'That is because we are alone': A relational qualitative study of socio-spatial inequities in maternal and newborn health programme coverage in rural Uttar Pradesh, India.

This qualitative study was conducted in Uttar Pradesh state, India to explore how interrelated socio-economic position and spatial characteristics of four diverse villages may have influenced equity in coverage of community-based maternal and newborn health (MNH) services. We conducted social mapping and three focus group discussions in each village, among women of lower and higher socio-economic position who recently gave birth, and with community health workers (n = 134). Data were analysed in NVivo 11.0 using thematic framework analysis. The extent of socio-economic hierarchies and spatial disparateness within the village, combined with distance to larger centers, together shaped villages' level of socio-spatial remoteness. Disadvantaged socio-economic groups expressed being more often spatially isolated, with less access to infrastructure, resources or services, which was heightened if the village was physically distant from larger centers. In more socio-spatially remote villages, inequities in coverage of MNH services that disadvantaged lower socio-economic position groups were compounded as these groups more often experienced ASHA vacancies, as well as greater distance to and poorer perceived quality of health services nearest the village. The results inform a conceptual framework of 'socio-spatial remoteness' that can guide public health research and programmes to more comprehensively address health inequities within India and beyond.

Childhood obesity's influence on socioeconomic disparities in young adolescents' mental health.

PURPOSE: We investigated whether socioeconomic inequalities in young adolescents' mental health are partially due to the unequal distribution of childhood obesity across socioeconomic positions (SEP), i.e. differential exposure, or due to the effect of obesity on mental health being more detrimental among certain SEPs, i.e. differential impact. METHODS: We studied 4660 participants of the Generation R study, a population-based study in the Netherlands. SEP was estimated by mother's education and household income at age five of the child. We estimated the contribution of the mediating and moderating effects of high body fat percentage to the disparity in mental health. This was done through a four-way decomposition using marginal structural models with inverse probability of treatment weighting. RESULTS: Comparing children with the least to most educated mothers and the lowest to highest household income, the total disparity in emotional problems was 0.98 points (95%CI:0.35-1.63) and 1.68 points (95%CI:1.13-2.19), respectively. Of these total disparities in emotional problems, 0.50 points (95%CI:0.15-0.85) and 0.24 points (95%CI:0.09-0.46) were due to the differential exposure to obesity. Obesity did not contribute to disparities in behavioural problems. CONCLUSION: Addressing the heightened obesity prevalence among children in low SEP families may reduce inequalities in emotional problems in early adolescence.

Climate distress, climate-sensitive risk factors, and mental health among Tanzanian youth: a cross-sectional study.

BACKGROUND: Climate change threatens youth mental health through multiple mechanisms, yet empirical studies typically focus on single pathways. We explored feelings of distress over climate change among Tanzanian youth, considering associations with climate change awareness and climate-sensitive risk factors, and assessed how these factors relate to mental health. METHODS: Tanzanian youth (aged 18-23 years) from a cluster randomised controlled trial in Mbeya and Iringa regions of Tanzania were interviewed between Jan 25, and March 3, 2021, and included in this cross-sectional study. A threshold of at least 10 on the ten-item Centre for Epidemiological Studies Depression Scale was used to classify symptom severity indicative of depression. Regardless of climate change awareness, respondents were asked about their feelings of distress on climate change using inclusive language (changing weather patterns or changing seasons). We estimated rate differences in climate change distress (slight or moderate or extreme vs none) by youth characteristics, extent of climate awareness, and climate-sensitive livelihoods (eg, agriculture, tending livestock) and climate-sensitive living conditions (eg, food or water insecurity), using generalised linear models. We compared depression prevalence by extent of climate change distress and climate-sensitive living conditions. FINDINGS: Among 2053 youth (1123 [55%] were male and 930 [45%] were female) included in this analysis, 946 (46%) had reported any distress about climate change. Distress was higher among female, more educated, more religious, older youth, and those working in extreme temperatures. Adjusting for climate awareness-a factor strongly associated with climate distress-helped to explain some of these associations. Depression was 23 percentage points (95% CI 17-28) higher among youth who had severe water insecurity than those who did not. Similarly, youth who had severe food insecurity had 23 percentage points higher depression (95% CI 17-28) compared with those who did not. Those reporting climate change distress also had worse mental health-extremely distressed youth had 18 percentage points (95% CI 6-30) higher depression than those reporting none. INTERPRETATION: Living in conditions worsened by climate change and feeling distressed over climate change have mental health implications among young people from low-resource settings, indicating that climate change can impact youth mental health through multiple pathways. FUNDING: Erasmus Trustfonds, Centre for Global Health Inequalities Research, UK's Foreign, Commonwealth, and Development Office, Oak Foundation, UNICEF, UK's Department of International Development, the Swedish Development Cooperation Agency, Irish Aid.

