Financial incentives and coverage of child health interventions: a systematic review and meta-analysis

Effective interventions for improving routine childhood immunisation in low and middle-income countries: a systematic review of systematic reviews

OBJECTIVE

An umbrella review providing a comprehensive synthesis of the interventions that are effective in providing routine immunisation outcomes for children in low and middle-income countries (L&MICs).

DESIGN

A systematic review of systematic reviews, or an umbrella review.

DATA SOURCES

We comprehensively searched 11 academic databases and 23 grey literature sources. The search was adopted from an evidence gap map on routine child immunisation sector in L&MICs, which was done on 5 May 2020. We updated the search in October 2021.

ELIGIBILITY CRITERIA

We included systematic reviews assessing the effectiveness of any intervention on routine childhood immunisation outcomes in L&MICs.

DATA EXTRACTION AND SYNTHESIS

Search results were screened by two reviewers independently applying predefined inclusion and exclusion criteria. Data were extracted by two researchers independently. The Specialist Unit for Review Evidence checklist was used to assess review quality. A mixed-methods synthesis was employed focusing on meta-analytical and narrative elements to accommodate both the quantitative and qualitative information available from the included reviews.

RESULTS

62 systematic reviews are included in this umbrella review. We find caregiver-oriented interventions have large positive and statistically significant effects, especially those focusing on short-term sensitisation and education campaigns as well as written messages to caregivers. For health system-oriented interventions the evidence base is thin and derived from narrative synthesis suggesting positive effects for home visits, mixed effects for pay-for-performance schemes and inconclusive effects for contracting out services to non-governmental providers. For all other interventions under this category, the evidence is either limited or not available. For community-oriented interventions, a recent high-quality mixed-methods review suggests positive but small effects. Overall, the evidence base is highly heterogenous in terms of scope, intervention types and outcomes.

CONCLUSION

Interventions oriented towards caregivers and communities are effective in improving routine child immunisation outcomes. The evidence base on health system-oriented interventions is scant not allowing us to reach firm conclusions, except for home visits. Large evidence gaps exist and need to be addressed. For example, more high-quality evidence is needed for specific caregiver-oriented interventions (eg, monetary incentives) as well as health system-oriented (eg, health workers and data systems) and community-oriented interventions. We also need to better understand complementarity of different intervention types.

Global disability-adjusted life years and deaths attributable to child and maternal malnutrition from 1990 to 2019

Background

Child and maternal malnutrition (CMM) caused heavy disability-adjusted life years (DALY) and deaths globally. It is crucial to understand the global burden associated with CMM in order to prioritize prevention and control efforts. We performed a comprehensive analysis of the global DALY and deaths attributable to CMM from 1990 to 2019 in this study.

Methods

The age-standardized CMM related burden including DALY and death from 1990 to 2019 were accessed from the Global Burden of Disease study 2019 (GBD 2019). The changing trend were described by average annual percentage change (AAPC). The relationship between sociodemographic factors and burden attributable to CMM were explored by generalized linear model (GLM).

Results

Globally, in 2019, the age-standardized DALY and death rates of CMM were 4,425.24/100,000 (95% UI: 3,789.81/100,000-5,249.55/100,000) and 44.72/100,000 (95% UI: 37.83/100,000-53.47/100,000), respectively. The age-standardized DALY rate (AAPC = -2.92, 95% CI: -2.97% to -2.87%) and death rates (AAPC = -3.19, 95% CI: -3.27% to -3.12%) presented significantly declining trends during past 30 years. However, CMM still caused heavy burden in age group of <28 days, Sub-Saharan Africa and low SDI regions. And, low birth weight and short gestation has identified as the primary risk factors globally. The GLM indicated that the highly per capita gross domestic product, per capita current health expenditure, physicians per 1,000 people were contributed to reduce the burden attributable to CMM.

Conclusion

Although global burden attributable to CMM has significantly declined, it still caused severe health burden annually. To strengthen interventions and address resources allocation in the vulnerable population and regions is necessary.

Evaluating the impact of cash transfers on tuberculosis (ExaCT TB): a stepped wedge cluster randomised controlled trial

Background

Mitigating financial barriers to tuberculosis (TB) diagnosis and treatment is a core priority of the global TB agenda. We evaluated the impact of a cash transfer intervention on completion of TB testing and treatment initiation in Uganda.

Methods

We conducted a pragmatic complete stepped wedge randomised trial of a one-time unconditional cash transfer at 10 health centres between September 2019 and March 2020. People referred for sputum-based TB testing were enrolled to receive UGX 20 000 (∼USD 5.39) upon sputum submission. The primary outcome was the number initiating treatment for micro-bacteriologically confirmed TB within 2 weeks of initial evaluation. The primary analysis included cluster-level intent-to-treat and per-protocol analyses using negative binomial regression.

Results

4288 people were eligible. The number diagnosed with TB initiating treatment was higher in the intervention period versus the pre-intervention period (adjusted rate ratio (aRR)=1.34) with a 95% CI of 0.62-2.91 (p=0.46), indicating a wide range of plausible true intervention effects. More were referred for TB testing (aRR=2.60, 95% CI 1.86-3.62; p<0.001) and completed TB testing (aRR=3.22, 95% CI 1.37-7.60; p=0.007) per National Guidelines. Results were similar but attenuated in per-protocol analyses. Surveys revealed that while the cash transfer supported testing completion, it was insufficient to address long-term underlying social/economic barriers.

Interpretation

While it is uncertain whether a single unconditional cash transfer increased the number of people diagnosed and treated for TB, it did support higher completion of diagnostic evaluation in a programmatic setting. A one-time cash transfer may offset some but not all of the social/economic barriers to improving TB diagnosis outcomes.

Community Mobilization and Community Incentivization (CoMIC) Strategy for Child Health in a Rural Setting of Pakistan: Study Protocol for a Randomized Controlled Trial

Despite the decline in under-five mortality by over 60% in the last three decades, majority of child mortality is still attributable to communicable and infectious diseases that are not only preventable, but they are also treatable. We evaluated the potential impact of a participatory community engagement and innovative community incentivization (C3I) strategy for improving the coverage of child health interventions in a rural setting in Pakistan. We first undertook formative research to assess community knowledge and the likelihood of collective community strategy and conditional incentives for improving existing preventive and care-seeking practices for childhood diarrhea and pneumonia. We developed options for community incentivization and improving group practices, taking local norms and customs into account in the design of the community mobilization strategies and messages. These interventions were then formally evaluated prospectively in a three-arm cluster randomized controlled trial. Clusters were randomly assigned by a computer algorithm using restricted randomization by an external statistician (1:1:1) into three groups: community mobilization and incentivization (CMI); community mobilization only using an enhanced communication package (CM); and control group. The C3I was an innovative strategy as it involved serial incremental targets of collective improvement in community behavior related to improvement in the coverage of a composite indicator of fully immunized children (FIC), oral rehydration salt (ORS), and the sanitation index (SI). The evaluation was done by an independent data collection and analysis team at baseline and end line (after 24 months).

Association between cash transfer programs and oral health-A scoping review

OBJECTIVES

The aims of this scoping review are to assess the literature investigating the association between cash transfer programs and oral health; and to identify the theoretical frameworks applied to guide this literature.

METHODS

A search strategy to identify studies published until December 2020 was applied to a range of databases. Observational and interventional studies that had cash transfer programs as exposure/intervention and oral health as outcome were considered. Dental health services utilization, as well as access to dental health services, were considered secondary outcomes. Cash transfer programs were considered programs based on conditional or unconditional cash transfer carried out as part of national social protection schemes, and interventional studies on the impact of cash transfer on oral health were also considered eligible. Data charting was performed in two steps and a narrative synthesis was conducted.

RESULTS

Of 6344 articles identified, four articles were included. These articles investigated three different conditional cash transfer programs, Universal Child Allowance (Argentina), Bolsa Família (Brazil) and Family Rewards (USA). Inconsistencies were identified in findings on the effect of conditional cash transfer programs on the prevalence of dental caries and these differences may be due to the comparison group selected for each study. Concerning dental visits, the results point in different directions, which makes these findings still inconclusive. No explicit theoretical framework was reported in the articles to guide the expected association.

CONCLUSION

Although cash transfers play an important role in improving certain health outcomes, there is limited evidence to suggest an association between cash transfers and oral health.

Identifying intervention strategies to improve HPV vaccine decision-making using behaviour change theory

Although the HPV vaccine is highly safe and effective, its uptake is sub-optimal in many countries, including Ireland. There is therefore a need to identify appropriate interventions that will increase HPV vaccine acceptance by parents. In this study, we took a systematic approach to understand the factors that influence HPV vaccine uptake by parents of adolescent girls in Ireland to define suitable behaviour change interventions that would support positive vaccine decision-making in the future. Specifically, we conducted semi-structured interviews, used a Theoretical Domains Framework (TDF)-based topic guide, to gain insight into the knowledge, beliefs, attitudes and current behaviours of parents with respect to their HPV vaccine decision. Transcripts were analysed using the TDF. The Behaviour Change Wheel (BCW) was used to identify relevant intervention functions and the Behaviour Change Technique Taxonomy version 1 (BCTTv1), to identify relevant intervention techniques. All parents discussed the essential role of healthcare providers in vaccine decision-making. Complacency and confidence were important factors in decision-making by vaccine hesitant parents. Five BCW intervention functions were identified as appropriate, namely; education; persuasion; environmental restructuring; modelling and enablement. To our knowledge, this is the first study to systematically evaluate HPV vaccine decision-making using behaviour change theory and identify suitable intervention strategies to promote positive vaccine decision-making using this approach.

Is the intention to vaccinate enough? Systematic variation in the value of timely vaccinations and preferences for monetary vs non-monetary incentives among pregnant women in southern Tanzania

Background

Globally, approximately 19.7 million children remain under-vaccinated; many more receive delayed vaccinations. Sustained progress towards global vaccination targets requires overcoming, or compensating for, incrementally greater barriers to vaccinating hard-to-reach and hard-to-vaccinate children. We prospectively assessed pregnant women's valuations of routine childhood vaccinations and preferences for alternative incentives to inform interventions aiming to increase vaccination coverage and timeliness in southern Tanzania.

