Department For International Development Research Articles

Factors associated with medical consumable availability in level 1 facilities in Malawi: a secondary analysis of a facility census.

Medical consumable stock-outs negatively affect health outcomes not only by impeding or delaying the effective delivery of services but also by discouraging patients from seeking care. Consequently, supply chain strengthening is being adopted as a key component of national health strategies. However, evidence on the factors associated with increased consumable availability is limited. In this study, we used the 2018-19 Harmonised Health Facility Assessment data from Malawi to identify the factors associated with the availability of consumables in level 1 facilities, ie, rural hospitals or health centres with a small number of beds and a sparsely equipped operating room for minor procedures. We estimate a multilevel logistic regression model with a binary outcome variable representing consumable availability (of 130 consumables across 940 facilities) and explanatory variables chosen based on current evidence. Further subgroup analyses are carried out to assess the presence of effect modification by level of care, facility ownership, and a categorisation of consumables by public health or disease programme, Malawi's Essential Medicine List classification, whether the consumable is a drug or not, and level of average national availability. Our results suggest that the following characteristics had a positive association with consumable availability-level 1b facilities or community hospitals had 64% (odds ratio [OR] 1·64, 95% CI 1·37-1·97) higher odds of consumable availability than level 1a facilities or health centres, Christian Health Association of Malawi and private-for-profit ownership had 63% (1·63, 1·40-1·89) and 49% (1·49, 1·24-1·80) higher odds respectively than government-owned facilities, the availability of a computer had 46% (1·46, 1·32-1·62) higher odds than in its absence, pharmacists managing drug orders had 85% (1·85, 1·40-2·44) higher odds than a drug store clerk, proximity to the corresponding regional administrative office (facilities greater than 75 km away had 21% lower odds [0·79, 0·63-0·98] than facilities within 10 km of the district health office), and having three drug order fulfilments in the 3 months before the survey had 14% (1·14, 1·02-1·27) higher odds than one fulfilment in 3 months. Further, consumables categorised as vital in Malawi's Essential Medicine List performed considerably better with 235% (OR 3·35, 95% CI 1·60-7·05) higher odds than other essential or non-essential consumables and drugs performed worse with 79% (0·21, 0·08-0·51) lower odds than other medical consumables in terms of availability across facilities. Our results provide evidence on the areas of intervention with potential to improve consumable availability. Further exploration of the health and resource consequences of the strategies discussed will be useful in guiding investments into supply chain strengthening. UK Research and Innovation as part of the Global Challenges Research Fund (Thanzi La Onse; reference MR/P028004/1), the Wellcome Trust (Thanzi La Mawa; reference 223120/Z/21/Z), the UK Medical Research Council, the UK Department for International Development, and the EU (reference MR/R015600/1).

External technical assistance andits contribution to donor transition andlong-term sustainability: experience from China andGeorgia.

External technical assistance has played a vital role in facilitating the transitions of donor-supported health projects/programmes (or their key components) to domestic health systems in China and Georgia. Despite large differences in size and socio-political systems, these two upper-middle-income countries have both undergone similar trajectories of 'graduating' from external assistance for health and gradually established strong national ownership in programme financing and policymaking over the recent decades. Although there have been many documented challenges in achieving effective and sustainable technical assistance, the legacy of technical assistance practices in China and Georgia provides many important lessons for improving technical assistance outcomes and achieving more successful donor transitions with long-term sustainability. In this innovation and practice report, we have selected five projects/programmes in China and Georgia supported by the following external health partners: the World Bank and the UK Department for International Development, Gavi Alliance and the Global Fund to Fight AIDS, Tuberculosis and Malaria. These five projects/programmes covered different health focus areas, ranging from rural health system strengthening to opioid substitution therapy. We discuss three innovative practices of technical assistance identified by the cross-country research teams: (1) talent cultivation for key decision-makers and other important stakeholders in the health system; (2) long-term partnerships between external and domestic experts; and (3) evidence-based policy advocacy nurtured by local experiences. However, the main challenge of implementation is insufficient domestic budgets for capacity building during and post-transition. We further identify two enablers for these practices to facilitate donor transition: (1) a project/programme governance structure integrated into the national health system and (2) a donor-recipient dynamic that enabled deep and far-reaching engagements with external and domestic stakeholders. Our findings shed light on the practices of technical assistance that strengthen long-term post-transition sustainability across multiple settings, particularly in middle-income countries.

