Economic Evaluations of Preventive Interventions for Dental Caries and Periodontitis: A Systematic Review.

OBJECTIVES: To critically examine the methods used for full economic evaluations of preventive interventions for dental caries and periodontitis. METHODS: Published literature post-2000 was searched to April 2021. Based on a developed intervention classification framework for dental caries and periodontitis, only universal, selective or indicated interventions were included in this review. The Drummond 10-point checklist was used for quality appraisal. RESULTS: Of 3,007 unique records screened for relevance, 73 studies were reviewed. Most model-based studies (61/73) used cost-effectiveness analysis (49%) or cost-benefit analysis (28%). Trial-based studies (16/73) commonly used cost-effectiveness analysis (59%). Four studies used both economic evaluation methods. Sixty-four papers (88%) were on dental caries, eight papers (11%) focused on periodontitis, and one paper (1%) included both oral diseases; 72% of model-based and 82% of trial-based studies were of good quality. The most frequently investigated dental caries preventive interventions were water fluoridation (universal intervention; cost-saving or cost-effective), fissure sealant and fluoride varnish (selective and indicated interventions; cost-effectiveness outcomes were inconsistent). Supportive periodontal therapy with oral health education (indicated intervention; cost-effective) was the most frequently evaluated preventive intervention for periodontitis. Thirty percent of studies with a time horizon > 1 year did not apply an appropriate discount rate and 26% did not comprehensively discuss other important considerations beyond the technical analysis. CONCLUSIONS: Generic health outcome measures should be incorporated for economic evaluations on preventive interventions for dental caries and periodontitis, and an increased focus to prevent periodontitis using economic evaluation methods is needed to inform resource allocation and policy decision-making.

Cost-effectiveness and economic returns of group-based parenting interventions to promote early childhood development: Results from a randomized controlled trial in rural Kenya.

BACKGROUND: Early childhood development (ECD) programs can help address disadvantages for the 43% of children under 5 in low- and middle-income countries (LMICs) experiencing compromised development. However, very few studies from LMIC settings include information on their program's cost-effectiveness or potential returns to investment. We estimated the cost-effectiveness, benefit-cost ratios (BCRs), and returns on investment (ROIs) for 2 effective group-based delivery models of an ECD parenting intervention that utilized Kenya's network of local community health volunteers (CHVs). METHODS AND FINDINGS: Between October 1 and November 12, 2018, 1,152 mothers with children aged 6 to 24 months were surveyed from 60 villages in rural western Kenya. After baseline, villages were randomly assigned to one of 3 intervention arms: a group-only delivery model with 16 fortnightly sessions, a mixed-delivery model combining 12 group sessions with 4 home visits, and a control group. At endline (August 5 to October 31, 2019), 1,070 children were retained and assessed for primary outcomes including cognitive and receptive language development (with the Bayley Scales of Infant Development, Third Edition) and socioemotional development (with the Wolke scale). Children in the 2 intervention arms showed better developmental outcomes than children in the control arm, although the group-only delivery model generally had larger effects on children. Total program costs included provider's implementation costs collected during the intervention period using financial reports from the local nongovernmental organization (NGO) implementer, as well as societal costs such as opportunity costs to mothers and delivery agents. We combined program impacts with these total costs to estimate incremental cost-effectiveness ratios (ICERs), as well as BCRs and the program's ROI for the government based on predictions of future lifetime wages and societal costs. Total costs per child were US$140 in the group-only arm and US$145 in the mixed-delivery arm. Because of higher intention-to-treat (ITT) impacts at marginally lower costs, the group-only model was the most cost-effective across all child outcomes. Focusing on child cognition in this arm, we estimated an ICER of a 0.37 standard deviation (SD) improvement in cognition per US$100 invested, a BCR of 15.5, and an ROI of 127%. A limitation of our study is that our estimated BCR and ROI necessarily make assumptions about the discount rate, income tax rates, and predictions of intervention impacts on future wages and schooling. We examine the sensitivity of our results to these assumptions. CONCLUSIONS: To the best of our knowledge, this study is the first economic evaluation of an effective ECD parenting intervention targeted to young children in sub-Saharan Africa (SSA) and the first to adopt a societal perspective in calculating cost-effectiveness that accounts for opportunity costs to delivery agents and program participants. Our cost-effectiveness and benefit-cost estimates are higher than most of the limited number of prior studies from LMIC settings providing information about costs. Our results represent a strong case for scaling similar interventions in impoverished rural settings, and, under reasonable assumptions about the future, demonstrate that the private and social returns of such investments are likely to largely outweigh their costs. TRIAL REGISTRATION: This trial is registered at ClinicalTrials.gov, NCT03548558, June 7, 2018. American Economic Association RCT Registry trial AEARCTR-0002913.