Methods

Between August and December 2017, 406 women in their last trimester of pregnancy were enrolled from health facilities and communities in the Mtwara region of Tanzania and asked contingent valuation questions about their willingness to vaccinate their child if they were (a) given an incentive, or (b) facing a cost for each vaccination. Interval censored regressions assessed correlates of women's willingness to pay (WTP) for timely vaccinations. Participants were asked to rank monetary and non-monetary incentive options for the timely vaccination of their children.

Findings

All women expected to get their children vaccinated according to the recommended schedule, even without incentives. Nearly all women (393; 96.8 %) were willing to pay for vaccinations. The average WTP was Tanzania Shilling (Tsh) 3,066 (95 % confidence interval Tsh 2,523-3,610; 1 USD ∼ Tsh 2,200) for each vaccination. Women's valuations of timely vaccinations varied significantly with vaccine-related knowledge and attitudes, economic status, and rural vs urban residence. Women tended to prefer non-monetary over monetary incentives for the timely vaccination of their children.

Interpretation

Women placed a high value on timely childhood vaccinations, suggesting that unexpected system-level barriers rather than individual-level demand factors are likely to be the primary drivers of missed vaccinations. Systematic variation in the value of vaccinations across women reflects variation in perceived benefits and opportunity costs. In this setting, nonmonetary incentives and other interventions to increase demand and compensate for system-level barriers hold significant potential for improving vaccination coverage and timeliness.

ClinicalTrialsgov Protocol

NCT03252288.

Health behaviors and care seeking practices for childhood diarrhea and pneumonia in a rural district of Pakistan: A qualitative study

Diarrhea and pneumonia are the leading causes of morbidity and mortality in children under five, and Pakistan is amongst the countries with the highest burden and low rates of related treatment coverage. We conducted a qualitative study as part of the formative phase to inform the design of the Community Mobilization and Community Incentivization (CoMIC) cluster randomized control trial (NCT03594279) in a rural district of Pakistan. We conducted in-dept interviews and focused group discussions with key stakeholders using a semi-structured study guide. Data underwent rigorous thematic analysis and major themes identified included socio-cultural dynamics, community mobilization and incentives, behavioral patterns and care seeking practices for childhood diarrhea and pneumonia, infant and young child feeding practices (IYCF), immunization, water sanitation and hygiene (WASH) and access to healthcare. This study highlights shortcomings in knowledge, health practices and health systems. There was to a certain extent awareness of the importance of hygiene, immunization, nutrition, and care-seeking, but the practices were poor due to various reasons. Poverty and lifestyle were considered prime factors for poor health behaviors, while health system inefficiencies added to these as rural facilities lack equipment and supplies, resources, and funding. The community identified that intensive inclusive community engagement and demand creation strategies tied to conditioned short term tangible incentives could help foster behavior change.

Effect of the free healthcare policy on socioeconomic inequalities in care seeking for fever in children under five years in Burkina Faso: a population-based surveys analysis

Background

In 2016, Burkina Faso implemented a free healthcare policy as an initiative to remove user fees for women and under-5 children to improve access to healthcare. Socioeconomic inequalities create disparities in the use of health services which can be reduced by removing user fees. This study aimed to assess the effect of the free healthcare policy (FHCP) on the reduction of socioeconomic inequalities in the use of health services in Burkina Faso.

Methods

Data were obtained from three nationally representative population based surveys of 2958, 2617, and 1220 under-5 children with febrile illness in 2010, 2014, and 2017–18 respectively. Concentration curves were constructed for the periods before and after policy implementation to assess socioeconomic inequalities in healthcare seeking. In addition, Erreyger’s corrected concentration indices were computed to determine the magnitude of these inequalities.

Results

Prior to the implementation of the FHCP, inequalities in healthcare seeking for febrile illnesses in under-5 children favoured wealthier households [Erreyger’s concentration index = 0.196 (SE = 0.039, p = 0.039) and 0.178 (SE = 0.039, p < 0.001) in 2010 and 2014, respectively]. These inequalities decreased after policy implementation in 2017–18 [Concentration Index (CI) = 0.091, SE = 0.041; p = 0.026]. Furthermore, existing pro-rich disparities in healthcare seeking between regions before the implementation of the FHCP diminished after its implementation, with five regions having a high CI in 2010 (0.093–0.208), four regions in 2014, and no region in 2017 with such high CI. In 2017–18, pro-rich inequalities were observed in ten regions (CI:0.007–0.091),whereas in three regions (Plateau Central, Centre, and Cascades), the CI was negative indicating that healthcare seeking was in favour of poorest households.

Conclusion

This study demonstrated that socioeconomic inequalities for under-5 children with febrile illness seeking healthcare in Burkina Faso reduced considerably following the implementation of the free healthcare policy. To reinforce the reduction of these disparities, policymakers should maintain the policy and focus on tackling geographical, cultural, and social barriers, especially in regions where healthcare seeking still favours rich households.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01732-2.

Impact of social protection on gender equality in low- and middle-income countries: A systematic review of reviews

Background

More than half of the global population is not effectively covered by any type of social protection benefit and women's coverage lags behind. Most girls and boys living in low-resource settings have no effective social protection coverage. Interest in these essential programmes in low and middle-income settings is rising and in the context of the COVID-19 pandemic the value of social protection for all has been undoubtedly confirmed. However, evidence on whether the impact of different social protection programmes (social assistance, social insurance and social care services and labour market programmes) differs by gender has not been consistently analysed. Evidence is needed on the structural and contextual factors that determine differential impacts. Questions remain as to whether programme outcomes vary according to intervention implementation and design.

Objectives

This systematic review aims to collect, appraise, and synthesise the evidence from available systematic reviews on the differential gender impacts of social protection programmes in low and middle-income countries. It answers the following questions: 1.What is known from systematic reviews on the gender-differentiated impacts of social protection programmes in low and middle-income countries?2.What is known from systematic reviews about the factors that determine these gender-differentiated impacts?3.What is known from existing systematic reviews about design and implementation features of social protection programmes and their association with gender outcomes?

Search Methods

We searched for published and grey literature from 19 bibliographic databases and libraries. The search techniques used were subject searching, reference list checking, citation searching and expert consultations. All searches were conducted between 10 February and 1 March 2021 to retrieve systematic reviews published within the last 10 years with no language restrictions.

Selection Criteria

We included systematic reviews that synthesised evidence from qualitative, quantitative or mixed-methods studies and analysed the outcomes of social protection programmes on women, men, girls, and boys with no age restrictions. The reviews included investigated one or more types of social protection programmes in low and middle-income countries. We included systematic reviews that investigated the effects of social protection interventions on any outcomes within any of the following six core outcome areas of gender equality: economic security and empowerment, health, education, mental health and psychosocial wellbeing, safety and protection and voice and agency.

Data Collection and Analysis

A total of 6265 records were identified. After removing duplicates, 5250 records were screened independently and simultaneously by two reviewers based on title and abstract and 298 full texts were assessed for eligibility. Another 48 records, identified through the initial scoping exercise, consultations with experts and citation searching, were also screened. The review includes 70 high to moderate quality systematic reviews, representing a total of 3289 studies from 121 countries. We extracted data on the following areas of interest: population, intervention, methodology, quality appraisal, and findings for each research question. We also extracted the pooled effect sizes of gender equality outcomes of meta-analyses. The methodological quality of the included systematic reviews was assessed, and framework synthesis was used as the synthesis method. To estimate the degree of overlap, we created citation matrices and calculated the corrected covered area.

Main Results

Most reviews examined more than one type of social protection programme. The majority investigated social assistance programmes (77%, N = 54), 40% (N = 28) examined labour market programmes, 11% (N = 8) focused on social insurance interventions and 9% (N = 6) analysed social care interventions. Health was the most researched (e.g., maternal health; 70%, N = 49) outcome area, followed by economic security and empowerment (e.g., savings; 39%, N = 27) and education (e.g., school enrolment and attendance; 24%, N = 17). Five key findings were consistent across intervention and outcomes areas: (1) Although pre-existing gender differences should be considered, social protection programmes tend to report higher impacts on women and girls in comparison to men and boys; (2) Women are more likely to save, invest and share the benefits of social protection but lack of family support is a key barrier to their participation and retention in programmes; (3) Social protection programmes with explicit objectives tend to demonstrate higher effects in comparison to social protection programmes without broad objectives; (4) While no reviews point to negative impacts of social protection programmes on women or men, adverse and unintended outcomes have been attributed to design and implementation features. However, there are no one-size-fits-all approaches to design and implementation of social protection programmes and these features need to be gender-responsive and adapted; and (5) Direct investment in individuals and families' needs to be accompanied by efforts to strengthen health, education, and child protection systems. Social assistance programmes may increase labour participation, savings, investments, the utilisation of health care services and contraception use among women, school enrolment among boys and girls and school attendance among girls. They reduce unintended pregnancies among young women, risky sexual behaviour, and symptoms of sexually transmitted infections among women. Social insurance programmes increase the utilisation of sexual, reproductive, and maternal health services, and knowledge of reproductive health; improve changes in attitudes towards family planning; increase rates of inclusive and early initiation of breastfeeding and decrease poor physical wellbeing among mothers. Labour market programmes increase labour participation among women receiving benefits, savings, ownership of assets, and earning capacity among young women. They improve knowledge and attitudes towards sexually transmitted infections, increase self-reported condom use among boys and girls, increase child nutrition and overall household dietary intake, improve subjective wellbeing among women. Evidence on the impact of social care programmes on gender equality outcomes is needed.

Authors' Conclusions

Although effectiveness gaps remain, current programmatic interests are not matched by a rigorous evidence base demonstrating how to appropriately design and implement social protection interventions. Advancing current knowledge of gender-responsive social protection entails moving beyond effectiveness studies to test packages or combinations of design and implementation features that determine the impact of these interventions on gender equality. Systematic reviews investigating the impact of social care programmes, old age pensions and parental leave on gender equality outcomes in low and middle-income settings are needed. Voice and agency and mental health and psychosocial wellbeing remain under-researched gender equality outcome areas.

