Pattern and predictors of non-adherence to diabetes self-management recommendations among patients in peripheral district of Bangladesh.

OBJECTIVES: This study was designed to determine the extent of non-adherence to the different dimensions of diabetes self-management and to identify the factors influencing non-adherence among peripheral patients in Bangladesh. METHODS: A cross-sectional study was conducted among 990 adult diabetic patients residing in Thakurgaon district, Bangladesh. Data were collected through face-to-face interviews including socio-demographic information, disease and therapeutic, health services, knowledge and adherence to self-management components. RESULTS: The proportion of non-adherence to drug prescription was 66.7%, dietary regimen (68.9%), physical exercise (58.0%), follow-up visit/blood glucose test (88.2%), stopping tobacco (50.6%), and regular foot care (93.9%). Significant predictors for non-adherence to drug were poorest socio-economic status (OR = 2.47), absence of diabetic complications (OR = 1.43), using non-clinical therapy (OR = 5.61), and moderate level of knowledge (OR = 1.87). Non-adherence to dietary recommendations was higher for women (OR = 1.72), poorest socio-economic status (OR = 3.17), and poor technical knowledge (OR = 4.68). Non-adherence to physical exercise was lower for women (OR = 0.62), combined family (OR = 0.63), middle socio-economic status (OR = 0.54), and moderate knowledge on physical exercise (OR = 0.55). Non-adherence to follow-up visits/blood glucose test was higher among patients who did not have diabetic complications (OR = 1.81) and with own transport (OR = 2.57), and respondents from high-income group (OR = 0.23) were less likely to be non-adherent. Non-adherence to stopping tobacco was higher for older individuals (OR = 1.86); but lower for women (OR = 0.48), individuals with higher education level (OR = 0.17) and patients sick for a longer time (OR = 0.52). Non-adherence to foot care was higher for patients who needed longer time to go to hospital (OR = 4.07) and had poor basic knowledge on diabetes (OR = 17.80). CONCLUSION: An alarmingly high proportion of diabetic patients did not adhere to diabetes self-management. Major predictors for non-adherence were related to patient's demographic characteristics and their experience with disease, treatment and health care services.

Child Survival and Annual Crop Yield Reductions in Rural Burkina Faso: Critical Windows of Vulnerability Around Early-Life Development.

Populations that are reliant on subsistence farming are particularly vulnerable to climatic effects on crop yields. However, empirical evidence on the role of the timing of exposure to crop yield deficits in early-life development is limited. We examined the relationship between child survival and annual crop yield reductions at different stages of early-life development in a subsistence farming population in Burkina Faso. Using shared frailty Cox proportional hazards models adjusting for confounders, we analyzed 57,288 children under 5 years of age followed by the Nouna Health and Demographic Surveillance System (1994-2016) in relation to provincial food-crop yield levels experienced in 5 nonoverlapping time windows (12 months before conception, gestation, birth-age 5.9 months, ages 6.0 months-1.9 years, and ages 2.0-4.9 years) and their aggregates (birth-1.9 years, first 1,000 days from conception, and birth-4.9 years). Of the nonoverlapping windows, point estimates were largest for child survival related to food-crop yields for the time window of 6.0 months-1.9 years: The adjusted mortality hazard ratio was 1.10 (95% confidence interval: 1.03, 1.19) for a 90th-to-10th percentile yield reduction. These findings suggest that child survival in this setting is particularly vulnerable to cereal-crop yield reductions during the period of nonexclusive breastfeeding.

'Climate change mitigation is a hot topic, but not when it comes to hospitals': a qualitative study on hospital stakeholders' perception and sense of responsibility for greenhouse gas emissions.

