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Pathare S, Joag K, Kalha J, Pandit D, Krishnamoorthy S, Chauhan A, Shields-Zeeman L. Atmiyata, a community champion led psychosocial intervention for common mental disorders: A stepped wedge cluster randomized controlled trial in rural Gujarat, India. PLoS One 2023; 18:e0285385. [PMID: 37289730 PMCID: PMC10249851 DOI: 10.1371/journal.pone.0285385] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 04/11/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND While effective lay-health worker models for mental health care have been demonstrated through efficacy trials, there is limited evidence of the effectiveness of these models implemented in rural LMIC settings. AIM To evaluate the impact of a volunteer community-led intervention on reduction in depression and anxiety symptoms and improvement in functioning, and social participation among people living in rural Gujarat, India. METHODS Stepped-wedge cluster randomized controlled trial was used to assess the effectiveness of delivery of psychosocial intervention across 645 villages in Mehsana district of Gujarat, India between April 2017 and August 2019. The primary outcome was an improvement in depression and/or anxiety symptoms assessed using GHQ-12 at 3-month follow-up. Secondary outcomes were improvement in (a) depression and anxiety (Patient Health Questionnaire, (PHQ-9), Generalized Anxiety Disorder (GAD-7) & Self-Reporting Questionnaire-20 (SRQ-20); b) quality of life (EQ- 5D); c) functioning (WHO-DAS-12), and social participation (Social Participation Scale SPS). Generalized linear mixed-effects models were used to assess the independent effect of the intervention. RESULTS Out of a total of 1191 trial participants (608- intervention & 583-control), 1014 (85%) completed 3-month follow-up. In an adjusted analysis, participants in the intervention condition showed significant recovery from symptoms of depression or anxiety (OR 2.2; 95% CI 1.2 to 4.6; p<0.05) at the end of 3-months, with effects sustained at 8-month follow-up (OR 3.0; 95% CI 1.6 to 5.9). Intervention participants had improved scores on the PHQ-9 (Adjusted mean difference (AMD) -1.8; 95%CI -3.0 to -0.6), and SRQ-20 (AMD -1.7; 95%CI -2.7 to -0.6), at 3-months and PHQ-9, GAD-7, SRQ-20, EQ-5D and WHO-DAS at 8 months follow-up. CONCLUSION Findings suggest that Atmiyata had a significant effect on recovery from symptoms of depression and anxiety with sustained effects at 8-month follow-up. TRIAL REGISTRATION Trial registration details. The trial was registered prospectively with the "Clinical Trial Registry in India" (registry number: CTRI/2017/03/008139).
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Affiliation(s)
- Soumitra Pathare
- Centre for Mental Health Law and Policy, Indian Law Society, Pune, India
| | - Kaustubh Joag
- Centre for Mental Health Law and Policy, Indian Law Society, Pune, India
| | - Jasmine Kalha
- Centre for Mental Health Law and Policy, Indian Law Society, Pune, India
| | - Deepa Pandit
- Centre for Mental Health Law and Policy, Indian Law Society, Pune, India
| | | | | | - Laura Shields-Zeeman
- Trimbos Institute (Netherlands Institute for Mental Health and Addiction), Utrecht, the Netherlands
- Faculty of Interdisciplinary Social Sciences, Utrecht University, Utrecht, the Netherlands
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Baynes C, Steyn P, Soi C, Dinis A, Tembe S, Mehrtash H, Narasimhan M, Kiarie J, Sherr K. Use of implementation science to advance family planning programs in low- and middle-income countries: A systematic review. Front Glob Womens Health 2022; 3:1038297. [PMID: 36561275 PMCID: PMC9763469 DOI: 10.3389/fgwh.2022.1038297] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/11/2022] [Indexed: 12/12/2022] Open
Abstract
Objective As environmental and economic pressures converge with demands to achieve sustainability development goals, low- and middle-income countries (LMIC) increasingly require strategies to strengthen and scale-up evidence-based practices (EBP) related to family planning (FP). Implementation science (IS) can help these efforts. The purpose of this article is to elucidate patterns in the use of IS in FP research and identify ways to maximize the potential of IS to advance FP in LMIC. Design and methods We conducted a systematic review that describes how IS concepts and principles have been operationalized in LMIC FP research published from 2007-2021. We searched six databases for implementation studies of LMIC FP interventions. Our review synthesizes the characteristics of implementation strategies and research efforts used to enhance the performance of FP-related EBP in these settings, identifying gaps, strengths and lessons learned. Results Four-hundred and seventy-two studies were eligible for full-text review. Ninety-two percent of studies were carried out in one region only, whereas 8 percent were multi-country studies that took place across multiple regions. 