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1.  Defining Catastrophic Costs and Comparing Their Importance for Adverse Tuberculosis Outcome with Multi-Drug Resistance: A Prospective Cohort Study, Peru 
PLoS Medicine  2014;11(7):e1001675.
Tom Wingfield and colleagues investigate the relationship between catastrophic costs and tuberculosis outcomes for patients receiving free tuberculosis care in Peru.
Please see later in the article for the Editors' Summary
Background
Even when tuberculosis (TB) treatment is free, hidden costs incurred by patients and their households (TB-affected households) may worsen poverty and health. Extreme TB-associated costs have been termed “catastrophic” but are poorly defined. We studied TB-affected households' hidden costs and their association with adverse TB outcome to create a clinically relevant definition of catastrophic costs.
Methods and Findings
From 26 October 2002 to 30 November 2009, TB patients (n = 876, 11% with multi-drug-resistant [MDR] TB) and healthy controls (n = 487) were recruited to a prospective cohort study in shantytowns in Lima, Peru. Patients were interviewed prior to and every 2–4 wk throughout treatment, recording direct (household expenses) and indirect (lost income) TB-related costs. Costs were expressed as a proportion of the household's annual income. In poorer households, costs were lower but constituted a higher proportion of the household's annual income: 27% (95% CI = 20%–43%) in the least-poor houses versus 48% (95% CI = 36%–50%) in the poorest. Adverse TB outcome was defined as death, treatment abandonment or treatment failure during therapy, or recurrence within 2 y. 23% (166/725) of patients with a defined treatment outcome had an adverse outcome. Total costs ≥20% of household annual income was defined as catastrophic because this threshold was most strongly associated with adverse TB outcome. Catastrophic costs were incurred by 345 households (39%). Having MDR TB was associated with a higher likelihood of incurring catastrophic costs (54% [95% CI = 43%–61%] versus 38% [95% CI = 34%–41%], p<0.003). Adverse outcome was independently associated with MDR TB (odds ratio [OR] = 8.4 [95% CI = 4.7–15], p<0.001), previous TB (OR = 2.1 [95% CI = 1.3–3.5], p = 0.005), days too unwell to work pre-treatment (OR = 1.01 [95% CI = 1.00–1.01], p = 0.02), and catastrophic costs (OR = 1.7 [95% CI = 1.1–2.6], p = 0.01). The adjusted population attributable fraction of adverse outcomes explained by catastrophic costs was 18% (95% CI = 6.9%–28%), similar to that of MDR TB (20% [95% CI = 14%–25%]). Sensitivity analyses demonstrated that existing catastrophic costs thresholds (≥10% or ≥15% of household annual income) were not associated with adverse outcome in our setting. Study limitations included not measuring certain “dis-saving” variables (including selling household items) and gathering only 6 mo of costs-specific follow-up data for MDR TB patients.
Conclusions
Despite free TB care, having TB disease was expensive for impoverished TB patients in Peru. Incurring higher relative costs was associated with adverse TB outcome. The population attributable fraction indicated that catastrophic costs and MDR TB were associated with similar proportions of adverse outcomes. Thus TB is a socioeconomic as well as infectious problem, and TB control interventions should address both the economic and clinical aspects of this disease.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Caused by the infectious microbe Mycobacterium tuberculosis, tuberculosis (or TB) is a global health problem. In 2012, an estimated 8.6 million people fell ill with TB, and 1.3 million were estimated to have died because of the disease. Poverty is widely recognized as an important risk factor for TB, and developing nations shoulder a disproportionate burden of both poverty and TB disease. For example, in Lima (the capital of Peru), the incidence of TB follows the poverty map, sparing residents living in rich areas of the city while spreading among poorer residents that live in overcrowded households.
The Peruvian government, non-profit organizations, and the World Health Organization (WHO) have extended healthcare programs to provide free diagnosis and treatment for TB and drug-resistant strains of TB in Peru, but rates of new TB cases remain high. For example, in Ventanilla (an area of 16 shantytowns located in northern Lima), the rate of infection was higher during the study period, at 162 new cases per 100,000 people per year, than the national average. About one-third of the 277,895 residents of Ventanilla live on under US$1 per day.
Why Was This Study Done?
Poverty increases the risks associated with contracting TB infection, but the disease also affects the most economically productive age group, and the income of TB-affected households often decreases post-diagnosis, exacerbating poverty. A recent WHO consultation report proposed a target of eradicating catastrophic costs for TB-affected families by 2035, but hidden TB-related costs remain understudied, and there is no international consensus defining catastrophic costs incurred by patients and households affected by TB. Lost income and the cost of transport are among hidden costs associated with free treatment programs; these costs and their potential impact on patients and their households are not well defined. Here the researchers sought to clarify and characterize TB-related costs and explore whether there is a relationship between the hidden costs associated with free TB treatment programs and the likelihood of completing treatment and becoming cured of TB.
What Did the Researchers Do and Find?
Over a seven-year period (2002–2009), the researchers recruited 876 study participants with TB diagnosed at health posts located in Ventanilla. To provide a comparative control group, a sample of 487 healthy individuals was also recruited to participate. Participants were interviewed prior to treatment, and households' TB-related direct expenses and indirect expenses (lost income attributed to TB) were recorded every 2–4 wk. Data were collected during scheduled household visits.
TB patients were poorer than controls, and analysis of the data showed that accessing free TB care was expensive for TB patients, especially those with multi-drug-resistant (MDR) TB. Total expenses were similar pre-treatment compared to during treatment for TB patients, despite receiving free care (1.1 versus 1.2 times the same household's monthly income). Even though direct expenses (for example, costs of medical examinations and medicines other than anti-TB therapy) were lower in the poorest households, their total expenses (direct and indirect) made up a greater proportion of their household annual income: 48% for the poorest households compared to 27% in the least-poor households.
The researchers defined costs that were equal to or above one-fifth (20%) of household annual income as catastrophic because this threshold marked the greatest association with adverse treatment outcomes such as death, abandoning treatment, failing to respond to treatment, or TB recurrence. By calculating the population attributable fraction—the proportional reduction in population adverse treatment outcomes that could occur if a risk factor was reduced to zero—the authors estimate that adverse TB outcomes explained by catastrophic costs and MDR TB were similar: 18% for catastrophic costs and 20% for MDR TB.
What Do These Findings Mean?
The findings of this study indicate a potential role for social protection as a means to improve TB disease control and health, as well as defining a novel, evidence-based threshold for catastrophic costs for TB-affected households of 20% or more of annual income. Addressing the economic impact of diagnosis and treatment in impoverished communities may increase the odds of curing TB.
Study limitations included only six months of follow-up data being gathered on costs for each participant and not recording “dissavings,” such as selling of household items in response to financial shock. Because the study was observational, the authors aren't able to determine the direction of the association between catastrophic costs and TB outcome. Even so, the study indicates that TB is a socioeconomic as well as infectious problem, and that TB control interventions should address both the economic and clinical aspects of the disease.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001675.
The World Health Organization provides information on all aspects of tuberculosis, including the Global Tuberculosis Report 2013
The US Centers for Disease Control and Prevention has information about tuberculosis
Médecins Sans Frontières's TB&ME blog provides patients' stories of living with MDR TB
TB Alert, a UK-based charity that promotes TB awareness worldwide, has information on TB in several European, African, and Asian languages
More information is available about the Innovation For Health and Development (IFHAD) charity and its research team's work in Peru
doi:10.1371/journal.pmed.1001675
PMCID: PMC4098993  PMID: 25025331
2.  Health and Human Rights in Chin State, Western Burma: A Population-Based Assessment Using Multistaged Household Cluster Sampling 
PLoS Medicine  2011;8(2):e1001007.
Sollom and colleagues report the findings from a household survey study carried out in Western Burma; they report a high prevalence of human rights violations such as forced labor, food theft, forced displacement, beatings, and ethnic persecution.
Background
The Chin State of Burma (also known as Myanmar) is an isolated ethnic minority area with poor health outcomes and reports of food insecurity and human rights violations. We report on a population-based assessment of health and human rights in Chin State. We sought to quantify reported human rights violations in Chin State and associations between these reported violations and health status at the household level.
Methods and Findings
Multistaged household cluster sampling was done. Heads of household were interviewed on demographics, access to health care, health status, food insecurity, forced displacement, forced labor, and other human rights violations during the preceding 12 months. Ratios of the prevalence of household hunger comparing exposed and unexposed to each reported violation were estimated using binomial regression, and 95% confidence intervals (CIs) were constructed. Multivariate models were done to adjust for possible confounders. Overall, 91.9% of households (95% CI 89.7%–94.1%) reported forced labor in the past 12 months. Forty-three percent of households met FANTA-2 (Food and Nutrition Technical Assistance II project) definitions for moderate to severe household hunger. Common violations reported were food theft, livestock theft or killing, forced displacement, beatings and torture, detentions, disappearances, and religious and ethnic persecution. Self reporting of multiple rights abuses was independently associated with household hunger.
Conclusions
Our findings indicate widespread self-reports of human rights violations. The nature and extent of these violations may warrant investigation by the United Nations or International Criminal Court.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
More than 60 years after the adoption of the Universal Declaration of Human Rights, thousands of people around the world are still deprived of their basic human rights—life, liberty, and security of person. In many countries, people live in fear of arbitrary arrest and detention, torture, forced labor, religious and ethnic persecution, forced displacement, and murder. In addition, ongoing conflicts and despotic governments deprive them of the ability to grow sufficient food (resulting in food insecurity) and deny them access to essential health care. In Burma, for example, the military junta, which seized power in 1962, frequently confiscates land unlawfully, demands forced labor, and uses violence against anyone who protests. Burma is also one of the world's poorest countries in terms of health indicators. Its average life expectancy is 54 years, its maternal mortality rate (380 deaths among women from pregnancy-related causes per 100,000 live births) is nearly ten times higher than that of neighboring Thailand, and its under-five death rate (122/1000 live births) is twice that of nearby countries. Moreover, nearly half of Burmese children under 5 are stunted, and a third of young children are underweight, indicators of malnutrition in a country that, on paper, has a food surplus.
Why Was This Study Done?
Investigators are increasingly using population-based methods to quantify the associations between human rights violations and health outcomes. In eastern Burma, for example, population-based research has recently revealed a link between human rights violations and reduced access to maternal health-care services. In this study, the researchers undertake a population-based assessment of health and human rights in Chin State, an ethnic minority area in western Burma where multiple reports of human rights abuses have been documented and from which thousands of people have fled. In particular, the researchers investigate correlations between household hunger and household experiences of human rights violations—food security in Chin State is affected by periodic expansions of rat populations that devastate crop yields, by farmers being forced by the government to grow an inedible oil crop (jatropha), and by the Burmese military regularly stealing food and livestock.
What Did the Researchers Do and Find?
Local surveyors questioned the heads of randomly selected households in Chin State about their household's access to health care and its health status, and about forced labor and other human rights violations experienced by the household during the preceding 12 months. They also asked three standard questions about food availability, the answers to which were combined to provide a measure of household hunger. Of the 621 households interviewed, 91.9% reported at least one episode of a household member being forced to work in the preceding 12 months. The Burmese military imposed two-thirds of these forced labor demands. Other human rights violations reported included beating or torture (14.8% of households), religious or ethnic persecutions (14.1% of households), and detention or imprisonment of a family member (5.9% of households). Forty-three percent of the households met the US Agency for International Development Food and Nutrition Technical Assistance (FANTA) definition for moderate to severe household hunger, and human rights violations related to food insecurity were common. For example, more than half the households were forced to give up food out of fear of violence. A statistical analysis of these data indicated that the prevalence of household hunger was 6.51 times higher in households that had experienced three food-related human rights violations than in households that had not experienced such violations.
What Do These Findings Mean?
These findings quantify the extent to which the Chin ethnic minority in Burma is subjected to multiple human rights violations and indicate the geographical spread of these abuses. Importantly, they show that the health impacts of human rights violations in Chin State are substantial. In addition, they suggest that the indirect health outcomes of human rights violations probably dwarf the mortality from direct killings. Although this study has some limitations (for example, surveyors had to work in secret and it was not safe for them to collect biological samples that could have given a more accurate indication of the health status of households than questions alone), these findings should encourage the international community to intensify its efforts to reduce human rights violations in Burma.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001007.
The UN Universal Declaration of Human Rights is available in numerous languages
The Burma Campaign UK and Human Rights Watch provide detailed information about human rights violations in Burma (in several languages)
The World Health Organization provides information on health in Burma and on human rights (in several languages)
The Mae Tao clinic also provides general information about Burma and its health services (including some information in Thai)
A PLoS Medicine Research Article by Luke Mullany and colleagues provides data on human rights violations and maternal health in Burma
The Chin Human Rights Organization is working to protect and promote the rights of the Chin people
The Global Health Access Program (GHAP) provides information on health in Burma
FANTA works to improve nutrition and global food security policies
doi:10.1371/journal.pmed.1001007
PMCID: PMC3035608  PMID: 21346799
3.  Mortality in Iraq Associated with the 2003–2011 War and Occupation: Findings from a National Cluster Sample Survey by the University Collaborative Iraq Mortality Study 
PLoS Medicine  2013;10(10):e1001533.
Based on a survey of 2,000 randomly selected households throughout Iraq, Amy Hagopian and colleagues estimate that close to half a million excess deaths are attributable to the recent Iraq war and occupation.
Please see later in the article for the Editors' Summary
Background
Previous estimates of mortality in Iraq attributable to the 2003 invasion have been heterogeneous and controversial, and none were produced after 2006. The purpose of this research was to estimate direct and indirect deaths attributable to the war in Iraq between 2003 and 2011.
Methods and Findings
We conducted a survey of 2,000 randomly selected households throughout Iraq, using a two-stage cluster sampling method to ensure the sample of households was nationally representative. We asked every household head about births and deaths since 2001, and all household adults about mortality among their siblings. We used secondary data sources to correct for out-migration. From March 1, 2003, to June 30, 2011, the crude death rate in Iraq was 4.55 per 1,000 person-years (95% uncertainty interval 3.74–5.27), more than 0.5 times higher than the death rate during the 26-mo period preceding the war, resulting in approximately 405,000 (95% uncertainty interval 48,000–751,000) excess deaths attributable to the conflict. Among adults, the risk of death rose 0.7 times higher for women and 2.9 times higher for men between the pre-war period (January 1, 2001, to February 28, 2003) and the peak of the war (2005–2006). We estimate that more than 60% of excess deaths were directly attributable to violence, with the rest associated with the collapse of infrastructure and other indirect, but war-related, causes. We used secondary sources to estimate rates of death among emigrants. Those estimates suggest we missed at least 55,000 deaths that would have been reported by households had the households remained behind in Iraq, but which instead had migrated away. Only 24 households refused to participate in the study. An additional five households were not interviewed because of hostile or threatening behavior, for a 98.55% response rate. The reliance on outdated census data and the long recall period required of participants are limitations of our study.
Conclusions
Beyond expected rates, most mortality increases in Iraq can be attributed to direct violence, but about a third are attributable to indirect causes (such as from failures of health, sanitation, transportation, communication, and other systems). Approximately a half million deaths in Iraq could be attributable to the war.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
War is a major public health problem. Its health effects include violent deaths among soldiers and civilians as well as indirect increases in mortality and morbidity caused by conflict. Unlike those of other causes of death and disability, however, the consequences of war on population health are rarely studied scientifically. In conflict situations, deaths and diseases are not reliably measured and recorded, and estimating the proportion caused, directly or indirectly, by a war or conflict is challenging. Population-based mortality survey methods—asking representative survivors about deaths they know about—were developed by public health researchers to estimate death rates. By comparing death rate estimates for periods before and during a conflict, researchers can derive the number of excess deaths that are attributable to the conflict.
Why Was This Study Done?
A number of earlier studies have estimated the death toll in Iraq since the beginning of the war in March 2003. The previous studies covered different periods from 2003 to 2006 and derived different rates of overall deaths and excess deaths attributable to the war and conflict. All of them have been controversial, and their methodologies have been criticized. For this study, based on a population-based mortality survey, the researchers modified and improved their methodology in response to critiques of earlier surveys. The study covers the period from the beginning of the war in March 2003 until June 2011, including a period of high violence from 2006 to 2008. It provides population-based estimates for excess deaths in the years after 2006 and covers most of the period of the war and subsequent occupation.
What Did the Researchers Do and Find?
Interviewers trained by the researchers conducted the survey between May 2011 and July 2011 and collected data from 2,000 randomly selected households in 100 geographical clusters, distributed across Iraq's 18 governorates. The interviewers asked the head of each household about deaths among household members from 2001 to the time of the interview, including a pre-war period from January 2001 to March 2003 and the period of the war and occupation. They also asked all adults in the household about deaths among their siblings during the same period. From the first set of data, the researchers calculated the crude death rates (i.e., the number of deaths during a year per 1,000 individuals) before and during the war. They found the wartime crude death rate in Iraq to be 4.55 per 1,000, more than 50% higher than the death rate of 2.89 during the two-year period preceding the war. By multiplying those rates by the annual Iraq population, the authors estimate the total excess Iraqi deaths attributable to the war through mid-2011 to be about 405,000. The researchers also estimated that an additional 56,000 deaths were not counted due to migration. Including this number, their final estimate is that approximately half a million people died in Iraq as a result of the war and subsequent occupation from March 2003 to June 2011.