OBJECTIVE: Physical and mental well-being are threatened by climate change. Since hospitals in high-income countries contribute significantly to climate change through their greenhouse gas (GHG) emissions, the medical ethics imperative of 'do no harm' imposes a responsibility on hospitals to decarbonise. We investigated hospital stakeholders' perceptions of hospitals' GHG emissions sources and the sense of responsibility for reducing GHG emissions in a hospital. METHODS: We conducted 29 semistructured qualitative expert interviews at one of Germany's largest hospitals, Heidelberg University Hospital. Five patients, 12 clinical and 12 administrative employees on different levels were selected using purposive maximum variation sampling. Interviews were transcribed verbatim and analysed using the framework approach. RESULTS: Concerning GHG emissions, hospital stakeholders perceived energy and waste as most relevant emission sources followed by mobility. Climate change mitigation in general was considered as important. However, in their role as patients or employees, hospital stakeholders felt less responsible for climate change mitigation. They saw providing best possible medical care to be the top priority in hospitals and were often concerned that patients' health could be jeopardised by climate change mitigation measures. CONCLUSION: Perceptions of most important emission sources did not coincide with those in literature, highlighting the need to inform stakeholders, for instance, about pharmaceuticals as important emission source. A frequently perceived conflict between reducing emissions and providing high-quality medical care could be eased, if reducing emissions would not only be justified as a contribution to mitigation, but also as a contribution to preventing ill health-a basic principle of medical ethics.

Dietary habits associated with growth development of children aged < 5 years in the Nouna Health and Demographic Surveillance System, Burkina Faso.

BACKGROUND: Knowing which dietary habits are associated with child growth could lead to better long-term health outcomes and improve the design of food-based interventions. We aimed to identify dietary habits that are associated with the growth development of children aged < 5 years living in rural Burkina Faso. METHODS: This study used cross-sectional baseline data from 514 children (8-59 months) within the Nouna Health and Demographic Surveillance System (HDSS) in 2018. Household socio-demographics and child dietary habits, height and weight were assessed. We constructed scores for dietary diversity (DDS) and food variety (FVS), and extracted exploratory dietary pattern scores (DPS) using principal component analysis (PCA). Child growth was measured using height-for-age (HAZ) and weight-for-height z-scores (WHZ). We used multiple-adjusted linear regressions considering for socio-economic factors to quantify associations. RESULTS: In this study population (median 36 ± 14 months old), stunting (HAZ < - 2) was seen in 26% and wasting (WHZ < - 2) in 7%. The DDS (median 7 ± 2 food groups) was positively associated with WHZ, while the FVS (median 13 ± 8 food items) was inversely associated with HAZ. We identified 4 dietary patterns: leaves-based, beans and poultry-based, maize and fish-based, and millet and meat-based diets. Only the maize and fish-based diet showed a statistically significant and here positive trend for associations with WHZ. CONCLUSION: Growth development of children aged < 5 years continues to be a health problem in the Nouna HDSS. A higher dietary diversity and food variety and dietary patterns characterized by maize and fish and beans and poultry intake appear to be beneficial for growth of young children in this area.

The influence of mobile phone-based health reminders on patient adherence to medications and healthy lifestyle recommendations for effective management of diabetes type 2: a randomized control trial in Dhaka, Bangladesh.

BACKGROUND: In 2017, 80% of 425 million adults with diabetes worldwide were living in low and middle-income countries. Diabetes affected 6.9 million adults in Bangladesh and accounted for 3% of the country's total mortality. Proper management of diabetes is the key to positive health outcomes. This study investigated how mobile phone-based health intervention could increase patient adherence and thereby improve the disease outcomes for diabetes type 2 in Bangladesh. METHODS: A mobile phone-based health project (including mobile phone reminders and 24/7 call center) was implemented in Dhaka District, Bangladesh from January to December 2014. A randomized control trial was carried out, recruiting randomly in intervention and control groups among the patients receiving treatment for type 2 diabetes at the Bangladesh Institute of Health Sciences Hospital, Dhaka, Bangladesh. A total of 320 patients from both groups at baseline and 273 at endline were interviewed. RESULTS: A significant improvement in patient adherence to diet, physical exercise, the cessation of use of tobacco and betel nut, and blood glycaemic control was found in the intervention group, whereas no such significant improvement was found in the control group. Cost and other co-morbidities were found to be the main reasons for non-adherence. CONCLUSION: A mobile-health intervention should be considered as an additional option for non-communicable disease programs.

Reduction of malaria vector mosquitoes in a large-scale intervention trial in rural Burkina Faso using Bti based larval source management.