37 percent of studies were conducted in East Africa, 21 percent in West and Central Africa, 19 percent in Southern Africa and South Asia, respectively, and fewer than 5 percent in other Asian countries, Latin America and Middle East and North Africa, respectively. Fifty-four percent were on strategies that promoted individuals' uptake of FP. Far fewer were on strategies to enhance the coverage, implementation, spread or sustainability of FP programs. Most studies used quantitative methods only and evaluated user-level outcomes over implementation outcomes. Thirty percent measured processes and outcomes of strategies, 15 percent measured changes in implementation outcomes, and 31 percent report on the effect of contextual factors. Eighteen percent reported that they were situated within decision-making processes to address locally identified implementation issues. Fourteen percent of studies described measures to involve stakeholders in the research process. Only 7 percent of studies reported that implementation was led by LMIC delivery systems or implementation partners. Conclusions IS has potential to further advance LMIC FP programs, although its impact will be limited unless its concepts and principles are incorporated more systematically. To support this, stakeholders must focus on strategies that address a wider range of implementation outcomes; adapt research designs and blend methods to evaluate outcomes and processes; and establish collaborative research efforts across implementation, policy, and research domains. Doing so will expand opportunities for learning and applying new knowledge in pragmatic research paradigms where research is embedded in usual implementation conditions and addresses critical issues such as scale up and sustainability of evidence-informed FP interventions.Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier: CRD42020199353.
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Affiliation(s)
- Colin Baynes
- Department of Global Health, University of Washington, Seattle, WA, United States,Correspondence: Colin Baynes
| | - Petrus Steyn
- Department of Sexual and Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Geneva, Switzerland
| | - Caroline Soi
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Aneth Dinis
- Department of Global Health, University of Washington, Seattle, WA, United States,The National Directorate of Public Health, Ministry of Health of Mozambique, Maputo, Mozambique
| | - Stelio Tembe
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Hedieh Mehrtash
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Manjulaa Narasimhan
- Department of Sexual and Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Geneva, Switzerland
| | - James Kiarie
- Department of Sexual and Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Geneva, Switzerland
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, United States,Department of Epidemiology, University of Washington, Seattle, WA, United States,Department of Industrial and Systems Engineering, University of Washington, Seattle, WA, United States
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Shamu S, Farirai T, Kuwanda L, Slabbert J, Guloba G, Johnson S, Khupakonke S, Masihleho N, Kamera J, Nkhwashu N. Social franchising of community-based HIV testing and linkage to HIV care and treatment services: an evaluation of a pilot study in Tshwane, South Africa. J Int AIDS Soc 2018; 21:e25216. [PMID: 30569625 PMCID: PMC6300754 DOI: 10.1002/jia2.25216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 11/14/2018] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Although HIV testing services (HTS) have been successfully task-shifted to lay counsellors, no model has tested the franchising of HTS to lay counsellors as independent small-scale business owners. This paper evaluates the effectiveness of a social franchisee (SF) HTS-managed pilot project compared to the Foundation for Professional Development (FPD) employee-managed HTS programme in testing and linking clients to care. METHODS Unemployed, formally employed or own business individuals were engaged as franchisees, trained and supported to deliver HTS services under a common brand in high HIV-prevalent communities in Tshwane district between 2016 and 2017. SFs were remunerated per-HIV test and received larger payments per-HIV-positive client linked to care. In the standard HTS, FPD employed counsellors received similar training and observed similar standards as in the SF HTS, but were remunerated through the normal payroll. We assessed the proportion of clients tested, HIV positivity, linkage to care and per-counsellor cost of HIV test and linkage to care in the two HTS groups. RESULTS The SF HTS had 19 HIV counsellors while FPD HTS employed 20. A combined total of 84,556 clients were tested by SFs (50.5%: 95% confidence interval (CI) 50.2 to 50.8)) and FPD (49.5%: 49.2 to 49.8). SFs tested more females than FPD (54.1%: 53.6 to 54.6 vs. 48%: 47.7 to 48.7). SFs identified more first-time testers than FPD (21.5%: 21.1 to 21.9 vs. 8.9%: 8.6 to 9.1). Overall, 8%: 7.9 to 8.2 tested positive with more clients testing positive in the SF (10.2%: 9.9 to 10.5) than FPD (5.9%: 5.6 to 6.1) group. The SFs identified more female HIV-positive clients (11.1%: 10.7 to 11.6) than FPD (6.5%: 6.2 to 6.9). The SFs linked fewer clients to HIV care and treatment (60.0%: 58.5 to 61.5) than FPD (80.3%: 78.7 to 81.9%). It cost four times less to conduct an HIV test using SFs ($3.90 per SF HIV test) than FPD ($13.98) and five times less to link a client to care with SFs ($62.74) than FPD ($303.13). CONCLUSIONS SF HTS was effective in identifying more clients, first-time HIV testers and more HIV-positive people, but less effective in linking clients to care than FPD HTS. The SF HTS model was cheaper than the FPD-employee model. We recommend strengthening SFs particularly their linkage to care activities.