Regional anesthesia educational material utilization varies by World Bank income category: A mobile health application data study.

INTRODUCTION: Regional anesthesia offers an alternative to general anesthesia and may be advantageous in low resource environments. There is a paucity of data regarding the practice of regional anesthesia in low- and middle-income countries. Using access data from a free Android app with curated regional anesthesia learning modules, we aimed to estimate global interest in regional anesthesia and potential applications to clinical practice stratified by World Bank income level. METHODS: We retrospectively analyzed data collected from the free Android app "Anesthesiologist" from December 2015 to April 2020. The app performs basic anesthetic calculations and provides links to videos on performing 12 different nerve blocks. Users of the app were classified on the basis of whether or not they had accessed the links. Nerve blocks were also classified according to major use (surgical block, postoperative pain adjunct, rescue block). RESULTS: Practitioners in low- and middle-income countries accessed the app more frequently than in high-income countries as measured by clicks. Users from low- and middle-income countries focused mainly on surgical blocks: ankle, axillary, infraclavicular, interscalene, and supraclavicular blocks. In high-income countries, more users viewed postoperative pain blocks: adductor canal, popliteal, femoral, and transverse abdominis plane blocks. Utilization of the app was constant over time with a general decline with the start of the COVID-19 pandemic. CONCLUSION: The use of an in app survey and analytics can help identify gaps and opportunities for regional anesthesia techniques and practices. This is especially impactful in limited-resource areas, such as lower-income environments and can lead to targeted educational initiatives.

Health system interventions for adults with type 2 diabetes in low- and middle-income countries: A systematic review and meta-analysis.

BACKGROUND: Effective health system interventions may help address the disproportionate burden of diabetes in low- and middle-income countries (LMICs). We assessed the impact of health system interventions to improve outcomes for adults with type 2 diabetes in LMICs. METHODS AND FINDINGS: We searched Ovid MEDLINE, Cochrane Library, EMBASE, African Index Medicus, LILACS, and Global Index Medicus from inception of each database through February 24, 2020. We included randomized controlled trials (RCTs) of health system interventions targeting adults with type 2 diabetes in LMICs. Eligible studies reported at least 1 of the following outcomes: glycemic change, mortality, quality of life, or cost-effectiveness. We conducted a meta-analysis for the glycemic outcome of hemoglobin A1c (HbA1c). GRADE and Cochrane Effective Practice and Organisation of Care methods were used to assess risk of bias for the glycemic outcome and to prepare a summary of findings table. Of the 12,921 references identified in searches, we included 39 studies in the narrative review of which 19 were cluster RCTs and 20 were individual RCTs. The greatest number of studies were conducted in the East Asia and Pacific region (n = 20) followed by South Asia (n = 7). There were 21,080 total participants enrolled across included studies and 10,060 total participants in the meta-analysis of HbA1c when accounting for the design effect of cluster RCTs. Non-glycemic outcomes of mortality, health-related quality of life, and cost-effectiveness had sparse data availability that precluded quantitative pooling. In the meta-analysis of HbA1c from 35 of the included studies, the mean difference was -0.46% (95% CI -0.60% to -0.31%, I2 87.8%, p < 0.001) overall, -0.37% (95% CI -0.64% to -0.10%, I2 60.0%, n = 7, p = 0.020) in multicomponent clinic-based interventions, -0.87% (-1.20% to -0.53%, I2 91.0%, n = 13, p < 0.001) in pharmacist task-sharing studies, and -0.27% (-0.50% to -0.04%, I2 64.1%, n = 7, p = 0.010) in trials of diabetes education or support alone. Other types of interventions had few included studies. Eight studies were at low risk of bias for the summary assessment of glycemic control, 15 studies were at unclear risk, and 16 studies were at high risk. The certainty of evidence for glycemic control by subgroup was moderate for multicomponent clinic-based interventions but was low or very low for other intervention types. Limitations include the lack of consensus definitions for health system interventions, differences in the quality of underlying studies, and sparse data availability for non-glycemic outcomes. CONCLUSIONS: In this meta-analysis, we found that health system interventions for type 2 diabetes may be effective in improving glycemic control in LMICs, but few studies are available from rural areas or low- or lower-middle-income countries. Multicomponent clinic-based interventions had the strongest evidence for glycemic benefit among intervention types. Further research is needed to assess non-glycemic outcomes and to study implementation in rural and low-income settings.