BACKGROUND: Malaria remains one of the most important causes of morbidity and death in sub-Saharan Africa. Along with early diagnosis and treatment of malaria cases and intermittent preventive treatment in pregnancy (IPTp), vector control is an important tool in the reduction of new cases. Alongside the use of long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS), targeting the vector larvae with biological larvicides, such as Bacillus thuringiensis israelensis (Bti) is gaining importance as a means of reducing the number of mosquito larvae before they emerge to their adult stage. This study presents data corroborating the entomological impact of such an intervention in a rural African environment. METHODS: The study extended over 2 years and researched the impact of biological larviciding with Bti on malaria mosquitoes that were caught indoors and outdoors of houses using light traps. The achieved reductions in female Anopheles mosquitoes were calculated for two different larviciding choices using a regression model. RESULTS: In villages that received selective treatment of the most productive breeding sites, the number of female Anopheles spp. dropped by 61% (95% CI 54-66%) compared to the pre-intervention period. In villages in which all breeding sites were treated, the number of female Anopheles spp. was reduced by 70% (95% CI 64-74%) compared to the pre-intervention period. CONCLUSION: It was shown that malaria vector abundance can be dramatically reduced through larviciding of breeding habitats and that, in many geographical settings, they are a viable addition to current malaria control measures.

Lessons learned on teaching a global audience with massive open online courses (MOOCs) on health impacts of climate change: a commentary.

BACKGROUND: The adverse health impacts of climate change are increasing on a global level. However, knowledge about climate change and health is still unavailable to many global citizens, in particular on adaptation measures and co-benefits of health mitigation. Educational technologies, such as massive open online courses (MOOCs), may have a high potential for providing access to information about climate change links to health for a global audience. MAIN BODY: We developed three MOOCs addressing the link between climate change and health to take advantage of the methodology's broad reach and accelerate knowledge dissemination on the nexus of climate change and health. The primary objective was to translate an existing face-to-face short course that only reached a few participants on climate change and health into globally accessible learning opportunities. In the following, we share and comment on our lessons learned with the three MOOCs, with a focus on global teaching in the realm of climate change and health. CONCLUSIONS: Overall, the three MOOCs attracted a global audience with diverse educational backgrounds, and a large number of participants from low-income countries. Our experience highlights that MOOCs may play a part in global capacity building, potentially for other health-related topics as well, as we have found that our MOOCs have attracted participants within low-resource contexts. MOOCs may be an effective method for teaching and training global students on health topics, in this case on the complex links and dynamics between climate change and health and may further act as an enabler for equitable access to quality education.

[Health Co-benefits of climate change mitigation measures-how houeseholds and policy makers can benefit]. / Gesundheitliche Vorteile von Klimaschutzmaßnahmen ­ wie Haushalte und Politik profitieren können.

In discussions on climate change and health, negative impacts of climate change usually dominate the discussion. However to motivate households and policy makers to climate action, one should also point out the health opportunities of climate change mitigation measures.We draw on the current literature to present the concept of health co-benefits of climate change mitigation measures (A). In the empirical part of the paper we first use a quantitative and qualitative text analysis to look at the link of climate change and health in EU legislation from 1990-2015 (B). We then describe results from qualitative in-depth interviews with 18 German households, in which we investigate how knowledge of health co-benefits influences households in implementing climate action. The interviews were part of a bigger European mixed-methods study.A: From the household perspective, we define direct health co-benefits, which can be influenced and experienced by an individual, and indirect health co-benefits, which are dependent on societal action. B: Health is mentioned in EU climate change legislation. However, EU legislation only touches upon health co-benefits in general and doesn't mention direct health co-benefits at all. C: Households consider health co-benefits in their lifestyle decisions. Yet, as there are many determinants of lifestyle, information on health co-benefits alone does not seem to be sufficient to trigger climate friendly and healthy behavior.First, synergies between health and climate change mitigation need to be recognized on a political level. Then, effective intersectoral policies need to be implemented to support households on multiple levels in implementing healthy and climate-friendly lifestyles.

Annual Crop-Yield Variation, Child Survival, and Nutrition Among Subsistence Farmers in Burkina Faso.

