Stagnation of maternal mortality decline in Bangladesh between 2010 and 2016 in spite of an increase in health services utilisation: Examining data from three large cross-sectional surveys.

Background: After a 40% reduction in maternal mortality ratio (MMR) during 2001-2010 in Bangladesh, the MMR level stagnated between 2010 and 2016 despite a steady increase in maternal health services use and improvements in overall socioeconomic status. We revisited the factors that contributed to MMR decline during 2001-2010 and examined the changes in these factors between 2010 and 2016 to explain the MMR stagnation in Bangladesh. Methods: We used data from the 2001, 2010, and 2016 Bangladesh Maternal Mortality Surveys, which sampled 566 115 households in total, to estimate the changes in the risk of dying of maternal causes associated with a pregnancy or birth between 2001-2010 and 2010-2016. We carried out Poisson regression analyses with random effects at the sub-district level to explore the relationship between the change in risk of maternal death from 2001 to 2016 and a range of demographic, socioeconomic, and health care factors. Results: Between 2001 and 2016, the proportion of high-risk pregnancies decreased, except for teenage pregnancies. Meanwhile, there were notable improvements in socioeconomic status, access to health services, and the utilisation of maternal health services. A comparison of factors affecting the risk of maternal death between 2001-2010 and 2010-2016 indicated that first pregnancies continued to offer significant protection against maternal deaths. However, subsequent pregnancies among girls under 20 years became a significant risk factor during 2010-2016, increasing the risk of maternal deaths by nearly 3-fold. Among the key maternal health services, only skilled birth attendants (SBA) were identified as a key contributor to MMR reduction during 2001-2010. However, SBA is no longer significantly associated with reducing mortality risk during 2010-2016. Conclusions: Despite continued improvements in the overall socioeconomic status and access to maternal health services in Bangladesh, the stagnation of MMR decline between 2010 and 2016 is associated with multiple teenage pregnancies and the lack of capacity in health facilities to provide quality delivery services, as SBA has been primarily driven by facility delivery. The findings provide a strong rationale for targeting at-risk mothers and strengthening reproductive health services, including family planning, to further reduce maternal mortality in Bangladesh.

The efficacy and safety of endoscopic sphincterotomy in patients with Sphincter of Oddi dysfunction: a systematic review and meta-analysis.

OBJECTIVE: Sphincter of Oddi dysfunction (SOD) has been used to describe patients with RUQ abdominal pain without an etiology. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of ES (endoscopic sphincterotomy) for SOD. METHODS: The study methodology follows the PRISMA guidelines. A comprehensive search was conducted using MEDLINE and EMBASE databases for RCTs with ES in patients with SOD. The primary outcome assessed was the improvement of abdominal pain after ES/sham. A random effects model was used to calculate pooled estimates for each outcome of interest. RESULTS: Of the initial 55 studies, 23 were screened and thoroughly reviewed. The final analysis included 3 studies. 340 patients (89.7% women) with SOD were included. All patients had a cholecystectomy. Most included patients had SOD type II and III. The pooled rate of technical success of ERCP was 100%. The average clinical success rate was 50%. The pooled cumulative rate of overall AEs related to all ERCP procedures was 14.6%. In the sensitivity analysis, only one study significantly affected the outcome or the heterogeneity. CONCLUSION: ES appears no better than placebo in patients with SOD type III. Sphincterotomy could be considered in patients with SOD type II and elevated SO basal pressure.

Estimating the effects of COVID-19 on essential health services utilization in Uganda and Bangladesh using data from routine health information systems.

Background: Since March 2020, the coronavirus disease 2019 (COVID-19) pandemic has been a major shock to health systems across the world. We examined national usage patterns for selected basic, essential health services, before and during the COVID-19 pandemic in Uganda and Bangladesh, to determine whether COVID-19 affected reporting of service utilization and the use of health services in each country. Methods: We used routine health information system data since January 2017 to analyze reporting and service utilization patterns for a variety of health services. Using time series models to replicate pre-COVID-19 trajectories over time we estimated what levels would have been observed if COVID-19 had not occurred during the pandemic months, starting in March 2020. The difference between the observed and predicted levels is the COVID-19 effect on health services. Results: The time trend models for Uganda and Bangladesh closely replicated the levels and trajectories of service utilization during the 38 months prior to the COVID-19 pandemic. Our results indicate that COVID-19 had severe effects across all services, particularly during the first months of the pandemic, but COVID-19 impacts on health services and subsequent recovery varied by service type. In general, recovery to expected levels was slow and incomplete across the most affected services. Conclusion: Our analytical approach based on national information system data could be very useful as a form of surveillance for health services disruptions from any cause leading to rapid responses from health service managers and policymakers.