Economic evaluation of participatory women's groups scaled up by the public health system to improve birth outcomes in Jharkhand, eastern India.

An estimated 2.4 million newborn infants died in 2020, 80% of them in sub-Saharan Africa and South Asia. To achieve the Sustainable Development Target for neonatal mortality reduction, countries with high mortality need to implement evidence-based, cost-effective interventions at scale. Our study aimed to estimate the cost, cost-effectiveness, and benefit-cost ratio of a participatory women's groups intervention scaled up by the public health system in Jharkhand, eastern India. The intervention was evaluated through a pragmatic cluster non-randomised controlled trial in six districts. We estimated the cost of the intervention at scale from a provider perspective, with a 42-month time horizon for 20 districts. We estimated costs using a combination of top-down and bottom-up approaches. All costs were adjusted for inflation, discounted at 3% per year, and converted to 2020 International Dollars (INT$). Incremental cost-effectiveness ratios (ICERs) were estimated using extrapolated effect sizes for the impact of the intervention in 20 districts, in terms of cost per neonatal deaths averted and cost per life year saved. We assessed the impact of uncertainty on results through one-way and probabilistic sensitivity analyses. We also estimated benefit-cost ratio using a benefit transfer approach. Total intervention costs for 20 districts were INT$ 15,017,396. The intervention covered an estimated 1.6 million livebirths across 20 districts, translating to INT$ 9.4 per livebirth covered. ICERs were estimated at INT$ 1,272 per neonatal death averted or INT$ 41 per life year saved. Net benefit estimates ranged from INT$ 1,046 million to INT$ 3,254 million, and benefit-cost ratios from 71 to 218. Our study suggests that participatory women's groups scaled up by the Indian public health system were highly cost-effective in improving neonatal survival and had a very favourable return on investment. The intervention can be scaled up in similar settings within India and other countries.

Moderators of an intervention on emotional and behavioural problems: household- and school-level parental education.

BACKGROUND: Children of lower-educated parents and children in schools with a relatively high percentage of peers with lower-educated parents (lower parental education schools) are more likely to develop emotional and behavioural problems compared to children in higher-educated households and schools. Universal school-based preventive interventions, such as the Good Behaviour Game (GBG), are generally effective in preventing the development of emotional and behavioural problems, but information about potential moderators is limited. This study examined whether the effectiveness of the GBG in preventing emotional and behavioural problems differs between children in lower- and higher-educated households and schools. METHODS: Using a longitudinal multi-level randomized controlled trial design, 731 children (Mage=6.02 towards the end of kindergarten) from 31 mainstream schools (intervention arm: 21 schools, 484 children; control arm: 10 schools, 247 children) were followed annually from kindergarten to second grade (2004-2006). The GBG was implemented in first and second grades. RESULTS: Overall, the GBG prevented the development of emotional and behavioural problems. However, for emotional problems, the GBG-effect was slightly more pronounced in higher parental education schools than in lower parental education schools (Bhigher parental education schools =-0.281, P <0.001; Blower parental education schools =-0.140, P = 0.016). No moderation by household-level parental education was found. CONCLUSIONS: Studies into universal school-based preventive interventions, and in particular the GBG, should consider and incorporate school-level factors when studying the effectiveness of such interventions. More attention should be directed towards factors that may influence universal prevention effectiveness, particularly in lower parental education schools.

Children's behavioral and emotional problems and peer relationships across elementary school: Associations with individual- and school-level parental education.