Insurance and the contradictions of the climate-development-finance nexus: The case of the African Risk Capacity

This article considers recent efforts at extending the scope of green finance into insurance schemes to manage the losses associated with the climate crisis in vulnerable countries. Focusing on the case of the African Risk Capacity (ARC), the article argues that these efforts are particularly revealing of the contradictions of what we term the ‘climate-development-finance nexus’ – growing efforts to bridge climate and development activities, with an emphasis on mobilizing green finance in order to do so. In particular, the case of ARC shows how the promotion of insurance should be read as a set of ultimately failed efforts to navigate relations of international financial subordination. Approaching the ARC in this way helps us to understand why the latter has fallen into a shape at odds with the intentions of either member states or the donors who have supported it, the latter illustrated primarily by considering the role of the British Department for International Development. This case, then, is revealing of how green finance more generally is strongly shaped by statecraft within the constraints of existing patterns of financial subordination.

Exploring the Association between Poverty, Livelihoods, Institutions, and Sustainable Community Development. A Conceptual Analysis

The aim of this paper is to assess the links or interfaces between poverty, livelihoods, institutions, and sustainable community development through a literature review. To realize this objective, the study used the Department for International Development’s (United Kingdom) Sustainable Livelihoods Approach as an overarching theoretical foundation. A descriptive method of data analysis using secondary data and a qualitative research approach were followed. The current state of the problem has been explored by means of a deductive approach. The results of the conceptual analysis show that the interactions between poverty, livelihoods, institutions, and community development are significant. The study also revealed that institutions are crucial for the formation of livelihood possibilities and strategies for the poor and marginalized groups, and they play a significant role in sustainable development. Existing empirical evidence demonstrates that livelihood outcomes may be positive or negative based on vulnerability contexts, the nature of livelihood, institutional frameworks, and livelihood strategies followed. The study concludes that institutional influence is pivotal since it directly or indirectly affects the access to livelihood, determines livelihood strategies and outcomes. Policymakers are therefore expected to consider and comprehend the relationship between these notions before formulating policies, plans or programs to alleviate poverty and promote sustainable development effectively.

Nigeria’s Female Educational Development Crises under Recessive Economy; The Way Forward

In any case, it is of relevance and worthy to note that for a proper understanding of the study entitled “Nigeria’s Female Educational Development Crises Under Recessive Economy; The way forward” it would be interesting to note that it is an intellectual attempt to highlight the meaning and examine the concept of “female education from gender point of view, purely for the liberation of women against the bondage of gender inequality. The subject matter of the write – up largely centers on the explored and examined obstacles militating against Girl-Child Education with reference to its situation in some Northern states in the 21stCentury.Both oral, published and unpublished sources were used in conducting the study. However, among the major causes of low level of enrolment and other impediments include, socio-economic, political and religious factors such as evolution of religious, economic and commercial ideologies of kidnapping, bargaining, ransom, activities of insurgencies, bandits, moral decadence, poverty, unemployment, failure of the parents and governments to reciprocate the gestures and unfortunate state of the parents and the Nigerian economies. The study found that it is very disheartening to highlight that fifteen Northern states are below average regarding the ratio of their girls in schools. The states are: Bauchi, Katsina, Benue, Jigawa, Adamawa, Niger, Sokoto and others, However, the study further shows that Katsina, Sokoto and Zamafara are as 23.6% of female enrolment. The international agencies, UK, Department for International Development in its commitment to support female education has as a result donated the sum of E25 million, Katsina, Sokoto, Benue, Borno, Niger and Jigawa are the beneficiaries, at the tail end, the study proffers the way forward

Effectiveness of long-lasting insecticidal nets with pyriproxyfen–pyrethroid, chlorfenapyr–pyrethroid, or piperonyl butoxide–pyrethroid versus pyrethroid only against malaria in Tanzania: final-year results of a four-arm, single-blind, cluster-randomised trial