Area-specific covid-19 effects on health services utilization in the Democratic Republic of the Congo using routine health information system data.

BACKGROUND: Since March 2020, the COVID-19 pandemic has shocked health systems worldwide. This analysis investigated the effects of the pandemic on basic health services utilization in the Democratic Republic of the Congo (DRC) and examined the variability of COVID effects in the capital city Kinshasa, in other urban areas, and in rural areas. METHODS: We estimated time trends models using national health information system data to replicate pre-COVID-19 (i.e., January 2017-February 2020) trajectories of health service utilization, and then used those models to estimate what the levels would have been in the absence of COVID-19 during the pandemic period, starting in March 2020 through March 2021. We classified the difference between the observed and predicted levels as the effect of COVID-19 on health services. We estimated 95% confidence intervals and p-values to examine if the effect of the pandemic, nationally and within specific geographies, was statistically significant. RESULTS: Our results indicate that COVID-19 negatively impacted health services and subsequent recovery varied by service type and by geographical area. COVID-19 had a lasting impact on overall service utilization as well as on malaria and pneumonia-related visits among young children in the DRC. We also found that the effects of COVID-19 were even more immediate and stronger in the capital city of Kinshasa compared with the national effect. Both nationally and in Kinshasa, most affected services had slow and incomplete recovery to expected levels. Therefore, our analysis indicates that COVID-19 continued to affect health services in the DRC throughout the first year of the pandemic. CONCLUSIONS: The methodology used in this article allows for examining the variability in magnitude, timing, and duration of the COVID effects within geographical areas of the DRC and nationally. This analytical procedure based on national health information system data could be applied to surveil health service disruptions and better inform rapid responses from health service managers and policymakers.

Impacts of cash transfer and "cash plus" programs on self- perceived stress in Africa: Evidence from Ghana, Malawi, and Tanzania.

Poverty and poor mental health are closely linked. Cash transfers have significantly expanded globally. Given their objectives around poverty reduction and improving food security, a major chronic stressor in Africa, cash transfers may affect mental health outcomes. We examine impacts of three large-scale government cash transfer or cash plus programs in Ghana, Malawi, and Tanzania on self-perceived stress using an innovative, newly adapted measure for rural African settings. Linear regression models were used to estimate treatment impacts. We find that cash transfers reduced self-perceived stress in Malawi, but programs in Ghana and Tanzania had no impacts on self-perceived stress. These mixed findings, combined with recent reviews on cash transfers and mental health, suggest that cash transfers may play a role in improving mental health. However, cash alone may not be sufficient to overcome many challenges related to poverty, and complementary programming may also be needed to improve mental health.

HIV Treatment and Mental Health Outcomes Among Gay, Bisexual, and Other Men Who Have Sex With Men Living With HIV in a Pilot Multicomponent Intervention in Guatemala City.

Globally, gay, bisexual, and other men who have sex with men (GBMSM) are disproportionately affected by HIV, but few interventions address mental health and HIV outcomes among GBMSM living with HIV. The purpose of this study was to pilot a multicomponent intervention, integrating emotional well-being (EW) and health navigation for GBMSM living with HIV in Guatemala City. We implemented a 12-month intervention, including a four-session EW component and a health navigation component among newly diagnosed and reengaged GBMSM with HIV (n = 112). We conducted socio-behavioral surveys at baseline and endline to measure patient characteristics and HIV, and mental health outcomes as well as viral load testing. We documented participation in EW sessions and used a smartphone application to track navigation mode, frequency, and content. Using first-difference estimation modeling, we assessed associations between participation in EW and navigation and mental health (depression and anxiety symptoms) and HIV outcomes (HIV treatment adherence, viral suppression). Acceptability was high for EW (86%) and navigation (99%). During the intervention, viral suppression increased significantly and anxiety and depression decreased significantly. Participation in EW sessions and greater navigation frequency and duration were associated with being suppressed, whereas higher emotional navigator support was associated with being unsuppressed. Participation in EW sessions was associated with reduced anxiety. Findings suggest that multicomponent interventions integrating individual counseling and navigation may promote EW and sustained viral suppression. Future intervention research is needed to confirm whether HIV and mental health outcomes are attributable to the intervention and to assess mechanisms of influence.

