Community-level interventions for improving access to food in low- and middle-income countries.

BACKGROUND: After decades of decline since 2005, the global prevalence of undernourishment reverted and since 2015 has increased to levels seen in 2010 to 2011. The prevalence is highest in low- and middle-income countries (LMICs), especially Africa and Asia. Food insecurity and associated undernutrition detrimentally affect health and socioeconomic development in the short and long term, for individuals, including children, and societies. Physical and economic access to food is crucial to ensure food security. Community-level interventions could be important to increase access to food in LMICs. OBJECTIVES: To determine the effects of community-level interventions that aim to improve access to nutritious food in LMICs, for both the whole community and for disadvantaged or at-risk individuals or groups within a community, such as infants, children and women; elderly, poor or unemployed people; or minority groups. SEARCH METHODS: We searched for relevant studies in 16 electronic databases, including trial registries, from 1980 to September 2019, and updated the searches in six key databases in February 2020. We applied no language or publication status limits. SELECTION CRITERIA: We included randomised controlled trials (RCTs), cluster randomised controlled trials (cRCTs) and prospective controlled studies (PCS). All population groups, adults and children, living in communities in LMICs exposed to community-level interventions aiming to improve food access were eligible for inclusion. We excluded studies that only included participants with specific diseases or conditions (e.g. severely malnourished children). Eligible interventions were broadly categorised into those that improved buying power (e.g. create income-generation opportunities, cash transfer schemes); addressed food prices (e.g. vouchers and subsidies); addressed infrastructure and transport that affected physical access to food outlets; addressed the social environment and provided social support (e.g. social support from family, neighbours or government). DATA COLLECTION AND ANALYSIS: Two authors independently screened titles and abstracts, and full texts of potentially eligible records, against the inclusion criteria. Disagreements were resolved through discussion or arbitration by a third author, if necessary. For each included study, two authors independently extracted data and a third author arbitrated disagreements. However, the outcome data were extracted by one author and checked by a biostatistician. We assessed risk of bias for all studies using the Effective Practice and Organization of Care (EPOC) risk of bias tool for studies with a separate control group. We conducted meta-analyses if there was a minimum of two studies for interventions within the same category, reporting the same outcome measure and these were sufficiently homogeneous. Where we were able to meta-analyse, we used the random-effects model to incorporate any existing heterogeneity. Where we were unable to conduct meta-analyses, we synthesised using vote counting based on effect direction. MAIN RESULTS: We included 59 studies, including 214 to 169,485 participants, and 300 to 124, 644 households, mostly from Africa and Latin America, addressing the following six intervention types (three studies assessed two different types of interventions). Interventions that improved buying power: Unconditional cash transfers (UCTs) (16 cRCTs, two RCTs, three PCSs): we found high-certainty evidence that UCTs improve food security and make little or no difference to cognitive function and development and low-certainty evidence that UCTs may increase dietary diversity and may reduce stunting. The evidence was very uncertain about the effects of UCTs on the proportion of household expenditure on food, and on wasting. Regarding adverse outcomes, evidence from one trial indicates that UCTs reduce the proportion of infants who are overweight. Conditional cash transfers (CCTs) (nine cRCTs, five PCSs): we found high-certainty evidence that CCTs result in little to no difference in the proportion of household expenditure on food and that they slightly improve cognitive function in children; moderate-certainty evidence that CCTs probably slightly improve dietary diversity and low-certainty evidence that they may make little to no difference to stunting or wasting. Evidence on adverse outcomes (two PCSs) shows that CCTs make no difference to the proportion of overweight children. Income generation interventions (six cRCTs, 11 PCSs): we found moderate-certainty evidence that income generation interventions probably make little or no difference to stunting or wasting; and low-certainty evidence that they may result in little to no difference to food security or that they may improve dietary diversity in children, but not for households. Interventions that addressed food prices: Food vouchers (three cRCTs, one RCT): we found moderate-certainty evidence that food vouchers probably reduce stunting; and low-certainty evidence that that they may improve dietary diversity slightly, and may result in little to no difference in wasting. Food and nutrition subsidies (one cRCT, three PCSs): we found low-certainty evidence that food and nutrition subsidies may improve dietary diversity among school children. The evidence is very uncertain about the effects on household expenditure on healthy foods as a proportion of total expenditure on food (very low-certainty evidence). Interventions that addressed the social environment: Social support interventions (one cRCT, one PCS): we found moderate-certainty evidence that community grants probably make little or no difference to wasting; low-certainty evidence that they may make little or no difference to stunting. The evidence is very uncertain about the effects of village savings and loans on food security and dietary diversity. None of the included studies addressed the intervention category of infrastructure changes. In addition, none of the studies reported on one of the primary outcomes of this review, namely prevalence of undernourishment. AUTHORS' CONCLUSIONS: The body of evidence indicates that UCTs can improve food security. Income generation interventions do not seem to make a difference for food security, but the evidence is unclear for the other interventions. CCTs, UCTs, interventions that help generate income, interventions that help minimise impact of food prices through food vouchers and subsidies can potentially improve dietary diversity. UCTs and food vouchers may have a potential impact on reducing stunting, but CCTs, income generation interventions or social environment interventions do not seem to make a difference on wasting or stunting. CCTs seem to positively impact cognitive function and development, but not UCTs, which may be due to school attendance, healthcare visits and other conditionalities associated with CCTs.