New classes of long-lasting insecticidal nets (LLINs) containing two active ingredients have been recently recommended by WHO in areas where malaria vectors are resistant to pyrethroids. This policy was based on evidence generated by the first 2 years of our recently published trial in Tanzania. In this Article, we report the final third-year trial findings, which are necessary for assessing the long-term effectiveness of new classes of LLIN in the community and the replacement intervals required. A third year of follow-up of a four-arm, single-blind, cluster-randomised controlled trial of dual active ingredient LLINs was conducted between July 14, 2021, and Feb 10, 2022, in Misungwi, Tanzania. Restricted randomisation was used to assign 84 clusters to the four LLIN groups (1:1:1:1) to receive either standard pyrethroid (PY) LLINs (reference), chlorfenapyr-PY LLINs, pyriproxyfen-PY LLINs, or piperonyl butoxide (PBO)-PY LLINs. All households received one LLIN for every two people. Data collection was done in consenting households in the cluster core area with at least one child between 6 months and 15 years of age who permanently resided in the selected household. Exclusion criteria were householders absent during the visit, living in the cluster buffer area, no adult caregiver capable of giving informed consent, or eligible children who were severely ill. Field staff and study participants were masked to allocation, and those analysing data were not. The primary 24-month endpoint was reported previously; here, we present the secondary outcome, malaria infection prevalence in children at 36 months post LLIN distribution, reported in the intention-to-treat analysis. The trial was registered with ClinicalTrials.gov (NCT03554616) and is now complete. Overall usage of study nets was 1023 (22·3%) of 4587 people at 36 months post distribution. In the standard PY LLIN group, malaria infection was prevalent in 407 (37·4%) of 1088 participants, compared with 261 (22·8%) of 1145 in the chlorfenapyr-PY LLIN group (odds ratio 0·57, 95% CI 0·38-0·86; p=0·0069), 338 (32·2%) of 1048 in the PBO-PY LLIN group (0·95, 0·64-1·42; p=0·80), and 302 (28·8%) of 1050 in the pyriproxyfen-PY LLIN group (0·82, 0·55-1·23; p=0·34). None of the participants or caregivers reported side-effects. Despite low coverage, the protective efficacy against malaria offered by chlorfenapyr-PY LLINs was superior to that provided by standard PY LLINs over a 3-year LLIN lifespan. Appropriate LLIN replacement strategies to maintain adequate usage of nets will be necessary to maximise the full potential of these nets. Department for International Development, UK Medical Research Council, Wellcome Trust, Department of Health and Social Care, and Bill & Melinda Gates Foundation via the Innovative Vector Control Consortium.

Effects of next-generation, dual-active-ingredient, long-lasting insecticidal net deployment on insecticide resistance in malaria vectors in Tanzania: an analysis of a 3-year, cluster-randomised controlled trial

Insecticide resistance among malaria-vector species is a pervasive problem that might jeopardise global disease-control efforts. Novel vector-control tools with different modes of action, including long-lasting insecticidal nets (LLINs) incorporating new active ingredients, are urgently needed to delay the evolution and spread of insecticide resistance. We aimed to measure phenotypic and genotypic insecticide-resistance profiles among wild Anopheles collected over 3 years to assess the longitudinal effects of dual-active-ingredient LLINs on insecticide resistance. For this analysis, data nested in a 3-year, four parallel-arm, superiority cluster-randomised controlled trial (cRCT) in Tanzania, collected from 84 clusters (39 307 households) formed of 72 villages in the Misungwi district, were used to measure insecticide-resistance profiles among female Anopheles mosquitoes via insecticide-resistance bioassays and quantitative RT-PCR of metabolic-resistance genes. Wild, blood-fed, indoor-resting mosquitoes were collected annually during the rainy seasons from house walls in clusters from all four trial groups. Mosquitoes were morphologically identified as An gambiae sensu lato (SL) or An funestus SL before separate bioassay testing. The primary outcomes were lethal-dose values for α-cypermethrin, permethrin, and piperonyl butoxide pre-exposure plus permethrin-resistance intensity bioassays, mortality 72 h after insecticidal exposure for chlorfenapyr bioassays, fertility reduction 72 h after insecticidal exposure for pyriproxyfen bioassays, and fold change in metabolic-enzyme expression relative to an insecticide-susceptible laboratory strain. All primary outcomes were measured in An funestus SL 1 year, 2 years, and 3 years after LLIN distribution. Primary outcomes were also assessed in An gambiae SL if enough mosquitoes were collected. The cRCT is registered with ClinicalTrials.gov (NCT03554616). Between May 24, 2019, and Oct 25, 2021, 47 224 female Anopheles were collected for resistance monitoring. In the pyrethroid (PY)-LLIN group, there were significant increases in α-cypermethrin-resistance intensity (year 1 LD50=9·52 vs year 2 76·20, p<0·0001) and permethrin-resistance intensity (year 1 13·27 vs year 2 35·83, p=0·0019) in An funestus SL. In the pyriproxyfen PY-LLIN group, there was similar increase in α-cypermethrin-resistance intensity (year 1 0·71 vs year 2 81·56, p<0·0001) and permethrin-resistance intensity (year 1 5·68 vs year 2 50·14, p<0·0001). In the piperonyl butoxide PY-LLIN group, α-cypermethrin-resistance intensity (year 1 33·26 vs year 3 70·22, p=0·0071) and permethrin-resistance intensity (year 1 47·09 vs year 3 2635·29, p<0·0001) also increased over time. In the chlorfenapyr PY-LLIN group, there were no effects on α-cypermethrin-resistance intensity (year 1 0·42 vs year 3 0·99, p=0·54) or permethrin-resistance intensity (data were not estimable due to nearly 100% mortality). There were also minimal reductions in chlorfenapyr susceptibility. However, in the chlorfenapyr PY-LLIN group, a significant decline in piperonyl-butoxide synergy was seen by year 3 (year 1 0·02 vs year 3 0·26, p=0·020). Highly over-expressed detoxification enzymes showed dynamic patterns of selection throughout the trial. Our phenotypic data supports trial epidemiological findings; chlorfenapyr PY-LLINs provided superior protection from malaria across multiple transmission seasons, with few effects on insecticide-resistance selection. Rapid pyrethroid-resistance intensification in the piperonyl butoxide PY-LLIN group and pre-existing tolerance of pyriproxyfen in vector populations might explain the poorer performance of these two interventions regarding malaria outcomes. Further work is required to elucidate the potential mechanisms driving cross-resistance between pyrethroids and novel active ingredients to better inform the design of pre-emptive resistance-management strategies. UK Department for International Development; UK Medical Research Council; Wellcome Trust; UK Department of Health and Social Care; UK Foreign, Commonwealth and Development Office; and The Bill and Melinda Gates Foundation via the Innovative Vector Control Consortium.