Ghana's Livelihood Empowerment Against Poverty (1000) Program Seasonally Impacts Birthweight: A Difference-in-Differences Analysis.

Objectives: Low birthweight (LBW) prevalence remains high in African countries and evidence of cash transfer impacts on birthweight, particularly by season of infant birth, is limited. This study examines overall and seasonal cash transfer impacts on LBW in rural Ghana. Methods: Data come from a longitudinal, quasi-experimental impact evaluation of the Livelihood Empowerment Against Poverty (LEAP) 1,000 unconditional cash transfer program for impoverished pregnant or lactating women in rural districts of Northern Ghana. LEAP1000 program impacts on average birthweight and LBW were estimated for a multiply imputed sample of 3,258 and a panel sample of 1,567 infants using differences-in-differences models and triple difference models to assess impacts by season. Results: LEAP1000 decreased LBW prevalence by 3.5 and 4.1 percentage points overall and in the dry season, respectively. LEAP1000 increased average birthweight by 94, 109, and 79 g overall, in the dry season, and in the rainy season, respectively. Conclusion: Our findings of positive LEAP1000 impacts on birthweight across seasons and on LBW in the dry season demonstrate the need to take seasonal vulnerabilities into account when designing and implementing programs for rural populations in Africa.

Impact of community-based health insurance on health services utilisation among vulnerable households in Amhara region, Ethiopia.

BACKGROUND: Ethiopia piloted community-based health insurance in 2011, and as of 2019, the programme was operating in 770 districts nationwide, covering approximately 7 million households. Enrolment in participating districts reached 50%, holding promise to achieve the goal of Universal Health Coverage in the country. Despite the government's efforts to expand community-based health insurance to all districts, evidence is lacking on how enrolment in the programme nudges health seeking behaviour among the most vulnerable rural households. This study aims to examine the effect of community-based health insurance enrolment among the most vulnerable and extremely poor households participating in Ethiopia's Productive Safety Net Programme on the utilisation of healthcare services in the Amhara region. METHODS: Data for this study came from Amhara pilot integrated safety net programme baseline survey in Ethiopia and were collected between December 2018 and February 2019 from 5,398 households. We used propensity score matching method to estimate the impacts of enrolment in community-based health insurance on outpatient, maternal, and child preventive and curative healthcare services utilisation. RESULTS: Results show that membership in community-based health insurance increases the probabilities of visiting health facilities for curative care in the past month by 8.2 percentage points (95% CI 5.3 to 11.1), seeking care from a health professional by 8.4 percentage points (95% CI 5.5 to 11.3), and visiting a health facility to seek any medical assistance for illness and check-ups in the past 12 months by 13.9 percentage points (95% CI 10.5 to 17.4). Insurance also increases the annual household per capita health facility visits by 0.84 (95% CI 0.64 to 1.04). However, we find no significant effects of community-based health insurance membership on utilisation of maternal and child healthcare services. CONCLUSIONS: Findings that community-based health insurance increased outpatient services utilisation implies that it could also contribute towards universal health coverage and health equity in rural and informal sectors. The absence of significant effects on maternal and child healthcare services may be due to the free availability of such services for everyone at the public health facilities, regardless of insurance membership. Outpatient services use among insured households is still not universal, and understanding of the barriers to use, including supply-side constraints, will help improve universal health coverage.

Impact of a School-Based Nutrition Intervention in Preventing Overweight and Obesity in Children in Thailand.

