    Institute for Global Health, University College London, London, UK.
    Agrawal, Priya
    Bagra, Archana
    Haghparast-Bidgoli, Hassan
    Bozzani, Fiammetta
    Colbourn, Tim
    Greco, Giulia
    Hossain, Tanvir
    Sinha, Rajesh
    Thapa, Bidur
    Skordis-Worrall, Jolene
    Collecting and analysing cost data for complex public health trials: reflections on practice2014Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, s. 23257-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Current guidelines for the conduct of cost-effectiveness analysis (CEA) are mainly applicable to facility-based interventions in high-income settings. Differences in the unit of analysis and the high cost of data collection can make these guidelines challenging to follow within public health trials in low- and middle- income settings.

    OBJECTIVE: This paper reflects on the challenges experienced within our own work and proposes solutions that may be useful to others attempting to collect, analyse, and compare cost data between public health research sites in low- and middle- income countries.

    DESIGN: We describe the generally accepted methods (norms) for collecting and analysing cost data in a single-site trial from the provider perspective. We then describe our own experience applying these methods within eight comparable cluster randomised, controlled, trials. We describe the strategies used to maximise adherence to the norm, highlight ways in which we deviated from the norm, and reflect on the learning and limitations that resulted.

    RESULTS: When the expenses incurred by a number of small research sites are used to estimate the cost-effectiveness of delivering an intervention on a national scale, then deciding which expenses constitute 'start-up' costs will be a nontrivial decision that may differ among sites. Similarly, the decision to include or exclude research or monitoring and evaluation costs can have a significant impact on the findings. We separated out research costs and argued that monitoring and evaluation costs should be reported as part of the total trial cost. The human resource constraints that we experienced are also likely to be common to other trials. As we did not have an economist in each site, we collaborated with key personnel at each site who were trained to use a standardised cost collection tool. This approach both accommodated our resource constraints and served as a knowledge sharing and capacity building process within the research teams.

    CONCLUSIONS: Given the practical reality of conducting randomised, controlled trials of public health interventions in low- and middle- income countries, it is not always possible to adhere to prescribed guidelines for the analysis of cost effectiveness. Compromises are frequently required as researchers seek a pragmatic balance between rigor and feasibility. There is no single solution to this tension but researchers are encouraged to be mindful of the limitations that accompany compromise, whilst being reassured that meaningful analyses can still be conducted with the resulting data.

  • 3.
    Beck, Simon
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Pulkki-Brännström, Anni-Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Basic income – healthy outcome? Effects on health of an Indian basic income pilot project: a cluster randomised trial2015Inngår i: Journal of Development Effectiveness, ISSN 1943-9342, E-ISSN 1943-9407, Vol. 7, nr 1, s. 111-126Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    This article evaluates the effects on health of a basic income (BI) pilot project in Madhya Pradesh, India, between 2011 and 2012. BI can be defined as a non-contributory, universal and unconditional cash transfer paid out on an individual basis. The project was conducted as a cluster randomised trial involving 2034 households. Three health outcomes were examined: minor illnesses and injuries, illness and injuries requiring hospitalisation, and child vaccination coverage. The data were analysed with multiple imputation, propensity score matching and weighted logistic regression. BI was seen to significantly reduce the odds of minor illnesses and injuries by 46 per cent. No effect was seen on more serious illnesses and injuries, at least not in the time scale given, nor on child vaccination coverage which was already exceptionally high. Policymakers are encouraged to consider BI as an equitable policy of social protection, though further research on its impact on health is desirable.

  • 4.
    Colbourn, Tim
    et al.
    UCL Institute for Global Health, London, UK.
    Pulkki-Brännström, Anni-Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. UCL Institute for Global Health, London, UK.
    Nambiar, Bejoy
    UCL Institute for Global Health, London, UK.
    Kim, Sungwook
    UCL Institute for Global Health, London, UK.
    Bondo, Austin
    Capital City, Lilongwe 3, Malawi.
    Banda, Lumbani
    Capital City, Lilongwe 3, Malawi.
    Makwenda, Charles
    Capital City, Lilongwe 3, Malawi.
    Batura, Neha
    UCL Institute for Global Health, London, UK.
    Haghparast-Bidgoli, Hassan
    UCL Institute for Global Health, London, UK.
    Hunter, Rachael
    London, UK.
    Costello, Anthony
    UCL Institute for Global Health, London, UK.
    Baio, Gianluca
    London, UK.
    Skordis-Worrall, Jolene
    UCL Institute for Global Health, London, UK.
    Cost-effectiveness and affordability of community mobilisation through women's groups and quality improvement in health facilities (MaiKhanda trial) in Malawi2015Inngår i: Cost Effectiveness and Resource Allocation, ISSN 1478-7547, E-ISSN 1478-7547, Vol. 13, artikkel-id 1Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Understanding the cost-effectiveness and affordability of interventions to reduce maternal and newborn deaths is critical to persuading policymakers and donors to implement at scale. The effectiveness of community mobilisation through women's groups and health facility quality improvement, both aiming to reduce maternal and neonatal mortality, was assessed by a cluster randomised controlled trial conducted in rural Malawi in 2008-2010. In this paper, we calculate intervention cost-effectiveness and model the affordability of the interventions at scale.

    METHODS: Bayesian methods are used to estimate the incremental cost-effectiveness of the community and facility interventions on their own (CI, FI), and together (FICI), compared to current practice in rural Malawi. Effects are estimated with Monte Carlo simulation using the combined full probability distributions of intervention effects on stillbirths, neonatal deaths and maternal deaths. Cost data was collected prospectively from a provider perspective using an ingredients approach and disaggregated at the intervention (not cluster or individual) level. Expected Incremental Benefit, Cost-effectiveness Acceptability Curves and Expected Value of Information (EVI) were calculated using a threshold of $780 per disability-adjusted life-year (DALY) averted, the per capita gross domestic product of Malawi in 2013 international $.

    RESULTS: The incremental cost-effectiveness of CI, FI, and combined FICI was $79, $281, and $146 per DALY averted respectively, compared to current practice. FI is dominated by CI and FICI. Taking into account uncertainty, both CI and combined FICI are highly likely to be cost effective (probability 98% and 93%, EVI $210,423 and $598,177 respectively). Combined FICI is incrementally cost effective compared to either intervention individually (probability 60%, ICER $292, EIB $9,334,580 compared to CI). Future scenarios also found FICI to be the optimal decision. Scaling-up to the whole of Malawi, CI is of greatest value for money, potentially averting 13.0% of remaining annual DALYs from stillbirths, neonatal and maternal deaths for the equivalent of 6.8% of current annual expenditure on maternal and neonatal health in Malawi.

    CONCLUSIONS: Community mobilisation through women's groups is a highly cost-effective and affordable strategy to reduce maternal and neonatal mortality in Malawi. Combining community mobilisation with health facility quality improvement is more effective, more costly, but also highly cost-effective and potentially affordable in this context.