The risk of death at the peak of the conflict in 2006 almost tripled for men and rose by 70% for women. Respondents attributed 20% of household deaths to war-related violence. Violent deaths were attributed primarily to coalition forces (35%) and militia (32%). The majority (63%) of violent deaths were from gunshots. Twelve percent were attributed to car bombs. Based on the responses from adults in the surveyed households who reported on the alive-or-dead status of their siblings, the researchers estimated the total number of deaths among adults aged 15–60 years, from March 2003 to June 2011, to be approximately 376,000; 184,000 of these deaths were attributed to the conflict, and of those, the authors estimate that 132,000 were caused directly by war-related violence.
What Do These Findings Mean?
These findings provide the most up-to-date estimates of the death toll of the Iraq war and subsequent conflict. However, given the difficult circumstances, the estimates are associated with substantial uncertainties. The researchers extrapolated from a small representative sample of households to estimate Iraq's national death toll. In addition, respondents were asked to recall events that occurred up to ten years prior, which can lead to inaccuracies. The researchers also had to rely on outdated census data (the last complete population census in Iraq dates back to 1987) for their overall population figures. Thus, to accompany their estimate of 460,000 excess deaths from March 2003 to mid-2011, the authors used statistical methods to determine the likely range of the true estimate. Based on the statistical methods, the researchers are 95% confident that the true number of excess deaths lies between 48,000 and 751,000—a large range. More than two years past the end of the period covered in this study, the conflict in Iraq is far from over and continues to cost lives at alarming rates. As discussed in an accompanying Perspective by Salman Rawaf, violence and lawlessness continue to the present day. In addition, post-war Iraq has limited capacity to re-establish and maintain its battered public health and safety infrastructure.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001533
This study is further discussed in a PLOS Medicine Perspective by Salman Rawaf.
The Geneva Declaration on Armed Violence and Development website provides information on the global burden of armed violence.
The International Committee of the Red Cross provides information about war and international humanitarian law (in several languages).
Medact, a global health charity, has information on health and conflict.
Columbia University has a program on forced migration and health.
Johns Hopkins University runs the Center for Refugee and Disaster Response.
University of Washington's Health Alliance International website also has information about war and conflict.
doi:10.1371/journal.pmed.1001533
PMCID: PMC3797136  PMID: 24143140
4.  Access To Essential Maternal Health Interventions and Human Rights Violations among Vulnerable Communities in Eastern Burma 
PLoS Medicine  2008;5(12):e242.
Background
Health indicators are poor and human rights violations are widespread in eastern Burma. Reproductive and maternal health indicators have not been measured in this setting but are necessary as part of an evaluation of a multi-ethnic pilot project exploring strategies to increase access to essential maternal health interventions. The goal of this study is to estimate coverage of maternal health services prior to this project and associations between exposure to human rights violations and access to such services.
Methods and Findings
Selected communities in the Shan, Mon, Karen, and Karenni regions of eastern Burma that were accessible to community-based organizations operating from Thailand were surveyed to estimate coverage of reproductive, maternal, and family planning services, and to assess exposure to household-level human rights violations within the pilot-project target population. Two-stage cluster sampling surveys among ever-married women of reproductive age (15–45 y) documented access to essential antenatal care interventions, skilled attendance at birth, postnatal care, and family planning services. Mid-upper arm circumference, hemoglobin by color scale, and Plasmodium falciparum parasitemia by rapid diagnostic dipstick were measured. Exposure to human rights violations in the prior 12 mo was recorded. Between September 2006 and January 2007, 2,914 surveys were conducted. Eighty-eight percent of women reported a home delivery for their last pregnancy (within previous 5 y). Skilled attendance at birth (5.1%), any (39.3%) or ≥ 4 (16.7%) antenatal visits, use of an insecticide-treated bed net (21.6%), and receipt of iron supplements (11.8%) were low. At the time of the survey, more than 60% of women had hemoglobin level estimates ≤ 11.0 g/dl and 7.2% were Pf positive. Unmet need for contraceptives exceeded 60%. Violations of rights were widely reported: 32.1% of Karenni households reported forced labor and 10% of Karen households had been forced to move. Among Karen households, odds of anemia were 1.51 (95% confidence interval [CI] 0.95–2.40) times higher among women reporting forced displacement, and 7.47 (95% CI 2.21–25.3) higher among those exposed to food security violations. The odds of receiving no antenatal care services were 5.94 (95% CI 2.23–15.8) times higher among those forcibly displaced.
Conclusions
Coverage of basic maternal health interventions is woefully inadequate in these selected populations and substantially lower than even the national estimates for Burma, among the lowest in the region. Considerable political, financial, and human resources are necessary to improve access to maternal health care in these communities.
Luke Mullany and colleagues examine access to essential maternal health interventions and human rights violations within vulnerable communities in eastern Burma.
Editors' Summary
Background.
After decades of military rule, Burma has one of the world's worst health-care systems and high levels of ill health. For example, maternal mortality (deaths among women from pregnancy-related causes) is around 360 per 100,000 live births in Burma, whereas in neighboring Thailand it is only 44 per 100,000 live births. Maternal health is even worse in the Shan, Karenni, Karen and Mon states in eastern Burma where ethnic conflicts and enforced village relocations have internally displaced more than half a million people. Here, maternal mortality is thought to be about 1000 per 100, 000 live births. In an effort to improve access to life-saving maternal health interventions in these states, Burmese community-based health organizations, the Johns Hopkins Center for Public Health and Human Rights and the Global Health Access Program in the USA, and the Mae Tao Clinic (a health-worker training center in Thailand) recently set up the Mobile Obstetric Maternal Health Workers (MOM) Project. In this pilot project, local health workers from 12 communities in eastern Burma received training in antenatal care, emergency obstetrics (the care of women during childbirth), blood transfusion, and family planning at the Mae Tao Clinic. Back in Burma, these maternal health workers trained additional local health workers and traditional birth attendants. All these individuals now provide maternal health care to their communities.
Why Was This Study Done?
The effectiveness of the MOM project can only be evaluated if accurate baseline information on women's access to maternal health-care services is available. This information is also needed to ensure the wise use of scarce health-care resources. However, very little is known about reproductive and maternal health in eastern Burma. In this study, the researchers analyze the information on women's access to reproductive and maternal health-care services that was collected during the initial field implementation stage of the MOM project. In addition, they analyze whether exposure to enforced village relocations and other human rights violations affect access to maternal health-care services.
What Did the Researchers Do and Find?
Trained survey workers asked nearly 3000 ever-married women of reproductive age in the selected communities about their access to antenatal and postnatal care, skilled birth attendants, and family planning. They measured each woman's mid-upper arm circumference (an indicator of nutritional status) and tested them for anemia (iron deficiency) and infection with malaria parasites (a common cause of anemia in tropical countries). Finally, they asked the women about any recent violations of their human rights such as forced labour or relocation. Nearly 90% of the women reported a home delivery for their last baby. A skilled attendant was present at only one in 20 births and only one in three women had any antenatal care. One third of the women received postnatal care and only a third said they had access to effective contraceptives. Few women had received iron supplements or had used insecticide-treated bednets to avoid malaria-carrying mosquitos. Consequently, more than half the women were anemic and 7.2% were infected with malaria parasites. Many women also showed signs of poor nutrition. Finally, human rights violations were widely reported by the women. In Karen, the region containing most of the study communities, forced relocation tripled the risk of women developing anemia and greatly decreased their chances of receiving any antenatal care.
What Do These Findings Mean?
These findings show that access to maternal health-care interventions is extremely limited and that poor nutrition, anemia, and malaria, all of which increase the risk of pregnancy complications, are widespread in the communities in the MOM project. Because these communities had some basic health services and access to training in Thailand before the project started, these results probably underestimate the lack of access to maternal health-care services in eastern Burma. Nevertheless, it is clear that considerable political, financial, and human resources will be needed to improve maternal health in this region. Finally, the findings also reveal a link between human rights violations and reduced access to maternal health-care services. Thus, the scale of human rights violations will need to be considered when evaluating programs designed to improve maternal health in Burma and in other places where there is ongoing conflict.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050242.
This research article is further discussed in a PLoS Medicine Perspective by Macaya Douoguih
The World Health Organization provides information on all aspects of health in Burma (in several languages)
The Mae Tao Clinic also provides general information about Burma and its health services
More information about the MOM project is available in a previous publication by the researchers
The Burma Campaign UK and Human Rights Watch both provide detailed information about human rights violations in Burma
The United Nations Population Fund provides information about safe motherhood and ongoing efforts to save mothers' lives around the world
doi:10.1371/journal.pmed.0050242
PMCID: PMC2605890  PMID: 19108601
5.  The Effect of India's Total Sanitation Campaign on Defecation Behaviors and Child Health in Rural Madhya Pradesh: A Cluster Randomized Controlled Trial 
PLoS Medicine  2014;11(8):e1001709.
Sumeet Patil and colleagues conduct a cluster randomized controlled trial to measure the effect of India's Total Sanitation Campaign in Madhya Pradesh on the availability of individual household latrines, defecation behaviors, and child health.
Please see later in the article for the Editors' Summary
Background
Poor sanitation is thought to be a major cause of enteric infections among young children. However, there are no previously published randomized trials to measure the health impacts of large-scale sanitation programs. India's Total Sanitation Campaign (TSC) is one such program that seeks to end the practice of open defecation by changing social norms and behaviors, and providing technical support and financial subsidies. The objective of this study was to measure the effect of the TSC implemented with capacity building support from the World Bank's Water and Sanitation Program in Madhya Pradesh on availability of individual household latrines (IHLs), defecation behaviors, and child health (diarrhea, highly credible gastrointestinal illness [HCGI], parasitic infections, anemia, growth).
Methods and Findings
We conducted a cluster-randomized, controlled trial in 80 rural villages. Field staff collected baseline measures of sanitation conditions, behaviors, and child health (May–July 2009), and revisited households 21 months later (February–April 2011) after the program was delivered. The study enrolled a random sample of 5,209 children <5 years old from 3,039 households that had at least one child <24 months at the beginning of the study. A random subsample of 1,150 children <24 months at enrollment were tested for soil transmitted helminth and protozoan infections in stool. The randomization successfully balanced intervention and control groups, and we estimated differences between groups in an intention to treat analysis. The intervention increased percentage of households in a village with improved sanitation facilities as defined by the WHO/UNICEF Joint Monitoring Programme by an average of 19% (95% CI for difference: 12%–26%; group means: 22% control versus 41% intervention), decreased open defecation among adults by an average of 10% (95% CI for difference: 4%–15%; group means: 73% intervention versus 84% control). However, the intervention did not improve child health measured in terms of multiple health outcomes (diarrhea, HCGI, helminth infections, anemia, growth). Limitations of the study included a relatively short follow-up period following implementation, evidence for contamination in ten of the 40 control villages, and bias possible in self-reported outcomes for diarrhea, HCGI, and open defecation behaviors.
Conclusions
The intervention led to modest increases in availability of IHLs and even more modest reductions in open defecation. These improvements were insufficient to improve child health outcomes (diarrhea, HCGI, parasite infection, anemia, growth). The results underscore the difficulty of achieving adequately large improvements in sanitation levels to deliver expected health benefits within large-scale rural sanitation programs.
Trial Registration
ClinicalTrials.gov NCT01465204
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Diarrheal diseases are linked with the deaths of hundreds of thousands of young children each year in resource-limited countries. Infection with enteric pathogens (organisms such as bacteria, viruses, and parasites that infect the human intestine or gut) also affects the health and growth of many young children in these countries. A major contributor to the transmission of enteric pathogens is thought to be open defecation, which can expose individuals to direct contact with human feces containing infectious pathogens and also contaminate food and drinking water. Open defecation can be reduced by ensuring that people have access to and use toilets or latrines. Consequently, programs have been initiated in many resource-limited countries that aim to reduce open defecation by changing behaviors and by providing technical and financial support to help households build improved latrines (facilities that prevent human feces from re-entering the environment such as pit latrines with sealed squat plates; an example of an unimproved facility is a simple open hole). However, in 2011, according to the WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation, more than 1 billion people (15% of the global population) still defecated in the open.
Why Was This Study Done?
Studies of sewerage system provision in urban areas suggest that interventions that prevent human feces entering the environment reduce diarrheal diseases. However, little is known about how rural sanitation programs, which usually focus on providing stand-alone sanitation facilities, affect diarrheal disease, intestinal parasite infections, anemia (which can be caused by parasite infections), or growth in young children. Governments and international donors need to know whether large-scale rural sanitation programs improve child health before expending further resources on these interventions or to identify an urgency to improve the existing program design or implementation so that they deliver the health impact. In this study, the researchers investigate the effect of India's Total Sanitation Campaign (TSC) on the availability of individual household latrines, defecation behaviors, and child health in rural Madhya Pradesh, one of India's less developed states. Sixty percent of people who practice open defection live in India and a quarter of global child deaths from diarrheal diseases occur in the country. India's TSC, which was initiated in 1999, includes activities designed to change social norms and behaviors and provides technical and financial support for latrine building. So far there are no published studies that rigorously evaluated whether the TSC improved child health or not.
What Did the Researchers Do and Find?
A cluster randomized controlled trial randomly assigns groups of people to receive the intervention under study and compares the outcomes with a control group that does not receive the intervention. The researchers enrolled 5,209 children aged under 5 years old living in 3,039 households in 80 rural villages in Madhya Pradesh. Half of the villages (40), chosen at random, were included in the TSC (the intervention). Field staff collected data on sanitation conditions, defecation behaviors, and child health from caregivers in each household at the start of the study and after the TSC implementation was over in the intervention villages. A random subsample of children was also tested for infection with enteric parasites. The intervention increased the percentage of households in a village with improved sanitation facilities by 19% on average. Specifically, 41% of households in the intervention villages had improved latrines on average compared to 22% of households in the control villages. The intervention also decreased the proportion of adults who self-reported open defecation from 84% to 73%. However, the intervention did not improve child health measured on the basis of multiple health outcomes, including the prevalence of gastrointestinal illnesses and intestinal parasite infections, and growth.
What Do These Findings Mean?
These findings indicate that in rural Madhya Pradesh, the TSC implemented with support from the WSP only slightly increased the availability of individual household latrines and only slightly decreased the practice of open defecation. Importantly, these findings show that these modest improvements in sanitation and in defecation behaviors were insufficient to improve health outcomes among children. The accuracy of these findings may be limited by various aspects of the study. For example, several control villages actually received the intervention, which means that these findings probably underestimate the effect of the intervention under perfect conditions. Self-reporting of defecation behavior, availability of sanitation facilities, and gastrointestinal illnesses among children may also have biased these findings. Finally, because TSC implementation varies widely across India, these findings may not apply to other Indian states or variations in the TSC implementation strategies. Overall, however, these findings highlight the challenges associated with achieving large enough improvement in access to sanitation and correspondingly large reductions in the practice of open defecation to deliver health benefits within large-scale rural sanitation programs.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001709.
This study is further discussed in a PLOS Medicine Perspective by Clarissa Brocklehurst
A PLOS Medicine Collection on water and sanitation is available
The World Health Organization (WHO) provides information on water, sanitation, and health (in several languages), on diarrhea (in several languages), and on intestinal parasites (accessed through WHO's web page on neglected tropical diseases); the 2009 WHO/UNICEF report “Diarrhea: why children are still dying and what can be done”, is available online for download
The WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation monitors progress toward improved global sanitation; its 2014 update report is available online
The children's charity UNICEF, which protects the rights of children and young people around the world, provides information on water, sanitation, and hygiene, and on diarrhea (in several languages)
doi:10.1371/journal.pmed.1001709
PMCID: PMC4144850  PMID: 25157929
6.  Online Health Information Seeking Behaviors of Hispanics in New York City: A Community-Based Cross-Sectional Study 
Background
The emergence of the Internet has increased access to health information and can facilitate active individual engagement in health care decision making. Hispanics are the fastest-growing minority group in the United States and are also the most underserved in terms of access to online health information. A growing body of literature has examined correlates of online health information seeking behaviors (HISBs), but few studies have included Hispanics.
Objective
The specific aim of this descriptive, correlational study was to examine factors associated with HISBs of Hispanics.
Methods
The study sample (N=4070) was recruited from five postal zip codes in northern Manhattan for the Washington Heights Inwood Informatics Infrastructure for Comparative Effectiveness Research project. Survey data were collected via interview by bilingual community health workers in a community center, households, and other community settings. Data were analyzed using bivariate analyses and logistic regression.
Results
Among individual respondents, online HISBs were significantly associated with higher education (OR 3.03, 95% CI 2.15-4.29, P<.001), worse health status (OR 0.42, 95% CI 0.31-0.57, P<.001), and having no hypertension (OR 0.60, 95% CI 0.43-0.84, P=.003). Online HISBs of other household members were significantly associated with respondent factors: female gender (OR 1.60, 95% CI 1.22-2.10, P=.001), being younger (OR 0.75, 95% CI 0.62-0.90, P=.002), being married (OR 1.36, 95% CI 1.09-1.71, P=.007), having higher education (OR 1.80, 95% CI 1.404-2.316, P<.001), being in worse health (OR 0.59, 95% CI 0.46-0.77, P<.001), and having serious health problems increased the odds of their household members’ online HISBs (OR 1.83, 95% CI 1.29-2.60, P=.001).
Conclusions
This large-scale community survey identified factors associated with online HISBs among Hispanics that merit closer examination. To enhance online HISBs among Hispanics, health care providers and policy makers need to understand the cultural context of the Hispanic population. Results of this study can provide a foundation for the development of informatics-based interventions to improve the health of Hispanics in the United States.
doi:10.2196/jmir.3499
PMCID: PMC4129127  PMID: 25092120
Internet; information seeking behavior; health behavior; consumer health information; hispanic Americans
7.  The Effectiveness of Mobile-Health Technology-Based Health Behaviour Change or Disease Management Interventions for Health Care Consumers: A Systematic Review 
PLoS Medicine  2013;10(1):e1001362.