Barriers to voluntary participation in sport for children: a systematic review.

BACKGROUND: Numerous studies have detailed the physical health benefits of children's participation in sport and a growing body of research also highlights the benefits for mental health. Children who participate in sport have also been shown to be advantaged academically. However, despite the benefits there is evidence that children are leading increasingly sedentary lifestyles and are at greater risk of chronic disease than those with active lifestyles. Sport provides an important means for children to achieve their recommended amount of daily physical activity. This systematic review asks 'what are those barriers to children's participation in sport?' METHODS: Literature searches were carried out in June 2015 using; EMBASE, Medline, CINAHL and SportDiscus using the search terms barrier*, stop*, prevent*, participat*, taking part, Sports/, sport*, "physical education", PE, child*, young person*, adolescen*. These were supplemented with hand searches. A total of 3434 records were identified of which 22 were suitable for inclusion in the review, two additional studies were identified from Google Scholar in November 2016. Both qualitative and quantitative studies were included. Study's included in the review assessed children up to 18 years of age. Study quality was assessed using Critical Appraisal Skills Programme (CASP) tools. RESULTS: Studies took place in the school environment (n = 14), sports club (n = 1), community setting (n = 8) and adolescent care setting (n = 1). Frequently reported barriers across quantitative studies were 'time' (n = 4), 'cost' (n = 3), 'opportunity/accessibility' (n = 3) and 'friends' (n = 2). Frequently reported barriers across qualitative studies were 'time' (n = 6), 'cost' (n = 5), 'not being good at sport' (n = 6) and 'fear of being judged/embarrassed' (n = 6). CONCLUSION: Policy makers, parents and teachers should all be aware that 'cost' and 'time' are key barriers to participation in sport. More local sports opportunities are needed where costs are reduced. Schools and local clubs could better work together to provide more affordable local opportunities to increase children's participation in sport.

Sustainability in Health care by Allocating Resources Effectively (SHARE) 11: reporting outcomes of an evidence-driven approach to disinvestment in a local healthcare setting.