  • 5.
    Eid, Daniel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Department of Biomedical Sciences Research, Faculty of Medicine, San Simon University, Cochabamba, Bolivia.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Pulkki-Brännström, Anni-Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    "Cheaper and better": an economic analysis of changing first line treatment for cutaneous leishmaniasis in BoliviaManuskript (preprint) (Annet vitenskapelig)
    Abstract [en]

    Introduction: Cutaneous leishmaniasis (CL) is endemic in Bolivia, mostly affecting poor people in rainforest areas. The current first-line treatment consists of systemic pentavalent antimonials (SPA) for 20 days and is paid for by the Ministry of Health (MoH). Long periods of drug shortages, a lack of conditions to deliver treatment safely, treatment interruption are challenges to implementation. Intralesional pentavalent antimonials (ILPA) are an alternative to SPA. This study aims to compare the cost of ILPA and SPA, and to estimate the health and economic impacts of changing the first-line treatment for CL in an endemic area of Bolivia.

    Methods: The cost per patient treated was estimated for SPA and ILPA from the perspectives of the MoH and society. The quantity and unit costs of medications, staff time, transportation and loss of production were obtained through a health facility survey (N=12), official documents and key informants. A one-way sensitivity analysis was conducted on key parameters to evaluate the robustness of the results. The annual number of patients treated and the budget impact of switching to ILPA as the first-line treatment were estimated under different scenarios of increasing treatment utilization using previous estimates of the extent of underreporting. Costs were reported in 2016 international dollars (1 INT$ = 3.10 BOB).

    Results: Treating CL using ILPA was associated with a cost saving of $248 per patient treated from the MoH perspective, and $688 per patient treated from the societal perspective. ILPA was cost-saving even under a hypothetical increase of 80% in the number of cases treated. Switching first-line treatment would allow two-and-a-half times the current number of patients to be treated, while maintaining the current budget.

    Conclusions: The results of this study support a shift to ILPA as the first-line treatment for CL in Bolivia and possibly in other South American countries.

  • 6. Feldman, I.
    et al.
    Eurenius, Eva
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Haggstrom, J.
    Sampaio, F.
    Lindkvist, M.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Pulkki-Brännström, Anni-Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Ivarsson, Anneli
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Effectiveness of the Salut Program: a universal health promotion intervention for parents & children2016Konferansepaper (Fagfellevurdert)
  • 7. Feldman, Inna
    et al.
    Eurenius, Eva
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Häggstrom, Jenny
    Umeå universitet, Samhällsvetenskapliga fakulteten, Handelshögskolan vid Umeå universitet.
    Sampaio, Filipa
    Lindkvist, Marie
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Handelshögskolan vid Umeå universitet.
    Pulkki-Brannstrom, Anni-Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Ivarsson, Anneli
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Effectiveness and cost-effectiveness of the Salut Programme: a universal health promotion intervention for parents and children-protocol of a register-based retrospective observational study2016Inngår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 6, nr 8, artikkel-id e011202Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Introduction: There is inadequate evidence for the effectiveness and cost-effectiveness of health promotion interventions. The Salut Programme aims to reach all parents and children in the Vasterbotten County of Sweden with a combination of health promotion interventions initiated during pregnancy and continued over the childhood period. This study protocol describes an effectiveness study and an economic evaluation study, where the ongoing Salut Programme is compared to care-as-usual over the periods of pregnancy, delivery and the child's first 2 years of life. Methods: A register-based retrospective observational study design will be used with existing data sources with respect to exposures and outcomes. Outcomes of interest are clustered at 3 points: around the child's birth, 1 month after the child's birth and 2 years after the child's birth. We will simulate an experiment by retrospectively identifying and comparing children and their parents in the geographical areas where the Salut Programme was implemented since 2006 and onwards, and the areas where the Programme was not implemented before 2009. Outcomes will be analysed and compared for the premeasure period, and the postmeasure period for both groups. Our analysis combines difference-in-difference estimation with matching. A complementary analysis will be carried out on the longitudinal subsample of mothers who gave birth at least once during each of the time periods. The economic evaluation aims to capture the wider societal costs and benefits of the Salut Programme for the first 2 years of the children's lives. Incremental costs will be compared with incremental health gains and the results will be presented as a cost-consequence analysis. Ethics and dissemination: The Regional Ethical Review Board in Umea has given clearance for the Salut Programme research (2010-63-31M). No individual's identity will be revealed when presenting results. This study will provide information that can guide decision-makers to allocate resources optimally.

  • 8. Fottrell, Edward
    et al.
    Azad, Kishwar
    Kuddus, Abdul
    Younes, Layla
    Shaha, Sanjit
    Nahar, Tasmin
    Aumon, Bedowra Haq
    Hossen, Munir
    Beard, James
    Hossain, Tanvir
    Pulkki-Brännström, Anni-Maria
    Skordis-Worrall, Jolene
    Prost, Audrey
    Costello, Anthony
    Houweling, Tanja A J
    The effect of increased coverage of participatory women's groups on neonatal mortality in Bangladesh: A cluster randomized trial2013Inngår i: JAMA pediatrics, ISSN 2168-6211, Vol. 167, nr 9, s. 816-25Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    IMPORTANCE: Community-based interventions can reduce neonatal mortality when health systems are weak. Population coverage of target groups may be an important determinant of their effect on behavior and mortality. A women's group trial at coverage of 1 group per 1414 population in rural Bangladesh showed no effect on neonatal mortality, despite a similar intervention having a significant effect on neonatal and maternal death in comparable settings.

    OBJECTIVE: To assess the effect of a participatory women's group intervention with higher population coverage on neonatal mortality in Bangladesh.

    DESIGN: A cluster randomized controlled trial in 9 intervention and 9 control clusters.

    SETTING: Rural Bangladesh.

    PARTICIPANTS: Women permanently residing in 18 unions in 3 districts and accounting for 19 301 births during the final 24 months of the intervention.

    INTERVENTIONS: Women's groups at a coverage of 1 per 309 population that proceed through a participatory learning and action cycle in which they prioritize issues that affected maternal and neonatal health and design and implement strategies to address these issues.

    MAIN OUTCOMES AND MEASURES: Neonatal mortality rate.

    RESULTS: Analysis included 19 301 births during the final 24 months of the intervention. More than one-third of newly pregnant women joined the groups. The neonatal mortality rate was significantly lower in the intervention arm (21.3 neonatal deaths per 1000 live births vs 30.1 per 1000 in control areas), a reduction in neonatal mortality of 38% (risk ratio, 0.62 [95% CI, 0.43-0.89]) when adjusted for socioeconomic factors. The cost-effectiveness was US $220 to $393 per year of life lost averted. Cause-specific mortality rates suggest reduced deaths due to infections and those associated with prematurity/low birth weight. Improvements were seen in hygienic home delivery practices, newborn thermal care, and breastfeeding practices.

    CONCLUSIONS AND RELEVANCE: Women's group community mobilization, delivered at adequate population coverage, is a highly cost-effective approach to improve newborn survival and health behavior indicators in rural Bangladesh.

    TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN01805825.