Caroline Free and colleagues systematically review a fast-moving field, that of the effectiveness of mobile technology interventions delivered to healthcare consumers, and conclude that high-quality, adequately powered trials of optimized interventions are required to evaluate effects on objective outcomes.
Background
Mobile technologies could be a powerful media for providing individual level support to health care consumers. We conducted a systematic review to assess the effectiveness of mobile technology interventions delivered to health care consumers.
Methods and Findings
We searched for all controlled trials of mobile technology-based health interventions delivered to health care consumers using MEDLINE, EMBASE, PsycINFO, Global Health, Web of Science, Cochrane Library, UK NHS HTA (Jan 1990–Sept 2010). Two authors extracted data on allocation concealment, allocation sequence, blinding, completeness of follow-up, and measures of effect. We calculated effect estimates and used random effects meta-analysis. We identified 75 trials. Fifty-nine trials investigated the use of mobile technologies to improve disease management and 26 trials investigated their use to change health behaviours. Nearly all trials were conducted in high-income countries. Four trials had a low risk of bias. Two trials of disease management had low risk of bias; in one, antiretroviral (ART) adherence, use of text messages reduced high viral load (>400 copies), with a relative risk (RR) of 0.85 (95% CI 0.72–0.99), but no statistically significant benefit on mortality (RR 0.79 [95% CI 0.47–1.32]). In a second, a PDA based intervention increased scores for perceived self care agency in lung transplant patients. Two trials of health behaviour management had low risk of bias. The pooled effect of text messaging smoking cessation support on biochemically verified smoking cessation was (RR 2.16 [95% CI 1.77–2.62]). Interventions for other conditions showed suggestive benefits in some cases, but the results were not consistent. No evidence of publication bias was demonstrated on visual or statistical examination of the funnel plots for either disease management or health behaviours. To address the limitation of the older search, we also reviewed more recent literature.
Conclusions
Text messaging interventions increased adherence to ART and smoking cessation and should be considered for inclusion in services. Although there is suggestive evidence of benefit in some other areas, high quality adequately powered trials of optimised interventions are required to evaluate effects on objective outcomes.
Please see later in the article for the Editors' Summary
Editors’ Summary
Background
Every year, millions of people die from cardiovascular diseases (diseases of the heart and circulation), chronic obstructive pulmonary disease (a long-term lung disease), lung cancer, HIV infection, and diabetes. These diseases are increasingly important causes of mortality (death) in low- and middle-income countries and are responsible for nearly 40% of deaths in high-income countries. For all these diseases, individuals can adopt healthy behaviors that help prevent disease onset. For example, people can lower their risk of diabetes and cardiovascular disease by maintaining a healthy body weight, and, if they are smokers, they can reduce their risk of lung cancer and cardiovascular disease by giving up cigarettes. In addition, optimal treatment of existing diseases can reduce mortality and morbidity (illness). Thus, in people who are infected with HIV, antiretroviral therapy delays the progression of HIV infection and the onset of AIDS, and in people who have diabetes, good blood sugar control can prevent retinopathy (a type of blindness) and other serious complications of diabetes.
Why Was This Study Done?
Health-care providers need effective ways to encourage "health-care consumers" to make healthy lifestyle choices and to self-manage chronic diseases. The amount of information, encouragement and support that can be conveyed to individuals during face-to-face consultations or through traditional media such as leaflets is limited, but mobile technologies such as mobile phones and portable computers have the potential to transform the delivery of health messages. These increasingly popular technologies—more than two-thirds of the world's population now owns a mobile phone—can be used to deliver health messages to people anywhere and at the most relevant times. For example, smokers trying to quit smoking can be sent regular text messages to sustain their motivation, but can also use text messaging to request extra support when it is needed. But is "mHealth," the provision of health-related services using mobile communication technology, an effective way to deliver health messages to health-care consumers? In this systematic review (a study that uses predefined criteria to identify all the research on a given topic), the researchers assess the effectiveness of mobile technology-based health behavior change interventions and disease management interventions delivered to health-care consumers.
What Did the Researchers Do and Find?
The researchers identified 75 controlled trials (studies that compare the outcomes of people who do and do not receive an intervention) of mobile technology-based health interventions delivered to health-care consumers that met their predefined criteria. Twenty-six trials investigated the use of mobile technologies to change health behaviors, 59 investigated their use in disease management, most were of low quality, and nearly all were undertaken in high-income countries. In one high-quality trial that used text messages to improve adherence to antiretroviral therapy among HIV-positive patients in Kenya, the intervention significantly reduced the patients’ viral load but did not significantly reduce mortality (the observed reduction in deaths may have happened by chance). In two high-quality UK trials, a smoking intervention based on text messaging (txt2stop) more than doubled biochemically verified smoking cessation. Other lower-quality trials indicated that using text messages to encourage physical activity improved diabetes control but had no effect on body weight. Combined diet and physical activity text messaging interventions also had no effect on weight, whereas interventions for other conditions showed suggestive benefits in some but not all cases.
What Do These Findings Mean?
These findings provide mixed evidence for the effectiveness of health intervention delivery to health-care consumers using mobile technologies. Moreover, they highlight the need for additional high-quality controlled trials of this mHealth application, particularly in low- and middle-income countries. Specifically, the demonstration that text messaging interventions increased adherence to antiretroviral therapy in a low-income setting and increased smoking cessation in a high-income setting provides some support for the inclusion of these two interventions in health-care services in similar settings. However, the effects of these two interventions need to be established in other settings and their cost-effectiveness needs to be measured before they are widely implemented. Finally, for other mobile technology–based interventions designed to change health behaviors or to improve self-management of chronic diseases, the results of this systematic review suggest that the interventions need to be optimized before further trials are undertaken to establish their clinical benefits.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001362.
A related PLOS Medicine Research Article by Free et al. investigates the ability of mHealth technologies to improve health-care service delivery processes
Wikipedia has a page on mHealth (note: Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
mHealth: New horizons for health through mobile technologies is a global survey of mHealth prepared by the World Health Organization’s Global Observatory for eHealth (eHealth is health-care practice supported by electronic processes and communication)
The mHealth in Low-Resource Settings website, which is maintained by the Netherlands Royal Tropical Institute, provides information on the current use, potential, and limitations of mHealth in low-resource settings
More information about Txt2stop is available, the UK National Health Service Choices website provides an analysis of the Txt2stop trial and what its results mean, and the UK National Health Service Smokefree website provides a link to a Quit App for the iPhone
The US Centers for Disease Control and Prevention has launched a text messaging service that delivers regular health tips and alerts to mobile phones
doi:10.1371/journal.pmed.1001362
PMCID: PMC3548655  PMID: 23349621
8.  Measuring Coverage in MNCH: Population HIV-Free Survival among Children under Two Years of Age in Four African Countries 
PLoS Medicine  2013;10(5):e1001424.
Background
Population-based evaluations of programs for prevention of mother-to-child HIV transmission (PMTCT) are scarce. We measured PMTCT service coverage, regimen use, and HIV-free survival among children ≤24 mo of age in Cameroon, Côte D'Ivoire, South Africa, and Zambia.
Methods and Findings
We randomly sampled households in 26 communities and offered participation if a child had been born to a woman living there during the prior 24 mo. We tested consenting mothers with rapid HIV antibody tests and tested the children of seropositive mothers with HIV DNA PCR or rapid antibody tests. Our primary outcome was 24-mo HIV-free survival, estimated with survival analysis. In an individual-level analysis, we evaluated the effectiveness of various PMTCT regimens. In a community-level analysis, we evaluated the relationship between HIV-free survival and community PMTCT coverage (the proportion of HIV-exposed infants in each community that received any PMTCT intervention during gestation or breastfeeding). We also compared our community coverage results to those of a contemporaneous study conducted in the facilities serving each sampled community. Of 7,985 surveyed children under 2 y of age, 1,014 (12.7%) were HIV-exposed. Of these, 110 (10.9%) were HIV-infected, 851 (83.9%) were HIV-uninfected, and 53 (5.2%) were dead. HIV-free survival at 24 mo of age among all HIV-exposed children was 79.7% (95% CI: 76.4, 82.6) overall, with the following country-level estimates: Cameroon (72.6%; 95% CI: 62.3, 80.5), South Africa (77.7%; 95% CI: 72.5, 82.1), Zambia (83.1%; 95% CI: 78.4, 86.8), and Côte D'Ivoire (84.4%; 95% CI: 70.0, 92.2). In adjusted analyses, the risk of death or HIV infection was non-significantly lower in children whose mothers received a more complex regimen of either two or three antiretroviral drugs compared to those receiving no prophylaxis (adjusted hazard ratio: 0.60; 95% CI: 0.34, 1.06). Risk of death was not different for children whose mothers received a more complex regimen compared to those given single-dose nevirapine (adjusted hazard ratio: 0.88; 95% CI: 0.45, 1.72). Community PMTCT coverage was highest in Cameroon, where 75 of 114 HIV-exposed infants met criteria for coverage (66%; 95% CI: 56, 74), followed by Zambia (219 of 444, 49%; 95% CI: 45, 54), then South Africa (152 of 365, 42%; 95% CI: 37, 47), and then Côte D'Ivoire (3 of 53, 5.7%; 95% CI: 1.2, 16). In a cluster-level analysis, community PMTCT coverage was highly correlated with facility PMTCT coverage (Pearson's r = 0.85), and moderately correlated with 24-mo HIV-free survival (Pearson's r = 0.29). In 14 of 16 instances where both the facility and community samples were large enough for comparison, the facility-based coverage measure exceeded that observed in the community.
Conclusions
HIV-free survival can be estimated with community surveys and should be incorporated into ongoing country monitoring. Facility-based coverage measures correlate with those derived from community sampling, but may overestimate population coverage. The more complex regimens recommended by the World Health Organization seem to have measurable public health benefit at the population level, but power was limited and additional field validation is needed.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
For a pregnant woman who is HIV-positive, the discrepancy across the world in outlook for mother and child is stark. Mother-to-child transmission of HIV during pregnancy is now less than 1% in many high-income settings, but occurs much more often in low-income countries. Three interventions have a major impact on transmission of HIV to the baby: antiretroviral drugs, mode of delivery, and type of infant feeding. The latter two are complex, as the interventions commonly used in high-income countries (cesarean section if the maternal viral load is high; exclusive formula feeding) have their own risks in low-income settings. Minimizing the risks of transmitting HIV through effective drug regimes therefore becomes particularly important. Monitoring progress on reducing the incidence of mother-to-child HIV transmission is essential, but not always easy to achieve.
Why Was This Study Done?
A research group led by Stringer and colleagues recently reported a study from four countries in Africa: Cameroon, Côte D'Ivoire, South Africa, and Zambia. The study showed that even in the health facility setting (e.g., hospitals and clinics), only half of infants whose mothers were HIV-positive received the minimum recommended drug treatment (one dose of nevirapine during labor) to prevent HIV transmission. Across the population of these countries, it is possible that fewer receive antiretroviral drugs, as the study did not include women who did not access health facilities. Therefore, the next stage of the study by this research group, reported here, involved going into the communities around these health facilities to find out how many infants under two years old had been exposed to HIV, whether they had received drugs to prevent transmission, and what proportion were alive and not infected with HIV at two years old.
What Did the Researchers Do and Find?
The researchers tested all consenting women who had delivered a baby in the last two years in the surrounding communities. If the mother was found to be HIV-positive, then the infant was also tested for HIV. The researchers then calculated how many of the infants would be alive at two years and free of HIV infection.
Most mothers (78%) agreed to testing for themselves and their infants. There were 7,985 children under two years of age in this study, of whom 13% had been born to an HIV-positive mother. Less than half (46%) of the HIV-positive mothers had received any drugs to prevent HIV transmission. Of the children with HIV-positive mothers, 11% were HIV-infected, 84% were not infected with HIV, and 5% had died. Overall, the researchers estimated that around 80% of these children would be alive at two years without HIV infection. This proportion differed non-significantly between the four countries (ranging from 73% to 84%). The researchers found higher rates of infant survival than they had expected and knew that they might have missed some infant deaths (e.g., if households with infant deaths were less likely to take part in the study).
The researchers found that their estimates of the proportion of HIV-positive mothers who received drugs to prevent transmission were fairly similar between their previous study, looking at health facilities, and this study of the surrounding communities. However, in 14 out of 16 comparisons, the estimate from the community was lower than that from the facility.
What Do These Findings Mean?
This study shows that it would be possible to estimate how many infants are surviving free of HIV infection using a study based in the community, and that these estimates may be more accurate than those for studies based in health facilities. There are still a large proportion of HIV-positive mothers who are not receiving drugs to prevent transmission to the baby. The authors suggest that using two or three drugs to prevent HIV may help to reduce transmission.
There are already community surveys conducted in many low-income countries, but they have not included routine infant testing for HIV. It is now essential that organizations providing drugs, money, and infrastructure in this field consider more accurate means of monitoring incidence of HIV transmission from mother to infant, particularly at the community level.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001424.
The World Health Organization has more information on mother-to-child transmission of HIV
The United Nations Children's Fund has more information on the status of national PMTCT responses in the most affected countries
doi:10.1371/journal.pmed.1001424
PMCID: PMC3646218  PMID: 23667341
9.  The Effect of Handwashing at Recommended Times with Water Alone and With Soap on Child Diarrhea in Rural Bangladesh: An Observational Study 
PLoS Medicine  2011;8(6):e1001052.
By observing handwashing behavior in 347 households from 50 villages across rural Bangladesh in 2007, Stephen Luby and colleagues found that hand washing with soap or hand rinsing without soap before food preparation can both reduce the burden of childhood diarrhea.
Background
Standard public health interventions to improve hand hygiene in communities with high levels of child mortality encourage community residents to wash their hands with soap at five separate key times, a recommendation that would require mothers living in impoverished households to typically wash hands with soap more than ten times per day. We analyzed data from households that received no intervention in a large prospective project evaluation to assess the relationship between observed handwashing behavior and subsequent diarrhea.
Methods and Findings
Fieldworkers conducted a 5-hour structured observation and a cross-sectional survey in 347 households from 50 villages across rural Bangladesh in 2007. For the subsequent 2 years, a trained community resident visited each of the enrolled households every month and collected information on the occurrence of diarrhea in the preceding 48 hours among household residents under the age of 5 years. Compared with children living in households where persons prepared food without washing their hands, children living in households where the food preparer washed at least one hand with water only (odds ratio [OR] = 0.78; 95% confidence interval [CI] = 0.57–1.05), washed both hands with water only (OR = 0.67; 95% CI = 0.51–0.89), or washed at least one hand with soap (OR = 0.30; 95% CI = 0.19–0.47) had less diarrhea. In households where residents washed at least one hand with soap after defecation, children had less diarrhea (OR = 0.45; 95% CI = 0.26–0.77). There was no significant association between handwashing with or without soap before feeding a child, before eating, or after cleaning a child's anus who defecated and subsequent child diarrhea.
Conclusions
These observations suggest that handwashing before preparing food is a particularly important opportunity to prevent childhood diarrhea, and that handwashing with water alone can significantly reduce childhood diarrhea.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
The resurgence of donor interest in regarding water and sanitation as fundamental public health issues has been a welcome step forward and will do much to improve the health of the 1.1 billion people world-wide without access to clean water and the 2.4 billion without access to improved sanitation. However, improving hygiene practices is also very important—studies have consistently shown that handwashing with soap reduces childhood diarrheal disease—but in reality is particularly difficult to do as this activity involves complex behavioral changes. Therefore although public health programs in communities with high child mortality commonly promote handwashing with soap, this practice is still uncommon and washing hands with water only is still common practice—partly because of the high cost of soap relative to income, the risk that conveniently placed soap would be stolen or wasted, and the inconvenience of fetching soap.
Handwashing promotion programs often focus on five “key times” for handwashing with soap—after defecation, after handling child feces or cleaning a child's anus, before preparing food, before feeding a child, and before eating—which would require requesting busy impoverished mothers to wash their hands with soap more than ten times a day.
Why Was This Study Done?
In addition to encouraging handwashing only at the most critical times, clarifying whether handwashing with water alone, a behavior that is seemingly much easier for people to practice, but for which there is little evidence, may be a way forward. In order to guide more focused and evidence-based recommendations, the researchers evaluated the control group of a large handwashing, hygiene/sanitation, and water quality improvement program—Sanitation, Hygiene Education and Water supply-Bangladesh (SHEWA-B), organized and supported by the Bangladesh Government, UNICEF, and the UK's Department for International Development. The researchers analyzed the relationship between handwashing behavior as observed at baseline and the subsequent experience of child diarrhea in participating households to identify which specific handwashing behaviors were associated with less diarrhea in young children.
What Did the Researchers Do and Find?
The SHEWA-B intervention targeted 19.6 million people in rural Bangladesh in 68 subdistricts. In this study and with community and household consent, the researchers organized trained field workers, using a pretested instrument, to note handwashing behavior at key times and recorded handwashing behavior of all observed household at baseline in 50 randomly selected villages that served as nonintervention control households to compare with outcomes to communities receiving the SHEWA-B program. The fieldworkers recruited community monitors, female village residents who completed 3 days training on how to administer the monthly diarrhea survey, to record the frequency of diarrhea in children aged less than 3 years in control households for the subsequent two years. The researchers used statistical models to evaluate the association between the exposure variables (household characteristics and observed handwashing) and diarrhea.