BACKGROUND: This is the final paper in a thematic series reporting a program of Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. The SHARE Program was established to explore a systematic, integrated, evidence-based organisation-wide approach to disinvestment in a large Australian health service network. This paper summarises the findings, discusses the contribution of the SHARE Program to the body of knowledge and understanding of disinvestment in the local healthcare setting, and considers implications for policy, practice and research. DISCUSSION: The SHARE program was conducted in three phases. Phase One was undertaken to understand concepts and practices related to disinvestment and the implications for a local health service and, based on this information, to identify potential settings and methods for decision-making about disinvestment. The aim of Phase Two was to implement and evaluate the proposed methods to determine which were sustainable, effective and appropriate in a local health service. A review of the current literature incorporating the SHARE findings was conducted in Phase Three to contribute to the understanding of systematic approaches to disinvestment in the local healthcare context. SHARE differed from many other published examples of disinvestment in several ways: by seeking to identify and implement disinvestment opportunities within organisational infrastructure rather than as standalone projects; considering disinvestment in the context of all resource allocation decisions rather than in isolation; including allocation of non-monetary resources as well as financial decisions; and focusing on effective use of limited resources to optimise healthcare outcomes. CONCLUSION: The SHARE findings provide a rich source of new information about local health service decision-making, in a level of detail not previously reported, to inform others in similar situations. Multiple innovations related to disinvestment were found to be acceptable and feasible in the local setting. Factors influencing decision-making, implementation processes and final outcomes were identified; and methods for further exploration, or avoidance, in attempting disinvestment in this context are proposed based on these findings. The settings, frameworks, models, methods and tools arising from the SHARE findings have potential to enhance health care and patient outcomes.

Consumer-Centric Care: Latest Buzzword or New Reality?

With the industry in flux as federal healthcare reform legislation debates continue, leaders are preparing for what the post-Affordable Care Act world might look like. Predictions include patients assuming more responsibility for healthcare costs and therefore behaving like consumers, including choosing providers based on perceived value. What actions should chief nurse executives take to ensure the nursing enterprise responds to rising consumerism in healthcare?

Micro-Credit and Community Wildlife Management: Complementary Strategies to Improve Conservation Outcomes in Serengeti National Park, Tanzania.

Community wildlife management programs in African protected areas aim to deliver livelihood and social benefits to local communities in order to bolster support for their conservation objectives. Most of these benefits are delivered at the community level. However, many local people are also seeking more individual or household-level livelihood benefits from community wildlife management programs because it is at this level that many of the costs of protected area conservation are borne. Because community wildlife management delivers few benefits at this level, support for their conservation objectives amongst local people often declines. The study investigated the implications of this for reducing poaching in Serengeti National Park, Tanzania. Three community wildlife management initiatives undertaken by Park management were compared with regard to their capacity to deliver the individual and household-level benefits sought by local people: community conservation services, wildlife management areas and community conservation banks. Interviews were carried out with poachers and local people from four villages in the Western Serengeti including members of village conservation banks, as well as a number of key informants. The results suggest that community conservation banks could, as a complementary strategy to existing community wildlife management programs, potentially provide a more effective means of reducing poaching in African protected areas than community wildlife management programs alone.

An evaluation of the social dimensions in public participation in rural domestic waste source-separated collection in Guilin, China.

A comprehensive evaluation of public participation in rural domestic waste (RDW) source-separated collection in China was carried out within a social-dimension framework, specifically in terms of public perception, awareness, attitude, and willingness to pay for RDW management. The evaluation was based on a case study conducted in Guilin, Guangxi Zhuang Autonomous Region, China, which is a representative of most inland areas of the country with a GDP around the national average. It was found that unlike urban residents, rural residents maintained a high rate of recycling, but in a spontaneous manner; they paid more attention to issues closely related to their daily lives, but less attention to those at the general level; their awareness of RDW source-separated collection was low and different age groups showed significantly different preferences regarding the sources of knowledge acquirement. Among potential information sources, village committees played a very important role in knowledge dissemination; for the respondents' pro-environmental attitudes, the influencing factor of "lack of legislation/policy" was considered to be significant; mandatory charges for waste collection and disposal had a high rate of acceptance among rural residents; and high monthly incomes had a positive correlation with both public pro-environmental attitudes and public willingness to pay for extra charges levied by RDW management. These observations imply that, for decision-makers in the short term, implementing mandatory RDW source-separated collection programs with enforced guidelines and economic compensation is more effective, while in the long run, promoting pro-environmental education to rural residents is more important.