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Affiliation(s)
- Simukai Shamu
- Foundation for Professional DevelopmentPretoriaSouth Africa
- School of Public HealthUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Thato Farirai
- Foundation for Professional DevelopmentPretoriaSouth Africa
| | | | - Jean Slabbert
- Foundation for Professional DevelopmentPretoriaSouth Africa
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Penn-Kekana L, Powell-Jackson T, Haemmerli M, Dutt V, Lange IL, Mahapatra A, Sharma G, Singh K, Singh S, Shukla V, Goodman C. Process evaluation of a social franchising model to improve maternal health: evidence from a multi-methods study in Uttar Pradesh, India. Implement Sci 2018; 13:124. [PMID: 30249294 PMCID: PMC6154932 DOI: 10.1186/s13012-018-0813-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 09/06/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A prominent strategy to engage private sector health providers in low- and middle-income countries is clinical social franchising, an organisational model that applies the principles of commercial franchising for socially beneficial goals. The Matrika programme, a multi-faceted social franchise model to improve maternal health, was implemented in three districts of Uttar Pradesh, India, between 2013 and 2016. Previous research indicates that the intervention was not effective in improving the quality and coverage of maternal health services at the population level. This paper reports findings from an independent external process evaluation, conducted alongside the impact evaluation, with the aim of explaining the impact findings. It focuses on the main component of the programme, the "Sky" social franchise. METHODS We first developed a theory of change, mapping the key mechanisms through which the programme was hypothesised to have impact. We then undertook a multi-methods study, drawing on both quantitative and qualitative primary data from a wide range of sources to assess the extent of implementation and to understand mechanisms of impact and the role of contextual factors. We analysed the quantitative data descriptively to generate indicators of implementation. We undertook a thematic analysis of the qualitative data before holding reflective meetings to triangulate across data sources, synthesise evidence, and identify the main findings. Finally, we used the framework provided by the theory of change to organise and interpret our findings. RESULTS We report six key findings. First, despite the franchisor achieving its recruitment targets, the competitive nature of the market for antenatal care meant social franchise providers achieved very low market share. Second, all Sky health providers were branded but community awareness of the franchise remained low. Third, using lower-level providers and community health volunteers to encourage women to attend franchised antenatal care services was ineffective. Fourth, referral linkages were not sufficiently strong between antenatal care providers in the franchise network and delivery care providers. Fifth, Sky health providers had better knowledge and self-reported practice than comparable health providers, but overall, the evidence pointed to poor quality of care across the board. Finally, telemedicine was perceived by clients as an attractive feature, but problems in the implementation of the technology meant its effect on quality of antenatal care was likely limited. CONCLUSIONS These findings point towards the importance of designing programmes based on a strong theory of change, understanding market conditions and what patients value, and rigorously testing new technologies. The design of future social franchising programmes should take account of the challenges documented in this and other evaluations.