  • 9. Haghparast-Bidgoli, Hassan
    et al.
    Pulkki-Brännström, Anni-Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Institute for Global Health, University College London, London, UK.
    Lafort, Yves
    Beksinska, Mags
    Rambally, Letitia
    Roy, Anuradha
    Reza-Paul, Sushena
    Ombidi, Wilkister
    Gichangi, Peter
    Skordis-Worrall, Jolene
    Inequity in costs of seeking sexual and reproductive health services in India and Kenya2015Inngår i: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 14, artikkel-id 84Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Objective: This study aims to assess inequity in expenditure on sexual and reproductive health (SRH) services in India and Kenya. In addition, this analysis aims to measure the extent to which payments are catastrophic and to explore coping mechanisms used to finance health spending. Methods: Data for this study were collected as a part of the situational analysis for the "Diagonal Interventions to Fast Forward Enhanced Reproductive Health" (DIFFER) project, a multi-country project with fieldwork sites in three African sites; Mombasa (Kenya), Durban (South Africa) and Tete (Mozambique), and Mysore in India. Information on access to SRH services, the direct costs of seeking care and a range of socio-economic variables were obtained through structured exit interviews with female SRH service users in Mysore (India) and Mombasa (Kenya) (n = 250). The costs of seeking care were analysed by household income quintile (as a measure of socio-economic status). The Kakwani index and quintile ratios are used as measures of inequitable spending. Catastrophic spending on SRH services was calculated using the threshold of 10 % of total household income. Results: The results showed that spending on SRH services was highly regressive in both sites, with lower income households spending a higher percentage of their income on seeking care, compared to households with a higher income. Spending on SRH as a percentage of household income ranged from 0.02 to 6.2 % and 0.03-7.5 % in India and Kenya, respectively. There was a statistically significant difference in the proportion of spending on SRH services across income quintiles in both settings. In India, the poorest households spent two times, and in Kenya ten times, more on seeking care than the least poor households. The most common coping mechanisms in India and Kenya were "receiving [money] from partner or household members" (69 %) and "using own savings or regular income" (44 %), respectively. Conclusion: Highly regressive spending on SRH services highlights the heavier burden borne by the poorest when seeking care in resource-constrained settings such as India and Kenya. The large proportion of service users, particularly in India, relying on money received from family members to finance care seeking suggests that access would be more difficult for those with weak social ties, small social networks or weak bargaining positions within the family - although this requires further study.

  • 10.
    Hitimana, Regis
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Krantz, G.
    Nzayirambaho, M.
    Pulkki-Brännström, Anni-Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Systematic Review of Cost and Cost-effectiveness of Routine Ultrasound during pregnancyManuskript (preprint) (Annet vitenskapelig)
  • 11.
    Hitimana, Regis
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Krantz, G.
    Nzayirambaho, M.
    Semasaka Sengoma, J. P.
    Condo, J.
    Pulkki-Brännström, Anni-Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Health related quality of life determinants for Rwandan women after delivery2017Inngår i: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, nr Suppl_3, s. 436-Artikkel i tidsskrift (Annet vitenskapelig)
    Abstract [en]

    Health related quality of life determinants for Rwandan women after delivery. Does Antenatal care utilization matter? Maternal health conditions are still a major problem in most low-income countries. The postpartum health status and the effect of antenatal care utilization on health are relatively under researched. This study aims at (1) assessing whether receipt of antenatal care according to Rwandan guidelines is associated with mother’s health-related quality of life (HRQoL) and (2) exploring determinants associated with mother’s HRQoL in the first year (1-13 months) after delivery in Rwanda. In 2014 a cross-sectional survey was conducted on 922 women from Kigali City and Northern province of Rwanda, who gave birth in the period of 1–13 months prior to survey. The study population was randomly selected and interviewed using a questionnaire. HRQoL was measured using EQ-5D-3L. Average values of HRQoL were computed by demographic and socio-economic characteristics. The effect of adequate antenatal care on HRQoL was tested in two multivariable linear regression models - with EQ-5D weights and the Visual Analogue Scale score as outcomes respectively - with ANC adequacy and socio-demographic and psychosocial variables as predictors. Mean HRQoL was 0.92 using EQ-5D and 69.58 using EQ-VAS. Fifteen per cent reported moderate pain/discomfort and 1% reported extreme pain/discomfort, 16% reported being moderately anxious/depressed and 3% reported being extremely anxious/depressed. Having more than one child and being cohabitant or single/not married was associated with significantly lower HRQoL, while having good social support and belonging to the highest wealth quintile was associated with higher HRQoL. Antenatal care utilization was not associated with HRQoL among postpartum mothers. Policy makers should address the social determinants of health, and promote social networks among women. There is a need to assess the quality of Antenatal care in Rwanda.

    Key messages:

    • Health related quality of life among postpartum mothers is high. Pain or discomfort and anxiety of depression are most prevalent problems.
    • Antenatal care utilization was not associated with HRQoL among postpartum mothers. Rather social determinants of health are important in determining mother's HRQoL
  • 12.
    Hitimana, Regis
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Krantz, Gunilla
    Nzayirambaho, Manasse
    Condo, Jeanine
    Semasaka Sengoma, Jean Paul
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Obstetrik och gynekologi. School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.
    Pulkki-Brännström, Anni-Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Health-related quality of life determinants among Rwandan women after delivery: does antenatal care utilization matter? A cross-sectional study2018Inngår i: Journal of Health, Population and Nutrition, ISSN 1606-0997, E-ISSN 2072-1315, Vol. 37, artikkel-id 12Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Despite the widespread use of antenatal care (ANC), its effectiveness in low-resource settings remains unclear. In this study, self-reported health-related quality of life (HRQoL) was used as an alternative to other maternal health measures previously used to measure the effectiveness of antenatal care. The main objective of this study was to determine whether adequate antenatal care utilization is positively associated with women's HRQoL. Furthermore, the associations between the HRQoL during the first year (113 months) after delivery and socio-economic and demographic factors were explored in Rwanda.

    Methods: In 2014, we performed a cross-sectional population-based survey involving 922 women who gave birth 1-13 months prior to the data collection. The study population was randomly selected from two provinces in Rwanda, and a structured questionnaire was used. HRQoL was measured using the EQ-5D-3L and a visual analogue scale (VAS). The average HRQoL scores were computed by demographic and socio-economic characteristics. The effect of adequate antenatal care utilization on HRQoL was tested by performing two multivariable linear regression models with the EQ-5D and EQ-VAS scores as the outcomes and ANC utilization and socio-economic and demographic variables as the predictors.

    Results: Adequate ANC utilization affected women's HRQoL when the outcome was measured using the EQ-VAS. Social support and living in a wealthy household were associated with a better HRQoL using both the EQ-VAS and EQ-5D. Cohabitating, and single/unmarried women exhibited significantly lower HRQoL scores than did married women in the EQ-VAS model, and women living in urban areas exhibited lower HRQoL scores than women living in rural areas in the ED-5D model. The effect of education on HRQoL was statistically significant using the EQ-VAS but was inconsistent across the educational categories. The women's age and the age of their last child were not associated with their HRQoL.

    Conclusions: ANC attendance of at least four visits should be further promoted and used in low-income settings. Strategies to improve families' socio-economic conditions and promote social networks among women, particularly women at the reproductive age, are needed.

  • 13.
    Hitimana, Regis
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Krantz, Gunilla
    Nzayirambaho, Manasse
    Pulkki-Brännström, Anni-Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Cost of antenatal care for the health sector and for households in Rwanda2018Inngår i: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 18, artikkel-id 262Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Rwanda has made tremendous progress in reduction of maternal mortality in the last twenty years. Antenatal care is believed to have played a role in that progress. In late 2016, the World Health Organization published new antenatal care guidelines recommending an increase from four visits during pregnancy to eight contacts with skilled personnel, among other changes. There is ongoing debate regarding the cost implications and potential outcomes countries can expect, if they make that shift. For Rwanda, a necessary starting point is to understand the cost of current antenatal care practice, which, according to our knowledge, has not been documented so far.