This study examined (a) whether growing up with lower-educated parents and attending lower parental education schools associated with children's problem development within the behavioral, emotional, and peer relationship domains; and (b) whether the association of lower individual-level parental education with children's development within these three domains depended upon school-level parental education. To this end, 698 children (Mage = 7.08 in first grade) from 31 mainstream elementary schools were annually followed from first grade to sixth grade. Problems within the behavioral domain included conduct problems, oppositional defiant problems, attention-deficit and hyperactivity problems, and aggression. Problems within the emotional domain included depression and anxiety symptoms. Problems within the peer relationship domain included physical victimization, relational victimization, and peer dislike. Results from multi-level latent growth models showed that, as compared to children of higher-educated parents, children of lower-educated parents generally had higher levels of problems within all three domains in first grade and exhibited a faster growth rate of problems within the behavioral domain from first to sixth grade. Furthermore, as compared to children attending higher parental education schools, children attending lower parental education schools generally had higher levels of problems within the behavioral and emotional domains in first grade and showed a faster growth rate of peer dislike over time. In addition, cross-level interaction analyses showed that in higher parental education schools, children of lower-educated parents showed a faster growth rate of depression symptom levels than children of higher-educated parents. In lower parental education schools, the growth rate of depression symptom levels did not differ between children of higher- and lower-educated parents. Results highlight that addressing the needs of lower parental education schools and children growing up with lower-educated parents may be of primary importance.

Trajectories of socioeconomic inequality in early child development: a cohort analysis.

BACKGROUND: Addressing socioeconomic inequalities in early child development (ECD) is key to reducing the intergenerational transmission of health inequalities. Yet, little is known about how socioeconomic inequalities in ECD develop over the course of childhood. Our study aimed to describe how inequalities in ECD by maternal education develop from infancy to middle childhood. METHODS: We used data from Generation R, a prospective population-based cohort study in The Netherlands. Language skills were measured at ages 1, 1.5, 2, 3, and 4 years, using the Minnesota Child Development Inventory. Socioemotional (i.e. internalizing and externalizing) problems were measured at ages 1.5, 3, 5 and 9 years using the Child Behavior Checklist. We estimated inequalities in language skills and socioemotional problems across the above-mentioned ages, using linear mixed models with standardized scores at each wave. We used maternal education as indicator of socioeconomic position. RESULTS: Children of less educated mothers had more reported internalizing (B = 0.72, 95%CI = 0.51;0.95) and externalizing (B = 0.25, 95%CI = 0.10;0.40) problems at age 1.5 years, but better (caregiver reported) language skills at 1 year (B = 0.50, 95%CI = 0.36;0.64) than children of high educated mothers. Inequalities in internalizing and externalizing problems decreased over time. Inequalities in language scores reversed at age 2, and by the time children were 4 years old, children of less educated mothers had substantially lower language skills than children of high educated mothers (B = -0.38, 95%CI = -0.61;-0.15). CONCLUSIONS: Trajectories of socioeconomic inequality in ECD differ by developmental domain: whereas inequalities in socioemotional development decreased over time, inequalities increased for language development. Children of less educated mothers are at a language disadvantage even before entering primary education, providing further evidence that early interventions are needed.

Effects of Adolescent-Focused Integrated Social Protection on Depression: A Pragmatic Cluster-Randomized Controlled Trial of Tanzania's Cash Plus Intervention.

We assessed the impacts of Tanzania's adolescent-focused Cash Plus intervention on depression. In this pragmatic cluster-randomized controlled trial, 130 villages were randomly allocated to an intervention or control arm (1:1). Youth aged 14-19 years living in households receiving governmental cash transfers were invited to participate. The intervention included an intensive period (a 12-session course) and an aftercare period (9 months of mentoring, productive grants, and strengthened health services). We examined intervention impacts on a depressive symptoms scale (10-item Center for Epidemiologic Studies Depression Scale score (range, 0-30)) and rates of depressive symptomatology (score ≥10 points on the scale), recorded at study baseline (April-June 2017), midline (May-July 2018), and endline (June-August 2019). Using intention-to-treat methodology, we employed logistic and generalized linear models to estimate effects for binary and continuous outcomes, respectively. Quantile regression was used to estimate effects across the scale. From 2,458 baseline participants, 941 intervention and 992 control adolescents were reinterviewed at both follow-ups. At endline, the intervention reduced the odds of depressive symptomatology (adjusted odds ratio = 0.67, 95% confidence interval: 0.52, 0.86), with an undetectable mean scale difference (risk difference = -0.36, 95% confidence interval: -0.84, 0.11). Quantile regression results demonstrated an intervention effect along the upper distribution of the scale. Integration of multisectoral initiatives within existing social protection systems shows potential to improve mental health among youth in low-resource settings.