BACKGROUND: This study evaluated the impact of a school-based nutrition program on preventing overweight and obesity in children in Thailand from 2014 to 2019. METHODS: We used difference-in-differences with matched comparison group to evaluate program impact. Treatment schools were categorized into those that participated in phase 1 only, and those that participated in phase 1 and 2. We matched 311 treatment schools in phase 1 only with 1504 comparison schools, and 75 treatment schools in both phases with 216 comparison schools. Administrative data from Thailand Office of Basic Education Commission were used from 2014 (baseline), 2016 (first follow-up), and 2019 (second follow-up). RESULTS: Program resulted in a 0.6-1.1 percentage point reduction in the students' probability of overweight by the end of phase 1, and 1.7 percentage points by the end of phase 2. Impact on obesity was found only for schools participating in both phases (0.4 and 0.9 percentage points by the end of phase 1 and 2, respectively). IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: Program continuity and intensity are key to achieve a reduction in overweight and obesity in schoolchildren. CONCLUSIONS: The program was successful in reducing overweight and/or obesity given appropriate level of continuity and intensity.

'She showed me a new path, a way forward': exploring how navigation influences mental health among Guatemalan gay and bisexual men living with HIV.

Mental health problems, including anxiety and depression, are a common comorbidity among gay, bisexual and other men who have sex with men (GBMSM) living with HIV. Informed by social support theory, health navigation is a strengths-based intervention that has been demonstrated to improve HIV care outcomes. The purpose of this study was to explore how health navigation influences the mental health of GBMSM living with HIV. We analyzed longitudinal qualitative in-depth interviews conducted with GBMSM (n = 29) in a 12-month multi-component intervention to improve HIV care outcomes, including health navigation. We used narrative and thematic analytic approaches to identify salient themes, including if and how themes changed over time. Participants described that navigator support helped them maintain good mental health, prevent crises and respond to crises. Navigator support included providing motivational messaging, facilitating participants' control over their health and improving access to care, which aided with supporting mental health. Navigators also responded to acute crises by providing guidance for those newly diagnosed with HIV and support for those experiencing critical life events. Participants emphasized the importance of feeling heard and valued by their navigators and gaining hope for the future as key to their wellbeing. In conclusion, health navigation may be an effective intervention for promoting mental health among GBMSM living with HIV. Additional research is needed to examine mediating pathways between navigation and mental health, including informational support, or if navigator support moderates the relationship between stressors and mental health outcomes for GBMSM.

Health services availability and readiness moderate cash transfer impacts on health insurance enrolment: evidence from the LEAP 1000 cash transfer program in Ghana.

BACKGROUND: Expanding health insurance coverage is a priority under Sustainable Development Goal 3. To address the intersection between poverty and health and remove cost barriers, the government of Ghana established the National Health Insurance Scheme (NHIS). Government further linked NHIS with the Livelihood Empowerment Against Poverty (LEAP) 1000 cash transfer program by waiving premium fees for LEAP 1000 households. This linkage led to increased NHIS enrolment, however, large enrolment gaps remained. One potential reason for failure to enroll may relate to the poor quality of health services. METHODS: We examine whether LEAP 1000 impacts on NHIS enrolment were moderated by health facilities' service availability and readiness. RESULTS: We find that adults in areas with the highest service availability and readiness are 18 percentage points more likely to enroll in NHIS because of LEAP 1000, compared to program effects of only 9 percentage points in low service availability and readiness areas. Similar differences were seen for enrolment among children (20 v. 0 percentage points) and women of reproductive age (25 v. 10 percentage points). CONCLUSIONS: We find compelling evidence that supply-side factors relating to service readiness and availability boost positive impacts of a cash transfer program on NHIS enrolment. Our work suggests that demand-side interventions coupled with supply-side strengthening may facilitate greater population-level benefits down the line. In the quest for expanding financial protection towards accelerating the achievement of universal health coverage, policymakers in Ghana should prioritize the integration of efforts to simultaneously address demand- and supply-side factors. TRIAL REGISTRATION: This study is registered in the International Initiative for Impact Evaluation's (3ie) Registry for International Development Impact Evaluations ( RIDIE-STUDY-ID-55942496d53af ).