What can work and how? An overview of evidence-based interventions and delivery strategies to support health and human development from before conception to 20 years

Progress has been made globally in improving the coverage of key maternal, newborn, and early childhood interventions in low-income and middle-income countries, which has contributed to a decrease in child mortality and morbidity. However, inequities remain, and many children and adolescents are still not covered by life-saving and nurturing care interventions, despite their relatively low costs and high cost-effectiveness. This Series paper builds on a large body of work from the past two decades on evidence-based interventions and packages of care for survival, strategies for delivery, and platforms to reach the most vulnerable. We review the current evidence base on the effectiveness of a variety of essential and emerging interventions that can be delivered from before conception until age 20 years to help children and adolescents not only survive into adulthood, but also to grow and develop optimally, support their wellbeing, and help them reach their full developmental potential. Although scaling up evidence-based interventions in children younger than 5 years might have the greatest effect on reducing child mortality rates, we highlight interventions and evidence gaps for school-age children (5-9 years) and the transition from childhood to adolescence (10-19 years), including interventions to support mental health and positive development, and address unintentional injuries, neglected tropical diseases, and non-communicable diseases.

The effect of conditional cash transfers on the control of neglected tropical disease: a systematic review

BACKGROUND

Neglected tropical diseases (NTDs) are diseases of poverty and affect 1·5 billion people globally. Conditional cash transfer (CCTs) programmes alleviate poverty in many countries, potentially contributing to improved NTD outcomes. This systematic review examines the relationship between CCTs and screening, incidence, or treatment outcomes of NTDs.

METHODS

In this systematic review we searched MEDLINE, Embase, Lilacs, EconLit, Global Health, and grey literature websites on Sept 17, 2020, with no date or language restrictions. Controlled quantitative studies including randomised controlled trials (RCTs) and observational studies evaluating CCT interventions in low-income and middle-income countries were included. Any outcome measures related to WHO's 20 diseases classified as NTDs were included. Studies from high-income countries were excluded. Two authors (AA and TH) extracted data from published studies and appraised risk of biases using the Risk of Bias in Non-Randomised Studies of Interventions and Risk of Bias 2 tools. Results were analysed narratively. This study is registered with PROSPERO, CRD42020202480.

FINDINGS

From the search, 5165 records were identified; of these, 11 studies were eligible for inclusion covering four CCTs in Brazil, the Philippines, Mexico, and Zambia. Most studies were either RCTs or quasi-experimental studies and ten were assessed to be of moderate quality. Seven studies reported improved NTD outcomes associated with CCTs, in particular, reduced incidence of leprosy and increased uptake of deworming treatments. There was some evidence of greater benefit of CCTS in lower socioeconomic groups but subgroup analysis was scarce. Methodological weaknesses include self-reported outcomes, missing data, improper randomisation, and differences between CCT and comparator populations in observational studies. The available evidence is currently limited, covering a small proportion of CCTs and NTDs.

INTERPRETATION

CCTs can be associated with improved NTD outcomes, and could be driven by both improvements in living standards from cash benefits and direct health effects from conditionalities related to health-care use. This evidence adds to the knowledge of health-improving effects from CCTs in poor and vulnerable populations.

FUNDING

None.

Unconditional cash transfers for reducing poverty and vulnerabilities: effect on use of health services and health outcomes in low- and middle-income countries

BACKGROUND

Unconditional cash transfers (UCTs; provided without obligation) for reducing poverty and vulnerabilities (e.g. orphanhood, old age, or HIV infection) are a social protection intervention addressing a key social determinant of health (income) in low- and middle-income countries (LMICs). The relative effectiveness of UCTs compared with conditional cash transfers (CCTs; provided only if recipients follow prescribed behaviours, e.g. use a health service or attend school) is unknown.

OBJECTIVES

To assess the effects of UCTs on health services use and health outcomes in children and adults in LMICs. Secondary objectives are to assess the effects of UCTs on social determinants of health and healthcare expenditure, and to compare the effects of UCTs versus CCTs.

SEARCH METHODS

For this update, we searched 15 electronic academic databases, including CENTRAL, MEDLINE and EconLit, in September 2021. We also searched four electronic grey literature databases, websites of key organisations and reference lists of previous systematic reviews, key journals and included study records.

SELECTION CRITERIA

We included both parallel-group and cluster-randomised controlled trials (C-RCTs), quasi-RCTs, cohort studies, controlled before-and-after studies (CBAs), and interrupted time series studies of UCT interventions in children (0 to 17 years) and adults (≥ 18 years) in LMICs. Comparison groups received either no UCT, a smaller UCT or a CCT. Our primary outcomes were any health services use or health outcome.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened potentially relevant records for inclusion, extracted data and assessed the risk of bias. We obtained missing data from study authors if feasible. For C-RCTs, we generally calculated risk ratios for dichotomous outcomes from crude frequency measures in approximately correct analyses. Meta-analyses applied the inverse variance or Mantel-Haenszel method using a random-effects model. Where meta-analysis was impossible, we synthesised results using vote counting based on effect direction. We assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included 34 studies (25 studies of 20 C-RCTs, six CBAs, and three cohort studies) involving 1,140,385 participants (45,538 children, 1,094,847 adults) and 50,095 households in Africa, the Americas and South-East Asia in our meta-analyses and narrative syntheses. These analysed 29 independent data sets. The 24 UCTs identified, including one basic universal income intervention, were pilot or established government programmes or research experiments. The cash value was equivalent to 1.3% to 81.9% of the annualised gross domestic product per capita. All studies compared a UCT with no UCT; three studies also compared a UCT with a CCT. Most studies carried an overall high risk of bias (i.e. often selection or performance bias, or both). Most studies were funded by national governments or international organisations, or both. Throughout the review, we use the words 'probably' to indicate moderate-certainty evidence, 'may/maybe' for low-certainty evidence, and 'uncertain' for very low-certainty evidence. Health services use We assumed greater use of any health services to be beneficial. UCTs may not have impacted the likelihood of having used any health service in the previous 1 to 12 months, when participants were followed up between 12 and 24 months into the intervention (risk ratio (RR) 1.04, 95% confidence interval (CI) 1.00 to 1.09; I² = 2%; 5 C-RCTs, 4972 participants; low-certainty evidence). Health outcomes At one to two years, UCTs probably led to a clinically meaningful, very large reduction in the likelihood of having had any illness in the previous two weeks to three months (RR 0.79, 95% CI 0.67 to 0.92; I² = 53%; 6 C-RCTs, 9367 participants; moderate-certainty evidence). UCTs may have increased the likelihood of having been food secure over the previous month, at 13 to 36 months into the intervention (RR 1.25, 95% CI 1.09 to 1.45; I² = 85%; 5 C-RCTs, 2687 participants; low-certainty evidence). UCTs may have increased participants' level of dietary diversity over the previous week, when assessed with the Household Dietary Diversity Score and followed up 24 months into the intervention (mean difference (MD) 0.59 food categories, 95% CI 0.18 to 1.01; I² = 79%; 4 C-RCTs, 9347 participants; low-certainty evidence). Despite several studies providing relevant evidence, the effects of UCTs on the likelihood of being moderately stunted and on the level of depression remain uncertain. We found no study on the effect of UCTs on mortality risk. Social determinants of health UCTs probably led to a clinically meaningful, moderate increase in the likelihood of currently attending school, when assessed at 12 to 24 months into the intervention (RR 1.06, 95% CI 1.04 to 1.09; I² = 0%; 8 C-RCTs, 7136 participants; moderate-certainty evidence). UCTs may have reduced the likelihood of households being extremely poor, at 12 to 36 months into the intervention (RR 0.92, 95% CI 0.87 to 0.97; I² = 63%; 6 C-RCTs, 3805 participants; low-certainty evidence). The evidence was uncertain for whether UCTs impacted livestock ownership, participation in labour, and parenting quality. Healthcare expenditure Evidence from eight cluster-RCTs on healthcare expenditure was too inconsistent to be combined in a meta-analysis, but it suggested that UCTs may have increased the amount of money spent on health care at 7 to 36 months into the intervention (low-certainty evidence). Equity, harms and comparison with CCTs The effects of UCTs on health equity (or unfair and remedial health inequalities) were very uncertain. We did not identify any harms from UCTs. Three cluster-RCTs compared UCTs versus CCTs with regard to the likelihood of having used any health services or had any illness, or the level of dietary diversity, but evidence was limited to one study per outcome and was very uncertain for all three.

AUTHORS' CONCLUSIONS

This body of evidence suggests that unconditional cash transfers (UCTs) may not impact a summary measure of health service use in children and adults in LMICs. However, UCTs probably or may improve some health outcomes (i.e. the likelihood of having had any illness, the likelihood of having been food secure, and the level of dietary diversity), two social determinants of health (i.e. the likelihoods of attending school and being extremely poor), and healthcare expenditure. The evidence on the relative effectiveness of UCTs and CCTs remains very uncertain.

Water, sanitation and hygiene (WASH) behaviour change research: why an analysis of contingencies of reinforcement is needed

Diarrheal disease associated with poor water, sanitation and hygiene (WASH) kills more than one million people every year. Safe WASH practices have the potential to greatly reduce these statistics but behaviour change interventions in the field have yielded little success to date. Currently, there is an emphasis on addressing cognitive processes to bring about changes in behaviour. In this review, a case is made for the benefits of a contingency-based perspective, focusing on the contextual antecedents and consequences of behaviour. The role of contingencies of reinforcement, not explored in previous WASH literature, is discussed as an explanatory framework for designing behaviour change strategies. A proper use of contrived reinforcers is recommended to counterbalance the natural reinforcers of convenience associated with risk practices. Recognising the role of consequences in the acquisition and maintenance of behaviour is an important step in the search for the answers urgently needed in the WASH field.

Free healthcare for some, fee-paying for the rest: adaptive practices and ethical issues in rural communities in the district of Boulsa, Burkina Faso

In Burkina Faso, in July 2016, user fees were removed at all public healthcare facilities, but only for children under 60 months of age and for "mothers", i.e. for reproductive care. This study was conducted in five rural communities in Boulsa District (Burkina Faso) (1) to understand the perceptions and practices of stakeholders regarding compliance with eligibility criteria for free care and (2) to explore the ethical tensions that may have resulted from this policy. Semi-directed individual interviews (n = 20) were conducted with healthcare personnel and mothers of young children. Interviews were recorded and transcribed, and a thematic content analysis was conducted. The study reveals the presence of practices to circumvent strict compliance with the eligibility criteria for free access. These include hiding the exact age of children over 60 months and using eligible persons for the benefit of others. These practices result from ethical and economic tensions experienced by the beneficiaries. They also raise dilemmas among healthcare providers, who have to enforce compliance with the eligibility criteria while realizing the households' deprivation. Informal adjustments are introduced at the community level to reconcile the healthcare providers' dissonance. Local reinvention mechanisms help in overcoming ethical tensions and in implementing the policy.