    Methods: Cost information was collected from Kigali City and Northern province of Rwanda through two cross-sectional surveys: a household-based survey among women who had delivered a year before the interview (N = 922) and a health facility survey in three public, two faith-based, and one private health facility. A micro costing approach was used to collect health facility data. Household costs included time and transport. Results are reported in 2015 USD.

    Results: The societal cost (household + health facility) of antenatal care for the four visits according to current Rwandan guidelines was estimated at $160 in the private health facility and $44 in public and faith-based health facilities. The first visit had the highest cost ($75 in private and $21 in public and faith-based health facilities) compared to the three other visits. Drugs and consumables were the main input category accounting for 54% of the total cost in the private health facility and for 73% in the public and faith-based health facilities.

    Conclusions: The unit cost of providing antenatal care services is considerably lower in public than in private health facilities. The household cost represents a small proportion of the total, ranging between 3% and 7%; however, it is meaningful for low-income families. There is a need to do profound equity analysis regarding the accessibility and use of antenatal care services, and to consider ways to reduce households’ time cost as a possible barrier to the use of antenatal care.

  • 14.
    Hitimana, Regis
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Mogren, Ingrid
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Obstetrik och gynekologi.
    Krantz, Gunilla
    Nzayirambaho, Manasse
    Semasaka Sengoma, Jean Paul
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Obstetrik och gynekologi. School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.
    Pulkki-Brännström, Anni-Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Incremental cost and health gains of the 2016 WHO antenatal care recommendations for Rwanda: results from expert elicitation2019Inngår i: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 17, artikkel-id 36Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    OBJECTIVES: High-quality evidence of effectiveness and cost-effectiveness is rarely available and relevant for health policy decisions in low-resource settings. In such situations, innovative approaches are needed to generate locally relevant evidence. This study aims to inform decision-making on antenatal care (ANC) recommendations in Rwanda by estimating the incremental cost-effectiveness of the recent (2016) WHO antenatal care recommendations compared to current practice in Rwanda.

    METHODS: Two health outcome scenarios (optimistic, pessimistic) in terms of expected maternal and perinatal mortality reduction were constructed using expert elicitation with gynaecologists/obstetricians currently practicing in Rwanda. Three costing scenarios were constructed from the societal perspective over a 1-year period. The two main inputs to the cost analyses were a Monte Carlo simulation of the distribution of ANC attendance for a hypothetical cohort of 373,679 women and unit cost estimation of the new recommendations using data from a recent primary costing study of current ANC practice in Rwanda. Results were reported in 2015 USD and compared with the 2015 Rwandan per-capita gross domestic product (US$ 697).

    RESULTS: Incremental health gains were estimated as 162,509 life-years saved (LYS) in the optimistic scenario and 65,366 LYS in the pessimistic scenario. Incremental cost ranged between $5.8 and $11 million (an increase of 42% and 79%, respectively, compared to current practice) across the costing scenarios. In the optimistic outcome scenario, incremental cost per LYS ranged between $36 (for low ANC attendance) and $67 (high ANC attendance), while in the pessimistic outcome scenario, it ranged between $90 (low ANC attendance) and $168 (high ANC attendance) per LYS. Incremental cost effectiveness was below the GDP-based thresholds in all six scenarios.

    DISCUSSION: Implementing the new WHO ANC recommendations in Rwanda would likely be very cost-effective; however, the additional resource requirements are substantial. This study demonstrates how expert elicitation combined with other data can provide an affordable source of locally relevant evidence for health policy decisions in low-resource settings.

  • 15.
    Häggström, Jenny
    et al.
    Umeå universitet, Samhällsvetenskapliga fakulteten, Handelshögskolan vid Umeå universitet, Statistik.
    Sampaio, Filipa
    Eurenius, Eva
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Pulkki-Brännström, Anni-Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Ivarsson, Anneli
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Lindkvist, Marie
    Umeå universitet, Samhällsvetenskapliga fakulteten, Handelshögskolan vid Umeå universitet, Statistik. Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Feldman, Inna
    Is the Salut Programme an effective and cost-effective universal health promotion intervention for parents and their children?: a register-based retrospective observational study2017Inngår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, nr 9, artikkel-id e016732Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    OBJECTIVES: This study investigates the effectiveness and cost-effectiveness of the Salut Programme, a universal health promotion intervention, compared with care-as-usual, over the periods of pregnancy, delivery and the child's first 2 years of life.

    METHOD: We adopted a register-based retrospective observational design using existing data sources with respect to both exposures and outcomes. Health outcomes and costs were compared between geographical areas that received care-as-usual (non-Salut area) and areas where the programme was implemented (Salut area). We included mothers and their children from both the Salut and non-Salut areas if: (1) the child was born 2002-2004 (premeasure period) or (2) the child was born 2006-2008 (postmeasure period). The effectiveness study adopted two strategies: (1) a matched difference-in-difference analysis using data from all participants and (2) a longitudinal analysis restricted to mothers who had given birth twice, that is, both in the premeasure and postmeasure periods. The economic evaluation was performed from a healthcare and a limited societal perspective. Outcomes were clustered during pregnancy, delivery and birth and the child's first 2 years.

    RESULTS: Difference-in-difference analyses did not yield any significant effect on the outcomes. Longitudinal analyses resulted in significant positive improvement in Apgar scores, reflecting the newborn's physical condition, with more children having a normal Apgar score (1 min +3%, 5 min +1%). The cost of the programme was international dollar (INT$)308/child. From both costing perspectives, the programme yielded higher effects and lower costs than care-as-usual, being thus cost-saving (probability of around 50%).

    CONCLUSIONS: Our findings suggest that the Salut Programme is an effective universal intervention to improve maternal and child health, and it may be good value for money; however, there is large uncertainty around the cost estimates.

  • 16. Kim, Sung
    et al.
    Pulkki-Brännström, Anni-Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Skordis-Worrall, Jolene
    Comparing the cost effectiveness of harm reduction strategies: a case study of the Ukraine2014Inngår i: Cost Effectiveness and Resource Allocation, ISSN 1478-7547, E-ISSN 1478-7547, Vol. 12, artikkel-id 25Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background

    Harm reduction strategies commonly include needle and syringe programmes (NSP), opioid substitution therapy (OST) and interventions combining these two strategies. Despite the proven effectiveness of harm-reduction strategies in reducing human immunodeficiency virus (HIV) infection among injecting drug users (IDUs), no study has compared the cost-effectiveness of these interventions, nor the incremental cost effectiveness of combined therapy. Using data from the Global Fund, this study compares the cost-effectiveness of harm reduction strategies in Eastern Europe and Central Asia, using the Ukraine as a case study.

    Methods

    A Markov Monte Carlo simulation is carried out using parameters from the literature and cost data from the Global Fund. Effectiveness is presented as both QALYs and infections averted. Costs are measured in 2011 US dollars.

    Results

    The Markov Monte Carlo simulation estimates the cost-effectiveness ratio per infection averted as $487.4 [95% CI: 488.47-486.35] in NSP and $1145.9 [95% CI: 1143.39-1148.43] in OST. Combined intervention is more costly but more effective than the alternative strategies with a cost effectiveness ratio of $851.6[95% CI: 849.82-853.55].