Examining How Health Navigation Affects Mental Health Among Gay, Bisexual, and Other Men Who Have Sex with Men Living with Human Immunodeficiency Virus in Guatemala.

Gay, bisexual, and other men who have sex with men (GBMSM) are disproportionately affected by mental health problems and human immunodeficiency virus (HIV). Health navigation has the potential to improve both HIV and mental health outcomes; however, few studies have measured the impact of navigation on mental health among people living with HIV. We analyzed longitudinal data from a sociobehavioral survey and navigation monitoring system with GBMSM living with HIV in Guatemala (n = 346) that participated in a 12-month differentiated care intervention. We examined relationships between navigation characteristics (frequency, duration, mode of interactions, and level of emotional, instrumental, and informational navigation support) and anxiety and depression using fixed-effects regression. We also examined if these relationships were moderated by baseline social support. We found that as navigation interactions increased, anxiety significantly improved [B = -0.03, standard error (SE) = 0.01 p = 0.05]. Participants who received high levels of informational navigator support also experienced a significant improvement in anxiety compared with those receiving low levels of informational support (B = -0.81, SE = 0.40, p = 0.04). Unexpectedly, we found that as the proportion of in-person navigation interactions increased, anxiety worsened (B = 1.12, SE = 0.54, p = 0.04). No aspects of navigation were significantly associated with depression and baseline social support did not moderate the relationship between navigation and anxiety and depression. To improve the mental health of key populations affected by HIV, health navigation programs should prioritize frequent interaction and informational navigation support for clients with anxiety while considering other strategies that specifically target reducing depressive symptoms, including other cost-effective modalities, such as mobile apps.

Patients With Unexplained Dilated Pancreatic Duct Have High Risk of Biliopancreatic Malignancy Detected by EUS.

INTRODUCTION: Patients with unexplained dilated common bile duct (CBD) and/or dilated main pancreatic duct (MPD) on noninvasive abdominal imaging tests are often referred for endoscopic ultrasound (EUS) in order to rule out biliopancreatic cancer. The aim of the study was to evaluate the diagnostic yield of EUS in this patient group. METHODS: A prospective study was conducted. Patients with unexplained dilated CBD and/or MPD on abdominal imaging, who underwent EUS, were enrolled. RESULTS: Fifty-four patients underwent EUS (CBD dilation n=38, MPD dilation n=5 or both n=11). In 31/54 patients (57.4%), EUS revealed pathologic findings. Sixteen patients (29.6%) had EUS evidence of biliopancreatic cancer and 15 patients (27.7%) had benign pathology. Ten (62.5%) of the patients with biliopancreatic cancer had MPD dilation. MPD dilation was significantly associated with malignancy (P=0.017). CONCLUSION: Patients with unexplained dilated MPD on noninvasive image have a high risk of biliopancreatic malignancy detected by EUS.

Impact of the 'Seguro Médico Siglo XXI' medical insurance programme on neonatal and infant mortality in Mexico, 2006-14: an ecological approach to estimation.

The 'Seguro Médico Siglo XXI' (SMSXXI), a universal coverage medical insurance programme for children under 5 years of age, started in 2006 to help avoid catastrophic health expenditures in poor families without social security in Mexico. The study used information from the National Health Information System for the 2006-14 period. An ecological approach was followed with a panel of the 2457 municipalities of Mexico as the units of analysis. The outcome variables were the municipality-level neonatal mortality and infant mortality rates in population without access to social security. The programme variable was the coverage of the SMSXXI programme at the municipality level, expressed as a proportion. Demographic and economic variables defined at the municipality level were included as covariates. Impact was estimated by fitting a fixed-effects negative binomial regression model. Results reveal that the SMSXXI significantly reduced both infant and neonatSal mortality in the target population, although in a non-linear fashion, with minimum mortality levels found around the 70% coverage range. The effect is mostly given by the transition from the first quintile to the fourth quintile of coverage (<13% vs 70.5-93.7% coverage), and it is attenuated significantly at coverage levels very close to or at 100%. The observed risk reduction amounted to an estimated total of 11 358 infant deaths being avoided due to the SMSXXI during the 2006-14 period, of which 48% were neonatal. In conclusion, we found a significant impact of the SMSXXI programme on both infant mortality and neonatal mortality. An attenuation of the effect of the insurance on mortality rates at levels close to 100% coverage may reflect the saturation of health units in detriment of the quality of care.