Socioeconomic inequalities in stillbirth and neonatal mortality rates: evidence on Particularly Vulnerable Tribal Groups in eastern India.

BACKGROUND: Tribal peoples are among the most marginalised groups worldwide. Evidence on birth outcomes in these groups is scant. We describe inequalities in Stillbirth Rate (SBR), Neonatal Mortality Rate (NMR), and uptake of maternal and newborn health services between tribal and less disadvantaged groups in eastern India, and examine the contribution of poverty and education to these inequalities. METHODS: We used data from a demographic surveillance system covering a 1 million population in Jharkhand State (March 2017 - August 2019) to describe SBR, NMR, and service uptake. We used logistic regression analysis combined with Stata's adjrr-command to estimate absolute and relative inequalities by caste/tribe (comparing Particularly Vulnerable Tribal Groups (PVTG) and other Scheduled Tribes (ST) with the less marginalised Other Backward Class (OBC)/none, using the Indian government classification), and by maternal education and household wealth. RESULTS: PVTGs had a higher NMR (59/1000) than OBC/none (31/1000) (rate ratio (RR): 1.92, 95%CI: 1.55-2.38). This was partly explained by wealth and education, but inequalities remained large after adjustment (adjusted RR: 1.59, 95%CI: 1.28-1.98). NMR was also higher among other STs (44/1000), but disparities were smaller (RR: 1.47, 95%CI: 1.23-1.75). There was a systematic gradient in NMR by maternal education and household wealth. SBRs were only higher in poorer groups (RRpoorest vs. least poor:1.56, 95%CI: 1.14-2.13). Uptake of facility-based services was low among PVTGs (e.g. institutional birth: 25% vs. 69% in OBC/none) and among poorer and less educated women. However, 65% of PVTG women with an institutional birth used a maternity vehicle vs. 34% among OBC/none. Visits from frontline workers (Accredited Social Health Activists [ASHAs]) were similar across groups, and ASHA accompaniment of institutional births was similar across caste/tribe groups, and higher among poorer and less educated women. Attendance in participatory women's groups was similar across caste/tribe groups, and somewhat higher among richer and better educated women. CONCLUSIONS: PVTGs are highly disadvantaged in terms of birth outcomes. Targeted interventions that reduce geographical barriers to facility-based care and address root causes of high poverty and low education in PVTGs are a priority. For population-level impact, they are to be combined with broader policies to reduce socio-economic mortality inequalities. Community-based interventions reach disadvantaged groups and have potential to reduce the mortality gap.

Do Conditional Cash Transfers Improve Mental Health? Evidence From Tanzania's Governmental Social Protection Program.

PURPOSE: Cash transfer interventions broadly improve the lives of the vulnerable, making them exceedingly popular. However, evidence of impacts on mental health is limited, particularly for conditional cash transfer (CCT) programs. We examined the impacts of Tanzania's government-run CCT program on depressive symptoms of youth aged 14-28. METHODS: We utilized cluster randomized controlled trial data of 84 communities (48 intervention; 36 control). The intervention administered bimonthly CCTs to eligible households, while control communities were assigned to delayed intervention. The analysis included youth with measurements of depression (10-item Centre for Epidemiological Studies Depression Scale) at baseline and 18 months later. We determined impacts using analysis of covariance models, adjusting for youth characteristics (including baseline depression), district-level fixed effects, and community-level random effects. Differential effects by sex and baseline social support were also estimated. RESULTS: Although no evidence was found to suggest that the intervention impacted depressive symptoms among the full sample (n = 880) (effect -.20, 95% confidence interval [CI] -.88 to .48, p = .562), subsample results indicated that depressive symptoms were reduced 1.5 points among males (95% CI -2.56 to -.04, p = .007) and increased 1.1 points among females (95% CI .11-2.09, p = .029). Females 18+ years old (effect 1.55, 95% CI .27-2.83, p = .018) and females with children (effect 1.32, 95% CI -.13 to 2.78, p = .074) drove this negative impact. Social support did not moderate impacts. CONCLUSIONS: Despite no overall intervention effects, results suggest that receiving a CCT has differential effects on mental health by sex. Although males benefited from the intervention, conditions which rely on stereotypically female roles may result in negative consequences among women.

Associations between community health workers' home visits and education-based inequalities in institutional delivery and perinatal mortality in rural Uttar Pradesh, India: a cross-sectional study.