    The ICER of the combined strategy is $1086.9/QALY [95% CI: 1077.76:1096.24] compared with NSP, and $461.0/infection averted [95% CI: 452.98:469.04] compared with OST. These results are consistent with previous studies.

    Conclusions

    Despite the inherent limitations of retrospective data, this study provides evidence that harm-reduction interventions are a cost-effective way to reduce HIV prevalence. More research on into cost effectiveness in different settings, and the availability of fiscal space for government uptake of programmes, is required.

  • 17. Kim, Sung Wook
    et al.
    Skordis-Worrall, Jolene
    Haghparast-Bidgoli, Hassan
    Pulkki-Brännström, Anni-Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Socio-economic inequity in HIV testing in Malawi2016Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 9, s. 1-15Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Human immunodeficiency virus (HIV) is a significant contributor to Malawi's burden of disease. Despite a number of studies describing socio-economic differences in HIV prevalence, there is a paucity of evidence on socio-economic inequity in HIV testing in Malawi.

    OBJECTIVE: To assess horizontal inequity (HI) in HIV testing in Malawi.

    DESIGN: Data from the Demographic and Health Surveys (DHSs) 2004 and 2010 in Malawi are used for the analysis. The sample size for DHS 2004 was 14,571 (women =11,362 and men=3,209), and for DHS 2010 it was 29,830 (women=22,716 and men=7,114). The concentration index is used to quantify the amount of socio-economic-related inequality in HIV testing. The inequality is a primary method in this study. Corrected need, a further adjustment of the standard decomposition index, was calculated. Standard HI was compared with corrected need-adjusted inequity. Variables used to measure health need include symptoms of sexually transmitted infections. Non-need variables include wealth, education, literacy and marital status.

    RESULTS: Between 2004 and 2010, the proportion of the population ever tested for HIV increased from 15 to 75% among women and from 16 to 54% among men. The need for HIV testing among men was concentrated among the relatively wealthy in 2004, but the need was more equitably distributed in 2010. Standard HI was 0.152 in 2004 and 0.008 in 2010 among women, and 0.186 in 2004 and 0.04 in 2010 among men. Rural-urban inequity also fell in this period, but HIV testing remained pro-rich among rural men (HI 0.041). The main social contributors to inequity in HIV testing were wealth in 2004 and education in 2010.

    CONCLUSIONS: Inequity in HIV testing in Malawi decreased between 2004 and 2010. This may be due to the increased support to HIV testing by global donors over this period.

  • 18. Lewycka, Sonia
    et al.
    Mwansambo, Charles
    Rosato, Mikey
    Kazembe, Peter
    Phiri, Tambosi
    Mganga, Andrew
    Chapota, Hilda
    Malamba, Florida
    Kainja, Esther
    Newell, Marie-Louise
    Greco, Giulia
    Pulkki-Brännström, Anni-Maria
    Skordis-Worrall, Jolene
    Vergnano, Stefania
    Osrin, David
    Costello, Anthony
    Effect of women's groups and volunteer peer counselling on rates of mortality, morbidity, and health behaviours in mothers and children in rural Malawi (MaiMwana): a factorial, cluster-randomised controlled trial2013Inngår i: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 381, nr 9879, s. 1721-35Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Women's groups and health education by peer counsellors can improve the health of mothers and children. We assessed their effects on mortality and breastfeeding rates in rural Malawi.

    METHODS: We did a 2×2 factorial, cluster-randomised trial in 185,888 people in Mchinji district. 48 equal-sized clusters were randomly allocated to four groups with a computer-generated number sequence. 24 facilitators guided groups through a community action cycle to tackle maternal and child health problems. 72 trained volunteer peer counsellors made home visits at five timepoints during pregnancy and after birth to support breastfeeding and infant care. Primary outcomes for the women's group intervention were maternal, perinatal, neonatal, and infant mortality rates (MMR, PMR, NMR, and IMR, respectively); and for the peer counselling were IMR and exclusive breastfeeding (EBF) rates. Analysis was by intention to treat. The trial is registered as ISRCTN06477126.

    FINDINGS: We monitored outcomes of 26,262 births between 2005 and 2009. In a factorial model adjusted only for clustering and the volunteer peer counselling intervention, in women's group areas, for years 2 and 3, we noted non-significant decreases in NMR (odds ratio 0.93, 0.64-1.35) and MMR (0.54, 0.28-1.04). After adjustment for parity, socioeconomic quintile, and baseline measures, effects were larger for NMR (0.85, 0.59-1.22) and MMR (0.48, 0.26-0.91). Because of the interaction between the two interventions, a stratified analysis was done. For women's groups, in adjusted analyses, MMR fell by 74% (0.26, 0.10-0.70), and NMR by 41% (0.59, 0.40-0.86) in areas with no peer counsellors, but there was no effect in areas with counsellors (1.09, 0.40-2.98, and 1.38, 0.75-2.54). Factorial analysis for the peer counselling intervention for years 1-3 showed a fall in IMR of 18% (0.82, 0.67-1.00) and an improvement in EBF rates (2.42, 1.48-3.96). The results of the stratified, adjusted analysis showed a 36% reduction in IMR (0.64, 0.48-0.85) but no effect on EBF (1.18, 0.63-2.25) in areas without women's groups, and in areas with women's groups there was no effect on IMR (1.05, 0.82-1.36) and an increase in EBF (5.02, 2.67-9.44). The cost of women's groups was US$114 per year of life lost (YLL) averted and that of peer counsellors was $33 per YLL averted, using stratified data from single intervention comparisons.

    INTERPRETATION: Community mobilisation through women's groups and volunteer peer counsellor health education are methods to improve maternal and child health outcomes in poor rural populations in Africa.

  • 19.
    Lindholm, Lars
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Ivarsson, Anneli
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Löfgren, Curt
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Meili, Kaspar
    Nygren, Lennart
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för socialt arbete.
    Pulkki-Brännström, Anni-Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Sahlen, Klas-Göran
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Nytt sätt att mäta livskvalitet öppnar för effektivare insatser2018Inngår i: Dagens samhälle, ISSN 1652-6511, nr 31, s. 26-26Artikkel i tidsskrift (Annet (populærvitenskap, debatt, mm))
  • 20. Prost, Audrey
    et al.
    Colbourn, Tim
    Seward, Nadine
    Azad, Kishwar
    Coomarasamy, Arri
    Copas, Andrew
    Houweling, Tanja A J
    Fottrell, Edward
    Kuddus, Abdul
    Lewycka, Sonia
    MacArthur, Christine
    Manandhar, Dharma
    Morrison, Joanna
    Mwansambo, Charles
    Nair, Nirmala
    Nambiar, Bejoy
    Osrin, David
    Pagel, Christina
    Phiri, Tambosi
    Pulkki-Brännström, Anni-Maria
    Rosato, Mikey
    Skordis-Worrall, Jolene
    Saville, Naomi
    More, Neena Shah
    Shrestha, Bhim
    Tripathy, Prasanta
    Wilson, Amie
    Costello, Anthony
    Women's groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis2013Inngår i: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 381, nr 9879, s. 1736-46Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Maternal and neonatal mortality rates remain high in many low-income and middle-income countries. Different approaches for the improvement of birth outcomes have been used in community-based interventions, with heterogeneous effects on survival. We assessed the effects of women's groups practising participatory learning and action, compared with usual care, on birth outcomes in low-resource settings.