Increasing Human Papillomavirus Vaccination and Cervical Cancer Screening in Nigeria: An Assessment of Community-Based Educational Interventions.

We explored the impact of two community-based educational interventions on Nigerian adults' knowledge and intention to take or encourage human papillomavirus (HPV) vaccine and cervical screenings. Face-to-face presentation and printed pamphlet intervention were delivered to 266 men and women aged 18 to 65 years in 12 locations in urban setting. At baseline, the majority (80%) had poor knowledge of HPV, and less than 12% had ever received or have a family member who had received HPV vaccine or cervical screening. Postintervention, there was significant increase (>70%) in the participants knowledge and intention to take or encourage HPV vaccination and cervical screening. In addition, more than half were willing to pay for HPV vaccine and screening even when expensive. Gender-focused and context-specific low-cost community-based educational interventions are effective in increasing HPV vaccine and cervical screening in sub-Saharan Africa.

Mathematical Model for Optimal Control of Soil-Transmitted Helminth Infection.

In this paper, we study the dynamics of soil-transmitted helminth infection. We formulate and analyse a deterministic compartmental model using nonlinear differential equations. The basic reproduction number is obtained and both disease-free and endemic equilibrium points are shown to be asymptotically stable under given threshold conditions. The model may exhibit backward bifurcation for some parameter values, and the sensitivity indices of the basic reproduction number with respect to the parameters are determined. We extend the model to include control measures for eradication of the infection from the community. Pontryagian's maximum principle is used to formulate the optimal control problem using three control strategies, namely, health education through provision of educational materials, educational messages to improve the awareness of the susceptible population, and treatment by mass drug administration that target the entire population(preschool- and school-aged children) and sanitation through provision of clean water and personal hygiene. Numerical simulations were done using MATLAB and graphical results are displayed. The cost effectiveness of the control measures were done using incremental cost-effective ratio, and results reveal that the combination of health education and sanitation is the best strategy to combat the helminth infection. Therefore, in order to completely eradicate soil-transmitted helminths, we advise investment efforts on health education and sanitation controls.

A RE-AIM Analysis of an Intergenerational Dementia Education Program.

Objectives: Children often have a lack of dementia understanding and poor attitudes toward people with dementia. Intergenerational programs are increasingly common, but the effects on knowledge and attitudes related to dementia are mixed, especially in the long-term (6 months). Using a RE-AIM framework, we quantitatively evaluated the effects of an educational dementia program (with and without an intergenerational program) on dementia attitudes in the short and long-term, and qualitatively, which elements of the program facilitated this change. Methods: Eighty-one children (9.63 ± 0.52 years, 35 males) from three classes participated in an 8-week dementia education program and 52 also interacted with older adults through an intergenerational experience. Program reach was measured as the percentage of children who participated in the study. The Kids Insight into Dementia Survey (KIDS) was implemented to measure dementia knowledge and attitudes: efficacy and maintenance. Qualitative interviews with all participant groups informed both adoption and implementation. Cost-benefit analysis was used as a secondary outcome measure for efficacy. Results: The program demonstrated strong levels of impact reaching 93% of school children across the three included classes. Efficacy was demonstrated by a positive change in children's dementia knowledge and attitudes immediately post program, which remained increased (as compared to baseline) 6- months post intervention; there were no differences between groups (those who interacted with older adults and those who did not). Interviews identified positive changes in children's empathy and improved community awareness. Barriers to adoption included the project scope, time constraints incurred by school terms and the management of children-to-adult ratios. Conclusions: These findings provide the first evidence that school-based dementia education improves knowledge of and attitudes toward people with dementia long-term. We demonstrated programs such as this can be successful in both primary school and wider community settings, with support from school and community partners key to the success.

Economic Return on Investment of Parent Training Programmes for the Prevention of Child Externalising Behaviour Problems.