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Affiliation(s)
- Loveday Penn-Kekana
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | - Timothy Powell-Jackson
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | - Manon Haemmerli
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | - Varun Dutt
- Sambodhi Research and Communications, Noida, Uttar Pradesh India
| | - Isabelle L. Lange
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | | | - Gaurav Sharma
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | - Kultar Singh
- Sambodhi Research and Communications, Noida, Uttar Pradesh India
| | | | - Vasudha Shukla
- Sambodhi Research and Communications, Noida, Uttar Pradesh India
| | - Catherine Goodman
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
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Powell-Jackson T, Fabbri C, Dutt V, Tougher S, Singh K. Effect and cost-effectiveness of educating mothers about childhood DPT vaccination on immunisation uptake, knowledge, and perceptions in Uttar Pradesh, India: A randomised controlled trial. PLoS Med 2018; 15:e1002519. [PMID: 29509769 PMCID: PMC5839535 DOI: 10.1371/journal.pmed.1002519] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 01/26/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND To assess the effect of health information on immunisation uptake in rural India, we conducted an individually randomised controlled trial of health information messages targeting the mothers of unvaccinated or incompletely vaccinated children through home visits in rural Uttar Pradesh, India. METHODS AND FINDINGS The study tested a brief intervention that provided mothers face-to-face with information on the benefits of the tetanus vaccine. Participants were 722 mothers of children aged 0-36 months who had not received 3 doses of diphtheria-pertussis-tetanus (DPT) vaccine (DPT3). Mothers were randomly assigned in a ratio of 1:1:1 to 1 of 3 study arms: mothers in the first treatment group received information framed as a gain (e.g., the child is less likely to get tetanus and more likely to be healthy if vaccinated), mothers in the second treatment group received information framed in terms of a loss (e.g., the child is more likely to get tetanus and suffer ill health if not vaccinated), and the third arm acted as a control group, with no information given to the mother. Surveys were conducted at baseline (September 2015) and after the intervention (April 2016). The primary outcome was the proportion of children who had received DPT3 measured after 7 months of follow-up. The analysis was by intention to treat. A total of 16 (2.2%) participants were lost to follow-up. The coverage of DPT3 was 28% in the control group and 43% in the pooled information groups, giving a risk difference of 15 percentage points (95% CI: 7% to 22%, p < 0.001) and a relative risk of 1.52 (95% CI: 1.2 to 1.9, p < 0.001). The information intervention increased the rate of measles vaccination by 22 percentage points (risk difference: 22%, 95% CI: 14% to 30%, p < 0.001; relative risk: 1.53, 95% CI: 1.29 to 1.80) and the rate of full immunisation by 14 percentage points (risk difference: 14%, 95% CI: 8% to 21%, p < 0.001; relative risk: 1.72, 95% CI: 1.29 to 2.29). It had a large positive effect on knowledge of the causes, symptoms, and prevention of tetanus but no effect on perceptions of vaccine efficacy. There was no difference in the proportion of children with DPT3 between the group that received information framed as a loss and the group that received information framed as a gain (risk difference: 4%, 95% CI: -5% to 13%; p = 0.352; relative risk: 1.11, 95% CI: 0.90 to 1.36). The cost per disability-adjusted life year averted of providing information was US$186, making the intervention highly cost-effective with respect to the WHO-recommended threshold of once the gross domestic product per capita (US$793 in the case of Uttar Pradesh). Key study limitations include the modest sample size for this trial, limiting power to detect small differences in the framing of information, and the potential for contamination among households. CONCLUSIONS Providing mothers of unvaccinated/incompletely vaccinated children with information on tetanus and the benefits of DPT vaccination substantially increased immunisation coverage and was highly cost-effective. The framing of the health information message did not appear to matter. TRIAL REGISTRATION The trial is registered with ISRCTN, number ISRCTN84560580.
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Affiliation(s)
- Timothy Powell-Jackson
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Camilla Fabbri
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Varun Dutt
- Sambodhi Research and Communications, Noida, Uttar Pradesh, India
| | - Sarah Tougher
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Kultar Singh
- Sambodhi Research and Communications, Noida, Uttar Pradesh, India
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Effect of a multifaceted social franchising model on quality and coverage of maternal, newborn, and reproductive health-care services in Uttar Pradesh, India: a quasi-experimental study. LANCET GLOBAL HEALTH 2018; 6:e211-e221. [DOI: 10.1016/s2214-109x(17)30454-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 10/26/2017] [Accepted: 11/10/2017] [Indexed: 11/23/2022]
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Sharma G, Powell-Jackson T, Haldar K, Bradley J, Filippi V. Quality of routine essential care during childbirth: clinical observations of uncomplicated births in Uttar Pradesh, India. Bull World Health Organ 2017; 95:419-429. [PMID: 28603308 PMCID: PMC5463813 DOI: 10.2471/blt.16.179291] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 12/30/2016] [Accepted: 01/03/2017] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To evaluate the quality of essential care during normal labour and childbirth in maternity facilities in Uttar Pradesh, India. METHODS Between 26 May and 8 July 2015, we used clinical observations to assess care provision for 275 mother-neonate pairs at 26 hospitals. Data on 42 items of care were collected, summarized into 17 clinical practices and three aggregate scores and then weighted to obtain population-based estimates. We examined unadjusted differences in quality between the public and private facilities. Multilevel linear mixed-effects models were used to adjust for birth attendant, facility and maternal characteristics. FINDINGS The quality of care we observed was generally poor in both private and public facilities; the mean percentage of essential clinical care practices completed for each woman was 35.7%. Weighted estimates indicate that unqualified personnel provided care for 73.0% and 27.0% of the mother-neonate pairs in public and private facilities, respectively. Obstetric, neonatal and overall care at birth appeared better in the private facilities than in the public ones. In the adjusted analysis, the score for overall quality of care in private facilities was found to be six percentage points higher than the corresponding score for public facilities. CONCLUSION In 2015, the personnel providing labour and childbirth care in maternity facilities were often unqualified and adherence to care protocols was generally poor. Initiatives to measure and improve the quality of care during labour and childbirth need to be developed in the private and public facilities in Uttar Pradesh.