INTRODUCTION: India's National Health Mission has trained community health workers called Accredited Social Health Activists (ASHAs) to visit and counsel women before and after birth. Little is known about the extent to which exposure to ASHAs' home visits has reduced perinatal health inequalities as intended. This study aimed to examine whether ASHAs' third trimester home visits may have contributed to equitable improvements in institutional delivery and reductions in perinatal mortality rates (PMRs) between women with varying education levels in Uttar Pradesh (UP) state, India. METHODS: Cross-sectional survey data were collected from a representative sample of 52 615 women who gave birth in the preceding 2 months in rural areas of 25 districts of UP in 2014-2015. We analysed the data using generalised linear modelling to examine the associations between exposure to home visits and education-based inequalities in institutional delivery and PMRs. RESULTS: Third trimester home visits were associated with higher institutional delivery rates, in particular public facility delivery rates (adjusted risk ratio (aRR) 1.32, 95% CI 1.30 to 1.34), and to a lesser extent private facility delivery rates (aRR 1.09, 95% CI 1.04 to 1.13), after adjusting for confounders. Associations were stronger among women with lower education levels. Having no compared with any third trimester home visits was associated with higher perinatal mortality (aRR 1.18, 95% CI 1.09 to 1.28). Having any versus no visits was more highly associated with lower perinatal mortality among women with lower education levels than those with the most education, and most notably among public facility births. CONCLUSIONS: The results suggest that ASHAs' home visits in the third trimester contributed to equitable improvements in institutional deliveries and lower PMRs, particularly within the public sector. Broader strategies must reinforce the role of ASHAs' home visits in reaching the sustainable development goals of improving maternal and newborn health and leaving no one behind.

Understanding the roles of community health workers in improving perinatal health equity in rural Uttar Pradesh, India: a qualitative study.

BACKGROUND: Despite substantial reductions in perinatal deaths (stillbirths and early neonatal deaths), India's perinatal mortality rates remain high, both nationally and in individual states. Rates are highest among disadvantaged socio-economic groups. To address this, India's National Health Mission has trained community health workers called Accredited Social Health Activists (ASHAs) to counsel and support women by visiting them at home before and after childbirth. We conducted a qualitative study to explore the roles of ASHAs' home visits in improving equity in perinatal health between socio-economic position groups in rural Uttar Pradesh (UP), India. METHODS: We conducted social mapping in four villages of two districts in UP, followed by three focus group discussions in each village (12 in total) with ASHAs and women who had recently given birth belonging to 'higher' and 'lower' socio-economic position groups (n = 134 participants). We analysed the data in NVivo and Dedoose using a thematic framework approach. RESULTS: Home visits enabled ASHAs to build trusting relationships with women, offer information about health services, schemes and preventive care, and provide practical support for accessing maternity care. This helped many women and families prepare for birth and motivated them to deliver in health facilities. In particular, ASHAs encouraged women who were poorer, less educated or from lower caste groups to give birth in public Community Health Centres (CHCs). However, women who gave birth at CHCs often experienced insufficient emergency obstetric care, mistreatment from staff, indirect costs, lack of medicines, and referrals to higher-level facilities when complications occurred. Referrals often led to delays and higher fees that placed the greatest burden on families who were considered of lower socio-economic position or living in remote areas, and increased their risk of experiencing perinatal loss. CONCLUSIONS: The study found that ASHAs built relationships, counselled and supported many pregnant women of lower socio-economic positions. Ongoing inequities in health facility births and perinatal mortality were perpetuated by overlapping contextual issues beyond the ASHAs' purview. Supporting ASHAs' integration with community organisations and health system strategies more broadly is needed to address these issues and optimise pathways between equity in intervention coverage, processes and perinatal health outcomes.

COVID-19 and Tuberculosis-Related Catastrophic Costs.

The COVID-19 pandemic has created an unprecedented health crisis and a substantial socioeconomic impact. It also affects tuberculosis (TB) control severely worldwide. Interruptions of many TB control programs because of the COVID-19 pandemic could result in significant setbacks. One of the targets that can be affected is the WHO's End TB Strategy goal to eliminate catastrophic costs of TB-affected households by 2030. Disruptions to TB programs and healthcare services due to COVID-19 could potentially prolong diagnostic delays and worsen TB treatment adherence and outcomes. The economic recession caused by the pandemic could significantly impact household financial capacity because of the reduction of income and the rise in unemployment rates. All of these factors increase the risk of TB incidence and the gravity of economic impact on TB-affected households, and hamper efforts to eliminate catastrophic costs and control TB. Therefore, efforts to eliminate the incidence of TB-affected households facing catastrophic costs will be very challenging. Because financial constraint plays a significant role in TB control, the improvement of health and social protection systems is critical. Even before the pandemic, many TB-high-burden countries (HBCs) lacked robust health and social protection systems. These challenges highlight the substantial need for a more robust engagement of patients and civil society organizations and international support in addressing the consequences of COVID-19 on the control of TB.