Economic models to inform decision-making are gaining popularity, especially for preventive interventions. However, there are few estimates of the long-term returns to parenting interventions used to prevent mental health problems in children. Using data from a randomised controlled trial evaluating five indicated parenting interventions for parents of children aged 5-12, we modeled the economic returns resulting from reduced costs in the health care and education sector, and increased long-term productivity in a Swedish setting. Analyses done on the original trial population, and on various sized local community populations indicated positive benefit-cost ratios. Even smaller local authorities would financially break-even, thus interventions were of good value-for-money. Benefit-cost analyses of such interventions may improve the basis for resource allocation within local decision-making.

Motivational Interviewing to Encourage Quit Attempts Among Smokers Not Ready to Quit: A Trial-Based Economic Analysis.

INTRODUCTION: This study used data from a randomized controlled trial evaluating the efficacy of motivational interviewing (MI) relative to health education (HE) and brief advice (BA) to encourage quit attempts and cessation in order to determine their relative cost-effectiveness. AIMS AND METHODS: Urban community residents (n = 255) with low desire to quit smoking were randomized to MI, HE, or BA which differed in communication style and/or number of treatment sessions. Incremental cost-effectiveness ratios were used to compare the intensive interventions (MI and HE) to BA for facilitating quit attempts and smoking cessation. Costs were calculated from the perspective of an agency that might engage in program delivery. Sensitivity analysis examined different assumptions for MI training and pharmacotherapy costs. RESULTS: Total intervention delivery time costs per participant for MI, HE, and BA were $46.63, $42.87, and $2.4, respectively. Cost-effectiveness ratios per quit attempt at 24 weeks were $380 for MI, $272 for HE, and $209 for BA. The cost per additional quit attempt for MI and HE relative to BA was $508 and $301, respectively. The cost per additional quit for MI and HE relative to BA was $2030 and $752, respectively. Four separate sensitivity analyses conducted in our study did not change the conclusion the HE had a lower Incremental Cost-Effectiveness Ratio for both quit attempts and cessation. CONCLUSIONS: HE was the most cost-effective of the three types of smoking cessation induction therapies and therefore may be preferable for smokers who are less motivated to quit. Providing valuable cost information in choosing different clinical methods for motivating smokers to quit. IMPLICATIONS: All direct costs and activity-based time costs associated with delivering the intervention were analyzed from the perspective of an agency that may wish to replicate these strategies. A randomized controlled trial evaluating the efficacy of MI relative to HE and BA to encourage quit attempts and cessation determined their relative cost-effectiveness. HE was the most cost-effective of the three types of smoking cessation induction therapies and therefore may be preferable. Despite guideline recommendations, MI may not be the best approach to encourage quit attempts in diverse populations. Rather, a structured, intensive HE intervention might be the most cost-effective alternative.

Can Cartoons Which Depict Autistic Characters Improve Attitudes Towards Autistic Peers?

This study aimed to assess the efficacy of two cartoons which depict autistic characters in improving attitudes towards autistic peers in two separate studies. Forty-six children participated in study 1 (4-7 years), and 47 children participated in study 2 (8-11 years). Both the conative (behavioural) component of attitudes and knowledge about autism were measured before and after the cartoon interventions. Knowledge of autism increased after watching the cartoons in both studies but attitudes to autism only improved in study 1. Knowledge was shown to correlate with change in some but not all attitude measures. The findings suggest that cartoons can improve attitudes to autism, but this may depend on how information is presented.

Preventing child mental health problems through parenting interventions in Southeastern Europe (RISE): Protocol for a multi-country cluster randomized factorial study.

BACKGROUND: Child mental health problems continue to be a major global concern, especially in low- and middle-income countries (LMICs). Parenting interventions have been shown to be effective for reducing child behavior problems in high-income countries, with emerging evidence supporting similar effects in LMICs. However, there remain substantial barriers to scaling up evidence-based interventions due to limited human and financial resources in such countries. METHODS: This protocol is for a multi-center cluster randomized factorial trial of an evidence-based parenting intervention, Parenting for Lifelong Health for Young Children, for families with children ages 2-9 years with subclinical levels of behavior problems in three Southeastern European countries, Republic of Moldova, North Macedonia, and Romania (8 conditions, 48 clusters, 864 families, 108 per condition). The trial will test three intervention components: length (5 vs. 10 sessions), engagement (basic vs. enhanced package), and fidelity (on-demand vs. structured supervision). Primary outcomes are child aggressive behavior, dysfunctional parenting, and positive parenting. Analyses will examine the main effect and cost-effectiveness of each component, as well as potential interaction effects between components, in order to identify the most optimal combination of program components. DISCUSSION: This study is the first factorial experiment of a parenting program in LMICs. Findings will inform the subsequent testing of the optimized program in a multisite randomized controlled trial in 2021. TRIAL REGISTRATION: NCT03865485 registered in ClinicalTrials.gov on March 5, 2019.