Whether year-to-year variation in crop yields affects the nutrition, health, and survival of subsistence-farming populations is relevant to the understanding of the potential impacts of climate change. However, the empirical evidence is limited. We examined the associations of child survival with interannual variation in food crop yield and middle-upper arm circumference (MUAC) in a subsistence-farming population of rural Burkina Faso. The study was of 44,616 children aged <5 years included in the Nouna Health and Demographic Surveillance System, 1992-2012, whose survival was analyzed in relation to the food crop yield in the year of birth (which ranged from 65% to 120% of the period average) and, for a subset of 16,698 children, to MUAC, using shared-frailty Cox proportional hazards models. Survival was appreciably worse in children born in years with low yield (full-adjustment hazard ratio = 1.11 (95% confidence interval: 1.02, 1.20) for a 90th- to 10th-centile decrease in annual crop yield) and in children with small MUAC (hazard ratio = 2.72 (95% confidence interval: 2.15, 3.44) for a 90th- to 10th-centile decrease in MUAC). These results suggest an adverse impact of variations in crop yields, which could increase under climate change.

A qualitative study of community perception and acceptance of biological larviciding for malaria mosquito control in rural Burkina Faso.

BACKGROUND: Vector and malaria parasite's rising resistance against pyrethroid-impregnated bed nets and antimalarial drugs highlight the need for additional control measures. Larviciding against malaria vectors is experiencing a renaissance with the availability of environmentally friendly and target species-specific larvicides. In this study, we analyse the perception and acceptability of spraying surface water collections with the biological larvicide Bacillus thuringiensis israelensis in a single health district in Burkina Faso. METHODS: A total of 12 focus group discussions and 12 key informant interviews were performed in 10 rural villages provided with coverage of various larvicide treatments (all breeding sites treated, the most productive breeding sites treated, and untreated control). RESULTS: Respondents' knowledge about the major risk factors for malaria transmission was generally good. Most interviewees stated they performed personal protective measures against vector mosquitoes including the use of bed nets and sometimes mosquito coils and traditional repellents. The acceptance of larviciding in and around the villages was high and the majority of respondents reported a relief in mosquito nuisance and malarial episodes. There was high interest in the project and demand for future continuation. CONCLUSION: This study showed that larviciding interventions received positive resonance from the population. People showed a willingness to be involved and financially support the program. The positive environment with high acceptance for larviciding programs would facilitate routine implementation. An essential factor for the future success of such programs would be inclusion in regional or national malaria control guidelines.

Systematic review of current efforts to quantify the impacts of climate change on undernutrition.

Malnutrition is a challenge to the health and productivity of populations and is viewed as one of the five largest adverse health impacts of climate change. Nonetheless, systematic evidence quantifying these impacts is currently limited. Our aim was to assess the scientific evidence base for the impact of climate change on childhood undernutrition (particularly stunting) in subsistence farmers in low- and middle-income countries. A systematic review was conducted to identify peer-reviewed and gray full-text documents in English with no limits for year of publication or study design. Fifteen manuscripts were reviewed. Few studies use primary data to investigate the proportion of stunting that can be attributed to climate/weather variability. Although scattered and limited, current evidence suggests a significant but variable link between weather variables, e.g., rainfall, extreme weather events (floods/droughts), seasonality, and temperature, and childhood stunting at the household level (12 of 15 studies, 80%). In addition, we note that agricultural, socioeconomic, and demographic factors at the household and individual levels also play substantial roles in mediating the nutritional impacts. Comparable interdisciplinary studies based on primary data at a household level are urgently required to guide effective adaptation, particularly for rural subsistence farmers. Systemization of data collection at the global level is indispensable and urgent. We need to assimilate data from long-term, high-quality agricultural, environmental, socioeconomic, health, and demographic surveillance systems and develop robust statistical methods to establish and validate causal links, quantify impacts, and make reliable predictions that can guide evidence-based health interventions in the future.

Household cereal crop harvest and children's nutritional status in rural Burkina Faso.