PBMs skip insurers in new direct-to-consumer deals.

"The healthcare supply chain is very complicated, and it's wild that in the USA you can pay hundreds of dollars and assume you're getting the lowest negotiated price, even though that's not the case.

Consumer Cost-Sharing in Marketplace vs. Employer Health Insurance Plans, 2015.

Using data from 49 states and Washington, D.C., we analyzed changes in cost-sharing under health plans offered to individuals and families through state and federal exchanges from 2014 to 2015. We examined eight vehicles for cost-sharing, including deductibles, copayments, coinsurance, and out-of-pocket limits, and compared findings with cost-sharing under employer-based insurance. We found cost-sharing under marketplace plans remained essentially unchanged from 2014 to 2015. Stable premiums during that period do not reflect greater costs borne by enrollees. Further, 56 percent of enrollees in marketplace plans attained cost-sharing reductions in 2015. However, for people without cost-sharing reductions, average copayments, deductibles, and out-of-pocket limits under catastrophic, bronze, and silver plans are considerably higher than under employer-based plans on average, while cost-sharing under gold plans is similar employer-based plans on average. Marketplace plans are far more likely than employer-based plans to require enrollees to meet deductibles before they receive coverage for prescription drugs.

Do disabled elderly Medicare beneficiaries with major depression make less use of a consumer-directed home care voucher benefit?

Older adults with major depression may underutilize consumer-directed long-term care. Systematic underutilization would create disparities in outcomes, undermining program effectiveness. The Medicare Primary and Consumer-Directed Care Demonstration included a consumer-directed indemnity benefit that paid for goods and services not financed by traditional Medicare. Overall and for most categories of goods and services there was little difference in use and expenditures between those with and without major depression. However, among those using the benefit to hire in-home workers, arguably the most important consumer-directed purchase, average spending for workers was about 30% lower for depressed persons. While our findings are generally reassuring for public policy, future research is needed to verify that major depression is associated with less spending on in-home workers.

Selective Special Drive (SSD): an effective tool to promote new case detection through community participation--an experience during 2005-2010 in Mumbai slums.

As per the Guidelines of National Leprosy Eradication Programme (NLEP), Government of India, new case detection (NCD) in leprosy is to be promoted by voluntary reporting through Information, Education and Communication (IEC). Accordingly, in addition to the routine IEC activities, Maharashtra Lokahita Seva Mandal (MLSM) carried out Selective Special Drive (SSD) in slum pockets in Mumbai since 2005-06. The SSD methodology prescribed under Leprosy Elimination Action Program (LEAP) of ALERT-INDIA was adopted which included selection of slum pockets, identification and training of Community Volunteers (CVs), door-to-door focused IEC through CVs using standard IEC material and referral of voluntarily reported suspected cases to nearby Health Posts under General Health Services or to Leprosy Referral Centre (LRC) established through MLSM for diagnosis and treatment. During the years, 2005-06 to 2009-10, MLSM conducted five annual SSDs in 53 slum pockets having 187,391 house-holds with the total enumerated population of 882,114 of which 563,040 (63.8%) could be covered through house-to-house IEC by 772 trained CVs/CHVs. As a result, 108 new cases (PB - 79 and MB - 29) were detected with the NCD rate ranged between 13/100,000 and 34/100,000 which is much higher than the reported NCDR in Mumbai (i.e. 6/100,000). Of the new MB cases 6 were lepromatous leprosy cases. Voluntary reporting of new cases was also found to be enhanced during the subsequent period following SSD. SSD activity encourages intensified IEC with community participation and integrates General Health Services resulting into better voluntary reporting of new cases. It is, therefore recommended that the SSD with the methodology prescribed under LEAP may be considered for incorporation in NLEP.

The federal medical loss ratio rule: implications for consumers in year 2.