Systematic Review on the Impact of Conditional Cash Transfers on Child Health Service Utilisation and Child Health in Sub-Saharan Africa

Background: Conditional cash transfers (CCTs) are interventions which provide assistance in the form of cash to specific vulnerable groups on the condition that they meet pre-defined requirements. The impact of conditional cash transfers on children's access to health services and on their overall health has not been established in sub-Saharan Africa.

Method: We conducted a systematic review aimed at summarising the available information on the impact of conditional cash transfers on health service utilisation and child health in sub-Saharan Africa. We searched databases for peer-reviewed articles, websites of organisations involved in implementing conditional cash transfer programmes, and Google scholar to identify grey literature. Records were selected based on predefined eligibility criteria which were drawn from a programme impact framework. Records were eligible if one of the following outcomes was evaluated: health services utilisation, immunisation coverage, growth monitoring, anthropometry, illness reported, and mortality. Other records which reported on important intermediate outcomes or described mechanisms significantly contributing to impact were also included in the review. Data items were extracted from eligible records into an extraction form based on predefined data items. Study quality indicators were also extracted into a quality assessment form.

Results: Thematic narrative synthesis was conducted using data from nine included records. The review included five cluster randomised evaluations, one quasi-experimental clustered study, one randomised trial at the individual level, one mixed-method study and one purely qualitative study. There was insufficient evidence of an impact of conditional cash transfers on health service utilisation. There was also not enough evidence of an impact on nutritional status. No impact was observed on health status based on illness reports, nor on immunisation rates. None of the included records evaluated the impact on childhood mortality.

Conclusions: The findings of this review suggest that a positive impact may be observed in health service utilisation and nutrition, however, this may not translate into improved child health. Further research is needed to understand the mechanisms and pathways by which these interventions work, explore the effect of contextual factors on their impact, and assess their cost implication especially within resource-constrained settings.

Not just money: what mothers value in conditional cash transfer programs in India

Introduction

Conditional cash transfers (CCTs) have become an important policy tool for increasing demand for key maternal and child health services in low/middle-income countries. Yet, these programs have had variable success in increasing service use. Understanding beneficiary preferences for design features of CCTs can increase program effectiveness.

Methods

We conducted a Discrete choice experiment in two districts of Uttar Pradesh, India in 2018 with 405 mothers with young children (<3 years). Respondents were asked to choose between hypothetical CCT programme profiles described in terms of five attribute levels (cash, antenatal care visits, growth-monitoring and immunisation visits, visit duration and health benefit received) and responses were analysed using mixed logit regression.

Results

Mothers most valued the cash transfer amount, followed by the health benefit received from services. Mothers did not have a strong preference for conditionalities related to the number of health centre visits or for time spent seeking care; however, service delivery points were in close proximity to households. Mothers were willing to accept lower cash rewards for better perceived health benefits—they were willing to accept 2854 Indian rupees ($41) less for a programme that produced good health, which is about half the amount currently offered by India’s Maternal Benefits Program. Mothers who had low utilisation of health services, and those from poor households, valued the cash transfer and the health benefit significantly more than others.

Conclusion

Both cash transfers and the perceived health benefit from services are highly valued, particularly by infrequent service users. In CCTs, this highlights the importance of communicating value of services to beneficiaries by informing about health benefits of services and providing quality care. Conditionalities requiring frequent health centre visits or time taken for seeking care may not have large negative effects on CCT participation in contexts of good service coverage.

Impact of mobile phone delivered reminders and unconditional incentives on measles-containing vaccine timeliness and coverage: a randomised controlled trial in western Kenya

Introduction

Short message service (SMS) reminders coupled with a small monetary incentive conditioned on prompt vaccination have been shown to improve first-dose measles-containing vaccine (MCV1) uptake. We assessed whether SMS reminders and unconditional monetary incentives—more amenable to programmatic implementation—can improve MCV1 uptake in Kenya.

Methods

Caregivers of eligible infants aged 6–8 months were enrolled into an individually randomised controlled trial and assigned to receive either: no intervention (control), two SMS reminders (SMS) sent 3 days, and 1 day before the scheduled MCV1 date, or SMS reminders coupled with a Kenya Shilling (KES) 150 incentive (SMS +150 KES) sent 3 days before the scheduled MCV1 date. Study staff conducted a household follow-up visit at age 12 months to ascertain vaccination status. Log-binomial regression was used to estimate the relative and absolute difference in MCV1 timely coverage (by age 10 months), the primary outcome.

Results

Between 6 December 2016 and 31 March 2017, 179 infants were enrolled into each of the three study arms. Follow-up visits were completed between 19 April 2017 and 8 October 2017 for control (n=170), SMS (n=157) and SMS + 150 KES (n=158) children. MCV1 timely coverage was 68% among control arm infants compared with 78% in each intervention arm. This represented a non-statistically significant increase in the SMS arm (adjusted relative risk 1.13; 95% CI 0.99 to 1.30; p=0.070; adjusted risk difference 9.2%; 95% CI: −0.6 to 19.0%; p=0.066), but a statistically significant increase in the SMS + 150 KES arm (1.16; 95% CI 1.01 to 1.32; p=0.035; 10.6%; 95% CI 0.8 to 20.3%; p=0.034).

Conclusion

These findings suggest that the effect of SMS reminders coupled with a small unconditional monetary incentive on MCV1 uptake is comparable to that of SMS reminders alone, limiting their utility. Further studies in the absence of unexpected supply-side constraints are needed.

Trial registration number

NCT02904642

PROTOCOL: Impact of social protection on gender equality in low- and middle-income countries: A systematic review of reviews

This is the protocol for a Campbell review. The review aims to systematically collect, appraise, map and synthesise the evidence from systematic reviews on the differential gender impacts of social protection programmes in Low- and Middle-Income Countries (LMICs). Therefore, it will answer the following questions: (1) What is known from systematic reviews on the gender-differentiated impacts of social protection programmes in LMICs? (2) What is known from systematic reviews about the factors that determine these gender-differentiated impacts? (3) What is known from existing systematic reviews about design and implementation features of social protection programmes and their association with gender outcomes?

Effective interventions to address maternal and child malnutrition: an update of the evidence

Malnutrition-consisting of undernutrition, overweight and obesity, and micronutrient deficiencies-continues to afflict millions of women and children, particularly in low-income and middle-income countries (LMICs). Since the 2013 Lancet Series on maternal and child nutrition, evidence on the ten recommended interventions has increased, along with evidence of newer interventions. Evidence on the effectiveness of antenatal multiple micronutrient supplementation in reducing the risk of stillbirths, low birthweight, and babies born small-for-gestational age has strengthened. Evidence continues to support the provision of supplementary food in food-insecure settings and community-based approaches with the use of locally produced supplementary and therapeutic food to manage children with acute malnutrition. Some emerging interventions, such as preventive small-quantity lipid-based nutrient supplements for children aged 6-23 months, have shown positive effects on child growth. For the prevention and management of childhood obesity, integrated interventions (eg, diet, exercise, and behavioural therapy) are most effective, although there is little evidence from LMICs. Lastly, indirect nutrition strategies, such as malaria prevention, preconception care, water, sanitation, and hygiene promotion, delivered inside and outside the health-care sector also provide important nutritional benefits. Looking forward, greater effort is required to improve intervention coverage, especially for the most vulnerable, and there is a crucial need to address the growing double burden of malnutrition (undernutrition, and overweight and obesity) in LMICs.

User fees removal and community-based management of undernutrition in Burkina Faso: what effects on children's nutritional status?

OBJECTIVE

To examine the effect of an intervention combining user fees removal with community-based management of undernutrition on the nutrition status in children under 5 years of age in Burkina Faso.

DESIGN

The study was a non-equivalent control group post-test-only design based on household survey data collected 4 years after the intervention onset in the intervention and comparison districts. Additionally, we used propensity score weighting to achieve balance on covariates between the two districts, followed by logistic multilevel modelling.

SETTING

Two health districts in the Sahel region.

PARTICIPANTS

Totally, 1116 children under 5 years of age residing in 41 intervention communities and 1305 from 51 control communities.

RESULTS

When comparing children living in the intervention district to children living in a non-intervention district, we determined no differences in terms of stunting (OR = 1·13; 95 % CI 0·83, 1·54) and wasting (OR = 1·21; 95 % CI 0·90, 1·64), nor in severely wasted (OR = 1·27; 95 % CI 0·79, 2·04) and severely stunted (OR = 0·99; 95 % CI 0·76, 1·26). However, we determined that 3 % of the variance of wasting (95 % CI 1·25, 10·42) and 9·4 % of the variance of stunting (95 % CI 6·45, 13·38) were due to systematic differences between communities of residence. The presence of the intervention in the communities explained 2 % of the community-level variance of stunting and 3 % of the community-level variance of wasting.

CONCLUSIONS

With the scaling-up of the national free health policy in Africa, we stress the need for rigorous evaluations and the means to measure expected changes in order to better inform health interventions.

Children's moderate-to-vigorous physical activity on weekdays versus weekend days: a multi-country analysis

Purpose

The Structured Days Hypothesis (SDH) posits that children’s behaviors associated with obesity – such as physical activity – are more favorable on days that contain more ‘structure’ (i.e., a pre-planned, segmented, and adult-supervised environment) such as school weekdays, compared to days with less structure, such as weekend days. The purpose of this study was to compare children’s moderate-to-vigorous physical activity (MVPA) levels on weekdays versus weekend days using a large, multi-country, accelerometer-measured physical activity dataset.