Using these methods, the researchers found that compared to no handwashing at all before food preparation, children living in households where the food preparer washed at least one hand with water only, washed both hands with water only, or washed at least one hand with soap, had less diarrhea with odds ratios (ORs) of 0.78, 0.67, and 0.19, respectively. In households where residents washed at least one hand with soap after defecation, children had less diarrhea (OR = 0.45), but there was no significant association between handwashing with or without soap before feeding a child, before eating, or after cleaning a child's anus, and subsequent child diarrhea.
What Do These Findings Mean?
These findings from 50 villages across rural Bangladesh where fecal environmental contamination, undernutrition, and diarrhea are common, suggest that handwashing before preparing food is a particularly important opportunity to prevent childhood diarrhea, and also that handwashing with water alone can significantly reduce childhood diarrhea. In contrast to current standard recommendations, these results suggest that promoting handwashing exclusively with soap may be unwarranted. Handwashing with water alone might be seen as a step on the handwashing ladder: handwashing with water is good; handwashing with soap is better. Therefore, handwashing promotion programs in rural Bangladesh should not attempt to modify handwashing behavior at all five key times, but rather, should focus primarily on handwashing after defecation and before food preparation. Furthermore, research to develop and evaluate handwashing messages that account for the limited time and soap supplies available for low-income families, and are focused on those behaviors where there is the strongest evidence for a health benefit could help identify more effective strategies.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001052.
A four-part collection of Policy Forum articles published in November 2010 in PLoS Medicine, called “Water and Sanitation,” provides information on water, sanitation, and hygiene
Hygiene Central provides information on improving hygiene practices
doi:10.1371/journal.pmed.1001052
PMCID: PMC3125291  PMID: 21738452
10.  Reducing the Impact of the Next Influenza Pandemic Using Household-Based Public Health Interventions 
PLoS Medicine  2006;3(9):e361.
Background
The outbreak of highly pathogenic H5N1 influenza in domestic poultry and wild birds has caused global concern over the possible evolution of a novel human strain [1]. If such a strain emerges, and is not controlled at source [2,3], a pandemic is likely to result. Health policy in most countries will then be focused on reducing morbidity and mortality.
Methods and Findings
We estimate the expected reduction in primary attack rates for different household-based interventions using a mathematical model of influenza transmission within and between households. We show that, for lower transmissibility strains [2,4], the combination of household-based quarantine, isolation of cases outside the household, and targeted prophylactic use of anti-virals will be highly effective and likely feasible across a range of plausible transmission scenarios. For example, for a basic reproductive number (the average number of people infected by a typically infectious individual in an otherwise susceptible population) of 1.8, assuming only 50% compliance, this combination could reduce the infection (symptomatic) attack rate from 74% (49%) to 40% (27%), requiring peak quarantine and isolation levels of 6.2% and 0.8% of the population, respectively, and an overall anti-viral stockpile of 3.9 doses per member of the population. Although contact tracing may be additionally effective, the resources required make it impractical in most scenarios.
Conclusions
National influenza pandemic preparedness plans currently focus on reducing the impact associated with a constant attack rate, rather than on reducing transmission. Our findings suggest that the additional benefits and resource requirements of household-based interventions in reducing average levels of transmission should also be considered, even when expected levels of compliance are only moderate.
Voluntary household-based quarantine and external isolation are likely to be effective in limiting the morbidity and mortality of an influenza pandemic, even if such a pandemic cannot be entirely prevented, and even if compliance with these interventions is moderate.
Editors' Summary
Background.
Naturally occurring variation in the influenza virus can lead both to localized annual epidemics and to less frequent global pandemics of catastrophic proportions. The most destructive of the three influenza pandemics of the 20th century, the so-called Spanish flu of 1918–1919, is estimated to have caused 20 million deaths. As evidenced by ongoing tracking efforts and news media coverage of H5N1 avian influenza, contemporary approaches to monitoring and communications can be expected to alert health officials and the general public of the emergence of new, potentially pandemic strains before they spread globally.
Why Was This Study Done?
In order to act most effectively on advance notice of an approaching influenza pandemic, public health workers need to know which available interventions are likely to be most effective. This study was done to estimate the effectiveness of specific preventive measures that communities might implement to reduce the impact of pandemic flu. In particular, the study evaluates methods to reduce person-to-person transmission of influenza, in the likely scenario that complete control cannot be achieved by mass vaccination and anti-viral treatment alone.
What Did the Researchers Do and Find?
The researchers developed a mathematical model—essentially a computer simulation—to simulate the course of pandemic influenza in a hypothetical population at risk for infection at home, through external peer networks such as schools and workplaces, and through general community transmission. Parameters such as the distribution of household sizes, the rate at which individuals develop symptoms from nonpandemic viruses, and the risk of infection within households were derived from demographic and epidemiologic data from Hong Kong, as well as empirical studies of influenza transmission. A model based on these parameters was then used to calculate the effects of interventions including voluntary household quarantine, voluntary individual isolation in a facility outside the home, and contact tracing (that is, asking infectious individuals to identify people whom they may have infected and then warning those people) on the spread of pandemic influenza through the population. The model also took into account the anti-viral treatment of exposed, asymptomatic household members and of individuals in isolation, and assumed that all intervention strategies were put into place before the arrival of individuals infected with the pandemic virus.
  Using this model, the authors predicted that even if only half of the population were to comply with public health interventions, the proportion infected during the first year of an influenza pandemic could be substantially reduced by a combination of household-based quarantine, isolation of actively infected individuals in a location outside the household, and targeted prophylactic treatment of exposed individuals with anti-viral drugs. Based on an influenza-associated mortality rate of 0.5% (as has been estimated for New York City in the 1918–1919 pandemic), the magnitude of the predicted benefit of these interventions is a reduction from 49% to 27% in the proportion of the population who become ill in the first year of the pandemic, which would correspond to 16,000 fewer deaths in a city the size of Hong Kong (6.8 million people). In the model, anti-viral treatment appeared to be about as effective as isolation when each was used in combination with household quarantine, but would require stockpiling 3.9 doses of anti-viral for each member of the population. Contact tracing was predicted to provide a modest additional benefit over quarantine and isolation, but also to increase considerably the proportion of the population in quarantine.
What Do These Findings Mean?
This study predicts that voluntary household-based quarantine and external isolation can be effective in limiting the morbidity and mortality of an influenza pandemic, even if such a pandemic cannot be entirely prevented, and even if compliance with these interventions is far from uniform. These simulations can therefore inform preparedness plans in the absence of data from actual intervention trials, which would be impossible outside (and impractical within) the context of an actual pandemic. Like all mathematical models, however, the one presented in this study relies on a number of assumptions regarding the characteristics and circumstances of the situation that it is intended to represent. For example, the authors found that the efficacy of policies to reduce the rate of infection vary according to the ease with which a given virus spreads from person to person. Because this parameter (known as the basic reproductive ratio, R0) cannot be reliably predicted for a new viral strain based on past epidemics, the authors note that in an actual influenza pandemic rapid determinations of R0 in areas already involved would be necessary to finalize public health responses in threatened areas. Further, the implementation of the interventions that appear beneficial in this model would require devoting attention and resources to practical considerations, such as how to staff isolation centers and provide food and water to those in household quarantine. However accurate the scientific data and predictive models may be, their effectiveness can only be realized through well-coordinated local, as well as international, efforts.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030361.
• World Health Organization influenza pandemic preparedness page
• US Department of Health and Human Services avian and pandemic flu information site
• Pandemic influenza page from the Public Health Agency of Canada
• Emergency planning page on pandemic flu from the England Department of Health
• Wikipedia entry on pandemic influenza with links to individual country resources (note: Wikipedia is a free Internet encyclopedia that anyone can edit)
doi:10.1371/journal.pmed.0030361
PMCID: PMC1526768  PMID: 16881729
11.  Effect of Household-Based Drinking Water Chlorination on Diarrhoea among Children under Five in Orissa, India: A Double-Blind Randomised Placebo-Controlled Trial 
PLoS Medicine  2013;10(8):e1001497.
Sophie Boisson and colleagues conducted a double-blind, randomized placebo-controlled trial in Orissa, a state in southeast India, to evaluate the effect of household water treatment in preventing diarrheal illnesses in children aged under five years of age.
Please see later in the article for the Editors' Summary
Background
Boiling, disinfecting, and filtering water within the home can improve the microbiological quality of drinking water among the hundreds of millions of people who rely on unsafe water supplies. However, the impact of these interventions on diarrhoea is unclear. Most studies using open trial designs have reported a protective effect on diarrhoea while blinded studies of household water treatment in low-income settings have found no such effect. However, none of those studies were powered to detect an impact among children under five and participants were followed-up over short periods of time. The aim of this study was to measure the effect of in-home water disinfection on diarrhoea among children under five.
Methods and Findings
We conducted a double-blind randomised controlled trial between November 2010 and December 2011. The study included 2,163 households and 2,986 children under five in rural and urban communities of Orissa, India. The intervention consisted of an intensive promotion campaign and free distribution of sodium dichloroisocyanurate (NaDCC) tablets during bi-monthly households visits. An independent evaluation team visited households monthly for one year to collect health data and water samples. The primary outcome was the longitudinal prevalence of diarrhoea (3-day point prevalence) among children aged under five. Weight-for-age was also measured at each visit to assess its potential as a proxy marker for diarrhoea. Adherence was monitored each month through caregiver's reports and the presence of residual free chlorine in the child's drinking water at the time of visit. On 20% of the total household visits, children's drinking water was assayed for thermotolerant coliforms (TTC), an indicator of faecal contamination. The primary analysis was on an intention-to-treat basis. Binomial regression with a log link function and robust standard errors was used to compare prevalence of diarrhoea between arms. We used generalised estimating equations to account for clustering at the household level. The impact of the intervention on weight-for-age z scores (WAZ) was analysed using random effect linear regression.
Over the follow-up period, 84,391 child-days of observations were recorded, representing 88% of total possible child-days of observation. The longitudinal prevalence of diarrhoea among intervention children was 1.69% compared to 1.74% among controls. After adjusting for clustering within household, the prevalence ratio of the intervention to control was 0.95 (95% CI 0.79–1.13). The mean WAZ was similar among children of the intervention and control groups (−1.586 versus −1.589, respectively). Among intervention households, 51% reported their child's drinking water to be treated with the tablets at the time of visit, though only 32% of water samples tested positive for residual chlorine. Faecal contamination of drinking water was lower among intervention households than controls (geometric mean TTC count of 50 [95% CI 44–57] per 100 ml compared to 122 [95% CI 107–139] per 100 ml among controls [p<0.001] [n = 4,546]).
Conclusions
Our study was designed to overcome the shortcomings of previous double-blinded trials of household water treatment in low-income settings. The sample size was larger, the follow-up period longer, both urban and rural populations were included, and adherence and water quality were monitored extensively over time. These results provide no evidence that the intervention was protective against diarrhoea. Low compliance and modest reduction in water contamination may have contributed to the lack of effect. However, our findings are consistent with other blinded studies of similar interventions and raise additional questions about the actual health impact of household water treatment under these conditions.
Trial Registration
ClinicalTrials.gov NCT01202383
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Millennium Development Goal 7 calls for halving the proportion of the global population without sustainable access to safe drinking water between 1990 and 2015. Although this target was met in 2010, according to latest figures, 768 million people world-wide still rely on unimproved drinking water sources. Access to clean drinking water is integral to good health and a key strategy in reducing diarrhoeal illness: Currently, 1.3 million children aged less than five years die of diarrhoeal illnesses every year with a sixth of such deaths occurring in one country—India. Although India has recently made substantial progress in improving water supplies throughout the country, currently almost 90% of the rural population does not have a water connection to their house and drinking water supplies throughout the country are extensively contaminated with human waste. A strategy internationally referred to as Household Water Treatment and Safe Storage (HWTS), which involves people boiling, chlorinating, and filtering water at home, has been recommended by the World Health Organization and UNICEF to improve water quality at the point of delivery.
Why Was This Study Done?
The WHO and UNICEF strategy to promote HWTS is based on previous studies from low-income settings that found that such interventions could reduce diarrhoeal illnesses by between 30%–40%. However, these studies had several limitations including reporting bias, short follow up periods, and small sample sizes; and importantly, in blinded studies (in which both the study participants and researchers are unaware of which participants are receiving the intervention or the control) have found no evidence that HWTS is protective against diarrhoeal illnesses. So the researchers conducted a blinded study (a double-blind, randomized placebo-controlled trial) in Orissa, a state in southeast India, to address those shortcomings and evaluate the effect of household water treatment in preventing diarrhoeal illnesses in children under five years of age.
What Did the Researchers Do and Find?
The researchers conducted their study in 11 informal settlements (where the inhabitants do not benefit from public water or sewers) in the state's capital city and also in 20 rural villages. 2,163 households were randomized to receive the intervention—the promotion and free distribution of sodium dichloroisocyanurate (chlorine) disinfection tablets with instruction on how to use them—or placebo tablets that were similar in appearance and had the same effervescent base as the chlorine tablets. Trained field workers visited households every month for 12 months (between December 2010 and December 2011) to record whether any child had experienced diarrhoea in the previous three days (as reported by the primary care giver). The researchers tested compliance with the intervention by asking participants if they had treated the water and also by testing for chlorine in the water.
Using these methods, the researchers found that over the 12-month follow-up period, the longitudinal prevalence of diarrhoea among children in the intervention group was 1.69% compared to 1.74% in the control group, a non-significant finding (a finding that could have happened by chance). There was also no difference in diarrhoea prevalence among other household members in the two groups and no difference in weight for age z scores (a measurement of growth) between children in the two groups. The researchers also found that although just over half (51%) of households in the intervention group reported treating their water, on testing, only 32% of water samples tested positive for chlorine. Finally, the researchers found that water quality (as measured by thermotolerant coliforms, TTCs) was better in the intervention group than the control group.
What Do These Findings Mean?
These findings suggest that treating water with chlorine tablets has no effect in reducing the prevalence of diarrhoea in both children aged under five years and in other household members in Orissa, India. However, poor compliance was a major issue with only a third of households in the intervention group confirmed as treating their water with chlorine tablets. Furthermore, these findings are limited in that the prevalence of diarrhoea was lower than expected, which may have also reduced the power of detecting a potential effect of the intervention. Nevertheless, this study raises questions about the health impact of household water treatment and highlights the key challenge of poor compliance with public health interventions.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001497.
The website of the World Health Organization has a section dedicated to household water treatment and safe storage, including a network to promote the use of HWTS and a toolkit to measure HWTS
The Water Institute hosts the communications portal for the International Network on Household Water Treatment and Safe Storage
doi:10.1371/journal.pmed.1001497
PMCID: PMC3747993  PMID: 23976883
12.  Measuring Adult Mortality Using Sibling Survival: A New Analytical Method and New Results for 44 Countries, 1974–2006 
PLoS Medicine  2010;7(4):e1000260.
Julie Rajaratnam and colleagues describe a novel method, called the Corrected Sibling Survival method, to measure adult mortality in countries without good vital registration by use of histories taken from surviving siblings.
Background
For several decades, global public health efforts have focused on the development and application of disease control programs to improve child survival in developing populations. The need to reliably monitor the impact of such intervention programs in countries has led to significant advances in demographic methods and data sources, particularly with large-scale, cross-national survey programs such as the Demographic and Health Surveys (DHS). Although no comparable effort has been undertaken for adult mortality, the availability of large datasets with information on adult survival from censuses and household surveys offers an important opportunity to dramatically improve our knowledge about levels and trends in adult mortality in countries without good vital registration. To date, attempts to measure adult mortality from questions in censuses and surveys have generally led to implausibly low levels of adult mortality owing to biases inherent in survey data such as survival and recall bias. Recent methodological developments and the increasing availability of large surveys with information on sibling survival suggest that it may well be timely to reassess the pessimism that has prevailed around the use of sibling histories to measure adult mortality.
Methods and Findings
We present the Corrected Sibling Survival (CSS) method, which addresses both the survival and recall biases that have plagued the use of survey data to estimate adult mortality. Using logistic regression, our method directly estimates the probability of dying in a given country, by age, sex, and time period from sibling history data. The logistic regression framework borrows strength across surveys and time periods for the estimation of the age patterns of mortality, and facilitates the implementation of solutions for the underrepresentation of high-mortality families and recall bias. We apply the method to generate estimates of and trends in adult mortality, using the summary measure 45q15—the probability of a 15-y old dying before his or her 60th birthday—for 44 countries with DHS sibling survival data. Our findings suggest that levels of adult mortality prevailing in many developing countries are substantially higher than previously suggested by other analyses of sibling history data. Generally, our estimates show the risk of adult death between ages 15 and 60 y to be about 20%–35% for females and 25%–45% for males in sub-Saharan African populations largely unaffected by HIV. In countries of Southern Africa, where the HIV epidemic has been most pronounced, as many as eight out of ten men alive at age 15 y will be dead by age 60, as will six out of ten women. Adult mortality levels in populations of Asia and Latin America are generally lower than in Africa, particularly for women. The exceptions are Haiti and Cambodia, where mortality risks are comparable to many countries in Africa. In all other countries with data, the probability of dying between ages 15 and 60 y was typically around 10% for women and 20% for men, not much higher than the levels prevailing in several more developed countries.