For the past two years, the Affordable Care Act has required health insurers to pay out a minimum percentage of premiums in the form of medical claims or quality improvement expenses--known as a medical loss ratio (MLR). Insurers with MLRs below the minimum must rebate the difference to consumers. This issue brief finds that total rebates for 2012 were $513 million, half the amount paid out in 2011, indicating greater compliance with the MLR rule. Spending on quality improvement remained low, at less than 1 percent of premiums. Insurers continued to reduce their administrative and sales costs, such as brokers' fees, without increasing profit margins, for a total reduction in overhead of $1.4 billion. In the first two years under this regulation, total consumer benefits related to the medical loss ratio--both rebates and reduced overhead--amounted to more than $3 billion.

The impact of patient and public involvement on UK NHS health care: a systematic review.

PURPOSE: Patient and public involvement (PPI) has become an integral part of health care with its emphasis on including and empowering individuals and communities in the shaping of health and social care services. The aims of this study were to identify the impact of PPI on UK National Health Service (NHS) healthcare services and to identify the economic cost. It also examined how PPI is being defined, theorized and conceptualized, and how the impact of PPI is captured or measured. DATA SOURCES: Seventeen key online databases and websites were searched, e.g. Medline and the King's Fund. STUDY SELECTION: UK studies from 1997 to 2009 which included service user involvement in NHS healthcare services. Date extraction Key themes were identified and a narrative analysis was undertaken. RESULTS OF DATA SYNTHESIS: The review indicates that PPI has a range of impacts on healthcare services. There is little evidence of any economic analysis of the costs involved. A key limitation of the PPI evidence base is the poor quality of reporting impact. Few studies define PPI, there is little theoretical underpinning or conceptualization reported, there is an absence of robust measurement of impact and descriptive evidence lacked detail. CONCLUSION: There is a need for significant development of the PPI evidence base particularly around guidance for the reporting of user activity and impact. The evidence base needs to be significantly strengthened to ensure the full impact of involving service users in NHS healthcare services is fully understood.

Designing health insurance exchanges: key decisions.

A cornerstone of health care reform is the establishment of state-level insurance exchanges where individuals and small businesses can purchase health insurance in an online marketplace. States are required to develop an exchange by 2014, or participate in a federal one. The exchanges will help people without employer-sponsored insurance find and choose a health plan to meet their needs. This Issue Brief reviews the experience of Massachusetts in developing a health insurance exchange and offers policymakers guidance on key features and likely consumer responses.

Livelihood sustainability and community based co-management of forest resources in China: changes and improvement.

Community-based co-management (CBCM) has been applied in some communities near natural reserves in China. This paper uses Gansu Baishuijiang National Natural Reserve in China as a case study for livelihood improvements under CBCM projects. We demonstrate change from 2006 to 2010 in five classes of livelihood capital (social, human, natural, physical and financial capitals), illustrating the effectiveness of CBCM projects. Specifically, there are increases in mean family income and improvements in forest conservation. However, some problems in the design and implementation of CBCM projects remain, including the complicated social and political relationship between government and community, social exclusion and uneven application of benefits within communities, and the lack of integration of indigenous cultures and traditional beliefs. Attention for special groups in community and improving the design of CBCM Projects. Study shows that under the cooperation of government, CBCM projects and local community residents, the harmonious development of sustainable livelihood improvement and forest resources conservation will be an important trend in the future.

Participatory impact assessment of soil and water conservation scenarios in Oum Zessar watershed, Tunisia.

Environmental threats and progressive degradation of natural resources are considered critical impediments to sustainable development. This paper reports on a participatory impact assessment of alternative soil and water conservation (SWC) scenarios in the Oum Zessar watershed, Tunisia. The first objective was to assess the impact of three SWC scenarios on key social, economic and environmental land use functions. The second objective was to test and evaluate the applicability of the 'Framework for Participatory Impact Assessment (FoPIA)' for assessing scenario impacts in the context of a developing country, in this case Tunisia. The assessed scenarios included: the originally planned SWC policy implementation at 85 % coverage of arable land of the watershed, the current implementation (70 %), and a hypothetical expansion of SWC measures to the entire watershed (100 %). Our results suggest that implementation of the SWC policy at 100 % coverage of arable land achieves the maximum socioeconomic benefit. However, if stakeholders' preferences regarding land use functions are taken into account, and considering the fact that the implementation of SWC measures also implies some negative changes to traditional landscapes and the natural system, SWC implementation at 85 % coverage of arable land might be preferable. The FoPIA approved to be a useful tool for conducting a holistic sustainability impact assessment of SWC scenarios and for studying the most intriguing sustainability problems while providing possible recommendations towards sustainable development. We conclude that participatory impact assessment contributes to an enhanced regional understanding of key linkages between policy effects and sustainable development, which provides the foundation for improved policy decision making.