Methods

Data were received from the International Children’s Accelerometer Database (ICAD) July 2019. The ICAD inclusion criteria for a valid day of wear, only non-intervention data (e.g., baseline intervention data), children with at least 1 weekday and 1 weekend day, and ICAD studies with data collected exclusively during school months, were included for analyses. Mixed effects models accounting for the nested nature of the data (i.e., days within children) assessed MVPA minutes per day (min/day MVPA) differences between weekdays and weekend days by region/country, adjusted for age, sex, and total wear time. Separate meta-analytical models explored differences by age and country/region for sex and child weight-status.

Results/findings

Valid data from 15 studies representing 5794 children (61% female, 10.7 ± 2.1 yrs., 24% with overweight/obesity) and 35,263 days of valid accelerometer data from 5 distinct countries/regions were used. Boys and girls accumulated 12.6 min/day (95% CI: 9.0, 16.2) and 9.4 min/day (95% CI: 7.2, 11.6) more MVPA on weekdays versus weekend days, respectively. Children from mainland Europe had the largest differences (17.1 min/day more MVPA on weekdays versus weekend days, 95% CI: 15.3, 19.0) compared to the other countries/regions. Children who were classified as overweight/obese or normal weight/underweight accumulated 9.5 min/day (95% CI: 6.9, 12.2) and 10.9 min/day (95% CI: 8.3, 13.5) of additional MVPA on weekdays versus weekend days, respectively.

Conclusions

Children from multiple countries/regions accumulated significantly more MVPA on weekdays versus weekend days during school months. This finding aligns with the SDH and warrants future intervention studies to prioritize less-structured days, such as weekend days, and to consider providing opportunities for all children to access additional opportunities to be active.

Mega-map of systematic reviews and evidence and gap maps on the interventions to improve child well-being in low- and middle-income countries

BACKGROUND

Despite a considerable reduction in child mortality, nearly six million children under the age of five die each year. Millions more are poorly nourished and in many parts of the world, the quality of education remains poor. Children are at risk from multiple violations of their rights, including child labour, early marriage, and sexual exploitation. Research plays a crucial role in helping to close the remaining gaps in child well-being, yet the global evidence base for interventions to meet these challenges is mostly weak, scattered and often unusable by policymakers and practitioners. This mega-map encourages the generation and use of rigorous evidence on effective ways to improve child well-being for policy and programming.

OBJECTIVES

The aim of this mega-map is to identify, map and provide an overview of the existing evidence synthesis on the interventions aimed at improving child well-being in low- and middle-income countries (LMICs).

METHODS

Campbell evidence and gap maps (EGMs) are based on a review of existing mapping standards (Saran & White, 2018) which drew in particular of the approach developed by 3ie (Snilstveit, Vojtkova, Bhavsar, & Gaarder, 2013). As defined in the Campbell EGM guidance paper; "Mega-map is a map of evidence synthesis, that is, systematic reviews, and does not include primary studies" (Campbell Collaboration, 2020). The mega-map on child well-being includes studies with participants aged 0-18 years, conducted in LMICs, and published from year 2000 onwards. The search followed strict inclusion criteria for interventions and outcomes in the domains of health, education, social work and welfare, social protection, environmental health, water supply and sanitation (WASH) and governance. Critical appraisal of included systematic reviews was conducted using "A Measurement Tool to Assess Systematic Reviews"-AMSTAR-2 rating scale (Shea, et al., 2017).

RESULTS

We identified 333 systematic reviews and 23 EGMs. The number of studies being published has increased year-on-year since 2000. However, the distribution of studies across World Bank regions, intervention and outcome categories are uneven. Most systematic reviews examine interventions pertaining to traditional areas of health and education. Systematic reviews in these traditional areas are also the most funded. There is limited evidence in social work and social protection. About 69% (231) of the reviews are assessed to be of low and medium quality. There are evidence gaps with respect to key vulnerable populations, including children with disabilities and those who belong to minority groups.

CONCLUSION

Although an increasing number of systematic reviews addressing child well-being topics are being published, some clear gaps in the evidence remain in terms of quality of reviews and some interventions and outcome areas. The clear gap is the small number of reviews focusing explicitly on either equity or programmes for disadvantaged groups and those who are discriminated against.

Soins de santé gratuits pour les uns, payants pour les autres : perceptions et stratégies d’adaptation dans le district de Boulsa (Burkina Faso)

Contexte : Les preuves des bienfaits des politiques de gratuité des soins sont réunies, mais les enjeux éthiques que ces politiques soulèvent dans les pays à faibles revenus ont été peu examinés. Au Burkina Faso, la gratuité a été introduite en juillet 2016 pour les enfants de moins de 5 ans et les femmes enceintes, en ce qui concerne les soins en santé reproductive. Il a été rapporté que les critères d’éligibilité sont parfois difficiles à interpréter ou à mettre en application. L’objectif de cette étude est double : 1) comprendre les perceptions et les pratiques du personnel de santé et des bénéficiaires à l’égard du respect des critères d’éligibilité à la gratuité et 2) explorer les tensions éthiques qui en ont découlé et les éventuels modes de résolution. Méthodologie : En 2018, une étude qualitative transversale a été menée dans cinq communautés rurales de Boulsa, au Burkina Faso, Des entrevues individuelles semi-dirigées ont été réalisées auprès du personnel soignant (n=10) et de mères de jeunes enfants (n=10), qui ont été sélectionnées avec l’aide d’agents de santé à base communautaire. Les enregistrements audios ont été traduits et retranscrits. Une analyse thématique de contenu a été réalisée sur l’ensemble du matériel. Les thèmes qui sont ressortis de l’analyse thématique ont été identifiés par les membres de l’équipe, qui en ont discuté et les ont reformulés. Résultats : L’étude suggère que les critères d’éligibilité à la gratuité ne sont pas toujours bien connus des bénéficiaires, ce qui peut entraîner des débordements involontaires. Elle révèle aussi l’adoption de pratiques pour contourner le respect strict des critères d’éligibilité à la gratuité, notamment pour en faire bénéficier les enfants de 5 ans et plus. Ces débordements délibérés résultent de tensions éthiques vécues par les bénéficiaires, et en soulèvent d’autres chez le personnel soignant. Des mécanismes sont mis en oeuvre officieusement pour réconcilier les dissonances ressenties par les prestataires. Conclusion : La mise en oeuvre de la politique de gratuité au Burkina Faso s’opère grâce à des mécanismes de réinvention locale pour surmonter les tensions éthiques liées au respect des critères d’éligibilité.

Assessing the challenges to women's access and implementation of text messages for nutrition behaviour change in rural Tanzania

OBJECTIVE

This process evaluation aimed to understand factors affecting the implementation of a government-sponsored short message service (SMS) programme for delivering nutrition information to rural populations, including message access, acceptability and putting messages into action.

DESIGN

The study was nested within a larger randomised controlled trial. Cross-sectional data collection included structured surveys and in-depth interviews. Data were analysed for key trends and themes using Stata and ATLAS.ti software.

SETTING

The study took place in Tanzania's Mtwara region.

PARTICIPANTS

Surveys were conducted with 205 women and 93 men already enrolled in the randomised controlled trial. A sub-set of 30 women and 14 men participated in the in-depth interviews.

RESULTS

Among women relying on a spouse's phone, sharing arrangements impeded regular SMS access; men were commonly away from home, forgot to share SMS or did not share them in women's preferred way. Phone-owning women faced challenges related to charging their phones and defective handsets. Once SMS were delivered, most participants viewed them as trustworthy and comprehensible. However, economic conditions limited the feasibility of applying certain recommendations, such as feeding meat to toddlers. A sub-set of participants concurrently enrolled in an interpersonal counselling (IPC) intervention indicated that the SMS provided reminders of lessons learned during the IPC; yet, the SMS did not help participants contextualise information and overcome the challenges of putting that information into practice.

CONCLUSIONS

The challenges to accessing and implementing SMS services highlighted here suggest that such platforms may work well as one component of a comprehensive nutrition intervention, yet not as an isolated effort.

User fee policies and women's empowerment: a systematic scoping review

BACKGROUND

Over the past decade, an increasing number of low- and middle-income countries have reduced or removed user fees for pregnant women and/or children under five as a strategy to achieve universal health coverage. Despite the large number of studies (including meta-analyses and systematic reviews) that have shown this strategy's positive effects impact on health-related indicators, the repercussions on women's empowerment or gender equality has been overlooked in the literature. The aim of this study is to systematically review the evidence on the association between user fee policies in low- and middle-income countries and women's empowerment.

METHODS

A systematic scoping review was conducted. Two reviewers conducted the database search in six health-focused databases (Pubmed, CAB Abstracts, Embase, Medline, Global Health, EBM Reviews) using English key words. The database search was conducted on February 20, 2020, with no publication date limitation. Qualitative analysis of the included articles was conducted using a thematic analysis approach. The material was organized based on the Gender at Work analytical framework.

RESULTS

Out of the 206 initial records, nine articles were included in the review. The study settings include three low-income countries (Burkina Faso, Mali, Sierra Leone) and two lower-middle countries (Kenya, India). Four of them examine a direct association between user fee policies and women's empowerment, while the others address this issue indirectly -mostly by examining gender equality or women's decision-making in the context of free healthcare. The evidence suggests that user fee removal contributes to improving women's capability to make health decisions through different mechanisms, but that the impact is limited. In the context of free healthcare, women's healthcare decision-making power remains undermined because of social norms that are prevalent in the household, the community and the healthcare centers. In addition, women continue to endure limited access to and control over resources (mainly education, information and economic resources).

CONCLUSION

User fee removal policies alone are not enough to improve women's healthcare decision-making power. Comprehensive and multi-sectoral approaches are needed to bring sustainable change regarding women's empowerment. A focus on "gender equitable access to healthcare" is needed to reconcile women's empowerment and the efforts to achieve universal health coverage.