A Cash Plus Program Reduces Youth Exposure to Physical Violence in Zimbabwe.

Violence against children and adolescents, a highly prevalent problem, is a clear violation of child rights and has detrimental effects on later life outcomes. Programs that alleviate poverty address a structural determinant of child vulnerability and can thereby reduce child abuse. This paper investigates whether the Government of Zimbabwe's Harmonized Social Cash Transfer (HSCT) Program, which combines cash transfers with complementary services, affects youth exposure to physical violence. The analysis uses data from a non-experimental impact evaluation and a difference-in-differences approach. Results show a 19-percentage point decline in the incidence of physical violence among youth four years into the program. HSCT-induced enhancements in beneficiary households' purchasing capacity and food security, improvements in caregiver subjective well-being, and reductions in youth participation in economic work for pay could be mediating the program's effects on youth abuse. This paper adds to the relatively scarce evidence on the impacts of anti-poverty policies on young people's susceptibility to physical violence in developing countries.

Availability of health facilities and utilization of maternal and newborn postnatal care in rural Malawi.

BACKGROUND: This study explored the role of health facility availability as it relates to maternal and newborn PNC use in rural Malawi. METHODS: Malawi Demographic and Health Survey (MDHS) 2015-16 data, MDHS 2015-16 household cluster GPS data, Malawi Service Provision Assessment (MSPA) 2013-14 data and MSPA 2013-14 facility GPS data were used. Household clusters were spatially linked with facilities using buffers. Descriptive analyses were performed and generalized estimating equations (GEE) were used to determine the effects of having different types of facilities at varying distances from household clusters on receipt of maternal and newborn PNC in rural Malawi. RESULTS: In rural Malawi, around 96% of women had facilities providing PNC within 10 km of where they live. Among women who have clinic-level facilities within 5 km of where they live, around 25% had clinic-level facilities that provide PNC. For rural women who gave birth in the past 5 years preceding the survey, only about 3% received maternal PNC within 24 h and about 16% received maternal PNC within the first week. As for newborn PNC, 3% of newborns had PNC within 24 h and about 26% had newborn PNC within the first week. PNC mostly took place at facilities (94% for women and 95% for newborns). For women who delivered at home, having a health center providing PNC within 5 km was positively associated with maternal and newborn PNC. For women who delivered at facilities, having a health center providing PNC within 5 km was positively associated with maternal PNC and having a health center providing PNC between 5 km and 10 km was positively associated with both maternal and newborn PNC. Regardless of the place of delivery and distance band, having a clinic-level facility providing PNC did not have significant positive effects on maternal and newborn PNC. CONCLUSIONS: Providers should be trained to perform quality PNC at all facilities. It would also be important to address concerns related to health workers. Lastly, it would be key to increase community awareness about the importance of seeking timely PNC and about the utility of lower-level facilities for receiving preventative PNC.

The impact of India's accredited social health activist (ASHA) program on the utilization of maternity services: a nationally representative longitudinal modelling study.

BACKGROUND: In 2006, the Government of India launched the accredited social health activist (ASHA) program, with the goal to connect marginalized communities to the health care system. We assessed the effect of the ASHA program on the utilization of maternity services. METHODS: We used data from Indian Human Development Surveys done in 2004-2005 and in 2011-2012 to assess demographic and socioeconomic factors associated with the receipt of ASHA services, and used difference-in-difference analysis with cluster-level fixed effects to assess the effect of the program on the utilization of at least one antenatal care (ANC) visit, four or more ANC visits, skilled birth attendance (SBA), and giving birth at a health facility. RESULTS: Substantial variations in the receipt of ASHA services were reported with 66% of women in northeastern states, 30% in high-focus states, and 16% of women in other states. In areas where active ASHA activity was reported, the poorest women, and women belonging to scheduled castes and other backward castes, had the highest odds of receiving ASHA services. Exposure to ASHA services was associated with a 17% (95% CI 11.8-22.1) increase in ANC-1, 5% increase in four or more ANC visits (95% CI - 1.6-11.1), 26% increase in SBA (95% CI 20-31.1), and 28% increase (95% CI 22.4-32.8) in facility births. CONCLUSIONS: Our results suggest that the ASHA program is successfully connecting marginalized communities to maternity health services. Given the potential of the ASHA in impacting service utilization, we emphasize the need to strengthen strategies to recruit, train, incentivize, and retain ASHAs.