Conclusions
Our results represent an expansion of direct knowledge of levels and trends in adult mortality in the developing world. The CSS method provides grounds for renewed optimism in collecting sibling survival data. We suggest that all nationally representative survey programs with adequate sample size ought to implement this critical module for tracking adult mortality in order to more reliably understand the levels and patterns of adult mortality, and how they are changing.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Governments and international health agencies need accurate information on births and deaths in populations to help them plan health care policies and monitor the effectiveness of public-health programs designed, for example, to prevent premature deaths from preventable causes such as tobacco smoking. In developed countries, full information on births and deaths is recorded in “vital registration systems.” Unfortunately, very few developing countries have complete vital registration systems. In most African countries, for example, less than one-quarter of deaths are counted through vital registration systems. To fill this information gap, scientists have developed several methods to estimate mortality levels (the proportion of deaths in populations) and trends in mortality (how the proportion of deaths in populations changes over time) from data collected in household surveys and censuses. A household survey collects data about family members (for example, number, age, and sex) for a national sample of households randomly selected from a list of households collected in a census (a periodic count of a population).
Why Was This Study Done?
To date, global public-health efforts have concentrated on improving child survival. Consequently, methods for calculating child mortality levels and trends from surveys are well-developed and generally yield accurate estimates. By contrast, although attempts have been made to measure adult mortality using sibling survival histories (records of the sex, age if alive, or age at death, if dead, of all the children born to survey respondents' mothers that are collected in many household surveys), these attempts have often produced implausibly low estimates of adult mortality. These low estimates arise because people do not always recall deaths accurately when questioned (recall bias) and because families that have fallen apart, possibly because of family deaths, are underrepresented in household surveys (selection bias). In this study, the researchers develop a corrected sibling survival (CSS) method that addresses the problems of selection and recall bias and use their method to estimate mortality levels and trends in 44 developing countries between 1974 and 2006.
What Did the Researchers Do and Find?
The researchers used a statistical approach called logistic regression to develop the CSS method. They then used the method to estimate the probability of a 15-year-old dying before his or her 60th birthday from sibling survival data collected by the Demographic and Health Surveys program (DHS, a project started in 1984 to help developing countries collect data on population and health trends). Levels of adult mortality estimated in this way were considerably higher than those suggested by previous analyses of sibling history data. For example, the risk of adult death between the ages of 15 and 60 years was 20%–35% for women and 25%–45% for men living in sub-Saharan African countries largely unaffected by HIV and 60% for women and 80% for men living in countries in Southern Africa where the HIV epidemic is worst. Importantly, the researchers show that their mortality level estimates compare well to those obtained from vital registration data and other data sources where available. So, for example, in the Philippines, adult mortality levels estimated using the CSS method were similar to those obtained from vital registration data. Finally, the researchers used the CSS method to estimate mortality trends. These calculations reveal, for example, that there has been a 3–4-fold increase in adult mortality since the late 1980s in Zimbabwe, a country badly affected by the HIV epidemic.
What Do These Findings Mean?
These findings suggest that the CSS method, which applies a correction for both selection and recall bias, yields more accurate estimates of adult mortality in developing countries from sibling survival data than previous methods. Given their findings, the researchers suggest that sibling survival histories should be routinely collected in all future household survey programs and, if possible, these surveys should be expanded so that all respondents are asked about sibling histories—currently the DHS only collects sibling histories from women aged 15–49 years. Widespread collection of such data and their analysis using the CSS method, the researchers conclude, would help governments and international agencies track trends in adult mortality and progress toward major health and development targets.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000260.
This study and two related PLoS Medicine Research Articles by Rajaratnam et al. and by Murray et al. are further discussed in a PLoS Medicine Perspective by Mathers and Boerma
Information is available about the Demographic and Health Surveys
The Institute for Health Metrics and Evaluation makes available high-quality information on population health, its determinants, and the performance of health systems
Grand Challenges in Global Health provides information on research into better ways for developing countries to measure their health status
The World Health Organization Statistical Information System (WHOSIS) is an interactive database that brings together core health statistics for WHO member states, including information on vital registration of deaths; the WHO Health Metrics Network is a global collaboration focused on improving sources of vital statistics
doi:10.1371/journal.pmed.1000260
PMCID: PMC2854132  PMID: 20405004
13.  Community Mobilization in Mumbai Slums to Improve Perinatal Care and Outcomes: A Cluster Randomized Controlled Trial 
PLoS Medicine  2012;9(7):e1001257.
David Osrin and colleagues report findings from a cluster-randomized trial conducted in Mumbai slums; the trial aimed to evaluate whether facilitator-supported women's groups could improve perinatal outcomes.
Introduction
Improving maternal and newborn health in low-income settings requires both health service and community action. Previous community initiatives have been predominantly rural, but India is urbanizing. While working to improve health service quality, we tested an intervention in which urban slum-dweller women's groups worked to improve local perinatal health.
Methods and Findings
A cluster randomized controlled trial in 24 intervention and 24 control settlements covered a population of 283,000. In each intervention cluster, a facilitator supported women's groups through an action learning cycle in which they discussed perinatal experiences, improved their knowledge, and took local action. We monitored births, stillbirths, and neonatal deaths, and interviewed mothers at 6 weeks postpartum. The primary outcomes described perinatal care, maternal morbidity, and extended perinatal mortality. The analysis included 18,197 births over 3 years from 2006 to 2009. We found no differences between trial arms in uptake of antenatal care, reported work, rest, and diet in later pregnancy, institutional delivery, early and exclusive breastfeeding, or care-seeking. The stillbirth rate was non-significantly lower in the intervention arm (odds ratio 0.86, 95% CI 0.60–1.22), and the neonatal mortality rate higher (1.48, 1.06–2.08). The extended perinatal mortality rate did not differ between arms (1.19, 0.90–1.57). We have no evidence that these differences could be explained by the intervention.
Conclusions
Facilitating urban community groups was feasible, and there was evidence of behaviour change, but we did not see population-level effects on health care or mortality. In cities with multiple sources of health care, but inequitable access to services, community mobilization should be integrated with attempts to deliver services for the poorest and most vulnerable, and with initiatives to improve quality of care in both public and private sectors.
Trial registration
Current Controlled Trials ISRCTN96256793
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Substantial progress is being made to reduce global child mortality (deaths of children before the age of 5 years) and maternal mortality (deaths among women because of complications of pregnancy and childbirth)—two of the Millennium Development Goals agreed by world leaders in 2000 to end extreme poverty. Even so, worldwide, in 2010, 7.6 million children died before their fifth birthday and there were nearly 360,000 maternal deaths. Almost all child and maternal deaths occur in developing countries—a fifth of under-five deaths and more than a quarter of neonatal deaths (deaths during the first month of life, which account for two-fifths of all child deaths) occur in India alone. Moreover, most child and maternal deaths are caused by avoidable conditions. Specifically, the major causes of neonatal death—complications of preterm delivery, breathing problems during or after delivery, and infections of the blood (sepsis) and lungs (pneumonia)—and of maternal deaths—hemorrhage (abnormal bleeding), sepsis, unsafe abortion, obstructed labor, and hypertensive diseases of pregnancy—could all be largely prevented by improved access to reproductive health services and skilled health care workers.
Why Was This Study Done?
Experts believe that improvements to maternal and newborn health in low-income settings require both health service strengthening and community action. That is, the demand for better services, driven by improved knowledge about maternal and newborn health (perinatal issues), has to be increased in parallel with the supply of those services. To date, community mobilization around perinatal issues has largely been undertaken in rural settings but populations in developing countries are becoming increasingly urban. In India, for example, 30% of the population now lives in cities. In this cluster randomized controlled trial (a study in which groups of people are randomly assigned to receive alternative interventions and the outcomes in the differently treated “clusters” are compared), City Initiative for Newborn Health (CINH) researchers investigate the effect of an intervention designed to help women's groups in the slums of Mumbai work towards improving local perinatal health. The CINH aims to improve maternal and newborn health in slum communities by improving public health care provision and by working with community members to improve maternal and newborn care practices and care-seeking behaviors.
What Did the Researchers Do and Find?
The researchers enrolled 48 Mumbai slum communities of at least 1,000 households into their trial. In each of the 24 intervention clusters, a facilitator supported local women's groups through a 36-meeting learning cycle during which group members discussed their perinatal experiences, improved their knowledge, and took action. To measure the effect of the intervention, the researchers monitored births, stillbirths, and neonatal deaths in all the clusters and interviewed mothers 6 weeks after delivery. During the 3-year trial, there were 18,197 births in the participating settlements. The women in the intervention clusters were enthusiastic about acquiring new knowledge and made substantial efforts to reach out to other women but were less successful in undertaking collective action such as negotiations with civic authorities for more amenities. There were no differences between the intervention and control communities in the uptake of antenatal care, reported work, rest, and diet in late pregnancy, institutional delivery, or in breast feeding and care-seeking behavior. Finally, the combined rate of stillbirths and neonatal deaths (the extended perinatal mortality rate) was the same in both arms of the trial, as was maternal mortality.
What Do These Findings Mean?
These findings indicate that it is possible to facilitate the discussion of perinatal health care by urban women's groups in the challenging conditions that exist in the slums of Mumbai. However, they fail to show any measureable effect of community mobilization through the facilitation of women's groups on perinatal health at the population level. The researchers acknowledge that more intensive community activities that target the poorest, most vulnerable slum dwellers might produce measurable effects on perinatal mortality, and they conclude that, in cities with multiple sources of health care and inequitable access to services, it remains important to integrate community mobilization with attempts to deliver services to the poorest and most vulnerable, and with initiatives to improve the quality of health care in both the public and private sector.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001257.
The United Nations Childrens Fund (UNICEF) works for children's rights, survival, development, and protection around the world; it provides information on the reduction of child mortality (Millennium Development Goal 4); its Childinfo website provides information about all the Millennium Development Goals and detailed statistics about on child survival and health, newborn care, and maternal health (some information in several languages)
The World Health Organization also has information about Millennium Development Goal 4 and Millennium Development Goal 5, the reduction of maternal mortality, provides information on newborn infants, and provides estimates of child mortality rates (some information in several languages)
Further information about the Millennium Development Goals is available
Information on the City Initiative for Newborn Health and its partners and a detailed description of its trial of community mobilization in Mumbai slums to improve care during pregnancy, delivery, postnatally and for the newborn are available
Further information about the Society for Nutrition, Education and Health Action (SNEHA) is available
doi:10.1371/journal.pmed.1001257
PMCID: PMC3389036  PMID: 22802737
14.  Estimates of Outcomes Up to Ten Years after Stroke: Analysis from the Prospective South London Stroke Register 
PLoS Medicine  2011;8(5):e1001033.
Charles Wolfe and colleagues collected data from the South London Stroke Register on 3,373 first strokes registered between 1995 and 2006 and showed that between 20% and 30% of survivors have poor outcomes up to 10 years after stroke.
Background
Although stroke is acknowledged as a long-term condition, population estimates of outcomes longer term are lacking. Such estimates would be useful for planning health services and developing research that might ultimately improve outcomes. This burden of disease study provides population-based estimates of outcomes with a focus on disability, cognition, and psychological outcomes up to 10 y after initial stroke event in a multi-ethnic European population.
Methods and Findings
Data were collected from the population-based South London Stroke Register, a prospective population-based register documenting all first in a lifetime strokes since 1 January 1995 in a multi-ethnic inner city population. The outcomes assessed are reported as estimates of need and included disability (Barthel Index <15), inactivity (Frenchay Activities Index <15), cognitive impairment (Abbreviated Mental Test < 8 or Mini-Mental State Exam <24), anxiety and depression (Hospital Anxiety and Depression Scale >10), and mental and physical domain scores of the Medical Outcomes Study 12-item short form (SF-12) health survey. Estimates were stratified by age, gender, and ethnicity, and age-adjusted using the standard European population. Plots of outcome estimates over time were constructed to examine temporal trends and sociodemographic differences. Between 1995 and 2006, 3,373 first-ever strokes were registered: 20%–30% of survivors had a poor outcome over 10 y of follow-up. The highest rate of disability was observed 7 d after stroke and remained at around 110 per 1,000 stroke survivors from 3 mo to 10 y. Rates of inactivity and cognitive impairment both declined up to 1 y (280/1,000 and 180/1,000 survivors, respectively); thereafter rates of inactivity remained stable till year eight, then increased, whereas rates of cognitive impairment fluctuated till year eight, then increased. Anxiety and depression showed some fluctuation over time, with a rate of 350 and 310 per 1,000 stroke survivors, respectively. SF-12 scores showed little variation from 3 mo to 10 y after stroke. Inactivity was higher in males at all time points, and in white compared to black stroke survivors, although black survivors reported better outcomes in the SF-12 physical domain. No other major differences were observed by gender or ethnicity. Increased age was associated with higher rates of disability, inactivity, and cognitive impairment.
Conclusions
Between 20% and 30% of stroke survivors have a poor range of outcomes up to 10 y after stroke. Such epidemiological data demonstrate the sociodemographic groups that are most affected longer term and should be used to develop longer term management strategies that reduce the significant poor outcomes of this group, for whom effective interventions are currently elusive.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Every year, 15 million people have a stroke. About 5 million of these people die within a few days, and another 5 million are left disabled. Stroke occurs when the brain's blood supply is suddenly interrupted by a blood clot blocking a blood vessel in the brain (ischemic stroke, the commonest type of stroke) or by a blood vessel in the brain bursting (hemorrhagic stroke). Deprived of the oxygen normally carried to them by the blood, the brain cells near the blockage die. The symptoms of stroke depend on which part of the brain is damaged but include sudden weakness or paralysis along one side of the body, vision loss in one or both eyes, and confusion or trouble speaking or understanding speech. Anyone experiencing these symptoms should seek immediate medical attention because prompt treatment can limit the damage to the brain. Risk factors for stroke include age (three-quarters of strokes occur in people over 65 years old), high blood pressure, and heart disease.
Why Was This Study Done?
Post-stroke rehabilitation can help individuals overcome the physical disabilities caused by stroke, and drugs and behavioral counseling can reduce the risk of a second stroke. However, people can also have problems with cognition (thinking, awareness, attention, learning, judgment, and memory) after a stroke, and they can become depressed or anxious. These “outcomes” can persist for many years, but although stroke is acknowledged as a long-term condition, most existing data on stroke outcomes are limited to a year after the stroke and often focus on disability alone. Longer term, more extensive information is needed to help plan services and to help develop research to improve outcomes. In this burden of disease analysis, the researchers use follow-up data collected by the prospective South London Stroke Register (SLSR) to provide long-term population-based estimates of disability, cognition, and psychological outcomes after a first stroke. The SLSR has recorded and followed all patients of all ages in an inner area of South London after their first-ever stroke since 1995.
What Did the Researchers Do and Find?
Between 1995 and 2006, the SLSR recorded 3,373 first-ever strokes. Patients were examined within 48 hours of referral to SLSR, their stroke diagnosis was verified, and their sociodemographic characteristics (including age, gender, and ethnic origin) were recorded. Study nurses and fieldworkers then assessed the patients at three months and annually after the stroke for disability (using the Barthel Index, which measures the ability to, for example, eat unaided), inactivity (using the Frenchay Activities Index, which measures participation in social activities), and cognitive impairment (using the Abbreviated Mental Test or the Mini-Mental State Exam). Anxiety and depression and the patients' perceptions of their mental and physical capabilities were also assessed. Using preset cut-offs for each outcome, 20%–30% of stroke survivors had a poor outcome over ten years of follow-up. So, for example, 110 individuals per 1,000 population were judged disabled from three months to ten years, rates of inactivity remained constant from year one to year eight, at 280 affected individuals per 1,000 survivors, and rates of anxiety and depression fluctuated over time but affected about a third of the population. Notably, levels of inactivity were higher among men than women at all time points and were higher in white than in black stroke survivors. Finally, increased age was associated with higher rates of disability, inactivity, and cognitive impairment.
What Do These Findings Mean?
Although the accuracy of these findings may be affected by the loss of some patients to follow-up, these population-based estimates of outcome measures for survivors of a first-ever stroke for up to ten years after the event provide concrete evidence that stroke is a lifelong condition with ongoing poor outcomes. They also identify the sociodemographic groups of patients that are most affected in the longer term. Importantly, most of the measured outcomes remain relatively constant (and worse than outcomes in an age-matched non-stroke-affected population) after 3–12 months, a result that needs to be considered when planning services for stroke survivors. In other words, these findings highlight the need for health and social services to provide long-term, ongoing assessment and rehabilitation for patients for many years after a stroke.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001033.
The US National Institute of Neurological Disorders and Stroke provides information about all aspects of stroke (in English and Spanish); the US National Institute of Health SeniorHealth Web site has additional information about stroke
The Internet Stroke Center provides detailed information about stroke for patients, families, and health professionals (in English and Spanish)
The UK National Health Service Choices Web site also provides information about stroke for patients and their families
MedlinePlus has links to additional resources about stroke (in English and Spanish)
More information about the South London Stroke Register is available
doi:10.1371/journal.pmed.1001033
PMCID: PMC3096613  PMID: 21610863
15.  A quasi-experimental assessment of the effectiveness of the Community Health Strategy on health outcomes in Kenya 
BMC Health Services Research  2014;14(Suppl 1):S3.
Background
Despite focused health policies and reform agenda, Kenya has challenges in improving households’ situation in poverty and ill health; interventions to address the Millennium Development Goals in maternal and child health, such as focused antenatal care and immunization of children, are yet to achieve success. Research has shown that addressing the demand side is critical in improving health outcomes. This paper presents a model for health systems performance improvement using a strategy that bridges the interface between the community and the health system.
Methods
The study employed quasi-experimental design, using pre- and post-intervention surveys in intervention and control sites. The intervention was the implementation of all components of the Kenyan Community Health Strategy, guided by policy. The two year intervention (2011 and 2012) saw the strategy introduced to selected district health management teams, service providers, and communities through a series of three-day training workshops that were held three times during the intervention period.