What influences child feeding in the Northern Triangle? A mixed-methods systematic review

Optimising child feeding behaviours could improve child health in Guatemala, Honduras and El Salvador, where undernutrition rates remain high. However, the design of interventions to improve child feeding behaviours is limited by piecemeal, theoretically underdeveloped evidence on factors that may influence these behaviours. Between July 2018 and January 2020, we systematically searched Cochrane, Medline, EMBASE, Global Health and LILACS databases, grey literature websites and reference lists, for evidence of region-specific causes of child feeding behaviours and the effectiveness of related interventions and policies. The Behaviour Change Wheel was used as a framework to synthesise and map the resulting literature. We identified 2,905 records and included 68 relevant studies of mixed quality, published between 1964 and 2019. Most (n = 50) were quantitative, 15 were qualitative and three used mixed methods. A total of 39 studies described causes of child feeding behaviour; 29 evaluated interventions or policies. Frequently cited barriers to breastfeeding included mothers' beliefs and perceptions of colostrum and breast milk sufficiency; fears around child illness; and familial and societal pressures, particularly from paternal grandmothers. Child diets were influenced by similar beliefs and mothers' lack of money, time and control over household finances and decisions. Interventions (n = 22) primarily provided foods or supplements with education, resulting in mixed effects on breastfeeding and child diets. Policy evaluations (n = 7) showed positive and null effects on child feeding practices. We conclude that interventions should address context-specific barriers to optimal feeding behaviours, use behaviour change theory to apply appropriate techniques and evaluate impact using robust research methods.

Interventions to improve birth outcomes of pregnant women living in low- and middle-income countries: a systematic review and network meta-analysis

Background: Improving the health of pregnant women is important to prevent adverse birth outcomes, such as preterm birth and low birthweight. We evaluated the comparative effectiveness of interventions under the domains of micronutrient, balanced energy protein, deworming, maternal education, and water sanitation and hygiene (WASH) for their effects on these adverse birth outcomes. Methods: For this network meta-analysis, we searched for randomized clinical trials (RCTs) of interventions provided to pregnant women in low- and middle-income countries (LMICs). We searched for reports published until September 17, 2019 and hand-searched bibliographies of existing reviews. We extracted data from eligible studies for study characteristics, interventions, participants' characteristics at baseline, and birth outcomes. We compared effects on preterm birth (<37 gestational week), low birthweight (LBW; <2500 g), and birthweight (continuous) using studies conducted in LMICs. Results: Our network meta-analyses were based on 101 RCTs (132 papers) pertaining to 206,531 participants. Several micronutrients and balanced energy food supplement interventions demonstrated effectiveness over standard-of-care. For instance, versus standard-of-care, micronutrient supplements for pregnant women, such as iron and calcium, decreased risks of preterm birth (iron: RR=0.70, 95% credible interval [Crl] 0.47, 1.01; calcium: RR=0.76, 95%Crl 0.56, 0.99). Daily intake of 1500kcal of local food decreased the risks of preterm birth (RR=0.36, 95%Crl 0.16, 0.77) and LBW (RR=0.17, 95%Crl 0.09, 0.29), respectively when compared to standard-of-care. Educational and deworming interventions did not show improvements in birth outcomes, and no WASH intervention trials reported on these adverse birth outcomes. Conclusion: We found several pregnancy interventions that improve birth outcomes. However, most clinical trials have only evaluated interventions under a single domain (e.g. micronutrients) even though the causes of adverse birth outcomes are multi-faceted. There is a need to combine interventions that of different domains as packages and test for their effectiveness. Registration: PROSPERO CRD42018110446; registered on 17 October 2018.

iSAY (incentives for South African youth): Stated preferences of young people living with HIV

High adherence to antiretroviral therapy (ART) is essential for achieving viral suppression and preventing HIV transmission. Yet adherence is suboptimal among adolescents who face unique adherence challenges. Little is known about the role of conditional economic incentives (CEIs) for increasing ART adherence in this population. During 2017-2019, we conducted a mixed-methods discrete choice experiment in Cape Town, South Africa to inform the optimal design of a CEI intervention for ART adherence among youth. In-depth interviews were conducted with n = 35 adolescents (10-19 years old) living with HIV and prescribed ART, to identify attributes of a youth-centered CEI intervention for ART adherence. A discrete choice experiment was subsequently conducted with N = 168 adolescents to elicit preferences for intervention components. A rank-ordered mixed logit model was used for main results; marginal willingness-to-accept (mWTA) was then estimated. Five attributes emerged from the qualitative research as important for a CEI-based intervention for youth ART adherence: (1) incentive amount, (2) incentive format, (3) incentive recipient, (4) delivery mode, and (5) program participants. Youth had a high probability of acceptance of any incentives program (88-100%), yet they did not have a strong preference of a quarterly over a monthly program. From a maximum incentive amount of R1920 (~US$115), youth were willing to forgo up to R126 per year (~US$9) if the incentive was given in cash (versus fashion vouchers); R274 (~US$19.6) if it was open to both previously adherent and non-adherent youth (instead of non-adherent only); and up to R91 (~US$6.5) to receive incentives at a clinic setting (instead of electronically). The use of incentives over the short term during the critical age- and developmental-transition, when adolescents begin to take sole responsibility for their medication-taking behaviors, holds great promise for habituating adherence into adulthood.

Strengthening vaccination programmes and health systems in the European Union: A framework for action

Vaccination is one of the most cost-effective public health interventions. However, the EU is facing increasing outbreaks of vaccine preventable diseases, with some fatal cases of measles. This paper reviews the main factors influencing vaccination uptake, and assesses measures expected to improve vaccination coverage. Obstacles to vaccination include concerns about vaccine safety and side effects, lack of trust, social norms, exposure to rumours and myths, and access barriers. Responses fall into three broad categories. Regulation, including the introduction of mandatory vaccination, can be justified but it is important to be sure that it is an appropriate solution to the existing problem and does not risk unintended consequences. Facilitation involves ensuring that there is an effective vaccination programme, comprehensive in nature, and reducing the many barriers, in terms of cost, distance, and time, to achieving high levels of uptake, especially for marginalised or vulnerable populations. Information is crucial, but whether in the form of public information campaigns or interactions between health workers and target populations, must be designed very carefully to avoid the risk of backfire. There is no universal solution to achieving high levels of vaccine uptake but rather a range or combinations of options. The choice of which to adopt in each country will depend on a detailed understanding of the problem, including which groups are most affected.

Systematic review of the costs and effectiveness of interventions to increase infant vaccination coverage in low- and middle-income countries

Background

In recent years, several large studies have assessed the costs of national infant immunization programs, and the results of these studies are used to support planning and budgeting in low- and middle-income countries. However, few studies have addressed the costs and cost-effectiveness of interventions to improve immunization coverage, despite this being a major focus of policy attention. Without this information, countries and international stakeholders have little objective evidence on the efficiency of competing interventions for improving coverage.

Methods

We conducted a systematic literature review on the costs and cost-effectiveness of interventions to improve immunization coverage in low- and middle-income countries, including both published and unpublished reports. We evaluated the quality of included studies and extracted data on costs and incremental coverage. Where possible, we calculated incremental cost-effectiveness ratios (ICERs) to describe the efficiency of each intervention in increasing coverage.

Results

A total of 14 out of 41 full text articles reviewed met criteria for inclusion in the final review. Interventions for increasing immunization coverage included demand generation, modified delivery approaches, cash transfer programs, health systems strengthening, and novel technology usage. We observed substantial heterogeneity in costing methods and incompleteness of cost and coverage reporting. Most studies reported increases in coverage following the interventions, with coverage increasing by an average of 23 percentage points post-intervention across studies. ICERs ranged from $0.66 to $161.95 per child vaccinated in 2017 USD. We did not conduct a meta-analysis given the small number of estimates and variety of interventions included.

Conclusions

There is little quantitative evidence on the costs and cost-effectiveness of interventions for improving immunization coverage, despite this being a major objective for national immunization programs. Efforts to improve the level of costing evidence—such as by integrating cost analysis within implementation studies and trials of immunization scale up—could allow programs to better allocate resources for coverage improvement. Greater adoption of standardized cost reporting methods would also enable the synthesis and use of cost data.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4468-4) contains supplementary material, which is available to authorized users.

Alternatives to SNAP: Global Approaches to Addressing Childhood Poverty and Food Insecurity

The Supplemental Nutrition Assistance Program (SNAP) in the United States is a key element of the nation's safety net. Yet, 12.5 million US children live in households that experience food insecurity, despite national spending of $65 billion on SNAP alone.In analyses integrating data from the 36 Organisation for Economic Co-operation and Development (OECD) countries, we found that child poverty and food insecurity are much higher in the United States than in most of the other OECD countries. The United States has higher total social spending than other OECD countries, but a lower rate of spending on children and families. This international comparison suggests that potentially effective solutions implemented in other countries might help further alleviate US childhood poverty and food insecurity.Broadly, we recommend increasing investments in families with children, particularly low-income families. Our specific recommendations include increasing SNAP benefits, establishing additional benefits to support low-income families with young children, and implementing a universal child allowance. Achieving substantial reductions in child poverty and food insecurity will require overcoming many challenges, including the current US political climate, a national history of underinvestment in social programs, a lack of political will, and a culture of structural racism.

Effect of cash incentives on tetanus toxoid vaccination among rural Nigerian women: a randomized controlled trial

Tetanus toxoid vaccination is freely available for most women in developing countries, yet maternal and neonatal tetanus are still prevalent in 13 countries, 9 of which are in sub-Saharan Africa. We evaluated whether providing cash incentives increases the uptake of tetanus toxoid vaccination among women of childbearing age in rural northern Nigeria. We randomized amounts of cash incentives to women in three groups: 5 Nigerian naira (C5), 300 naira (C300), and 800 naira (C800) (150 naira = 1 U.S. dollar). Overall, of 2,482 women from 80 villages, 1,803 (72.6%) women successfully received the vaccination (419 of 765 [54.8%] women in C5, 643 of 850 [75.7%] women in C300, and 741 of 867 [85.5%] women in C800). Women in C300 and C800 were significantly more likely to receive the vaccine than women in C5. We further found that transportation costs are one of the significant barriers that prevent women from receiving vaccination at clinics, and that cash incentives compensate for transportation costs unless such costs are large.

Program Impact Pathway Analysis Reveals Implementation Challenges that Limited the Incentive Value of Conditional Cash Transfers Aimed at Improving Maternal and Child Health Care Use in Mali

BACKGROUND

The program "Santé Nutritionnelle à Assise Communautaire à Kayes" (SNACK) in Mali aimed to improve child linear growth through a set of interventions targeted to mothers and children during pregnancy and up to the child's second birthday. Distributions of cash to mothers and/or lipid-based nutrient supplement to children 6-23 mo of age were added to SNACK to increase attendance at community health centers (CHCs).