Socioeconomic differences in caesarean section - are they explained by medical need? An analysis of patient record data of a large Kenyan hospital.

BACKGROUND: Caesarean section (C-section) rates are often low among the poor and very high among the better-off in low- and middle-income countries. We examined to what extent these differences are explained by medical need in an African context. METHODS: We analyzed electronic records of 12,209 women who gave birth in a teaching hospital in Kenya in 2014. C-section rates were calculated by socioeconomic position (SEP), using maternal occupation (professional, small business, housewife, student) as indicator. We assessed if women had documented clinical indications according to hospital guidelines and if socioeconomic differences in C-section rates were explained by indication. RESULTS: Indication for C-section according to hospital guidelines was more prevalent among professionals than housewives (16% vs. 9% of all births). The C-section rate was also higher among professionals than housewives (21.1% vs. 15.8% [OR 1.43; 95%CI 1.23-1.65]). This C-section rate difference was largely explained by indication (4.7 of the 5.3 percentage point difference between professionals and housewives concerned indicated C-sections, often with previous C-section as indication). Repeat C-sections were near-universal (99%). 43% of primary C-sections had no documented indication. Over-use was somewhat higher among professionals than housewives (C-section rate among women without indication: 6.6 and 5.5% respectively), which partly explained socioeconomic differences in primary C-section rate. CONCLUSIONS: Socioeconomic differences in C-section rates can be largely explained by unnecessary primary C-sections and higher supposed need due to previous C-section. Prevention of unnecessary primary C-sections and promoting safe trial of labor should be priorities in addressing C-section over-use and reducing inequalities. Unnecessary primary C-sections and ubiquitous repeat C-sections drive overall C-section rates and C-section inequalities.

Cost of seeking care for tuberculosis since the implementation of universal health coverage in Indonesia.

BACKGROUND: Although tuberculosis (TB) patients often incur high costs to access TB-related services, it was unclear beforehand whether the implementation of universal health coverage (UHC) in Indonesia in 2014 would reduce direct costs and change the pattern of care-seeking behaviour. After its introduction, we therefore assessed TB patients' care-seeking behaviour and the costs they incurred for diagnosis, and the determinants of both. METHODS: In this cross sectional study, we interviewed adult TB patients in urban, suburban, and rural districts of Indonesia in July-September 2016. We selected consecutively patients who had been treated for TB in primary health centers for at least 1 month until we reached at least 90 patients in each district. After establishing which direct and indirect costs they had incurred during the pre-diagnostic phase, we calculated the total costs (in US Dollars). To identify the determinants of these costs, we applied a general linear mixed model to adjust for our cluster-sampling design. RESULTS: Ninety-three patients of the 282 included in our analysis (33%) first sought care at a private clinic. The preference for such clinics was higher among those living in the rural district (aOR 1.88, 95% CI 0.85-4.15, P = 0.119) and among those with a low educational level (aOR 1.69, 95% CI 0.92-3.10, P = 0.090). Visiting a private clinic as the first contact also led to more visits (ß 0.90, 95% CI 0.57-1.24, P < 0.001) and higher costs than first visiting a Primary Health Centre, both in terms of direct costs (ß = 16.87, 95%CI 10.54-23.20, P < 0.001) and total costs (ß = 18.41, 95%CI 10.35-26.47, P < 0.001). CONCLUSION: Despite UHC, high costs of TB seeking care remain, with direct medical costs contributing most to the total costs. First seeking care from private providers tends to lead to more pre-diagnostic visits and higher costs. To reduce diagnostic delays and minimize patients' costs, it is essential to strengthen the public-private mix and reduce the fragmented system between the national health insurance scheme and the National TB Programme.

Catastrophic costs due to tuberculosis worsen treatment outcomes: a prospective cohort study in Indonesia.