Government of Malawi's unconditional cash transfer improves youth mental health.

We explore the impacts of Malawi's national unconditional cash transfer program targeting ultra-poor households on youth mental health. Experimental findings show that the program significantly improved mental health outcomes. Among girls in particular, the program reduces indications of depression by about 15 percentage points. We investigate the contribution of different possible pathways to the overall program impact, including education, health, consumption, caregiver's stress levels and life satisfaction, perceived social support, and participation in hard and unpleasant work. The pathways explain from 46 to 65 percent of the program impact, advancing our understanding of how economic interventions can affect mental health of youth in resource-poor settings. The findings underline that unconditional cash grants, which are used on an increasingly large scale as part of national social protection systems in Sub-Saharan Africa, have the potential to improve youth mental wellbeing and thus may help break the vicious cycle of poverty and poor mental health.

Reducing Inequity in Urban Health: Have the Intra-urban Differentials in Reproductive Health Service Utilization and Child Nutritional Outcome Narrowed in Bangladesh?

Bangladesh is undergoing a rapid urbanization process. About one-third of the population of major cities in the country live in slums, which are areas that exhibit pronounced concentrations of factors that negatively affect health and nutrition. People living in slums face greater challenge to improve their health than other parts of the country, which fuels the growing intra-urban health inequities. Two rounds of the Bangladesh Urban Health Survey (UHS), conducted in 2013 and 2006, were designed to examine the reproductive health status and service utilization between slum and non-slum residents. We applied an adaptation of the difference-in-differences (DID) model to pooled data from the 2006 and 2013 UHS rounds to examine changes over time in intra-urban differences between slums and non-slums in key health outcomes and service utilization and to identify the factors associated with the reduction in intra-urban gaps. In terms of change in intra-urban differentials during 2006-2013, DID regression analysis estimated that the gap between slums and non-slums for skilled birth attendant (SBA) during delivery significantly decreased. DID regression analysis also estimated that the gap between slums and non-slums for use of modern contraceptives among currently married women also narrowed significantly, and the gap reversed in favor of slums. However, the DID estimates indicate a small but not statistically significant reduction in the gap between slums and non-slums for child nutritional status. Results from extended DID regression model indicate that availability of community health workers in urban areas appears to have played a significant role in reducing the gap in SBA. The urban population in Bangladesh is expected to grow rapidly in the coming decades. Wide disparities between urban slums and non-slums can potentially push country performance off track during the post-2015 era, unless the specific health needs of the expanding slum communities are addressed. To our knowledge, this is the first systematic explanation and quantification of the role of various factors for improving intra-urban health equity in Bangladesh using nationally representative data. The findings provide a strong rationale for continuing and expanding community-based reproductive health services in urban areas by the NGOs with a focus on slum populations.

Cash Transfers, Early Marriage, and Fertility in Malawi and Zambia.

There is increasing interest in the ability of cash transfers to facilitate safe transitions to adulthood in low-income settings; however, evidence from scaled-up government programming demonstrating this potential is scarce. Using two experimental evaluations of unconditional cash transfers targeted to ultra-poor and labor-constrained households over approximately three years in Malawi and Zambia, we examine whether cash transfers delayed early marriage and pregnancy among youth aged 14 to 21 years at baseline. Although we find strong impacts on poverty and schooling, two main pathways hypothesized in the literature, we find limited impacts on safe transition outcomes for both males and females. In addition, despite hypotheses that social norms may constrain potential impacts of cash transfer programs, we show suggestive evidence that pre-program variation in social norms across communities does not significantly affect program impact. We conclude with policy implications and suggestions for future research.