Baseline and endline surveys were conducted in intervention and control sites where community unit assessment was undertaken to determine the status of health service utilization before and after the intervention. A community health unit consists of 1000 households, a population of about 5000, served by trained community health workers, each supporting about 20 to 50 households. Data was organized and analyzed using Excel, SPSS, Epi info, Stata Cal, and SAS.
Results
A number of health indicators, such as health facility delivery, antenatal care, water treatment, latrine use, and insecticide treated nets, improved in the intervention sites compared to non-interventions sites. The difference between intervention and control sites was statistically significant (p<0.0001) for antenatal care, health facility delivery, water treatment, latrine use, use of insecticide treated nets, presence of clinic card, and measles vaccination. Degree of improvement across the various indicators measured differed by socio-demographic contexts. The changes were greatest in the rural agrarian sites, compared to peri-urban and nomadic sites.
Conclusion
The study showed that most of the components of the strategy were implemented and sustained in different socio-demographic contexts, while participatory community planning based on household information drives improvement of health indicators.
doi:10.1186/1472-6963-14-S1-S3
PMCID: PMC4108865  PMID: 25079378
Community health strategy; community dialogue; quasi-experimental design; community health workers; health outcomes; stratégie en santé communautaire; dialogue communautaire; concept quasi expérimental; agents de santé communautaire; santé
16.  Configuring Balanced Scorecards for Measuring Health System Performance: Evidence from 5 Years' Evaluation in Afghanistan 
PLoS Medicine  2011;8(7):e1001066.
Anbrasi Edward and colleagues report the results of a balanced scorecard performance system used to examine 29 key performance indicators over a 5-year period in Afghanistan, between 2004 and 2008.
Background
In 2004, Afghanistan pioneered a balanced scorecard (BSC) performance system to manage the delivery of primary health care services. This study examines the trends of 29 key performance indicators over a 5-year period between 2004 and 2008.
Methods and Findings
Independent evaluations of performance in six domains were conducted annually through 5,500 patient observations and exit interviews and 1,500 provider interviews in >600 facilities selected by stratified random sampling in each province. Generalized estimating equation (GEE) models were used to assess trends in BSC parameters. There was a progressive improvement in the national median scores scaled from 0–100 between 2004 and 2008 in all six domains: patient and community satisfaction of services (65.3–84.5, p<0.0001); provider satisfaction (65.4–79.2, p<0.01); capacity for service provision (47.4–76.4, p<0.0001); quality of services (40.5–67.4, p<0.0001); and overall vision for pro-poor and pro-female health services (52.0–52.6). The financial domain also showed improvement until 2007 (84.4–95.7, p<0.01), after which user fees were eliminated. By 2008, all provinces achieved the upper benchmark of national median set in 2004.
Conclusions
The BSC has been successfully employed to assess and improve health service capacity and service delivery using performance benchmarking during the 5-year period. However, scorecard reconfigurations are needed to integrate effectiveness and efficiency measures and accommodate changes in health systems policy and strategy architecture to ensure its continued relevance and effectiveness as a comprehensive health system performance measure. The process of BSC design and implementation can serve as a valuable prototype for health policy planners managing performance in similar health care contexts.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Traditionally, the performance of a health system (the complete network of health care agencies, facilities, and providers in a defined geographical region) has been measured in terms of health outcomes: how many people have been treated, how many got better, and how many died. But, nowadays, with increased demand for improved governance and accountability, policy makers are seeking comprehensive performance measures that show in detail how innovations designed to strengthen health systems are affecting service delivery and health outcomes. One such performance measure is the “balanced scorecard,” an integrated management and measurement tool that enables organizations to clarify their vision and strategy and translate them into action. The balanced scorecard—essentially a list of key performance indicators and performance benchmarks in several domains—was originally developed for industry but is now becoming a popular strategic management tool in the health sector. For example, balanced scorecards have been successfully integrated into the Dutch and Italian public health care systems.
Why Was This Study Done?
Little is known about the use of balanced scorecards in the national public health care systems of developing countries but the introduction of performance management into health system reform in fragile states in particular (developing countries where the state fails to perform the fundamental functions necessary to meet its citizens' basic needs and expectations) could help to promote governance and leadership, and facilitate essential policy changes. One fragile state that has introduced the balanced scorecard system for public health care management is Afghanistan, which emerged from decades of conflict in 2002 with some of the world's worst health indicators. To deal with an extremely high burden of disease, the Ministry of Public Health (MOPH) designed a Basic Package of Health Services (BPHS), which is delivered by nongovernmental organizations and MOPH agencies. In 2004, the MOPH introduced the National Health Service Performance Assessment (NHSPA), an annual country-wide assessment of service provision and patient satisfaction and pioneered a balanced scorecard, which uses data collected in the NHSPA, to manage the delivery of primary health care services. In this study, the researchers examine the trends between 2004 and 2008 of the 29 key performance indicators in six domains included in this balanced scorecard, and consider the potential and limitations of the scorecard as a management tool to measure and improve health service delivery in Afghanistan and other similar countries.
What Did the Researchers Do and Find?
Each year of the study, a random sample of 25 facilities (district hospitals and comprehensive and basic health centers) in 28 of Afghanistan's 34 provinces was chosen (one province did not have functional facilities in 2004 and the other five missing provinces were inaccessible because of ongoing conflicts). NHSPA surveyors collected approximately 5,000 patient observations, 5,000 exit interviews with patients or their caregivers, and 1,500 health provider interviews by observing consultations involving five children under 5 years old and five patients over 5 years old in each facility. The researchers then used this information to evaluate the key performance indicators in the balanced scorecard and a statistical method called generalized estimating equation modeling to assess trends in these indicators. They report that there was a progressive improvement in national average scores in all six domains (patients and community satisfaction with services, provider satisfaction, capacity for service provision, quality of services, overall vision for pro-poor and pro-female health services, and financial systems) between 2004 and 2008.
What Do These Findings Mean?
These findings suggest that the balanced scorecard was successfully used to improve health system capacity and service delivery through performance benchmarking over the 5-year study period. Importantly, the use of the balanced scorecard helped to show the effects of investments, facilitate policy change, and create a more evidence-based decision-making culture in Afghanistan's primary health care system. However, the researchers warn that the continuing success of the balanced scorecard in Afghanistan will depend on its ability to accommodate changes in health systems policy. Furthermore, reconfigurations of the scorecard are needed to include measures of the overall effectiveness and efficiency of the health system such as mortality rates. More generally, the researchers conclude that the balanced scorecard offers a promising measure of health system performance that could be used to examine the effectiveness of health care strategies and innovations in other fragile and developing countries.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001066.
A 2010 article entitled An Afghan Success Story: The Balanced Scorecard and Improved Health Services in The Globe, a newsletter produced by the Department of International Health at the John Hopkins Bloomberg School of Public Health, provides a detailed description of the balanced scorecard used in this study
Wikipedia has a page on health systems and on balanced scorecards (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
The World Health Organization country profile of Afghanistan provides information on the country's health system and burden of disease (in several languages)
doi:10.1371/journal.pmed.1001066
PMCID: PMC3144209  PMID: 21814499
17.  Indoor Residual Spraying in Combination with Insecticide-Treated Nets Compared to Insecticide-Treated Nets Alone for Protection against Malaria: A Cluster Randomised Trial in Tanzania 
PLoS Medicine  2014;11(4):e1001630.
Philippa West and colleagues compare Plasmodium falciparum infection prevalence in children, anemia in young children, and entomological inoculation rate between study arms.
Please see later in the article for the Editors' Summary
Background
Insecticide-treated nets (ITNs) and indoor residual spraying (IRS) of houses provide effective malaria transmission control. There is conflicting evidence about whether it is more beneficial to provide both interventions in combination. A cluster randomised controlled trial was conducted to investigate whether the combination provides added protection compared to ITNs alone.
Methods and Findings
In northwest Tanzania, 50 clusters (village areas) were randomly allocated to ITNs only or ITNs and IRS. Dwellings in the ITN+IRS arm were sprayed with two rounds of bendiocarb in 2012. Plasmodium falciparum prevalence rate (PfPR) in children 0.5–14 y old (primary outcome) and anaemia in children <5 y old (secondary outcome) were compared between study arms using three cross-sectional household surveys in 2012. Entomological inoculation rate (secondary outcome) was compared between study arms.
IRS coverage was approximately 90%. ITN use ranged from 36% to 50%. In intention-to-treat analysis, mean PfPR was 13% in the ITN+IRS arm and 26% in the ITN only arm, odds ratio = 0.43 (95% CI 0.19–0.97, n = 13,146). The strongest effect was observed in the peak transmission season, 6 mo after the first IRS. Subgroup analysis showed that ITN users were additionally protected if their houses were sprayed. Mean monthly entomological inoculation rate was non-significantly lower in the ITN+IRS arm than in the ITN only arm, rate ratio = 0.17 (95% CI 0.03–1.08).
Conclusions
This is the first randomised trial to our knowledge that reports significant added protection from combining IRS and ITNs compared to ITNs alone. The effect is likely to be attributable to IRS providing added protection to ITN users as well as compensating for inadequate ITN use. Policy makers should consider deploying IRS in combination with ITNs to control transmission if local ITN strategies on their own are insufficiently effective. Given the uncertain generalisability of these findings, it would be prudent for malaria control programmes to evaluate the cost-effectiveness of deploying the combination.
Trial registration
www.ClinicalTrials.gov NCT01697852
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Every year, more than 200 million cases of malaria occur worldwide, and more than 600,000 people, mainly children living in sub-Saharan Africa, die from this parasitic infection. Malaria parasites, which are transmitted to people through the bites of infected night-flying mosquitoes, cause a characteristic fever that needs to be treated promptly with antimalarial drugs to prevent anaemia (a reduction in red blood cell numbers) and organ damage. Prompt treatment also helps to reduce malaria transmission, but the mainstays of global malaria control efforts are the provision of insecticide-treated nets (ITNs) for people to sleep under to avoid mosquito bites, and indoor residual spraying (IRS) of houses with insecticides, which prevents mosquitoes from resting in houses. Both approaches have been scaled up in the past decade. About 54% of households in Africa now own at least one ITN, and 8% of at-risk populations are protected by IRS. As a result of the widespread deployment of these preventative tools and the increased availability of effective antimalarial drugs, malaria-related deaths in Africa fell by 45% between 2000 and 2012.
Why Was This Study Done?
Some countries have chosen to use ITNs and IRS in combination, reasoning that this will increase the proportion of individuals who are protected by at least one intervention and may provide additional protection to people using both interventions rather than one alone. However, providing both interventions is costly, so it is important to know whether this rationale is correct. In this cluster randomised controlled trial (a study that compares outcomes of groups of people randomly assigned to receive different interventions) undertaken in the Muleba District of Tanzania during 2012, the researchers investigate whether ITNs plus IRS provide more protection against malaria than ITNs alone. Malaria transmission occurs throughout the year in Muleba District but peaks after the October–December and March–May rains. Ninety-one percent of the district's households own at least one ITN, and 58% of households own enough ITNs to cover all their sleeping places. Annual rounds of IRS have been conducted in the region since 2007.
What Did the Researchers Do and Find?
The researchers allocated 50 communities to the ITN intervention or to the ITN+IRS intervention. Dwellings allocated to ITN+IRS were sprayed with insecticide just before each of the malaria transmission peaks in 2012. The researchers used household surveys to collect information about ITN coverage in the study population, the proportion of children aged 0.5–14 years infected with the malaria parasite Plasmodium falciparum (the prevalence of infection), and the proportion of children under five years old with anaemia. IRS coverage in the ITN+IRS arm was approximately 90%, and 50% of the children in both intervention arms used ITNs at the start of the trial, declining to 36% at the end of the study. In an intention-to-treat analysis (which assumed that all study participants got the planned intervention), the average prevalence of infection was 13% in the ITN+IRS arm and 26% in the ITN arm. A per-protocol analysis (which considered data only from participants who received their allocated intervention) indicated that the combined intervention had a statistically significant protective effect on the prevalence of infection compared to ITNs alone (an effect that is unlikely to have arisen by chance). Finally, the proportion of young children with anaemia was lower in the ITN+IRS arm than in the ITN arm, but this effect was not statistically significant.
What Do These Findings Mean?
These findings provide evidence that IRS, when used in combination with ITNs, can provide better protection against malaria infection than ITNs used alone. This effect is likely to be the result of IRS providing added protection to ITN users as well as compensating for inadequate ITN use. The findings also suggest that the combination of interventions may reduce the prevalence of anaemia better than ITNs alone, but this result needs to be confirmed. Additional trials are also needed to investigate whether ITN+IRS compared to ITN reduces clinical cases of malaria, and whether similar effects are seen in other settings. Moreover, the cost-effectiveness of ITN+IRS and ITN alone needs to be compared. For now, though, these findings suggest that national malaria control programs should consider implementing IRS in combination with ITNs if local ITN strategies alone are insufficiently effective and cannot be improved.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001630.
Information is available from the World Health Organization on malaria (in several languages), including information on insecticide-treated bed nets and indoor residual spraying; the World Malaria Report 2013 provides details of the current global malaria situation
The US Centers for Disease Control and Prevention provides information on malaria, on insecticide-treated bed nets, and on indoor residual spraying; it also provides a selection of personal stories about malaria
Information is available from the Roll Back Malaria Partnership on the global control of malaria and on the Global Malaria Action Plan (in English and French); its website includes fact sheets about malaria in Africa and about nets and insecticides
MedlinePlus provides links to additional information on malaria (in English and Spanish)
doi:10.1371/journal.pmed.1001630
PMCID: PMC3988001  PMID: 24736370
18.  Facilitating the Recruitment of Minority Ethnic People into Research: Qualitative Case Study of South Asians and Asthma 
PLoS Medicine  2009;6(10):e1000148.
Aziz Sheikh and colleagues report on a qualitative study in the US and the UK to investigate ways to bolster recruitment of South Asians into asthma studies, including making inclusion of diverse populations mandatory.
Background
There is international interest in enhancing recruitment of minority ethnic people into research, particularly in disease areas with substantial ethnic inequalities. A recent systematic review and meta-analysis found that UK South Asians are at three times increased risk of hospitalisation for asthma when compared to white Europeans. US asthma trials are far more likely to report enrolling minority ethnic people into studies than those conducted in Europe. We investigated approaches to bolster recruitment of South Asians into UK asthma studies through qualitative research with US and UK researchers, and UK community leaders.
Methods and Findings
Interviews were conducted with 36 researchers (19 UK and 17 US) from diverse disciplinary backgrounds and ten community leaders from a range of ethnic, religious, and linguistic backgrounds, followed by self-completion questionnaires. Interviews were digitally recorded, translated where necessary, and transcribed. The Framework approach was used for analysis. Barriers to ethnic minority participation revolved around five key themes: (i) researchers' own attitudes, which ranged from empathy to antipathy to (in a minority of cases) misgivings about the scientific importance of the question under study; (ii) stereotypes and prejudices about the difficulties in engaging with minority ethnic populations; (iii) the logistical challenges posed by language, cultural differences, and research costs set against the need to demonstrate value for money; (iv) the unique contexts of the two countries; and (v) poorly developed understanding amongst some minority ethnic leaders of what research entails and aims to achieve. US researchers were considerably more positive than their UK counterparts about the importance and logistics of including ethnic minorities, which appeared to a large extent to reflect the longer-term impact of the National Institutes of Health's requirement to include minority ethnic people.
Conclusions
Most researchers and community leaders view the broadening of participation in research as important and are reasonably optimistic about the feasibility of recruiting South Asians into asthma studies provided that the barriers can be overcome. Suggested strategies for improving recruitment in the UK included a considerably improved support structure to provide academics with essential contextual information (e.g., languages of particular importance and contact with local gatekeepers), and the need to ensure that care is taken to engage with the minority ethnic communities in ways that are both culturally appropriate and sustainable; ensuring reciprocal benefits was seen as one key way of avoiding gatekeeper fatigue. Although voluntary measures to encourage researchers may have some impact, greater impact might be achieved if UK funding bodies followed the lead of the US National Institutes of Health requiring recruitment of ethnic minorities. Such a move is, however, likely in the short- to medium-term, to prove unpopular with many UK academics because of the added “hassle” factor in engaging with more diverse populations than many have hitherto been accustomed to.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
In an ideal world, everyone would have the same access to health care and the same health outcomes (responses to health interventions). However, health inequalities—gaps in health care and in health between different parts of the population—exist in many countries. In particular, people belonging to ethnic minorities in the UK, the US, and elsewhere have poorer health outcomes for several conditions than people belonging to the ethnic majority (ethnicity is defined by social characteristics such as cultural tradition or national origin). For example, in the UK, people whose ancestors came from the Indian subcontinent (also known as South Asians and comprising in the main of people of Indian, Pakistani, and Bangladeshi origin) are three times as likely to be admitted to hospital for asthma as white Europeans. The reasons underpinning ethnic health inequalities are complex. Some inequalities may reflect intrinsic differences between groups of people—some ethnic minorities may inherit genes that alter their susceptibility to a specific disease. Other ethnic health inequalities may arise because of differences in socioeconomic status or because different cultural traditions affect the uptake of health care services.
Why Was This Study Done?
Minority ethnic groups are often under-represented in health research, which could limit the generalizability of research findings. That is, an asthma treatment that works well in a trial where all the participants are white Europeans might not be suitable for South Asians. Clinicians might nevertheless use the treatment in all their patients irrespective of their ethnicity and thus inadvertently increase ethnic health inequality. So, how can ethnic minorities be encouraged to enroll into research studies? In this qualitative study, the investigators try to answer this question by talking to US and UK asthma researchers and UK community leaders about how they feel about enrolling ethnic minorities into research studies. The investigators chose to compare the feelings of US and UK asthma researchers because minority ethnic people are more likely to enroll into US asthma studies than into UK studies, possibly because the US National Institute of Health's (NIH) Revitalization Act 1993 mandates that all NIH-funded clinical research must include people from ethnic minority groups; there is no similar mandatory policy in the UK.