BACKGROUND: While the incidence of catastrophic costs due to tuberculosis (TB) remains high, there is little evidence about their impact on TB treatment outcomes and adherence. We assessed their effect on treatment outcomes and adherence in Indonesia. METHODS: We interviewed 282 adult TB patients who underwent TB treatment in urban, suburban and rural districts of Indonesia. One year after the interview, we followed up treatment adherence and outcomes. We applied multivariable analysis using generalized linear mixed models. RESULTS: Follow-up was complete for 252/282 patients. Eighteen (7%) patients had unsuccessful treatment and 40 (16%) had poor adherence. At a threshold of 30% of annual household income, catastrophic costs negatively impacted treatment outcomes (adjusted odds ratio [aOR] 4.15 [95% confidence interval {CI} 1.15 to 15.01]). At other thresholds, the associations showed a similar pattern but were not statistically significant. The association between catastrophic costs and treatment adherence is complex because of reverse causation. After adjustment, catastrophic costs negatively affected treatment adherence at the 10% and 15% thresholds (aOR 2.11 [95% CI 0.97 to 4.59], p = 0.059 and aOR 2.06 [95% CI 0.95 to 4.46], p = 0.07). There was no evidence of such an effect at other thresholds. CONCLUSIONS: Catastrophic costs negatively affect TB treatment outcomes and treatment adherence. To eliminate TB, it is essential to mitigate catastrophic costs.

Effects of community health worker interventions on socioeconomic inequities in maternal and newborn health in low-income and middle-income countries: a mixed-methods systematic review.

INTRODUCTION: Community health worker (CHW) interventions are promoted to improve maternal and newborn health in low-income and middle-income countries. We reviewed the evidence on their effectiveness in reducing socioeconomic inequities in maternal and newborn health outcomes, how they achieve these effects, and contextual processes that shape these effects. METHODS: We conducted a mixed-methods systematic review of quantitative and qualitative studies published between 1996 and 2017 in Medline, Embase, Web of Science and Scopus databases. We included studies examining the effects of CHW interventions in low-income and middle-income countries on maternal and newborn health outcomes across socioeconomic groups (wealth, occupation, education, class, caste or tribe and religion). We then conducted a narrative synthesis of evidence. RESULTS: We identified 1919 articles, of which 22 met the inclusion criteria. CHWs facilitated four types of interventions: home visits, community-based groups, cash transfers or combinations of these. Four studies found that CHWs providing home visits or facilitating women's groups had equitable coverage. Four others found that home visits and cash transfer interventions had inequitable coverage. Five studies reported equitable effects of CHW interventions on antenatal care, skilled birth attendance and/or essential newborn care. One study found that a CHW home visit intervention did not reduce wealth inequities in skilled birth attendance. A study of women's groups reported greater reductions in neonatal mortality among lower compared with higher socioeconomic groups. Equity was most improved when CHWs had relevant support for assisting women to improve health practices and access health care within community contexts. CONCLUSION: While current evidence remains limited, particularly for mortality, existing studies suggest that CHW interventions involving home visits, cash transfers, participatory women's groups or multiple components can improve equity in maternal and newborn health. Future mixed-methods research should explore intervention strategies and contextual processes shaping such effects on equity to optimise these efforts.

Exploring the equity impact of a maternal and newborn health intervention: a qualitative study of participatory women's groups in rural South Asia and Africa.

BACKGROUND: A consensus is developing on interventions to improve newborn survival, but little is known about how to reduce socioeconomic inequalities in newborn mortality in low- and middle-income countries. Participatory learning and action (PLA) through women's groups can improve newborn survival and home care practices equitably across socioeconomic strata, as shown in cluster randomised controlled trials. We conducted a qualitative study to understand the mechanisms that led to the equitable impact of the PLA approach across socioeconomic strata in four trial sites in India, Nepal, Bangladesh, and Malawi. METHODS: We conducted 42 focus group discussions (FGDs) with women who had attended groups and women who had not attended, in poor and better-off communities. We also interviewed six better-off women and nine poor women who had delivered babies during the trials and had demonstrated recommended behaviours. We conducted 12 key informant interviews and five FGDs with women's group facilitators and fieldworkers. RESULTS: Women's groups addressed a knowledge deficit in poor and better-off women. Women were engaged through visual learning and participatory tools, and learned from the facilitator and each other. Facilitators enabled inclusion of all socioeconomic strata, ensuring that strategies were low-cost and that discussions and advice were relevant. Groups provided a social support network that addressed some financial barriers to care and gave women the confidence to promote behaviour change. Information was disseminated through home visits and other strategies. The social process of learning and action, which led to increased knowledge, confidence to act, and acceptability of recommended practices, was key to ensuring behaviour change across social strata. These equitable effects were enabled by the accessibility, relevance, and engaging format of the intervention. CONCLUSIONS: Participatory learning and action led to increased knowledge, confidence to act, and acceptability of recommended practices. The equitable behavioural effects were facilitated by the accessibility, relevance, and engaging format of the intervention across socioeconomic groups, and by reaching-out to parts of the population usually not accessed. A PLA approach improved health behaviours across socioeconomic strata in rural communities, around issues for which there was a knowledge deficit and where simple changes could be made at home.