BACKGROUND: Reduction of child undernutrition is one of the Sustainable Development Goals for 2030. Achievement of this goal may be made more difficult in some settings by climate change through adverse impact on agricultural productivity. However, there is only limited quantitative evidence on the link between household crop harvests and child nutrition. We examined this link in a largely subsistence farming population in rural Burkina Faso. METHODS: Data on the middle-upper arm circumference (MUAC) of 975 children ≤5 years of age, household crop yields, and other parameters were obtained from the Nouna Health and Demographic Surveillance System. Multilevel modelling was used to assess the relationship between MUAC and the household crop harvest in the year 2009 estimated in terms of kilocalories per adult equivalent per day (kcal/ae/d). RESULTS: Fourteen percent of children had a MUAC <125 mm (a value indicative of acute undernutrition). The relationship between MUAC and annual household food energy production adjusted for age, sex, month of MUAC measurement, household wealth, whether a household member had a non-agricultural occupation, garden produce, village infrastructure and market presence, suggested a decline in MUAC below around 3000 kcal/ae/d. The mean MUAC was 2.49 (95% CI 0.45, 4.52) mm less at 1000 than at 3000 kcal/ae/d. CONCLUSIONS: Low per capita household crop production is associated with poorer nutritional status of children in a rural farming population in Burkina Faso. This and similar populations may thus be vulnerable to the adverse effects of weather on agricultural harvest, especially in the context of climate change.

Household preferences for reducing greenhouse gas emissions in four European high-income countries: Does health information matter? A mixed-methods study protocol.

BACKGROUND: It is now universally acknowledged that climate change constitutes a major threat to human health. At the same time, some of the measures to reduce greenhouse gas emissions, so-called climate change mitigation measures, have significant health co-benefits (e.g., walking or cycling more; eating less meat). The goal of limiting global warming to 1,5° Celsius set by the Conference of the Parties to the United Nations Framework Convention on Climate Change in Paris in 2015 can only be reached if all stakeholders, including households, take actions to mitigate climate change. Results on whether framing mitigation measures in terms of their health co-benefits increases the likelihood of their implementation are inconsistent. The present study protocol describes the transdisciplinary project HOPE (HOuseholds' Preferences for reducing greenhouse gas emissions in four European high-income countries) that investigates the role of health co-benefits in households' decision making on climate change mitigation measures in urban households in France, Germany, Norway and Sweden. METHODS: HOPE employs a mixed-methods approach combining status-quo carbon footprint assessments, simulations of the reduction of households' carbon footprints, and qualitative in-depth interviews with a subgroup of households. Furthermore, a policy analysis of current household oriented climate policies is conducted. In the simulation of the reduction of households' carbon footprints, half of the households are provided with information on health co-benefits of climate change mitigation measures, the other half is not. Households' willingness to implement the measures is assessed and compared in between-group analyses of variance. DISCUSSION: This is one of the first comprehensive mixed-methods approaches to investigate which mitigation measures households are most willing to implement in order to reach the 1,5° target set by the Paris Agreement, and whether health co-benefits can serve as a motivator for households to implement these measures. The comparison of the empirical data with current climate policies will provide knowledge for tailoring effective climate change mitigation and health policies.

Cost-effectiveness of an electronic clinical decision support system for improving quality of antenatal and childbirth care in rural Tanzania: an intervention study.

BACKGROUND: QUALMAT project aimed at improving quality of maternal and newborn care in selected health care facilities in three African countries. An electronic clinical decision support system was implemented to support providers comply with established standards in antenatal and childbirth care. Given that health care resources are limited and interventions differ in their potential impact on health and costs (efficiency), this study aimed at assessing cost-effectiveness of the system in Tanzania. METHODS: This was a quantitative pre- and post- intervention study involving 6 health centres in rural Tanzania. Cost information was collected from health provider's perspective. Outcome information was collected through observation of the process of maternal care. Incremental cost-effectiveness ratios for antenatal and childbirth care were calculated with testing of four models where the system was compared to the conventional paper-based approach to care. One-way sensitivity analysis was conducted to determine whether changes in process quality score and cost would impact on cost-effectiveness ratios. RESULTS: Economic cost of implementation was 167,318 USD, equivalent to 27,886 USD per health center and 43 USD per contact. The system improved antenatal process quality by 4.5% and childbirth care process quality by 23.3% however these improvements were not statistically significant. Base-case incremental cost-effectiveness ratios of the system were 2469 USD and 338 USD per 1% change in process quality for antenatal and childbirth care respectively. Cost-effectiveness of the system was sensitive to assumptions made on costs and outcomes. CONCLUSIONS: Although the system managed to marginally improve individual process quality variables, it did not have significant improvement effect on the overall process quality of care in the short-term. A longer duration of usage of the electronic clinical decision support system and retention of staff are critical to the efficiency of the system and can reduce the invested resources. Realization of gains from the system requires effective implementation and an enabling healthcare system. TRIAL REGISTRATION: Registered clinical trial at www.clinicaltrials.gov ( NCT01409824 ). Registered May 2009.