    METHODS: We did a systematic review and meta-analysis of randomised controlled trials undertaken in Bangladesh, India, Malawi, and Nepal in which the effects of women's groups practising participatory learning and action were assessed to identify population-level predictors of effect on maternal mortality, neonatal mortality, and stillbirths. We also reviewed the cost-effectiveness of the women's group intervention and estimated its potential effect at scale in Countdown countries.

    FINDINGS: Seven trials (119,428 births) met the inclusion criteria. Meta-analyses of all trials showed that exposure to women's groups was associated with a 37% reduction in maternal mortality (odds ratio 0.63, 95% CI 0.32-0.94), a 23% reduction in neonatal mortality (0.77, 0.65-0.90), and a 9% non-significant reduction in stillbirths (0.91, 0.79-1.03), with high heterogeneity for maternal (I(2)=58.8%, p=0.024) and neonatal results (I(2)=64.7%, p=0.009). In the meta-regression analyses, the proportion of pregnant women in groups was linearly associated with reduction in both maternal and neonatal mortality (p=0.026 and p=0.011, respectively). A subgroup analysis of the four studies in which at least 30% of pregnant women participated in groups showed a 55% reduction in maternal mortality (0.45, 0.17-0.73) and a 33% reduction in neonatal mortality (0.67, 0.59-0.74). The intervention was cost effective by WHO standards and could save an estimated 283,000 newborn infants and 41,100 mothers per year if implemented in rural areas of 74 Countdown countries.

    INTERPRETATION: With the participation of at least a third of pregnant women and adequate population coverage, women's groups practising participatory learning and action are a cost-effective strategy to improve maternal and neonatal survival in low-resource settings.

  • 21.
    Pulkki-Brännström, Anni-Maria
    Warwick Business School.
    Internal diffusion of new technology2009Doktoravhandling, monografi (Annet vitenskapelig)
  • 22. Pulkki-Brännström, Anni-Maria
    et al.
    Stoneman, Paul
    On the patterns and determinants of the global diffusion of new technologies2013Inngår i: Research Policy, ISSN 0048-7333, E-ISSN 1873-7625, Vol. 42, nr 10, s. 1768-1779Artikkel i tidsskrift (Fagfellevurdert)
  • 23.
    Pulkki-Brännström, Anni-Maria
    et al.
    UCL Centre for International Health and Development, UCL Institute of Child Health, London, UK.
    Wolff, Claudia
    Department of Economics, Stockholm School of Economics, Stockholm, Sweden.
    Brännström, Niklas
    Department of Mathematics, University of Helsinki, Helsinki, Finland.
    Skordis-Worrall, Jolene
    UCL Centre for International Health and Development, UCL Institute of Child Health, London, UK.
    Cost and cost effectiveness of long-lasting insecticide-treated bed nets - a model-based analysis2012Inngår i: Cost Effectiveness and Resource Allocation, ISSN 1478-7547, E-ISSN 1478-7547, Vol. 10, s. 5-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: The World Health Organization recommends that national malaria programmes universally distribute long-lasting insecticide-treated bed nets (LLINs). LLINs provide effective insecticide protection for at least three years while conventional nets must be retreated every 6-12 months. LLINs may also promise longer physical durability (lifespan), but at a higher unit price. No prospective data currently available is sufficient to calculate the comparative cost effectiveness of different net types. We thus constructed a model to explore the cost effectiveness of LLINs, asking how a longer lifespan affects the relative cost effectiveness of nets, and if, when and why LLINs might be preferred to conventional insecticide-treated nets. An innovation of our model is that we also considered the replenishment need i.e. loss of nets over time.

    METHODS: We modelled the choice of net over a 10-year period to facilitate the comparison of nets with different lifespan (and/or price) and replenishment need over time. Our base case represents a large-scale programme which achieves high coverage and usage throughout the population by distributing either LLINs or conventional nets through existing health services, and retreats a large proportion of conventional nets regularly at low cost. We identified the determinants of bed net programme cost effectiveness and parameter values for usage rate, delivery and retreatment cost from the literature. One-way sensitivity analysis was conducted to explicitly compare the differential effect of changing parameters such as price, lifespan, usage and replenishment need.

    RESULTS: If conventional and long-lasting bed nets have the same physical lifespan (3 years), LLINs are more cost effective unless they are priced at more than USD 1.5 above the price of conventional nets. Because a longer lifespan brings delivery cost savings, each one year increase in lifespan can be accompanied by a USD 1 or more increase in price without the cheaper net (of the same type) becoming more cost effective. Distributing replenishment nets each year in addition to the replacement of all nets every 3-4 years increases the number of under-5 deaths averted by 5-14% at a cost of USD 17-25 per additional person protected per annum or USD 1080-1610 per additional under-5 death averted.

    CONCLUSIONS: Our results support the World Health Organization recommendation to distribute only LLINs, while giving guidance on the price thresholds above which this recommendation will no longer hold. Programme planners should be willing to pay a premium for nets which have a longer physical lifespan, and if planners are willing to pay USD 1600 per under-5 death averted, investing in replenishment is cost effective.

  • 24. Saville, Naomi M.
    et al.
    Shrestha, Bhim P.
    Style, Sarah
    Harris-Fry, Helen
    Beard, B. James
    Sen, Aman
    Jha, Sonali
    Rai, Anjana
    Paudel, Vikas
    Sah, Raghbendra
    Paudel, Puskar
    Copas, Andrew
    Bhandari, Bishnu
    Neupane, Rishi
    Morrison, Joanna
    Gram, Lu
    Pulkki-Brännström, Anni-Maria
    UCL Institute for Global Health, University College London, London, United Kingdom.
    Skordis-Worrall, Jolene
    Basnet, Machhindra
    de Pee, Saskia
    Hall, Andrew
    Harthan, Jayne
    Thondoo, Meelan
    Klingberg, Sonja
    Messick, Janice
    Manandhar, Dharma S.
    Osrin, David
    Costello, Anthony
    Impact on birth weight and child growth of Participatory Learning and Action women’s groups with and without transfers of food or cash during pregnancy: Findings of the low birth weight South Asia cluster-randomised controlled trial (LBWSAT) in Nepal2018Inngår i: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 13, nr 5, artikkel-id e0194064Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background Undernutrition during pregnancy leads to low birthweight, poor growth and inter-generational undernutrition. We did a non-blinded cluster-randomised controlled trial in the plains districts of Dhanusha and Mahottari, Nepal to assess the impact on birthweight and weight-for-age z-scores among children aged 0–16 months of community-based participatory learning and action (PLA) women’s groups, with and without food or cash transfers to pregnant women. Methods We randomly allocated 20 clusters per arm to four arms (average population/cluster = 6150). All consenting married women aged 10–49 years, who had not had tubal ligation and whose husbands had not had vasectomy, were monitored for missed menses. Between 29 Dec 2013 and 28 Feb 2015 we recruited 25,092 pregnant women to surveillance and interventions: PLA alone (n = 5626); PLA plus food (10 kg/month of fortified wheat-soya ‘Super Cereal’, n = 6884); PLA plus cash (NPR750≈US$7.5/month, n = 7272); control (existing government programmes, n = 5310). 539 PLA groups discussed and implemented strategies to improve low birthweight, nutrition in pregnancy and hand washing. Primary outcomes were birthweight within 72 hours of delivery and weight-for-age z-scores at endline (age 0–16 months). Only children born to permanent residents between 4 June 2014 and 20 June 2015 were eligible for intention to treat analyses (n = 10936), while in-migrating women and children born before interventions had been running for 16 weeks were excluded. Trial status: completed. Results In PLA plus food/cash arms, 94–97% of pregnant women attended groups and received a mean of four transfers over their pregnancies. In the PLA only arm, 49% of pregnant women attended groups. Due to unrest, the response rate for birthweight was low at 22% (n = 2087), but response rate for endline nutritional and dietary measures exceeded 83% (n = 9242). Compared to the control arm (n = 464), mean birthweight was significantly higher in the PLA plus food arm by 78·0 g (95% CI 13·9, 142·0; n = 626) and not significantly higher in PLA only and PLA plus cash arms by 28·9 g (95% CI -37·7, 95·4; n = 488) and 50·5 g (95% CI -15·0, 116·1; n = 509) respectively. Mean weight-for-age z-scores of children aged 0–16 months (average age 9 months) sampled cross-sectionally at endpoint, were not significantly different from those in the control arm (n = 2091). Differences in weight for-age z-score were as follows: PLA only -0·026 (95% CI -0·117, 0·065; n = 2095); PLA plus cash -0·045 (95% CI -0·133, 0·044; n = 2545); PLA plus food -0·033 (95% CI -0·121, 0·056; n = 2507). Amongst many secondary outcomes tested, compared with control, more institutional deliveries (OR: 1.46 95% CI 1.03, 2.06; n = 2651) and less colostrum discarding (OR:0.71 95% CI 0.54, 0.93; n = 2548) were found in the PLA plus food arm but not in PLA alone or in PLA plus cash arms. Interpretation Food supplements in pregnancy with PLA women’s groups increased birthweight more than PLA plus cash or PLA alone but differences were not sustained. Nutrition interventions throughout the thousand-day period are recommended. Trial registration ISRCTN75964374.