Stroke Warning Information and Faster Treatment (SWIFT): Cost-Effectiveness of a Stroke Preparedness Intervention.

BACKGROUND: Less than 25% of stroke patients arrive to an emergency department within the 3-hour treatment window. OBJECTIVE: We evaluated the cost-effectiveness of a stroke preparedness behavioral intervention study (Stroke Warning Information and Faster Treatment [SWIFT]), a stroke intervention demonstrating capacity to decrease race-ethnic disparities in ED arrival times. METHODS: Using the literature and SWIFT outcomes for 2 interventions, enhanced educational (EE) materials, and interactive intervention (II), we assess the cost-effectiveness of SWIFT in 2 ways: (1) Markov model, and (2) cost-to-outcome ratio. The Markov model primary outcome was the cost per quality-adjusted life-year (QALY) gained using the cost-effectiveness threshold of $100 000/QALY. The primary cost-to-outcome endpoint was cost per additional patient with ED arrival <3 hours, stroke knowledge, and preparedness capacity. We assessed the ICER of II and EE versus standard care (SC) from a health sector and societal perspective using 2015 USD, a time horizon of 5 years, and a discount rate of 3%. RESULTS: The cost-effectiveness of the II and EE programs was, respectively, $227.35 and $74.63 per additional arrival <3 hours, $440.72 and $334.09 per additional person with stroke knowledge proficiency, and $655.70 and $811.77 per additional person with preparedness capacity. Using a societal perspective, the ICER for EE versus SC was $84 643 per QALY gained and the ICER for II versus EE was $59 058 per QALY gained. Incorporating fixed costs, EE and II would need to administered to 507 and 1693 or more patients, respectively, to achieve an ICER of $100 000/QALY. CONCLUSION: II was a cost-effective strategy compared with both EE and SC. Nevertheless, high initial fixed costs associated with II may limit its cost-effectiveness in settings with smaller patient populations.

Global nurse/midwife workforce and reproductive health through social ecology lens.

OBJECTIVE: To explore how community social ecology factors may be associated with country registered nurse/registered midwife (RN/RM) workforce supply and reproductive health globally. DESIGN: A cross-sectional design using a social ecology framework was employed. SAMPLE: Data were retrieved from publicly available websites for 107 countries. MEASUREMENTS: Dependent variables included RN/RM density, maternal mortality ratios (MMR), and adolescent birth rates (ABR). Independent variables included gender inequality, region, country income classification, education, gross domestic product per capita, government expenditure of spending on education and health, life expectancy, percent of female seats in legislature, and labor force participation factors. RESULTS: The best fit multivariable model of RN/RM density showed that after adjustment for region, country income and the GII, the percent of females with some secondary education explained most of variation in RN/RM density. The best fit models of MMR and ABR showed that gender inequality explained most of the variation. Other factors in the models were the percent of female seats in legislatures, region, country income class, and mean years of schooling. CONCLUSIONS: Employing a social ecology model can useful in RN/RM workforce planning and development as countries seek multisectoral strategies for increasing the RN/RM supply and improving reproductive health outcomes.

Cost-benefit analysis of a population-based education program on the wise use of antibiotics.

OBJECTIVE: In 2005, the Do Bugs Need Drugs (DBND) program was imported to British Columbia (BC) from Alberta with the goal of reducing unnecessary antibiotic use in the community. The objective of this study was to estimate the impact of the program on antibiotic-associated costs and cost-benefit. METHODS: We used data on antibiotic prescription and costs from BC PharmaNet for the period of 1996 to 2014. We conducted interrupted time series regression to formally interpret the impact of the DBND program. RESULTS: The average monthly prescription rate fell by 14.5%, from 54.3 to 46.4 per 1000 population between 2005 and 2014. The proportionate contribution of macrolide prescription decreased from 19.2% in 2005 to 13.2% in 2014 and for quinolones decreased from 13.1% in 2005 to 12% in 2014. The proportion of prescriptions for both penicillins and tetracyclines increased by > 35.5%. Before the program, the average monthly cost of antibiotics was increasing by CAD $8.12 per 1000 population (p < 0.001). After program introduction, average monthly cost decreased by CAD $18.19 per 1000 population (p < 0.001), creating an annual savings for BC in 2014 of CAD $83.6 million. In 2014, one Canadian dollar spent on the DBND program was associated with conservative savings of CAD $76.20. CONCLUSION: Significant cost savings have been observed in association with a community antimicrobial stewardship program focused on both public and prescribers. Such programs are an effective strategy in cost-benefit terms and should therefore be considered for universal adoption in Canadian healthcare systems.