A conceptual framework on the role of backward integration in sustainable access to malaria intervention commodities in Nigeria

BackgroundOver the last two decades, global stakeholders and the Nigerian government have invested approximately $2 billion in malaria control, reducing parasite prevalence to 23% from 42% to 2010. However, there is a risk that the modest gains will be reversed due to unmet resource gaps. Backward integration is presented in this paper as a viable option for sustainable funding of malaria intervention commodities in Nigeria.MethodsFollowing a critical appraisal of the resource profile and malaria expenditure, a conceptual framework on backward integration as a means of ensuring long-term supply of malaria intervention commodities was developed. The study analysed secondary annual data from the National Malaria Elimination Programme to estimate commodity needs for the period 2018–2020, as well as total resources committed and the financial gap.ResultsThe funds needed to implement national malaria interventions from 2018 to 2020 totaled US$ 1,122,332,318, of which US$ 531,228,984 (47.3%) were funded. The Nigerian government contributed 2.5%, the Global Fund (26.7%), the President’s Malaria Initiative (16.5%), and the UK Department for International Development (6.2%). The funding shortfall was $591,103,335, or 52.7% of the needs. Various funding scenarios were evaluated for their relative merits and limitations, including advocacy for more external funding, bank borrowing, increased domestic resources, and backward integration.ConclusionsThe study concluded that backward integration should be used, based on a government-led public-private partnership that will increase local production of malaria intervention commodities that are accessible and affordable through market-based demand and supply arrangements.

Electronic Payment Technology and Business Finance: A Randomized, Controlled Trial with Mobile Money

We conducted a randomized, controlled trial with small- and medium-sized enterprises in Kenya to estimate the causal impact of an electronic payment (e-payment) technology on business finance. Using an encouragement design, we exogenously increased e-payment usage among a random subset of firms by relaxing adoption transaction costs and information barriers. Sixteen months after the intervention, we find that the e-payment technology increased access to mobile loans (in the number of loans as well as in the amount borrowed) by at least 50% (0.17 standard deviation), likely because of the reduction of information asymmetries brought by an increase in digital transactions. We find no effect of the e-payment technology on sales and profits, but we do find a reduction of sales volatility and precautionary investment, especially for smaller firms. This suggests that mobile loans help smaller firms cope with short-term negative shocks. We provide a stylized model of business finance that rationalizes these findings. This paper was accepted by Bruno Biais, finance. Funding: This paper was produced under the framework of the “Enabling Innovation and Productivity Growth in Low Income Countries (EIP-LIC/PO5639)” project, funded by the Department for International Development (DFID) of the United Kingdom and implemented by Tilburg University. Supplemental Material: The data files and online appendix are available at https://doi.org/10.1287/mnsc.2023.4821 .