Routine implementation costs of larviciding with Bacillus thuringiensis israelensis against malaria vectors in a district in rural Burkina Faso.

BACKGROUND: The key tools in malaria control are early diagnosis and treatment of cases as well as vector control. Current strategies for malaria vector control in sub-Saharan Africa are largely based on long-lasting insecticide-treated nets (LLINs) and to a much smaller extent on indoor residual spraying (IRS). An additional tool in the fight against malaria vectors, larval source management (LSM), has not been used in sub-Saharan Africa on a wider scale since the abandonment of environmental spraying of DDT. Increasing concerns about limitations of LLINs and IRS and encouraging results from large larvicide-based LSM trials make a strong case for using biological larviciding as a complementary tool to existing control measures. Arguments that are often quoted against such a combined approach are the alleged high implementation costs of LSM. This study makes the first step to test this argument. The implementation costs of larval source management based on Bacillus thuringiensis israelensis (Bti) (strain AM65-52) spraying under different implementation scenarios were analysed in a rural health district in Burkina Faso. METHODS: The analysis draws on detailed cost data gathered during a large-scale LSM intervention between 2013 and 2015. All 127 villages in the study setup were assigned to two treatment arms and one control group. Treatment either implied exhaustive spraying of all available water collections or targeted spraying of the 50 % most productive larval sources via remote-sensing derived and entomologically validated risk maps. Based on the cost reports from both intervention arms, the per capita programme costs were calculated under the assumption of covering the whole district with either intervention scenario. Cost calculations have been generalized by providing an adaptable cost formula. In addition, this study assesses the sensitivity of per capita programme costs with respect to changes in the underlying cost components. RESULTS: The average annual per capita costs of exhaustive larviciding with Bti during the main malaria transmission period (June-October) in the Nouna health district were calculated to be US$ 1.05. When targeted spraying of the 50 % most productive larval sources is used instead, average annual per capita costs decrease by 27 % to US$ 0.77. Additionally, a high sensitivity of per capita programme costs against changes in total surface of potential larval sources and the number of spraying repetitions was found. DISCUSSION: The per capita costs for larval source management interventions with Bti are roughly a third of the annual per capita expenditures for anti-malarial drugs and those for LLINs in Burkina Faso which are US$ 3.80 and 3.00, respectively. The average LSM costs compare to those of IRS and LLINs for sub-Saharan Africa. The authors argue that in such a setting LSM based on Bti spraying is within the range of affordable anti-malarial strategies and, consequently, should deserve more attention in practice. Future research includes a cost-benefit calculation, based on entomological and epidemiological data collected during the research project.

Challenges of implementing a large scale larviciding campaign against malaria in rural Burkina Faso - lessons learned and recommendations derived from the EMIRA project.

BACKGROUND: Recent malaria control and elimination attempts show remarkable success in several parts of sub-Saharan Africa. Vector control via larval source management represents a new and to date underrepresented approach in low income countries to further reduce malaria transmission. Although the positive impact of such campaigns on malaria incidence has been researched, there is a lack of data on which prerequisites are needed for implementing such programs on a routine basis on large scale. Our objectives are to point out important steps in implementing an anti-malaria larviciding campaign in a resource and infrastructure restraint setting and share the lessons learned from our experience during a three-year intervention study in rural Burkina Faso. METHODS: We describe the approaches we followed and the challenges that have been encountered during the EMIRA project, a three-year study on the impact of environmental larviciding on vector ecology and human health. An inventory of all performed work packages and associated problems and peculiarities was assembled. RESULTS: Key to the successful implementation of the larviciding program within a health district was the support and infrastructure from the local research center run by the government. This included availability of trained scientific personnel for local project management, data collection and analysis by medical personnel, entomologists and demographers and teams of fieldworkers for the larviciding intervention. A detailed a priori assessment of the environment and vector breeding site ecology was essential to calculate personnel requirements and the need for larvicide and application apparel. In our case of a three-year project, solid funding for the whole duration was an important issue, which restricted the number of possible donors. We found the acquisition of qualified field personnel in fair numbers not to be always easy and training in application techniques and basic entomologic knowledge required several weeks of theoretical and practical formation. A further crucial point was to establish an effective quality control system that ensured the timely verification of larviciding success and facilitated in time data handling. While the experiences of running a larviciding campaign may vary globally, the experiences gained and the methods used in the Nouna health district may be employed in similar settings. CONCLUSIONS: Our observations highlight important components and strategies that should be taken into account when planning and running a similar larviciding program against malaria in a resource limited setting. A strong local partnership, meticulous planning with the possibility of ad-hoc adaption of project components and a reliable source of funding turned out to be crucial factors to successfully accomplish such a project.