  • 25. Saville, Naomi M
    et al.
    Shrestha, Bhim P
    Style, Sarah
    Harris-Fry, Helen
    Beard, B James
    Sengupta, Aman
    Jha, Sonali
    Rai, Anjana
    Paudel, Vikas
    Pulkki-Brännström, Anni-Maria
    University College London, Institute for Global Health.
    Copas, Andrew
    Skordis-Worrall, Jolene
    Bhandari, Bishnu
    Neupane, Rishi
    Morrison, Joanna
    Gram, Lu
    Sah, Raghbendra
    Basnet, Machhindra
    Harthan, Jayne
    Manandhar, Dharma S
    Osrin, David
    Costello, Anthony
    Protocol of the Low Birth Weight South Asia Trial (LBWSAT), a cluster-randomised controlled trial testing impact on birth weight and infant nutrition of Participatory Learning and Action through women's groups, with and without unconditional transfers of fortified food or cash during pregnancy in Nepal2016Inngår i: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 16, artikkel-id 320Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Low birth weight (LBW, < 2500 g) affects one third of newborn infants in rural south Asia and compromises child survival, infant growth, educational performance and economic prospects. We aimed to assess the impact on birth weight and weight-for-age Z-score in children aged 0-16 months of a nutrition Participatory Learning and Action behaviour change strategy (PLA) for pregnant women through women's groups, with or without unconditional transfers of food or cash to pregnant women in two districts of southern Nepal.

    METHODS: The study is a cluster randomised controlled trial (non-blinded). PLA comprises women's groups that discuss, and form strategies about, nutrition in pregnancy, low birth weight and hygiene. Women receive up to 7 monthly transfers per pregnancy: cash is NPR 750 (~US$7) and food is 10 kg of fortified sweetened wheat-soya Super Cereal per month. The unit of randomisation is a rural village development committee (VDC) cluster (population 4000-9200, mean 6150) in southern Dhanusha or Mahottari districts. 80 VDCs are randomised to four arms using a participatory 'tombola' method. Twenty clusters each receive: PLA; PLA plus food; PLA plus cash; and standard care (control). Participants are (mostly Maithili-speaking) pregnant women identified from 8 weeks' gestation onwards, and their infants (target sample size 8880 birth weights). After pregnancy verification, mothers may be followed up in early and late pregnancy, within 72 h, after 42 days and within 22 months of birth. Outcomes pertain to the individual level. Primary outcomes include birth weight within 72 h of birth and infant weight-for-age Z-score measured cross-sectionally on children born of the study. Secondary outcomes include prevalence of LBW, eating behaviour and weight during pregnancy, maternal and newborn illness, preterm delivery, miscarriage, stillbirth or neonatal mortality, infant Z-scores for length-for-age and weight-for-length, head circumference, and postnatal maternal BMI and mid-upper arm circumference. Exposure to women's groups, food or cash transfers, home visits, and group interventions are measured.

    DISCUSSION: Determining the relative importance to birth weight and early childhood nutrition of adding food or cash transfers to PLA women's groups will inform design of nutrition interventions in pregnancy.

    TRIAL REGISTRATION: ISRCTN75964374 , 12 Jul 2013.

  • 26.
    Semasaka Sengoma, Jean Paul
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Obstetrik och gynekologi. University of Rwanda.
    Mogren, Ingrid
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Obstetrik och gynekologi. La Trobe University.
    Krantz, Gunilla
    University of Gothenburg.
    Nzayirambaho, Manasse
    University of Rwanda.
    Munyanshongore, Cyprien
    University of Rwanda.
    Hitimana, Regis
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. University of Rwanda.
    Edvardsson, Kristina
    La Trobe University.
    Lindholm, Lars
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Pulkki-Brännström, Anni-Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Estimation of the economic costs of pregnancy and delivery-related complications in RwandaManuskript (preprint) (Annet vitenskapelig)
  • 27. Seward, Nadine
    et al.
    Osrin, David
    Li, Leah
    Costello, Anthony
    Pulkki-Brännström, Anni-Maria
    Houweling, Tanja A J
    Morrison, Joanna
    Nair, Nirmala
    Tripathy, Prasanta
    Azad, Kishwar
    Manandhar, Dharma
    Prost, Audrey
    Association between clean delivery kit use, clean delivery practices, and neonatal survival: pooled analysis of data from three sites in South Asia2012Inngår i: PLoS Medicine, ISSN 1549-1277, E-ISSN 1549-1676, Vol. 9, nr 2, s. e1001180-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Sepsis accounts for up to 15% of an estimated 3.3 million annual neonatal deaths globally. We used data collected from the control arms of three previously conducted cluster-randomised controlled trials in rural Bangladesh, India, and Nepal to examine the association between clean delivery kit use or clean delivery practices and neonatal mortality among home births.