Effect of financial support on reducing the incidence of catastrophic costs among tuberculosis-affected households in Indonesia: eight simulated scenarios.

BACKGROUND: The World Health Organization's End Tuberculosis Strategy states that no tuberculosis (TB)-affected households should endure catastrophic costs due to TB. To achieve this target, it is essential to provide adequate social protection. As only a few studies in many countries have evaluated social-protection programs to determine whether the target is being reached, we assessed the effect of financial support on reducing the incidence of catastrophic costs due to TB in Indonesia. METHODS: From July to September 2016, we interviewed adult patients receiving treatment for TB in 19 primary health centres in urban, sub-urban and rural area of Indonesia, and those receiving multidrug-resistant (MDR) TB treatment in an Indonesian national referral hospital. Based on the needs assessment, we developed eight scenarios for financial support. We assessed the effect of each simulated scenario by measuring reductions in the incidence of catastrophic costs. RESULTS: We analysed data of 282 TB and 64 MDR-TB patients. The incidences of catastrophic costs in affected households were 36 and 83%, respectively. Patients' primary needs for social protection were financial support to cover costs related to income loss, transportation, and food supplements. The optimum scenario, in which financial support would be provided for these three items, would reduce the respective incidences of catastrophic costs in TB and MDR-TB-affected households to 11 and 23%. The patients experiencing catastrophic costs in this scenario would, however, have to pay high remaining costs (median of USD 910; [interquartile range (IQR) 662] in the TB group, and USD 2613; [IQR 3442] in the MDR-TB group). CONCLUSIONS: Indonesia's current level of social protection is not sufficient to mitigate the socioeconomic impact of TB. Financial support for income loss, transportation costs, and food-supplement costs will substantially reduce the incidence of catastrophic costs, but financial support alone will not be sufficient to achieve the target of 0% TB-affected households facing catastrophic costs. This would require innovative social-protection policies and higher levels of domestic and external funding.

The equity impact of community women's groups to reduce neonatal mortality: a meta-analysis of four cluster randomized trials.

BACKGROUND: Socioeconomic inequalities in neonatal mortality are substantial in many developing countries. Little is known about how to address this problem. Trials in Asia and Africa have shown strong impacts on neonatal mortality of a participatory learning and action intervention with women's groups. Whether this intervention also reduces mortality inequalities remains unknown. We describe the equity impact of this women's groups intervention on the neonatal mortality rate (NMR) across socioeconomic strata. METHODS: We conducted a meta-analysis of all four participatory women's group interventions that were shown to be highly effective in cluster randomized trials in India, Nepal, Bangladesh and Malawi. We estimated intervention effects on NMR and health behaviours for lower and higher socioeconomic strata using random effects logistic regression analysis. Differences in effect between strata were tested. RESULTS: Analysis of 69120 live births and 2505 neonatal deaths shows that the intervention strongly reduced the NMR in lower (50-63% reduction depending on the measure of socioeconomic position used) and higher (35-44%) socioeconomic strata. The intervention did not show evidence of 'elite-capture': among the most marginalized populations, the NMR in intervention areas was 63% lower [95% confidence interval (CI) 48-74%] than in control areas, compared with 35% (95% CI: 15-50%) lower among the less marginalized in the last trial year (P-value for difference between most/less marginalized: 0.009). The intervention strongly improved home care practices, with no systematic socioeconomic differences in effect. CONCLUSIONS: Participatory women's groups with high population coverage benefit the survival chances of newborns from all socioeconomic strata, and perhaps especially those born into the most deprived households.