Assessment of livelihood sustainability during Urban Development-Induced Rural Displacement and Resettlement (UDIRDR): a literature review

ABSTRACT This study focuses on the impact of Urban Development-Induced Rural Displacement and Resettlement (UDIRDR) projects on the livelihood of the affected people through a literature review. Identifying various focus/objectives of previous studies on UDIRDR and eight dimensions of livelihood assets, it tries to build a link with the sustainable livelihood framework proposed by the Department for International Development (DFID), especially for rural communities. Finally, it proposes a conceptual framework for evaluating the livelihood scenario at the individual, household, and community levels affected by the UDIRDR projects and helping to achieve sustainable livelihood in the future.

A perspective of sustainable livelihood framework in analysis of sustainability of rural community livelihoods: evidence from Migori River watershed in Kenya

ABSTRACT Evaluation of livelihood sustainability in ecologically sensitive areas, impoverished regions, and disaster-stricken zones is critical for understanding sustainability challenges and administering poverty-relief interventions. This paper assesses the sustainability of rural households’ livelihoods in the Migori River watershed in Kenya by constructing a livelihood sustainability index (LSI). A cross-sectional survey design was used to collect data from 318 randomly selected households from the upstream, midstream, and downstream watershed zones. The LSI was constructed using the UK Department for International Development (DFID) methodology based on the five livelihood capitals, and one-way ANOVA was used to test for significant differences between watershed zones. The results of the analysis show that although the livelihoods of all the three watershed zones are moderately sustainable with no significant variations (at p < 0.05) between the zones, the livelihoods of midstream households are most sustainable followed by the upstream households and then downstream. The social (ranging from 0.64 to 0.69), physical (ranging from 0.60 to 0.67) and natural (ranging from 0.60 to 0.64) capitals registered relatively high index values across the watershed zones unlike the human (ranging 0.55–0.65) and financial (ranging from 0.44 to 0.57) capitals that recorded relatively low index values; which implies that human and the financial capitals are least possessed assets in the watershed. Therefore this paper recommends increasing the natural capital through sustained conservation of natural resources, increasing human capital by providing skills training to household on alternative livelihood options, and increasing access to financial capital by strengthening rural entrepreneurship. The paper suggests the usage of LSI by policy-makers as a practical tool to quantify the livelihood capital endowment of rural communities to help in prioritizing watershed management programs and the development of interventions aimed at a specific livelihood asset. It may also help policy-makers in project monitoring and evaluation, where it provides feedback critical for continual project improvement.

Differential impact of dual-active ingredient long-lasting insecticidal nets on primary malaria vectors: a secondary analysis of a 3-year, single-blind, cluster-randomised controlled trial in rural Tanzania

Gains in malaria control are threatened by widespread pyrethroid resistance in malaria vectors across sub-Saharan Africa. New long-lasting insecticidal nets (LLINs) containing two active ingredients (dual active-ingredient LLINs) have been developed to interrupt transmission in areas of pyrethroid resistance. We aimed to evaluate the effectiveness of three dual active-ingredient LLINs compared with standard pyrethroid LLINs against pyrethroid-resistant malaria vectors in rural Tanzania. In this study, we did a secondary analysis of entomological data from a four-group, 3 year, single-blind, cluster-randomised controlled trial carried out between Feb 18, 2019, and Dec 6, 2021. We conducted quarterly indoor mosquito collections using the Centers for Disease Control and Prevention light trap, in eight houses in each of the 84 study clusters in the Misungwi district, northwestern Tanzania. Anopheles vectors were then tested for malaria parasites and identified at species level, to distinguish between sibling species of the Anopheles gambiae and Anopheles funestus groups, using molecular laboratory techniques. The primary outcomes were density of different malaria vector species measured as the number of female Anopheles collected per household per night, the entomological inoculation rate (EIR), an indicator of malaria transmission, and sporozoite rate. Entomological outcomes were assessed on the basis of intention to treat, and the effect of the three dual active-ingredient LLINs was compared with the standard pyrethroid LLINs at household level. Dual active-ingredient LLINs had the greatest effect on Anopheles funestus sl, the most efficient vector in the study area, with comparatively weak effect on An arabiensis. An funestus density was 3∙1 per house per night in the pyrethroid LLIN group, 1∙2 in the chlorfenapyr pyrethroid LLIN group (adjusted density ratio [aDR]=0∙26, 95% CI 0∙17-0∙14, p<0∙0001), 1∙4 in the piperonyl-butoxide pyrethroid LLIN group (aDR=0∙49, 0∙32-0∙76, p=0∙0012), and 3∙0 in the pyriproxyfen pyrethroid LLIN group (aDR=0∙72, 0∙47-1∙11, p=0∙15). Malaria transmission intensity was also significantly lower in the chlorfenapyr pyrethroid group, with 0∙01 versus 0∙06 infective bites per household per night in the pyrethroid LLIN group (aDR=0∙21, 0∙14-0∙33, p<0∙0001). Ecological niche models indicated that vector-species distribution was stable following LLIN intervention despite the reductions observed in An funestus sl density. Chlorfenapyr pyrethroid LLINs were the most effective intervention against the main malaria vector An funestus sl over 3 years of community use, whereas the effect of piperonyl-butoxide pyrethroid LLIN was sustained for 2 years. The other vector, An arabiensis, was not controlled by any of the dual active-ingredient LLINs. Additional vector control tools and strategies targeted to locally prevalent vector species evading dual active-ingredient LLINs should be deployed to further reduce malaria transmission and achieve elimination. The Department for International Development, UK Medical Research Council, Wellcome Trust, the Department of Health and Social Care, and The Bill & Melinda Gates Foundation via the Innovative Vector Control Consortium.