What Did the Researchers Do and Find?
The investigators interviewed 16 UK and 17 US asthma researchers and three UK social researchers with experience of working with ethnic minorities. They also interviewed ten community leaders from diverse ethnic, religious and linguistic backgrounds. They then analyzed the interviews using the “Framework” approach, an analytical method in which qualitative data are classified and organized according to key themes and then interpreted. By comparing the data from the UK and US researchers, the investigators identified several barriers to ethnic minority participation in health research including: the attitudes of researchers towards the scientific importance of recruiting ethnic minority people into health research studies; prejudices about the difficulties of including ethnic minorities in health research; and the logistical challenges posed by language and cultural differences. In general, the US researchers were more positive than their UK counterparts about the importance and logistics of including ethnic minorities in health research. Finally, the investigators found that some community leaders had a poor understanding of what research entails and about its aims.
What Do These Findings Mean?
These findings reveal a large gap between US and UK researchers in terms of policy, attitudes, practices, and experiences in relation to including ethnic minorities in asthma research. However, they also suggest that most UK researchers and community leaders believe that it is both important and feasible to increase the participation of South Asians in asthma studies. Although some of these findings may have been affected by the study participants sometimes feeling obliged to give “politically correct” answers, these findings are likely to be generalizable to other diseases and to other parts of Europe. Given their findings, the researchers warn that a voluntary code of practice that encourages the recruitment of ethnic minority people into health research studies is unlikely to be successful. Instead, they suggest, the best way to increase the representation of ethnic minority people in health research in the UK might be to follow the US lead and introduce a policy that requires their inclusion in such research.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000148.
Families USA, a US nonprofit organization that campaigns for high-quality, affordable health care for all Americans, has information about many aspects of minority health in the US, including an interactive game about minority health issues
The US Agency for Healthcare Research and Quality has a section on minority health
The UK Department of Health provides information on health inequalities and a recent report on the experiences of patients in Black and minority ethnic groups
The UK Parliamentary Office of Science and Technology also has a short article on ethnicity and health
Information on the NIH Revitalization Act 1993 is available
NHS Evidences Ethnicity and Health has a variety of policy, clinical, and research resources on ethnicity and health
doi:10.1371/journal.pmed.1000148
PMCID: PMC2752116  PMID: 19823568
19.  Drivers of Inequality in Millennium Development Goal Progress: A Statistical Analysis 
PLoS Medicine  2010;7(3):e1000241.
David Stuckler and colleagues examine the impact of the HIV and noncommunicable disease epidemics on low-income countries' progress toward the Millennium Development Goals for health.
Background
Many low- and middle-income countries are not on track to reach the public health targets set out in the Millennium Development Goals (MDGs). We evaluated whether differential progress towards health MDGs was associated with economic development, public health funding (both overall and as percentage of available domestic funds), or health system infrastructure. We also examined the impact of joint epidemics of HIV/AIDS and noncommunicable diseases (NCDs), which may limit the ability of households to address child mortality and increase risks of infectious diseases.
Methods and Findings
We calculated each country's distance from its MDG goals for HIV/AIDS, tuberculosis, and infant and child mortality targets for the year 2005 using the United Nations MDG database for 227 countries from 1990 to the present. We studied the association of economic development (gross domestic product [GDP] per capita in purchasing-power-parity), the relative priority placed on health (health spending as a percentage of GDP), real health spending (health system expenditures in purchasing-power-parity), HIV/AIDS burden (prevalence rates among ages 15–49 y), and NCD burden (age-standardised chronic disease mortality rates), with measures of distance from attainment of health MDGs. To avoid spurious correlations that may exist simply because countries with high disease burdens would be expected to have low MDG progress, and to adjust for potential confounding arising from differences in countries' initial disease burdens, we analysed the variations in rates of change in MDG progress versus expected rates for each country. While economic development, health priority, health spending, and health infrastructure did not explain more than one-fifth of the differences in progress to health MDGs among countries, burdens of HIV and NCDs explained more than half of between-country inequalities in child mortality progress (R2-infant mortality  = 0.57, R2-under 5 mortality  = 0.54). HIV/AIDS and NCD burdens were also the strongest correlates of unequal progress towards tuberculosis goals (R2 = 0.57), with NCDs having an effect independent of HIV/AIDS, consistent with micro-level studies of the influence of tobacco and diabetes on tuberculosis risks. Even after correcting for health system variables, initial child mortality, and tuberculosis diseases, we found that lower burdens of HIV/AIDS and NCDs were associated with much greater progress towards attainment of child mortality and tuberculosis MDGs than were gains in GDP. An estimated 1% lower HIV prevalence or 10% lower mortality rate from NCDs would have a similar impact on progress towards the tuberculosis MDG as an 80% or greater rise in GDP, corresponding to at least a decade of economic growth in low-income countries.
Conclusions
Unequal progress in health MDGs in low-income countries appears significantly related to burdens of HIV and NCDs in a population, after correcting for potentially confounding socioeconomic, disease burden, political, and health system variables. The common separation between NCDs, child mortality, and infectious syndromes among development programs may obscure interrelationships of illness affecting those living in poor households—whether economic (e.g., as money spent on tobacco is lost from child health expenditures) or biological (e.g., as diabetes or HIV enhance the risk of tuberculosis).
Please see later in the article for the Editors' Summary
Editors' Summary
Background
In 2000, 189 countries adopted the United Nations (UN) Millennium Declaration, which commits the world to the eradication of extreme poverty by 2015. The Declaration lists eight Millennium Development Goals (MDGs), 21 quantifiable targets, and 60 indicators of progress. So, for example, MDG 4 aims to reduce child mortality (deaths). The target for this goal is to reduce the number of children who die each year before they are five years old (the under-five mortality rate) to two-thirds of its 1990 value by 2015. Indicators of progress toward this goal include the under-five mortality rate and the infant mortality rate. Because poverty and ill health are inextricably linked—ill health limits the ability of individuals and nations to improve their economic status, and poverty contributes to the development of many illnesses—two other MDGs also tackle public health issues. MDG 5 sets a target of reducing maternal mortality by three-quarters of its 1990 level by 2015. MDG 6 aims to halt and begin to reverse the spread of HIV/AIDS, malaria, and other major diseases such as tuberculosis by 2015.
Why Was This Study Done?
Although progress has been made toward achieving the MDGs, few if any of the targets are likely to be met by 2015. Worryingly, low-income countries are falling furthest behind their MDG targets. For example, although child mortality has been declining globally, in many poor countries there has been little or no progress. What is the explanation for this and other inequalities in progress toward the health MDGs? Some countries may simply lack the financial resources needed to combat epidemics or may allocate only a low proportion of their gross domestic product (GDP) to health. Alternatively, money allocated to health may not always reach the people who need it most because of an inadequate health infrastructure. Finally, coexisting epidemics may be hindering progress toward the MDG health targets. Thus, the spread of HIV/AIDS may be hindering attempts to limit the spread of tuberculosis because HIV infection increases the risk of active tuberculosis, and ongoing epidemics of diabetes and other noncommunicable diseases (NCDs) may be affecting the attainment of health MDGs by diverting scarce resources. In this study, the researchers investigate whether any of these possibilities is driving the inequalities in MDG progress.
What Did the Researchers Do and Find?
The researchers calculated how far 227 countries were from their MDG targets for HIV, tuberculosis, and infant and child mortality in 2005 using information collected by the UN. They then used statistical methods to study the relationship between this distance and economic development (GDP per person), health spending as a proportion of GDP (health priority), actual health system expenditures, health infrastructure, HIV burden, and NCD burden in each country. Economic development, health priority, health spending, and health infrastructure explained no more than one-fifth of the inequalities in progress toward health MDGs. By contrast, the HIV and NCD burdens explained more than half of inequalities in child mortality progress and were strongly associated with unequal progress toward tuberculosis goals. Furthermore, the researchers calculated that a 1% reduction in the number of people infected with HIV or a 10% reduction in rate of deaths from NCDs in a population would have a similar impact on progress toward the tuberculosis MDG target as a rise in GDP corresponding to at least a decade of growth in low-income countries.
What Do These Findings Mean?
These findings are limited by the quality of the available data on health indicators in low-income countries and, because the researchers used country-wide data, their findings only reveal possible drivers of inequalities in progress toward MDGs in whole countries and may mask drivers of within-country inequalities. Nevertheless, as one of the first attempts to analyze the determinants of global inequalities in progress toward the health MDGs, these findings have important implications for global health policy. Most importantly, the finding that unequal progress is related to the burdens of HIV and NCDs in populations suggests that programs designed to achieve health MDGs must consider all the diseases and factors that can trap households in vicious cycles of illness and poverty, especially since the achievement of feasible reductions in NCDs in low-income countries could greatly enhance progress towards health MDGs.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000241.
The United Nations Millennium Development Goals website provides detailed information about the Millennium Declaration, the MDGs, their targets and their indicators
The Millennium Development Goals Report 2009 and its progress chart provide an up-to-date assessment of progress towards the MDGs
The World Health Organization provides information about poverty and health and health and development
doi:10.1371/journal.pmed.1000241
PMCID: PMC2830449  PMID: 20209000
20.  Social Contacts and Mixing Patterns Relevant to the Spread of Infectious Diseases 
PLoS Medicine  2008;5(3):e74.
Background
Mathematical modelling of infectious diseases transmitted by the respiratory or close-contact route (e.g., pandemic influenza) is increasingly being used to determine the impact of possible interventions. Although mixing patterns are known to be crucial determinants for model outcome, researchers often rely on a priori contact assumptions with little or no empirical basis. We conducted a population-based prospective survey of mixing patterns in eight European countries using a common paper-diary methodology.
Methods and Findings
7,290 participants recorded characteristics of 97,904 contacts with different individuals during one day, including age, sex, location, duration, frequency, and occurrence of physical contact. We found that mixing patterns and contact characteristics were remarkably similar across different European countries. Contact patterns were highly assortative with age: schoolchildren and young adults in particular tended to mix with people of the same age. Contacts lasting at least one hour or occurring on a daily basis mostly involved physical contact, while short duration and infrequent contacts tended to be nonphysical. Contacts at home, school, or leisure were more likely to be physical than contacts at the workplace or while travelling. Preliminary modelling indicates that 5- to 19-year-olds are expected to suffer the highest incidence during the initial epidemic phase of an emerging infection transmitted through social contacts measured here when the population is completely susceptible.
Conclusions
To our knowledge, our study provides the first large-scale quantitative approach to contact patterns relevant for infections transmitted by the respiratory or close-contact route, and the results should lead to improved parameterisation of mathematical models used to design control strategies.
Surveying 7,290 participants in eight European countries, Joël Mossong and colleagues determine patterns of person-to-person contact relevant to controlling pathogens spread by respiratory or close-contact routes.
Editors' Summary
Background
To understand and predict the impact of infectious disease, researchers often develop mathematical models. These computer simulations of hypothetical scenarios help policymakers and others to anticipate possible patterns and consequences of the emergence of diseases, and to develop interventions to curb disease spread. Whether to prepare for an outbreak of infectious disease or to control an existing outbreak, models can help researchers and policy makers decide how to intervene. For example, they may decide to develop or stockpile vaccines or antibiotics, fund vaccination or screening programs, or mount health promotion campaigns to help citizens minimize their exposure to the infectious agent (e.g., handwashing, travel restrictions, or school closures).
Respiratory infections, including the common cold, flu, and pneumonia, are some of the most prevalent infections in the world. Much work has gone into modeling how many people would be affected by respiratory diseases under various conditions and what can be done to limit the consequences.
Why Was This Study Done?
Mathematical models have tended to use contact rates (the number of other people that a person encounters per day) as one of their main elements in predicting the outcomes of epidemics. In the past, contact rates were not based on direct observations, but were assumed to follow a certain pattern and calibrated against other indirect data sources such as serological or case notification data. This study aimed to estimate contact rates directly by asking people who they have met during the course of one day. This allowed the researchers to study in more detail different patterns of contacts, such as those between different groups of people (such as age groups) and in different social settings. This is particularly important for respiratory diseases, which are spread through the air and by close contact with an infected individual or surface.
What Did the Researchers Do and Find?
The researchers wanted to examine the social contacts that people have in order to better understand how respiratory infections might spread. They recruited 7,290 people from eight European countries (Belgium, Germany, Finland, Great Britain, Italy, Luxembourg, The Netherlands, and Poland) to participate in their study. They asked the participants to fill out a diary that documented their physical and nonphysical contacts for a single day. Physical contacts included interactions such as a kiss or a handshake. Nonphysical contacts were situations such as a two-way conversation without skin-to-skin contact. Participants detailed the location and duration of each contact. Diaries also contained basic demographic information about the participant and the contact.
They found that these 7,290 participants had 97,904 contacts during the study, which averaged to 13.4 contacts per day per person. There was a great deal of diversity among the contacts, which challenges the idea that contact rates alone provide a complete picture of transmission dynamics. The researchers identified varied types of contacts, duration of contacts, and mixing patterns. For example, children had more contacts than adults, and those living in larger households had more contacts. Weekdays resulted in more daily contacts than Sundays. More intense contacts (of longer duration or more frequent) tended to be physical. Approximately 70% of contacts made on a daily basis lasted longer than an hour, whereas three-quarters of contacts with people who were not previously known lasted less than 15 minutes. While mixing patterns were very similar across the eight countries, people of the same age tended to mix with each other.
Analyzing these contact patterns and applying mathematical and statistical techniques, the researchers created a model of the initial phase of a hypothetical respiratory infection epidemic. This model suggests that 5- to 19-year-olds will suffer the highest burden of respiratory infection during an initial spread. The high incidence of infection among school-aged children in the model results from these children having a large number of contacts compared to other groups and tending to make contacts within their own age group.
What Do These Findings Mean?
This work provides insight about contacts that can be supplemental to traditional measurements such as contact rates, which are usually generated from household or workplace size and transportation statistics. Incorporating contact patterns into the model allowed for a deeper understanding of the transmission patterns of a hypothetical respiratory epidemic among a susceptible population. Understanding the patterning of social contacts—between and within groups, and in different social settings—shows how diverse contacts and mixing between individuals really are. Physical exposure to an infectious agent, the authors conclude, is best modeled by taking into account the social network of close contacts and its patterning.
Additional Information.
Please access these Web sites via the online version of this summary at doi:10.1371/journal.pmed.0050074..
Wikipedia has technical discussions on the assumptions used in mathematical models of epidemiology (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
Plans for pandemic influenza are explained for the Government of Canada, the United Kingdom's Health Protection Agency, and the United States Department of Health and Human Services
doi:10.1371/journal.pmed.0050074
PMCID: PMC2270306  PMID: 18366252
21.  Monitoring of Mass Distribution Interventions for Trachoma in Plateau State, Nigeria 
Mass drug administration (MDA) with antibiotics is a key component of the SAFE strategy for trachoma control. Guidelines recommend that where MDA is warranted the whole population be targeted with 80% considered the minimum acceptable coverage. In other countries, MDA is usually conducted by salaried Ministry of Health personnel (MOH). In Plateau State, Nigeria, the existing network of volunteer Community Directed Distributors (CDD) was used for the first trachoma MDA. We conducted a population-based cluster random survey (CRS) of MDA participation to determine the true coverage and compared this to coverage reported from CDD registers. We surveyed 1,791 people from 352 randomly selected households in 24 clusters in three districts in Plateau State in January 2011, following the implementation of MDA. Households were enumerated and all individuals present were asked about MDA participation. Household heads were questioned about household-level characteristics and predictors of participation. Individual responses were compared with the CDD registers. MDA coverage was estimated as 60.3% (95% CI 47.9–73.8%) by the survey compared with 75.8% from administrative program reports. CDD registration books for comparison with responses were available in 19 of the 24 clusters; there was a match for 658/682 (96%) of verifiable responses. CDD registers did not list 481 (41.3%) of the individuals surveyed. Gender and age were not associated with individual participation. Overall MDA coverage was lower than the minimum 80% target. The observed discrepancy between the administrative coverage estimate from program reports and the CRS was largely due to identification of communities missed by the MDA and not reported in the registers. CRS for evaluation of MDA provides a useful additional monitoring tool to CDD registers. These data support modification of distributor training and MDA delivery to increase coverage in subsequent rounds of MDA.
Author Summary
The World Health Organization recommends that mass drug administration for trachoma control reach a minimum of 80% of the target population. Previous evaluations of MDA coverage have demonstrated that administrative reports can bias coverage estimates. A survey of participation in mass drug administration for trachoma control was implemented in three districts in Plateau State, Nigeria in 2011 to validate coverage calculated from treatment registers. A total of 352 households were surveyed from 24 randomly selected communities. Heads of household were interviewed to identify household-level characteristics and predictors of participation. Individual household members were enumerated and those present at the time of interview were asked to report individual participation in the MDA. Responses were verified against the community-drug distributor registration log. Approximately 60% of the sample reported receiving either tetracycline eye ointment or azithromycin for trachoma control. Administrative data on treatment estimated coverage at 76% for the three LGAs. The discrepancy between the coverage estimate from administrative data (calculated by the program) and the survey data suggest that cluster random surveys of MDA provide a useful monitoring tool to validate administrative data on treatment coverage. These data support modification of distributor training and MDA delivery to increase coverage in subsequent rounds of MDA.
doi:10.1371/journal.pntd.0001995
PMCID: PMC3542118  PMID: 23326617
22.  Solar Drinking Water Disinfection (SODIS) to Reduce Childhood Diarrhoea in Rural Bolivia: A Cluster-Randomized, Controlled Trial 
PLoS Medicine  2009;6(8):e1000125.