Effects of adding psychosocial stimulation for children of lactating mothers using an unconditional cash transfer platform on neurocognitive behavior of children in rural Bangladesh: protocol for a cluster randomized controlled trial.

BACKGROUND: There is sufficient evidence that psychosocial stimulation (PS) benefits children's neurocognitive behavior, however, there is no information on how it works when delivered through an Unconditional Cash Transfer (UCT) platform for poor rural population in developing countries. The objective of this study is to measure effects of adding PS for children of lactating mothers enrolled to receive UCT with health education (HE) on neurocognitive behavior of children in rural Bangladesh. METHODS: The study will be conducted at 11 unions of Ullapara sub-district in Bangladesh. The study is a cluster randomized controlled trial with three-arms; (i) PS and UCT with HE (ii) UCT with HE and iii) Comparison arm. The cluster will be considered as an old Ward of a Union, the lowest tier of local government system in rural Bangladesh. There are three old Wards in a union. These three clusters will be randomized to one of the three arms. Similarly, randomization will be done for each 11 Unions and then 11 clusters will be assigned to an arm. Eighteen participants will be recruited from each cluster randomly (n = 196 in each arm). The intervention designed for one year includes UCT with HE for the poor as a safety net program in rural Bangladesh with or without PS. An age-based curriculum of PS is already available for Bangladeshi children and this will be administered by trained local women; play leaders (PL) in intervention clusters. The government of Bangladesh is providing UCT of taka 500 ($6.25) as maternity allowance per month with HE. The primary outcomes will be cognitive, motor and language composite scores measured by Bayley-III and behavior using Wolke's behavior rating scale. The secondary outcomes will be children and mothers' growth, family food security status, health seeking behavior, mothers' depressive symptoms and self-esteem and violence against mothers. DISCUSSION: The study will provide a unique opportunity to assess an integrated early childhood development intervention using UCT platform to mitigate developmental delays in poor vulnerable children of rural Bangladesh. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT03281980, registered on September 13, 2017.

Effectiveness of antimalarial interventions in Nigeria: Evidence from facility-level longitudinal data.

OBJECTIVE: To evaluate the effectiveness of a program of antimalarial interventions implemented in 2010-2013 in Niger State, Nigeria. DATA SOURCES: Utilization reports from 99 intervention and 51 non-intervention health facilities from the Niger State Malaria Elimination Program, supplemented by data on facility-level characteristics from the Niger State Primary Health Care Development Agency and Local Government Malaria Control units. STUDY DESIGN: Estimated with mixed-effects negative binomial modeling, a difference-in-differences method was used to quantify the impact of the program on the number of febrile illness cases and confirmed malaria cases. Potential confounding factors, non-stationarity, seasonality, and autocorrelation were explicitly accounted for. DATA EXTRACTION METHODS: Data were retrieved from hard copies of utilization reports and manually inputted to create a panel of 5550 facility-month observations. PRINCIPAL FINDINGS: The program was implemented in two phases. The first phase (August 2010-June 2012) involved the provision of free artemisinin-based combination therapies, long-lasting insecticidal nets, and intermittent preventive treatments. In the second phase (July 2012-March 2013), the program introduced an additional intervention: free parasite-based rapid diagnostic tests. Compared to the pre-intervention period, the average number of monthly febrile illness and malaria cases increased by 20.876 (P < 0.01) and 22.835 (P < 0.01) in the first phase, and by 19.007 (P < 0.05) and 19.681 (P < 0.05) in the second phase, respectively. The results are consistent across different evaluation methods. CONCLUSIONS: This study suggests that user-fee removal leads to increased utilization of antimalarial services. It motivates future studies to cautiously select their investigative methods.

A systematic review of portable electronic technology for health education in resource-limited settings.