Applying for, reviewing and funding public health research in Germany and beyond.

Public health research is complex, involves various disciplines, epistemological perspectives and methods, and is rarely conducted in a controlled setting. Often, the added value of a research project lies in its inter- or trans-disciplinary interaction, reflecting the complexity of the research questions at hand. This creates specific challenges when writing and reviewing public health research grant applications. Therefore, the German Research Foundation (DFG), the largest independent research funding organization in Germany, organized a round table to discuss the process of writing, reviewing and funding public health research. The aim was to analyse the challenges of writing, reviewing and granting scientific public health projects and to improve the situation by offering guidance to applicants, reviewers and funding organizations. The DFG round table discussion brought together national and international public health researchers and representatives of funding organizations. Based on their presentations and discussions, a core group of the participants (the authors) wrote a first draft on the challenges of writing and reviewing public health research proposals and on possible solutions. Comments were discussed in the group of authors until consensus was reached. Public health research demands an epistemological openness and the integration of a broad range of specific skills and expertise. Applicants need to explicitly refer to theories as well as to methodological and ethical standards and elaborate on why certain combinations of theories and methods are required. Simultaneously, they must acknowledge and meet the practical and ethical challenges of conducting research in complex real life settings. Reviewers need to make the rationale for their judgments transparent, refer to the corresponding standards and be explicit about any limitations in their expertise towards the review boards. Grant review boards, funding organizations and research ethics committees need to be aware of the specific conditions of public health research, provide adequate guidance to applicants and reviewers, and ensure that processes and the expertise involved adequately reflect the topic under review.

Using a community-based definition of poverty for targeting poor households for premium subsidies in the context of a community health insurance in Burkina Faso.

BACKGROUND: One of the biggest challenges in subsidizing premiums of poor households for community health insurance is the identification and selection of these households. Generally, poverty assessments in developing countries are based on monetary terms. The household is regarded as poor if its income or consumption is lower than a predefined poverty cut-off. These measures fail to recognize the multi-dimensional character of poverty, ignoring community members' perception and understanding of poverty, leaving them voiceless and powerless in the identification process. Realizing this, the steering committee of Nouna's health insurance devised a method to involve community members to better define 'perceived' poverty, using this as a key element for the poor selection. The community-identified poor were then used to effectively target premium subsidies for the insurance scheme. METHODS: The study was conducted in the Nouna's Health District located in northwest Burkina Faso. Participants in each village were selected to take part in focus-group discussions (FGD) organized in 41 villages and 7 sectors of Nouna's town to discuss criteria and perceptions of poverty. The discussions were audio recorded, transcribed and analyzed in French using the software NVivo 9. RESULTS: From the FGD on poverty and the subjective definitions and perceptions of the community members, we found that poverty was mainly seen as scarcity of basic needs, vulnerability, deprivation of capacities, powerlessness, voicelessness, indecent living conditions, and absence of social capital and community networks for support in times of need. Criteria and poverty groups as described by community members can be used to identify poor who can then be targeted for subsidies. CONCLUSION: Policies targeting the poorest require the establishment of effective selection strategies. These policies are well-conditioned by proper identification of the poor people. Community perceptions and criteria of poverty are grounded in reality, to better appreciate the issue. It is crucial to take these perceptions into account in undertaking community development actions which target the poor. For most community-based health insurance schemes with limited financial resources, using a community-based definition of poverty in the targeting of the poorest might be a less costly alternative.