Daniel Maeusezahl and colleagues conducted a cluster-randomized controlled trial in rural Bolivia of solar drinking water disinfection, and find only moderate compliance with the intervention and no evidence of reduction in diarrhea among children.
Background
Solar drinking water disinfection (SODIS) is a low-cost, point-of-use water purification method that has been disseminated globally. Laboratory studies suggest that SODIS is highly efficacious in inactivating waterborne pathogens. Previous field studies provided limited evidence for its effectiveness in reducing diarrhoea.
Methods and Findings
We conducted a cluster-randomized controlled trial in 22 rural communities in Bolivia to evaluate the effect of SODIS in reducing diarrhoea among children under the age of 5 y. A local nongovernmental organisation conducted a standardised interactive SODIS-promotion campaign in 11 communities targeting households, communities, and primary schools. Mothers completed a daily child health diary for 1 y. Within the intervention arm 225 households (376 children) were trained to expose water-filled polyethyleneteraphtalate bottles to sunlight. Eleven communities (200 households, 349 children) served as a control. We recorded 166,971 person-days of observation during the trial representing 79.9% and 78.9% of the total possible person-days of child observation in intervention and control arms, respectively. Mean compliance with SODIS was 32.1%. The reported incidence rate of gastrointestinal illness in children in the intervention arm was 3.6 compared to 4.3 episodes/year at risk in the control arm. The relative rate of diarrhoea adjusted for intracluster correlation was 0.81 (95% confidence interval 0.59–1.12). The median length of diarrhoea was 3 d in both groups.
Conclusions
Despite an extensive SODIS promotion campaign we found only moderate compliance with the intervention and no strong evidence for a substantive reduction in diarrhoea among children. These results suggest that there is a need for better evidence of how the well-established laboratory efficacy of this home-based water treatment method translates into field effectiveness under various cultural settings and intervention intensities. Further global promotion of SODIS for general use should be undertaken with care until such evidence is available.
Trial Registration
www.ClinicalTrials.gov NCT00731497
Please see later in the article for Editors' Summary
Editors' Summary
Background
Thirsty? Well, turn on the tap and have a drink of refreshing, clean, safe water. Unfortunately, more than one billion people around the world don't have this option. Instead of the endless supply of safe drinking water that people living in affluent, developed countries take for granted, more than a third of people living in developing countries only have contaminated water from rivers, lakes, or wells to drink. Because of limited access to safe drinking water, poor sanitation, and poor personal hygiene, 1.8 million people (mainly children under 5 years old) die every year from diarrheal diseases. This death toll could be greatly reduced by lowering the numbers of disease-causing microbes in household drinking water. One promising simple, low-cost, point-of-use water purification method is solar drinking water disinfection (SODIS). In SODIS, recycled transparent plastic drinks bottles containing contaminated water are exposed to full sunlight for 6 hours. During this exposure, ultraviolet radiation from the sun, together with an increase in temperature, inactivates the disease-causing organisms in the water.
Why Was This Study Done?
SODIS has been promoted as an effective method to purify household water since 1999, and about 2 million people now use the approach (www.SODIS.ch). However, although SODIS works well under laboratory conditions, very few studies have investigated its ability to reduce the number of cases of diarrhea occurring in a population over a specific time period (the incidence of diarrhea) in the real world. Before any more resources are used to promote SODIS—its effective implementation requires intensive and on-going education—it is important to be sure that SODIS really does reduce the burden of diarrhea in communities in the developing world. In this study, therefore, the researchers undertake a cluster-randomized controlled trial (a study in which groups of people are randomly assigned to receive an intervention or to act as controls) in 22 rural communities in Bolivia to evaluate the ability of SODIS to reduce diarrhea in children under 5 years old.
What Did the Researchers Do and Find?
For their trial, the researchers enrolled 22 rural Bolivian communities that included at least 30 children under 5 years old and that relied on drinking water resources that were contaminated with disease-causing organisms. They randomly assigned 11 communities (225 households, 376 children) to receive the intervention—a standardized, interactive SODIS promotion campaign conducted by Project Concern International (a nongovernmental organization)—and 11 communities (200 households, 349 children) to act as controls. Households in the intervention arm were trained to expose water-filled plastic bottles for at least 6 hours to sunlight using demonstrations, role play, and videos. Mothers in both arms of the trial completed a daily child health diary for a year. Almost 80% of the households self-reported using SODIS at the beginning and end of the study. However, community-based field workers estimated that only 32.1% of households on average used SODIS. Data collected in the child health diaries, which were completed on more than three-quarters of days in both arms of the trial, indicated that the children in the intervention arm had 3.6 episodes of diarrhea per year whereas the children in the control arm had 4.3 episodes of diarrhea per year. The difference in episode numbers was not statistically significant, however. That is, the small difference in the incidence of diarrhea between the arms of the trial may have occurred by chance and may not be related to the intervention.
What Do These Findings Mean?
These findings indicate that, despite an intensive campaign to promote SODIS, less than a third of households in the trial routinely treated their water in the recommended manner. Moreover, these findings fail to provide strong evidence of a marked reduction of the incidence of diarrhea among children following implementation of SODIS although some aspects of the study design may have resulted in the efficacy of SODIS being underestimated. Thus, until additional studies of the effectiveness of SODIS in various real world settings have been completed, it may be unwise to extend the global promotion of SODIS for general use any further.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000125
The PLoS Medicine editors wrote an editorial arguing that water should be a human right
The World Health Organization provides information about household water treatment and safe storage http://www.who.int/household_water and about the importance of water, sanitation, and hygiene for health http://www.who.int/water_sanitation_health/en/index.html (in several languages)
The SODIS Reference Center provides detailed information about solar water disinfection (in several languages)
The SODIS Foundation in Bolivia provides practical information for the roll-out of solar water disinfection in Latin America (in Spanish and English)
Project Concern International provides information about its campaign to promote SODIS in Bolivia (in Spanish)
The Water Supply and Sanitation Collaborative Council (WSSCC) is a global multi-stakeholder partnership organization with a goal of advocating to achieve sustainable water supply and sanitation for all people
doi:10.1371/journal.pmed.1000125
PMCID: PMC2719054  PMID: 19688036
23.  The Adequacy of Household Survey Data for Evaluating the Nongroup Health Insurance Market 
Health Services Research  2007;42(4):1739-1757.
Objective
To evaluate the accuracy of household survey estimates of the size and composition of the nonelderly population covered by nongroup health insurance.
Data Sources/Study Setting
Health insurance enrollment statistics reported to New Jersey insurance regulators. Household data from the following sources: the 2002 Current Population Survey (CPS)-March Demographic Supplement, the 1997 and 1999 National Surveys of America's Families (NSAF), the 2001 New Jersey Family Health Survey (NJFHS), a 2002 survey of known nongroup health insurance enrollees, a small 2004 survey testing alternative health insurance question wording.
Study Design
To assess the extent of bias in estimates of the size of the nongroup health insurance market in New Jersey, enrollment trends are compared between official enrollment statistics reported by insurance carriers to state insurance regulators with estimates from three general population household surveys. Next, to evaluate possible bias in the demographic and socioeconomic composition of the New Jersey nongroup market, distributions of characteristics of the enrolled population are contrasted among general household surveys and a survey of known nongroup subscribers. Finally, based on inferences drawn from these comparisons, alternative health insurance question wording was developed and tested in a local survey to test the potential for misreporting enrollment in nongroup coverage in a low-income population.
Data Collection/Extraction Methods
Data for nonelderly New Jersey residents from the 2002 CPS (n = 5,028) and the 1997 and 1999 NSAF (n = 6,467 and 7,272, respectively) were obtained from public sources. The 2001 NJFHS (n = 5,580 nonelderly) was conducted for a sample drawn by random digit dialing and employed computer-assisted telephone interviews and trained, professional interviewers. Sampling weights are used to adjust for under-coverage of households without telephones and other factors. In addition, a modified version of the NJFHS was administered to a 2002 sample of known nongroup subscribers (n = 1,398) using the same field methods. These lists were provided by four of the five largest New Jersey nongroup insurance carriers, which represented 95 percent of all nongroup enrollees in the state. Finally, a modified version of the NJFHS questionnaire was fielded using similar methods as part of a local health survey in New Brunswick, New Jersey, in 2004 (n = 1,460 nonelderly).
Principal Findings
General household sample surveys, including the widely used CPS, yield substantially higher estimates of nongroup enrollment compared with administrative totals and yield estimates of the characteristics of the nongroup population that vary greatly from a survey of known nongroup subscribers. A small survey testing a question about source of payment for direct-purchased coverage suggests than many public coverage enrollees report nongroup coverage.
Conclusions
Nongroup health insurance has been subject to more than a decade of reform and is of continuing policy interest. Comparisons of unique data from a survey of known nongroup subscribers and administrative sources to household surveys strongly suggest that the latter overstates the number and misrepresent the composition of the nongroup population. Research on the nongroup market using available sources should be interpreted cautiously and survey methods should be reexamined.
doi:10.1111/j.1475-6773.2006.00662.x
PMCID: PMC1955284  PMID: 17610446
Health insurance; nongroup insurance; health care surveys
24.  Is Economic Growth Associated with Reduction in Child Undernutrition in India? 
PLoS Medicine  2011;8(3):e1000424.
An analysis of cross-sectional data from repeated household surveys in India, combined with data on economic growth, fails to find strong evidence that recent economic growth in India is associated with a reduction in child undernutrition.
Background
Economic growth is widely perceived as a major policy instrument in reducing childhood undernutrition in India. We assessed the association between changes in state per capita income and the risk of undernutrition among children in India.
Methods and Findings
Data for this analysis came from three cross-sectional waves of the National Family Health Survey (NFHS) conducted in 1992–93, 1998–99, and 2005–06 in India. The sample sizes in the three waves were 33,816, 30,383, and 28,876 children, respectively. After excluding observations missing on the child anthropometric measures and the independent variables included in the study, the analytic sample size was 28,066, 26,121, and 23,139, respectively, with a pooled sample size of 77,326 children. The proportion of missing data was 12%–20%. The outcomes were underweight, stunting, and wasting, defined as more than two standard deviations below the World Health Organization–determined median scores by age and gender. We also examined severe underweight, severe stunting, and severe wasting. The main exposure of interest was per capita income at the state level at each survey period measured as per capita net state domestic product measured in 2008 prices. We estimated fixed and random effects logistic models that accounted for the clustering of the data. In models that did not account for survey-period effects, there appeared to be an inverse association between state economic growth and risk of undernutrition among children. However, in models accounting for data structure related to repeated cross-sectional design through survey period effects, state economic growth was not associated with the risk of underweight (OR 1.01, 95% CI 0.98, 1.04), stunting (OR 1.02, 95% CI 0.99, 1.05), and wasting (OR 0.99, 95% CI 0.96, 1.02). Adjustment for demographic and socioeconomic covariates did not alter these estimates. Similar patterns were observed for severe undernutrition outcomes.
Conclusions
We failed to find consistent evidence that economic growth leads to reduction in childhood undernutrition in India. Direct investments in appropriate health interventions may be necessary to reduce childhood undernutrition in India.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Good nutrition during childhood is essential for health and survival. Undernourished children are more susceptible to infections and more likely to die from common ailments such as diarrhea than well-nourished children. Thus, globally, undernutrition contributes to more than a third of deaths among children under 5 years old. Experts use three physical measurements to determine whether a child is undernourished. An "underweight" child has a low weight for his or her age and gender when compared to the World Health Organization Child Growth Standards, which chart the growth of a reference population. A "stunted" child has a low height for his or her age; stunting is an indicator of chronic undernutrition. A "wasted" child has a low weight for his or her height; wasting is an indicator of acute undernutrition and often follows an earthquake, flood, or other emergency. The prevalence (how often a condition occurs within a population) of undernutrition is particularly high in India. Here, almost half of children under the age of 3 are underweight, about half are stunted, and a quarter are wasted.
Why Was This Study Done?
Although the prevalence of undernutrition in India is decreasing, progress is slow. Economic growth is widely regarded as the major way to reduce child undernutrition in India. Economic growth, the argument goes, will increase incomes, reduce poverty, and increase access to health services and nutrition. But some experts believe that better education for women and reduced household sizes might have a greater influence on child undernutrition than economic growth. And others believe that healthier, better fed populations lead to increased economic growth rather than the other way around. In this study, the researchers assess the association between economic growth and child undernutrition in India by analyzing the relationship between changes in per capita income in individual Indian states and the individual risk of undernutrition among children in India.
What Did the Researchers Do and Find?
For their analyses, the researchers used data on 77,326 Indian children that were collected in the 1992–93, 1998–99, and 2005–06 National Family Health Surveys; these surveys are part of the Demographic and Health Surveys, a project that collects health data in developing countries to aid health-system development. The researchers used eight "ecological" statistical models to investigate whether there was an association between underweight, stunting, or wasting and per capita income at the state level in each survey period; these ecological models assumed that the risk of undernutrition was the same for every child in a state. They also used 10 "multilevel" models to quantify the association between state-level growth and the individual-level risk of undernutrition. The multilevel models also took account of various combinations of additional factors likely to affect undernutrition (for example, mother's education and marital status). In five of the ecological models, there was no statistically significant association between state economic growth and average levels of child undernutrition at the state level (statistically significant associations are unlikely to have arisen by chance). Similarly, in eight of the multilevel models, there was no statistical evidence for an association between economic growth and undernutrition.
What Do These Findings Mean?
These findings provide little statistical support for the widely held assumption that there is an association between the risk of child undernutrition and economic growth in India. By contrast, a previous study that used data from 63 countries collected over 26 years did find evidence that national economic growth was inversely associated with the risk of child undernutrition. However, this study was an ecological study and did not, therefore, allow for the possibility that the risk of undernutrition might vary between children in one state and between states. Further, the target of inference in this study was "explaining" between-country differences, while the target of inference in this analysis was explaining within country differences over time. The researchers suggest several reasons why there might not be a clear association between economic growth and undernutrition in India. For example, they suggest, economic growth in India might have only benefitted privileged sections of society. Whether this or an alternative explanation accounts for the lack of an association, it seems likely that further reductions in the prevalence of child undernutrition in India (and possibly in other developing countries) will require direct investment in health and health-related programs; expecting economic growth to improve child undernutrition might not be a viable option after all.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000424.
The charity UNICEF, which protects the rights of children and young people around the world, provides detailed statistics on child undernutrition and on child nutrition and undernutrition in India
The WHO Child Growth Standards are available (in several languages)
More information on the Demographic and Health Surveys and on the Indian National Family Health Surveys is available
The United Nations Millennium Development Goals website provides information on ongoing world efforts to reduce hunger and child mortality
doi:10.1371/journal.pmed.1000424
PMCID: PMC3050933  PMID: 21408084
25.  An Experimental Study Using Opt-in Internet Panel Surveys for Behavioral Health Surveillance 
Objective
To present the design and preliminary results of a pilot study to investigate the use of opt-in Internet panel surveys for behavioral health surveillance.
Introduction
Today, surveyors in both the private and public sectors are facing considerable challenges with random digit dialed (RDD) landline telephone samples. The population coverage rates for landline telephone surveys are being eroded by wireless-only households, portable telephone numbers, telecommunication barriers (e.g., call forwarding, call blocking and pager connections), technological barriers (call-blocking, busy circuits) and increased refusal rates and privacy concerns. Addressing these issues increasingly drives up the costs associated with dual-frame telephone surveys designed to be representative of the target population as well as hinders their ability to be fully representative of the adult population of each state and territory in the United States.
In an effort to continue to meet these challenges head on and assist state and territorial public health professionals in the continued collection of data that are representative of their respective populations, novel approaches to behavioral health surveillance need continued examination. Both private and public sector researchers are evaluating the use of Internet opt-in panels to augment dual-frame RDD survey methods. Compared to dual-frame RDD, opt-in Internet panels offer lower costs, quick data collection and dissemination, and the ability to gather additional data on panelists over time. However, as with dual-frame RDD, this mode has similar challenges with coverage error and non-response. Nevertheless, survey methodologists are moving forward and exploring ways to reduce or eliminate biases between the sample and the target population.
Methods
A collaborative pilot project was designed to assess the feasibility and accuracy of opt-in Internet panel surveys for behavioral health surveillance. This pilot project is a collaboration between the CDC, four state departments of health, opt-in Internet panel providers and the leads of several large surveys and systems such as the Patient-Reported Outcome Measures Information System (PROMIS) and the Cooperative Congressional Election Study (CCES). Pilot projects were conducted in four states (GA, IL, NY, and TX) and four Metropolitan Statistical Areas (Atlanta, Chicago, New York City, and Houston). Data were collected using three different opt-in Internet panels and sampling methods that differ with respect to recruitment strategy, sample selection and sample matching to the adult population of each geography. A question bank consisting of 80 questions was developed to benchmark with other existing surveys used to assess various public health surveillance measures (e.g., the Behavioral Risk Factor Surveillance System, the PROMIS, National Survey on Drug Use and Health, and the CCES).
Results
We present comparative analyses that assess the advantages and disadvantages of different opt-in Internet panels sampling methodologies across a range of parameters including cost, geography, timeliness, usability, and ease of use for technology transfer to states and local communities. Recommendations for future efforts in behavioral health surveillance are given based on these results.
PMCID: PMC3692867
Random Digit Dialing; BRFSS; Survey Methods; Sample Matching; Representativeness

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