OBJECTIVE: The objective of this study is to conduct a systematic review of the literature of how portable electronic technologies with offline functionality are perceived and used to provide health education in resource-limited settings. METHODS: Three reviewers evaluated articles and performed a bibliography search to identify studies describing health education delivered by portable electronic device with offline functionality in low- or middle-income countries. Data extracted included: study population; study design and type of analysis; type of technology used; method of use; setting of technology use; impact on caregivers, patients, or overall health outcomes; and reported limitations. RESULTS: Searches yielded 5514 unique titles. Out of 75 critically reviewed full-text articles, 10 met inclusion criteria. Study locations included Botswana, Peru, Kenya, Thailand, Nigeria, India, Ghana, and Tanzania. Topics addressed included: development of healthcare worker training modules, clinical decision support tools, patient education tools, perceptions and usability of portable electronic technology, and comparisons of technologies and/or mobile applications. Studies primarily looked at the assessment of developed educational modules on trainee health knowledge, perceptions and usability of technology, and comparisons of technologies. Overall, studies reported positive results for portable electronic device-based health education, frequently reporting increased provider/patient knowledge, improved patient outcomes in both quality of care and management, increased provider comfort level with technology, and an environment characterized by increased levels of technology-based, informal learning situations. Negative assessments included high investment costs, lack of technical support, and fear of device theft. CONCLUSIONS: While the research is limited, portable electronic educational resources present promising avenues to increase access to effective health education in resource-limited settings, contingent on the development of culturally adapted and functional materials to be used on such devices.

Comparing the Effectiveness of Brief Versus In-Depth Gatekeeper Training on Behavioral Outcomes for Trainees.

BACKGROUND: A common suicide prevention strategy is training gatekeepers to identify at-risk individuals and refer them to services. AIMS: The study aimed to examine whether differences in training outcomes were observed for brief versus in-depth gatekeeper trainings for trainees from varied professional settings while controlling for differences in trainee characteristics and community context. METHOD: Trainees' identification and referral behavior 3 months after gatekeeper training was compared with a sample of respondents matched on individual- and community-level variables using propensity score-based techniques. The value was estimated, in terms of additional identification and associated costs, of adopting in-depth training. RESULTS: A higher proportion of trainees who participated in in-depth trainings from K-12 and community settings identified at-risk youth, and a higher proportion of in-depth trainees from mental health settings referred youth to services compared with participants of brief trainings from the same setting and with similar characteristics. The effect of training type on outcomes varied by professional role and community context. LIMITATIONS: Self-report measures were used to assess outcomes. Similar measures are used in other studies; their validity has not been conclusively established. CONCLUSION: Findings suggest certain individuals may benefit from in-depth training more than others, which favors targeting this intervention to particular gatekeepers.

Health, financial, and education gains of investing in preventive chemotherapy for schistosomiasis, soil-transmitted helminthiases, and lymphatic filariasis in Madagascar: A modeling study.

BACKGROUND: Neglected tropical diseases (NTDs) account for a large disease burden in sub-Saharan Africa. While the general cost-effectiveness of NTD interventions to improve health outcomes has been assessed, few studies have also accounted for the financial and education gains of investing in NTD control. METHODS: We built on extended cost-effectiveness analysis (ECEA) methods to assess the health gains (e.g. infections, disability-adjusted life years or DALYs averted), household financial gains (out-of-pocket expenditures averted), and education gains (cases of school absenteeism averted) for five NTD interventions that the government of Madagascar aims to roll out nationally. The five NTDs considered were schistosomiasis, lymphatic filariasis, and three soil-transmitted helminthiases (Ascaris lumbricoides, Trichuris trichiura, and hookworm infections). RESULTS: The estimated incremental cost-effectiveness for the roll-out of preventive chemotherapy for all NTDs jointly was USD125 per DALY averted (95% uncertainty range: 65-231), and its benefit-cost ratio could vary between 5 and 31. Our analysis estimated that, per dollar spent, schistosomiasis preventive chemotherapy, in particular, could avert a large number of infections (176,000 infections averted per $100,000 spent), DALYs (2,000 averted per $100,000 spent), and cases of school absenteeism (27,000 school years gained per $100,000 spent). CONCLUSION: This analysis incorporates financial and education gains into the economic evaluation of health interventions, and therefore provides information about the efficiency of attainment of three Sustainable Development Goals (SDGs). Our findings reveal how the national scale-up of NTD control in Madagascar can help address health (SDG3), economic (SDG1), and education (SDG4) goals. This study further highlights the potentially large societal benefits of investing in NTD control in low-resource settings.