OBJECTIVES

The aim of this study, which was embedded in a cluster-randomized impact evaluation of the program, was to assess the incentive value of the cash in relation to CHC attendance.

METHODS

We used a mixed-methods approach. We collected quantitative data on cash receipt and CHC attendance in a midline survey of mother-child pairs (n = 3443). A program impact pathway analysis guided qualitative data collection and analysis. Twelve CHCs were purposively selected in study groups that received cash. We conducted semistructured continuous observations of cash distributions in 11 CHCs (n = 22) and semistructured qualitative interviews with frontline workers (FLWs) (n = 71) and mothers (n = 22) who were purposively selected from the midline survey.

RESULTS

FLWs' knowledge of the objective and implementation plan of the cash program component was limited. A challenging physical environment and insufficient cash available for each distribution were identified as causes of irregularities in cash distributions. Most mothers mentioned having to return several times to receive their cash. Child health was identified as the main motivation to attend CHCs and cash was described as an additional benefit.

CONCLUSION

Implementation constraints related to remoteness and inaccessibility may have undermined the incentive value of the cash transfers in the SNACK program. Additional research is needed to identify interventions that not only incentivize mothers to participate but that can be implemented effectively and with high quality in challenging contexts such as rural areas of Mali.

Assessing the methodological quality of systematic reviews of interventions aimed at improving vaccination coverage using AMSTAR and ROBIS checklists

Introduction: Systematic reviews (SRs) are the backbone of evidence-based health care, but no gold standard exists to assess their methodological quality. Although the AMSTAR tool is accepted for analyzing the quality of SRs, the ROBIS instrument was recently developed. This study compared the capacity of both instruments to capture the quality of SRs of interventions for improving vaccination coverage.Methods: We conducted a comprehensive literature search in the Cochrane Library and PubMed. Two reviewers independently screened the search output, assessed study eligibility, and extracted data from eligible SRs; resolving differences through consensus. We conducted Principal Component Analysis (PCA) in Stata 14 to determine similarities and differences between AMSTAR and ROBIS.Results: A total of 2322 records were identified through the search and 75 full-text publications were assessed for eligibility, of which 57 met inclusion criteria. Using AMSTAR, we found 32%, 60% and 9% of SRs to have high, moderate and low quality, respectively. With ROBIS, we judged 74%, 14% and 12% of SRs to have low, unclear and high risk of bias. PCA showed that SRs with low risk of bias in ROBIS clustered together with SRs having high-quality in AMSTAR, and SRs with high risk of bias in ROBIS clustered with low-quality SRs in AMSTAR.Conclusions: Our findings suggest that there is an association between methodological quality and risk of bias in SRs of interventions focused on improving vaccination coverage. Therefore, either AMSTAR or ROBIS checklists can be used to evaluate methodological quality of SRs in vaccinology.

Optimising informed consent in school-based adolescent vaccination programmes in England: A multiple methods analysis

The process of obtaining informed consent for school-based adolescent immunisation provides an opportunity to engage families. However, the fact that parental consent needs to be obtained remotely adds complexity to the process and can have a detrimental effect on vaccine uptake. We conducted a multiple methods analysis to examine the practice of obtaining informed consent in adolescent immunisation programmes. This involved a thematic analysis of consent related data from 39 interviews with immunisation managers and providers collected as part of a 2017 service evaluation of the English adolescent girls' HPV vaccine programme and a descriptive statistical analysis of data from questions related to consent included in a 2017 survey of parents' and adolescents' attitudes to adolescent vaccination. The findings indicated that the non-return of consent forms was a significant logistical challenge for immunisation teams, and some were piloting opt-out consent mechanisms, increasing the proportion of adolescents consenting for their own immunisations, and introducing electronic consent. Communicating vaccine related information to parents and schools and managing uncertainties about obtaining adolescent self-consent for vaccination were the main practical challenges encountered. Survey data showed that parents and adolescents generally agreed on vaccine decisions although only 32% of parents discussed vaccination with their teenager. Parental awareness about the option for adolescents to self-consent for vaccination was limited and adolescents favoured leaving the decision-making to parents. From the interviews and variability of consent forms it was evident that health professionals were not always clear about the best way to manage the consent process. Some were also unfamiliar with self-consent processes and lacked confidence in assessing for 'Gillick competency'. Developing pathways and related interventions to improve the logistics and practice of consent in school-based adolescent immunisation programmes could help improve uptake.

Reporting quality of systematic reviews of interventions aimed at improving vaccination coverage: compliance with PRISMA guidelines

Systematic reviews have become increasingly important for informing clinical practice and policy; however, little is known about the reporting characteristics and quality of SRs of interventions to improve immunization coverage in different settings. The aim of this study was to assess the reporting quality of systematic reviews of interventions aimed at improving vaccination coverage using the recommended Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guideline.PubMed and Cochrane Library were searched to identify SRs of interventions to improve immunization coverage, indexed up to May 2016. Two authors independently screened the search output, assessed study eligibility, and extracted data from eligible SRs using a 27-item data collection form derived from PRISMA. Discrepancies in reviews assessments were resolved by discussion and consensus.A total of 57 reviews were included in this study with a mean percentage of applicable PRISMA items that were met across all studies of 66% (range 19-100%) and median compliance of 70%. 39 out of the 57 reviews were published after the release of the PRISMA statement in 2009. Highest compliance was observed in items related to the "description of rational", "description of eligibility criteria", "synthesis of results" and "provision of a general interpretation of the results" (items #3, #6, #14 and #26, respectively). Compliance was poorest in the items "describing summary of evidence" (item 24, 19%), "describing indication of review protocol and registration" (item 5, 26%) and "describing results of risk of bias across studies (item 22, 33%).The overall reporting quality of systematic reviews of interventions to improve vaccination coverage requires significant improvement. There remains a need for additional research targeted at addressing potential barriers to compliance and strategies to improve compliance with PRISMA guideline.

An Evaluation of Healthcare Use and Child Morbidity 4 Years After User Fee Removal in Rural Burkina Faso

Objectives Increasing financial access to healthcare is proposed to being essential for improving child health outcomes, but the available evidence on the relationship between increased access and health remains scarce. Four years after its launch, we evaluated the contextual effect of user fee removal intervention on the probability of an illness occurring and the likelihood of using health services among children under 5. We also explored the potential effect on the inequality in healthcare access. Methods We used a comparative cross-sectional design based upon household survey data collected years after the intervention onset in one intervention and one comparison district. Propensity scores weighting was used to achieve balance on covariates between the two districts, which was followed by logistic multilevel modelling to estimate average marginal effects (AME). Results We estimated that there was not a significant difference in the reduced probability of an illness occurring in the intervention district compared to the non-intervention district [AME 4.4; 95% CI  1.0-9.8)]. However, the probability of using health services was 17.2% (95% CI 15.0-26.6) higher among children living in the intervention district relative to the comparison district, which rose to 20.7% (95% CI 9.9-31.5) for severe illness episodes. We detected no significant differences in the probability of health services use according to socio-economic status [χ2 (5) = 12.90, p = 0.61]. Conclusions for Practice In our study, we found that user fee removal led to a significant increase in the use of health services in the longer term, but it is not adequate by itself to reduce the risk of illness occurrence and socioeconomic inequities in the use of health services.

Parental Perspectives on Financial Incentives for Adolescents: Findings From Qualitative Interviews

Background. Financial incentives are becoming more common to promote health behaviors; however, little is known about the acceptability of incentivizing adolescent health behaviors. Design. Qualitative semistructured phone interviews were conducted with 26 parents who had participated in a research study involving incentivizing a recommended, preventive adolescent health behavior (human papillomavirus vaccination). Data were coded and analyzed to identify themes. Interview domains included the following: preferred incentive distribution, ideal financial incentive amount, and general reactions to economic incentives for preventative services. Results. Parents held positive perceptions about incentives and most parents felt that the incentive could be provided directly to their adolescent child, rather than to the parent. Parents stated several benefits from incentivizing adolescent health behavior including creating an opportunity to teach their child about money, reimbursing families for time and effort, and motivating the adolescent to complete the health behavior. Topics for consideration when providing cash incentives to adolescents included the adolescent's maturity level, parents' desire to monitor adolescent's spending, and parents' want to remain involved in health care and financial decisions for their adolescent. Conclusions. This study demonstrates the potential for parental acceptance of financial incentives for adolescent health behaviors and explores areas of parental concern around financial incentives, which could help inform future health care-based incentive programs.

Determinants of delayed or incomplete diphtheria-tetanus-pertussis vaccination in parallel urban and rural birth cohorts of 30,956 infants in Tanzania

Background

Delayed vaccination increases the time infants are at risk for acquiring vaccine-preventable diseases. Factors associated with incomplete vaccination are relatively well characterized in resource-limited settings; however, few studies have assessed immunization timeliness.

Methods

We conducted a prospective cohort study examining Diphtheria-Tetanus-Pertussis (DTP) vaccination timing among newborns enrolled in a Neonatal Vitamin A supplementation trial (NEOVITA) conducted in urban Dar es Salaam (n = 11,189) and rural Morogoro Region (n = 19,767), Tanzania. We used log-binomial models to assess the relationship of demographic, socioeconomic, healthcare access, and birth characteristics with late or incomplete DTP1 and DTP3 immunization.

Results

The proportion of infants with either delayed or incomplete vaccination was similar in Dar es Salaam (DTP1 11.5% and DTP3 16.0%) and Morogoro (DTP1 9.2% and DTP3 17.3%); however, the determinants of delayed or incomplete vaccination as well as their magnitude of association differed by setting. Both maternal and paternal education were more strongly associated with vaccination status in rural Morogoro region as compared to Dar es Salaam (p-values for heterogeneity < 0.05). Infants in Morogoro who had fathers and mothers with no education had 36% (95% CI: 22–52%) and 22% (95% CI: 10–34%) increased risk of delayed or incomplete DTP3 vaccination as compared to those with primary school education, respectively. In Dar es Salaam, mothers who attended their first antenatal care (ANC) visit in the 3rd trimester had 1.55 (95% CI: 1.36–1.78) times the risk of delayed or not received vaccination as compared to those with a 2nd trimester booking, while there was no relationship in Morogoro. In rural Morogoro, infants born at home had 17% (95% CI: 8–27%) increased risk for delayed or no receipt of DTP3 vaccination. In both settings, younger maternal age and poorer households were at increased risk for delayed or incomplete vaccination.