A cost-effectiveness analysis of three components of a syndromic surveillance system for the early warning of epidemics in rural China.

BACKGROUND: Syndromic surveillance systems (SSSs) collect non-specific syndromes in early stages of disease outbreaks. This makes an SSS a promising tool for the early detection of epidemics. An Integrated Surveillance System in rural China (ISSC project), which added an SSS to the existing Chinese surveillance system for the early warning of epidemics, was implemented from April 2012 to March 2014 in Jiangxi and Hubei Provinces. This study aims to measure the costs and effectiveness of the three components of the SSS in the ISSC project. METHODS: The central measures of the cost-effectiveness analysis of the three components of the syndromic surveillance system were: 1) the costs per reported event, respectively, at the health facilities, the primary schools and the pharmacies; and 2) the operating costs per surveillance unit per year, respectively, at the health facilities, the primary schools and the pharmacies. Effectiveness was expressed by reporting outputs which were numbers of reported events, numbers of raw signals, and numbers of verified signals. The reported events were tracked through an internal data base. Signal verification forms and epidemiological investigation reports were collected from local country centers for disease control and prevention. We adopted project managers' perspective for the cost analysis. Total costs included set-up costs (system development and training) and operating costs (data collection, quality control and signal verification). We used self-designed questionnaires to collect cost data and received, respectively, 369 and 477 facility and staff questionnaires through a cross-sectional survey with a purposive sampling following the ISSC project. All data were entered into Epidata 3.02 and exported to Stata for descriptive analysis. RESULTS: The number of daily reported events per unit was the highest at pharmacies, followed by health facilities and finally primary schools. Variances existed within the three groups and also between Jiangxi and Hubei. During a 15-month surveillance period, the number of raw signals for early warning in Jiangxi province (n = 36) was nine times of that in Hubei. Health facilities and primary schools had equal numbers of raw signals (n = 19), which was 9.5 times of that from pharmacies. Five signals were confirmed as outbreaks, of which two were influenza, two were chicken pox and one was mumps. The cost per reported event was the highest at primary schools, followed by health facilities and then pharmacies. The annual operating cost per surveillance unit was the highest at pharmacies, followed by health facilities and finally primary schools. Both the cost per reported event and the annual operating cost per surveillance unit in Jiangxi in each of the three groups were higher than their counterparts in Hubei. CONCLUSIONS: Health facilities and primary schools are better sources of syndromic surveillance data in the early warning of outbreaks. The annual operating costs of all the three components of the syndromic surveillance system in the ISSC Project were low compared to general government expenditures on health and average individual income in rural China.

Measuring costs of data collection at village clinics by village doctors for a syndromic surveillance system-a cross sectional survey from China.

BACKGROUND: Studies into the costs of syndromic surveillance systems are rare, especially for estimating the direct costs involved in implementing and maintaining these systems. An Integrated Surveillance System in rural China (ISSC project), with the aim of providing an early warning system for outbreaks, was implemented; village clinics were the main surveillance units. Village doctors expressed their willingness to join in the surveillance if a proper subsidy was provided. This study aims to measure the costs of data collection by village clinics to provide a reference regarding the subsidy level required for village clinics to participate in data collection. METHODS: We conducted a cross-sectional survey with a village clinic questionnaire and a staff questionnaire using a purposive sampling strategy. We tracked reported events using the ISSC internal database. Cost data included staff time, and the annual depreciation and opportunity costs of computers. We measured the village doctors' time costs for data collection by multiplying the number of full time employment equivalents devoted to the surveillance by the village doctors' annual salaries and benefits, which equaled their net incomes. We estimated the depreciation and opportunity costs of computers by calculating the equivalent annual computer cost and then allocating this to the surveillance based on the percentage usage. RESULTS: The estimated total annual cost of collecting data was 1,423 Chinese Renminbi (RMB) in 2012 (P25 = 857, P75 = 3284), including 1,250 RMB (P25 = 656, P75 = 3000) staff time costs and 134 RMB (P25 = 101, P75 = 335) depreciation and opportunity costs of computers. CONCLUSIONS: The total costs of collecting data from the village clinics for the syndromic surveillance system was calculated to be low compared with the individual net income in County A.