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Affiliation(s)
- Gaurav Sharma
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, England
| | | | - Kaveri Haldar
- Sambodhi Research and Communications, New Delhi, India
| | - John Bradley
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, England
| | - Véronique Filippi
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, England
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Mohanan M, Giardili S, Das V, Rabin TL, Raj SS, Schwartz JI, Seth A, Goldhaber-Fiebert JD, Miller G, Vera-Hernández M. Evaluation of a social franchising and telemedicine programme and the care provided for childhood diarrhoea and pneumonia, Bihar, India. Bull World Health Organ 2017; 95:343-352E. [PMID: 28479635 PMCID: PMC5418816 DOI: 10.2471/blt.16.179556] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 12/20/2016] [Accepted: 01/31/2017] [Indexed: 11/27/2022] Open
Abstract
Objective To evaluate the impact on the quality of the care provided for childhood diarrhoea and pneumonia in Bihar, India, of a large-scale, social franchising and telemedicine programme – the World Health Partners’ Sky Program. Methods We investigated changes associated with the programme in the knowledge and performance of health-care providers by carrying out 810 assessments in a representative sample of providers in areas where the programme was and was not implemented. Providers were assessed using hypothetical patient vignettes and the standardized patient method both before and after programme implementation, in 2011 and 2014, respectively. Differences in providers’ performance between implementation and nonimplementation areas were assessed using multivariate difference-in-difference linear regression models. Findings The programme did not significantly improve health-care providers’ knowledge or performance with regard to childhood diarrhoea or pneumonia in Bihar. There was a persistent large gap between knowledge of appropriate care and the care actually delivered. Conclusion Social franchising has received attention globally as a model for delivering high-quality care in rural areas in the developing world but supporting data are scarce. Our findings emphasize the need for sound empirical evidence before social franchising programmes are scaled up.
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Affiliation(s)
- Manoj Mohanan
- Sanford School of Public Policy, Duke University, 302 Towerview Drive, 128 Rubenstein Hall, Durham, North Carolina, NC 27708, United States of America (USA)
| | - Soledad Giardili
- Department of Economics, Queen Mary University of London, London, England
| | - Veena Das
- Department of Anthropology, Johns Hopkins University, Baltimore, USA
| | - Tracy L Rabin
- Department of Internal Medicine, Yale University School of Medicine, New Haven, USA
| | - Sunil S Raj
- Indian Institute of Public Health, New Delhi, India
| | - Jeremy I Schwartz
- Department of Internal Medicine, Yale University School of Medicine, New Haven, USA
| | - Aparna Seth
- Sambodhi Research and Communications Pvt. Ltd., New Delhi, India
| | - Jeremy D Goldhaber-Fiebert
- Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, USA
| | - Grant Miller
- Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, USA
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Zhou H, Taber C, Arcona S, Li Y. Difference-in-Differences Method in Comparative Effectiveness Research: Utility with Unbalanced Groups. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2016; 14:419-429. [PMID: 27371369 PMCID: PMC4937082 DOI: 10.1007/s40258-016-0249-y] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
BACKGROUND Comparative effectiveness research (CER) often includes observational studies utilizing administrative data. Multiple conditioning methods can be used for CER to adjust for group differences, including difference-in-differences (DiD) estimation. OBJECTIVE This study presents DiD and demonstrates how to apply this conditioning method to estimate treatment outcomes in the CER setting by utilizing the MarketScan® Databases for multiple sclerosis (MS) patients receiving different therapies. METHODS The sample included 6762 patients, with 363 in the Test Cohort [glatiramer acetate (GA) switched to fingolimod (FTY)] and 6399 in the Control Cohort (GA only, no switch) from a US administrative claims database. A trend analysis was conducted to rule out concerns regarding regression to the mean and to compare relapse rates among treatment cohorts. DiD analysis