Patient Protection and Affordable Care Act; standards related to reinsurance, risk corridors, and risk adjustment. Final rule.

This final rule implements standards for States related to reinsurance and risk adjustment, and for health insurance issuers related to reinsurance, risk corridors, and risk adjustment consistent with title I of the Patient Protection and Affordable Care Act as amended by the Health Care and Education Reconciliation Act of 2010, referred to collectively as the Affordable Care Act. These programs will mitigate the impact of potential adverse selection and stabilize premiums in the individual and small group markets as insurance reforms and the Affordable Insurance Exchanges ("Exchanges") are implemented, starting in 2014. The transitional State-based reinsurance program serves to reduce uncertainty by sharing risk in the individual market through making payments for high claims costs for enrollees. The temporary Federally administered risk corridors program serves to protect against uncertainty in rate setting by qualified health plans sharing risk in losses and gains with the Federal government. The permanent State-based risk adjustment program provides payments to health insurance issuers that disproportionately attract high-risk populations (such as individuals with chronic conditions).

Medicaid program; eligibility changes under the Affordable Care Act of 2010. Final rule, Interim final rule.

This final rule implements several provisions of the Patient Protection and Affordable Care Act of 2010 and the Health Care and Education Reconciliation Act of 2010 (collectively referred to as the Affordable Care Act). The Affordable Care Act expands access to health insurance coverage through improvements to the Medicaid and Children's Health Insurance (CHIP) programs, the establishment of Affordable Insurance Exchanges ("Exchanges"), and the assurance of coordination between Medicaid, CHIP, and Exchanges. This final rule codifies policy and procedural changes to the Medicaid and CHIP programs related to eligibility, enrollment, renewals, public availability of program information and coordination across insurance affordability programs.

Patient Protection and Affordable Care Act; establishment of exchanges and qualified health plans; exchange standards for employers. Final rule, Interim final rule.

This final rule will implement the new Affordable Insurance Exchanges ("Exchanges"), consistent with title I of the Patient Protection and Affordable Care Act of 2010 as amended by the Health Care and Education Reconciliation Act of 2010, referred to collectively as the Affordable Care Act. The Exchanges will provide competitive marketplaces for individuals and small employers to directly compare available private health insurance options on the basis of price, quality, and other factors. The Exchanges, which will become operational by January 1, 2014, will help enhance competition in the health insurance market, improve choice of affordable health insurance, and give small businesses the same purchasing clout as large businesses.

Innovative strategies to help Consumer Operated and Oriented Plans (CO-OPs) compete in new insurance marketplaces.

The Affordable Care Act paves the way for groups to develop innovative, affordable health insurance and care options known as Consumer Operated and Oriented Plans (CO-OPs). These CO-OPs will be nonprofit, consumer-controlled entities that are designed to serve individuals and small businesses, especially in noncompetitive markets. The CO-OP provision was included in the Affordable Care Act to address the lack of affordable health plan alternatives in many state and regional markets and to counter a trend toward market concentration. Despite their promise, CO-OPs face a number of business challenges that go beyond typical start-up hurdles. This issue brief lays out a number of innovative strategies CO-OP organizers are developing to increase the odds of long-term sustainability and economic success. These strategies--aimed at building market share, creating integrated provider networks, and achieving cost savings through payment reform--could establish CO-OPs as a viable new entrant in the health care field.