    METHODS AND FINDINGS: Hierarchical, logistic regression models were used to explore the association between neonatal mortality and clean delivery kit use or clean delivery practices in 19,754 home births, controlling for confounders common to all study sites. We tested the association between kit use and neonatal mortality using a pooled dataset from all three sites and separately for each site. We then examined the association between individual clean delivery practices addressed in the contents of the kit (boiled blade and thread, plastic sheet, gloves, hand washing, and appropriate cord care) and neonatal mortality. Finally, we examined the combined association between mortality and four specific clean delivery practices (boiled blade and thread, hand washing, and plastic sheet). Using the pooled dataset, we found that kit use was associated with a relative reduction in neonatal mortality (adjusted odds ratio 0.52, 95% CI 0.39-0.68). While use of a clean delivery kit was not always accompanied by clean delivery practices, using a plastic sheet during delivery, a boiled blade to cut the cord, a boiled thread to tie the cord, and antiseptic to clean the umbilicus were each significantly associated with relative reductions in mortality, independently of kit use. Each additional clean delivery practice used was associated with a 16% relative reduction in neonatal mortality (odds ratio 0.84, 95% CI 0.77-0.92).

    CONCLUSIONS: The appropriate use of a clean delivery kit or clean delivery practices is associated with relative reductions in neonatal mortality among home births in underserved, rural populations.

  • 28. Skordis-Worrall, Jolene
    et al.
    Pace, Noemi
    Bapat, Ujwala
    Das, Sushmita
    More, Neena S
    Joshi, Wasundhara
    Pulkki-Brännstrom, Anni-Maria
    Osrin, David
    Maternal and neonatal health expenditure in Mumbai slums (India): a cross sectional study2011Inngår i: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 11, s. 150-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: The cost of maternity care can be a barrier to access that may increase maternal and neonatal mortality risk. We analyzed spending on maternity care in urban slum communities in Mumbai to better understand the equity of spending and the impact of spending on household poverty.

    METHODS: We used expenditure data for maternal and neonatal care, collected during post-partum interviews. Interviews were conducted in 2005-2006, with a sample of 1200 slum residents in Mumbai (India). We analysed expenditure by socio-economic status (SES), calculating a Kakwani Index for a range of spending categories. We also calculated catastrophic health spending both with and without adjustment for coping strategies. This identified the level of catastrophic payments incurred by a household and the prevalence of catastrophic payments in this population. The analysis also gave an understanding of the protection from medical poverty afforded by coping strategies (for example saving and borrowing).

    RESULTS: A high proportion of respondents spent catastrophically on care. Lower SES was associated with a higher proportion of informal payments. Indirect health expenditure was found to be (weakly) regressive as the poorest were more likely to use wage income to meet health expenses, while the less poor were more likely to use savings. Overall, the incidence of catastrophic maternity expenditure was 41%, or 15% when controlling for coping strategies. We found no significant difference in the incidence of catastrophic spending across wealth quintiles, nor could we conclude that total expenditure is regressive.

    CONCLUSIONS: High expenditure as a proportion of household resources should alert policymakers to the burden of maternal spending in this context. Differences in informal payments, significantly regressive indirect spending and the use of savings versus wages to finance spending, all highlight the heavier burden borne by the most poor. If a policy objective is to increase institutional deliveries without forcing households deeper into poverty, these inequities will need to be addressed. Reducing out-of-pocket payments and better regulating informal payments should have direct benefits for the most poor. Alternatively, targeted schemes aimed at assisting the most poor in coping with maternal spending (including indirect spending) could reduce the household impact of high costs.

  • 29. Skordis-Worrall, Jolene
    et al.
    Pulkki-Brännström, Anni-Maria
    Utley, Martin
    Kembhavi, Gayatri
    Bricki, Nouria
    Dutoit, Xavier
    Rosato, Mikey
    Pagel, Christina
    Development and formative evaluation of a visual e-tool to help decision makers navigate the evidence around health financing2012Inngår i: JMIR research protocols, ISSN 1929-0748, Vol. 1, nr 2, s. e25-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: There are calls for low and middle income countries to develop robust health financing policies to increase service coverage. However, existing evidence around financing options is complex and often difficult for policy makers to access.

    OBJECTIVE: To summarize the evidence on the impact of financing health systems and develop an e-tool to help decision makers navigate the findings.

    METHODS: After reviewing the literature, we used thematic analysis to summarize the impact of 7 common health financing mechanisms on 5 common health system goals. Information on the relevance of each study to a user's context was provided by 11 country indicators. A Web-based e-tool was then developed to assist users in navigating the literature review. This tool was evaluated using feedback from early users, collected using an online survey and in-depth interviews with key informants.

    RESULTS: The e-tool provides graphical summaries that allow a user to assess the following parameters with a single snapshot: the number of relevant studies available in the literature, the heterogeneity of evidence, where key evidence is lacking, and how closely the evidence matches their own context. Users particularly liked the visual display and found navigating the tool intuitive. However there was concern that a lack of evidence on positive impact might be construed as evidence against a financing option and that the tool might over-simplify the available financing options.

    CONCLUSIONS: Complex evidence can be made more easily accessible and potentially more understandable using basic Web-based technology and innovative graphical representations that match findings to the users' goals and context.

  • 30. Skordis-Worrall, Jolene
    et al.
    Sinha, Rajesh
    Kumar Ojha, Amit
    Sarangi, Soumendra
    Nair, Nirmala
    Tripathy, Prasanta
    Sachdev, H S
    Bhattacharyya, Sanghita
    Gope, Rajkumar
    Rath, Shibanand
    Rath, Suchitra
    Srivastava, Aradhana
    Batura, Neha
    Pulkki-Brännström, Anni-Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. University College London, Institute for Global Health, London, UK.
    Costello, Anthony
    Copas, Andrew
    Saville, Naomi
    Prost, Audrey
    Haghparast-Bidgoli, Hassan
    Protocol for the economic evaluation of a community-based intervention to improve growth among children under two in rural India (CARING trial)2016Inngår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 6, nr 11, artikkel-id e012046Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    INTRODUCTION: Undernutrition affects ∼165 million children globally and contributes up to 45% of all child deaths. India has the highest proportion of global undernutrition-related morbidity and mortality. This protocol describes the planned economic evaluation of a community-based intervention to improve growth in children under 2 years of age in two rural districts of eastern India. The intervention is being evaluated through a cluster-randomised controlled trial (cRCT, the CARING trial).

    METHODS AND ANALYSIS: A cost-effectiveness and cost-utility analysis nested within a cRCT will be conducted from a societal perspective, measuring programme, provider, household and societal costs. Programme costs will be collected prospectively from project accounts using a standardised tool. These will be supplemented with time sheets and key informant interviews to inform the allocation of joint costs. Direct and indirect costs incurred by providers will be collected using key informant interviews and time use surveys. Direct and indirect household costs will be collected prospectively, using time use and consumption surveys. Incremental cost-effectiveness ratios (ICERs) will be calculated for the primary outcome measure, that is, cases of stunting prevented, and other outcomes such as cases of wasting prevented, cases of infant mortality averted, life years saved and disability-adjusted life years (DALYs) averted. Sensitivity analyses will be conducted to assess the robustness of results.

    ETHICS AND DISSEMINATION: There is a shortage of robust evidence regarding the cost-effectiveness of strategies to improve early child growth. As this economic evaluation is nested within a large scale, cRCT, it will contribute to understanding the fiscal space for investment in early child growth, and the relative (in)efficiency of prioritising resources to this intervention over others to prevent stunting in this and other comparable contexts. The protocol has all necessary ethical approvals and the findings will be disseminated within academia and the wider policy sphere.

    TRIAL REGISTRATION NUMBER: ISRCTN51505201; pre-results.

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