was used to enable comparisons among the Test and Control Cohorts. Logistic regression was used to estimate the probability of relapse after switching from GA to FTY, and to compare group differences in the pre- and post-index periods. RESULTS Crude DiD analysis showed that in the pre-index period more patients in the Test Cohort experienced an MS relapse and had a higher mean number of relapses than in the Control Cohort. During the pre-index period, numeric and relative data for MS relapses in patients in the Test Cohort were significantly higher than in the Control Cohort, while no significant between-group differences emerged during the post-index period. Generalized linear modeling with DiD regression estimation showed that the mean number of MS relapses decreased significantly in the post-index period among patients in the Test Cohort compared with patients in the Control Cohort. CONCLUSION In this study, an MS population was utilized to demonstrate how DiD can be applied to estimate treatment effects in a heterogeneous population, where the Test and Control Cohorts varied greatly. The results show that DiD offers a robust method for comparing diverse cohorts when other risk-adjustment methods may not be adequate.
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Affiliation(s)
- Huanxue Zhou
- KMK Consulting, Inc., 7 North Tower, 23 Headquarters Plaza, Morristown, NJ, 07960, USA
| | - Christopher Taber
- Department of Economics, University of Wisconsin, 1180 Observatory Drive, Madison, WI, 53706, USA
| | - Steve Arcona
- Outcomes Research Methods and Analytics, US Health Economics and Outcome Research, Novartis Pharmaceuticals Corporation, One Health Plaza 135/584, East Hanover, NJ, 07936-1080, USA
| | - Yunfeng Li
- Outcomes Research Methods and Analytics, US Health Economics and Outcome Research, Novartis Pharmaceuticals Corporation, One Health Plaza 135/584, East Hanover, NJ, 07936-1080, USA.
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Powell-Jackson T, Pereira SK, Dutt V, Tougher S, Haldar K, Kumar P. Cash transfers, maternal depression and emotional well-being: Quasi-experimental evidence from India's Janani Suraksha Yojana programme. Soc Sci Med 2016; 162:210-8. [PMID: 27387651 DOI: 10.1016/j.socscimed.2016.06.034] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 05/31/2016] [Accepted: 06/11/2016] [Indexed: 11/17/2022]
Abstract
Maternal depression is an important public health concern. We investigated whether a national-scale initiative that provides cash transfers to women giving birth in government health facilities, the Janani Suraksha Yojana (JSY), reduced maternal depression in India's largest state, Uttar Pradesh. Using primary data on 1695 women collected in early 2015, our quasi-experimental design exploited the fact that some women did not receive the JSY cash due to administrative problems in its disbursement - reasons that are unlikely to be correlated with determinants of maternal depression. We found that receipt of the cash was associated with an 8.5% reduction in the continuous measure of maternal depression and a 36% reduction in moderate depression. There was no evidence of an association with measures of emotional well-being, namely happiness and worry. The results suggest that the JSY had a clinically meaningful effect in reducing the burden of maternal depression, possibly by lessening the financial strain of delivery care. They contribute to the evidence that financial incentive schemes may have public health benefits beyond improving uptake of targeted health services.
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Affiliation(s)
- Timothy Powell-Jackson
- Department of Global Health and Development, Faculty of Public Health and Policy, London School Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK.
| | - Shreya K Pereira
- Department of Global Health and Development, Faculty of Public Health and Policy, London School Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Varun Dutt
- Sambodhi Research and Communications Limited, C-162, Sector-2, Noida, Uttar Pradesh, India
| | - Sarah Tougher
- Department of Global Health and Development, Faculty of Public Health and Policy, London School Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Kaveri Haldar
- Sambodhi Research and Communications Limited, C-162, Sector-2, Noida, Uttar Pradesh, India
| | - Paresh Kumar
- Sambodhi Research and Communications Limited, C-162, Sector-2, Noida, Uttar Pradesh, India
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