Conclusion

We found some risk factors for delayed and incomplete vaccination were shared between urban and rural Tanzania; however, we found several context-specific risk factors as well as determinants that differed in their magnitude of risk between contexts. Immunization programs should be tailored to address context-specific barriers and enablers to improve timely and complete vaccination.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-3828-3) contains supplementary material, which is available to authorized users.

Health policy analysis of the non-implementation of HPV vaccination coverage in the pay for performance scheme in France

Background

The French National Cancer Control Plan (NCCP) launched in 2014 set the objective to improve human papillomavirus (HPV) vaccination coverage (VC). The NCCP included a measure to integrate a VC indicator in the pay for performance (P4P) scheme for general practitioners (GPs), which was not implemented. The objective of the study was to analyse the reasons for non-implementation of this measure, using the health policy analysis framework.

Methods

The policy from proposal to non-implementation of the HPV VC indicator into the P4P scheme was analysed through the actors involved, the content of the measure, the contextual factors and the processes of policy-making.

Results

The actors were the Ministry of Health (MOH) and National Cancer Institute as policy-makers, the public health insurance as an indirect target, and GPs as direct targets. The content of the policy was not evidence-informed and was not included into the NCCP preparation report. The context included vaccine hesitancy and ethical concerns from GPs in opposition with MOH. The process involved a diversity of stakeholders with a complex governance and no strict monitoring of the measure.

Conclusions

Complex vaccination policy governance associated with a non-evidence-informed policy content and an unfavourable context may have been the reasons for the policy failure.

Perceptions on using interactive voice response surveys for non-communicable disease risk factors in Uganda: a qualitative exploration

BACKGROUND

Decision-makers need up to date information on risk factors for effective prevention and control of non-communicable diseases (NCDs). Currently available surveys are infrequent and costly to implement. The objective of the study was to explore perceptions on using an interactive voice response (IVR) survey for data collection on NCD risk factors.

METHODS

Five focus group discussions (FGDs), including rural and urban, elderly and young adults, male and female groups; and eleven key informant interviews (KIIs) of researchers and NCD policy makers were conducted. Respondents were audio recorded and data were transcribed into text. Data were entered into QDA miner software for analysis. Meaningful units were generated and then merged into codes and categories. Quotes are presented highlighting findings.

RESULTS

At the individual level, age, gender, disability, past experience and being technology literate were perceived as key determinants on whether respondents would accept an IVR survey. Receiving the IVR at a time at which people are usually available to take calls increases participation. However, technological accessibility like presence of a mobile network signal and possession of mobile phones were critical for use of IVR. Participants recommended that community sensitization activities be provided, IVR be conducted at appropriate times and frequency, and that incentives may improve survey participation.

CONCLUSIONS

IVR has the potential to quickly collect data from a wide geographic scope. However, caution needs to be taken to ensure that certain categories of people are not excluded because of their location, ability, age or gender. Sensitization prior to the survey, proper timing and structured incentives could increase participation.

The State of Digital Interventions for Demand Generation in Low- and Middle-Income Countries: Considerations, Emerging Approaches, and Research Gaps

The recent introduction of digital health into generating demand for health commodities and services has provided practitioners with an expanded universe of potential tools to strengthen demand and ensure service delivery receipt. However, considerable gaps remain in our understanding of which interventions are effective, which characteristics mediate their benefit for different target populations and health domains, and what is necessary to ensure effective deployment. This paper first provides an overview of the types of digital health interventions for demand generation, including untargeted client communication, client-to-client communication, on-demand information services, personal health tracking, client financial transactions, and targeted client communication. It then provides a general overview of 118 studies published between January 1, 2010, and October 3, 2017, that used digital interventions to generate demand for health interventions. The majority (61%) of these studies used targeted client communication to provide health education or reminders to improve treatment adherence, and the most frequently (27%) studied health condition was HIV/AIDS. Intervention characteristics that have been found to have some effect on gains in demand generation include modality, directionality, tailoring, phrasing, and schedule. The paper also explores new emergent digital approaches that expand the potential effect of traditional demand generation in terms of personalization of content and services, continuity of care, and accountability tracking. Applying existing frameworks for monitoring and evaluation and reporting, research on emerging approaches will need to consider not only their feasibility but also their effectiveness in achieving demand generation outcomes. We propose a research agenda to help guide the field of digital demand generation studies and programs within a broader health systems strengthening agenda, including establishing and documenting the influence of intervention characteristics within different populations and health domains and examining the long-term effects and cost-effectiveness of digital demand generation interventions, as well as equity in access to such interventions.

Identifying health policy and systems research priorities for the sustainable development goals: social protection for health

BACKGROUND

There is an established body of evidence linking systems of social protection to health systems and health outcomes. The Sustainable Development Goals (SDGs) provide further emphasis on this linkage as necessary to achieving health and non-health goals. Existing literature on social protection and health has focused primarily on cash transfers. We sought to identify potential research priorities concerning social protection and health in low and middle-income countries, from multiple perspectives.

METHODS

Priority research questions were identified through two sources: 1) research reviews on social protection interventions and health, 2) interviews with 54 policy makers from Ministries of Health, multi-lateral or bilateral organizations, and NGOs. Data was collated and summarized using a framework analysis approach. The final refining and ranking of the questions was completed by researchers from around the globe through an online platform.

RESULTS

The overview of reviews identified 5 main categories of social protection interventions: cash transfers; financial incentives and other demand side financing interventions; food aid and nutritional interventions; parental leave; and livelihood/social welfare interventions. Policy-makers focused on the implementation and practice of social protection and health, how social protection programs could be integrated with other sectors, and how they should be monitored/evaluated. A collated list resulted in 31 priority research questions. Scale and sustainability of social protection programs ranked highest. The top 10 research questions focused heavily on design, implementation, and context, with a range of interventions that included cash transfers, social insurance, and labor market interventions.

CONCLUSIONS

There is potentially a rich field of enquiry into the linkages between health systems and social protection programs, but research within this field has focused on a few relatively narrowly defined areas. The SDGs provide an impetus to the expansion of research of this nature, with priority setting exercises such as this helping to align funder investment with researcher effort and policy-maker evidence needs.

The impact of cash transfers on social determinants of health and health inequalities in sub-Saharan Africa: a systematic review

Cash transfers (CTs) are now high on the agenda of most governments in low- and middle-income countries. Within the field of health promotion, CTs constitute a healthy public policy initiative as they have the potential to address the social determinants of health (SDoH) and health inequalities. A systematic review was conducted to synthesise the evidence on CTs' impacts on SDoH and health inequalities in sub-Saharan Africa, and to identify the barriers and facilitators of effective CTs. Twenty-one electronic databases and the websites of 14 key organizations were searched in addition to grey literature and hand searching of selected journals for quantitative and qualitative studies on CTs' impacts on SDoH and health outcomes. Out of 182 full texts screened for eligibility, 79 reports that reported findings from 53 studies were included in the final review. The studies were undertaken within 24 CTs comprising 11 unconditional CTs (UCTs), 8 conditional CTs (CCTs) and 5 combined UCTs and CCTs. The review found that CTs can be effective in tackling structural determinants of health such as financial poverty, education, household resilience, child labour, social capital and social cohesion, civic participation, and birth registration. The review further found that CTs modify intermediate determinants such as nutrition, dietary diversity, child deprivation, sexual risk behaviours, teen pregnancy and early marriage. In conjunction with their influence on SDoH, there is moderate evidence from the review that CTs impact on health and quality of life outcomes. The review also found many factors relating to intervention design features, macro-economic stability, household dynamics and community acceptance of programs that could influence the effectiveness of CTs. The external validity of the review findings is strong as the findings are largely consistent with those from Latin America. The findings thus provide useful insights to policy makers and managers and can be used to optimise CTs to reduce health inequalities.

Caregivers' compliance with referral advice: evidence from two studies introducing mRDTs into community case management of malaria in Uganda

Background

Several malaria endemic countries have implemented community health worker (CHW) programmes to increase access to populations underserved by health care. There is considerable evidence on CHW adherence to case management guidelines, however, there is limited evidence on the compliance to referral advice and the outcomes of children under-5 referred by CHWs. This analysis examined whether caregivers complied with CHWs referral advice.

Methods

Data from two cluster (village) randomised trials, one in a moderate-to-high malaria transmission setting, another in a low-transmission setting conducted between January 2010–July 2011 were analysed. CHW were trained to recognise signs and symptoms that required referral to a health centre. CHW in the intervention arm also had training on; malaria rapid diagnostic tests (mRDT) and administering artemisinin based combination therapy (ACT); CHW in the control arm were trained to treat malaria with ACTs based on fever symptoms. Caregivers’ referral forms were linked with CHW treatment forms to determine whether caregivers complied with the referral advice. Factors associated with compliance were examined with logistic regression.

Results

CHW saw 18,497 child visits in the moderate-to-high transmission setting and referred 15.2% (2815/18,497) of all visits; in the low-transmission setting, 35.0% (1135/3223) of all visits were referred. Compliance to referral was low, in both settings < 10% of caregivers complied with referral advice. In the moderate-to-high transmission setting compliance was higher if children were tested with mRDT compared to children who were not tested with mRDT. In both settings, nearly all children treated with pre-referral rectal artesunate failed to comply with referral and compliance was independently associated with factors such as health centre distance and day of referral by a CHW. In the moderate-to-high transmission setting, time of presentation, severity of referral were also associated with compliance, whilst in the low-transmission setting, compliance was low if an ACT was prescribed.

Conclusions

This analysis suggests there are several barriers to comply with CHWs referral advice by caregivers. This is concerning for children who received rectal artesunate. As CHW programmes continue scale-up, barriers to referral compliance need to be addressed to ensure a continuum of care from the community to the health centre.

Trial registration

The study was registered with ClinicalTrials.gov. Identifier NCT01048801, 13th January 2010.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3124-8) contains supplementary material, which is available to authorized users.