Immunogenicity and safety of fractional doses of 17D-213 yellow fever vaccine in HIV-infected people in Kenya (YEFE): a randomised, double-blind, non-inferiority substudy of a phase 4 trial

Evidence indicates that fractional doses of yellow fever vaccine are safe and sufficiently immunogenic for use during yellow fever outbreaks. However, there are no data on the generalisability of this observation to populations living with HIV. Therefore, we aimed to evaluate the immunogenicity of fractional and standard doses of yellow fever vaccine in HIV-positive adults. We conducted a randomised, double-blind, non-inferiority substudy in Kilifi, coastal Kenya to compare the immunogenicity and safety of a fractional dose (one-fifth of the standard dose) versus the standard dose of 17D-213 yellow fever vaccine among HIV-positive volunteers. HIV-positive participants aged 18-59 years, with baseline CD4+ T-cell count of at least 200 cells per mL, and who were not pregnant, had no previous history of yellow fever vaccination or infection, and had no contraindication for yellow fever vaccination were recruited from the community. Participants were randomly assigned 1:1 in blocks (variable block sizes) to either a fractional dose or a standard dose of the 17D-213 yellow fever vaccine. Vaccines were administered subcutaneously by an unblinded nurse and pharmacist; all other study personnel were blinded to the vaccine allocation. The primary outcome of the study was the proportion of participants who seroconverted by the plaque reduction neutralisation test (PRNT50) 28 days after vaccination for the fractional dose versus the standard dose in the per-protocol population. Secondary outcomes were assessment of adverse events and immunogenicity during the 1-year follow-up period. Participants were considered to have seroconverted if the post-vaccination antibody titre was at least 4 times greater than the pre-vaccination titre. We set a non-inferiority margin of not less than a 17% decrease in seroconversion in the fractional dose compared with the standard dose. This study is registered with ClinicalTrials.gov, NCT02991495. Between Jan 29, 2019, and May 17, 2019, 303 participants were screened, and 250 participants were included and vaccinated; 126 participants were assigned to the fractional dose and 124 to the standard dose. 28 days after vaccination, 112 (96%, 95% CI 90-99) of 117 participants in the fractional dose group and 115 (98%, 94-100) of 117 in the standard dose group seroconverted by PRNT50. The difference in seroconversion between the fractional dose and the standard dose was -3% (95% CI -7 to 2). Fractional dosing therefore met the non-inferiority criterion, and non-inferiority was maintained for 1 year. The most common adverse events were headache (n=31 [12%]), fatigue (n=23 [9%]), myalgia (n=23 [9%]), and cough (n=14 [6%]). Reported adverse events were either mild (182 [97%] of 187 adverse events) or moderate (5 [3%]) and were self-limiting. Fractional doses of the 17D-213 yellow fever vaccine were sufficiently immunogenic and safe demonstrating non-inferiority to the standard vaccine dose in HIV-infected individuals with CD4+ T cell counts of at least 200 cells per mL. These results provide confidence that fractional dose recommendations are applicable to populations with high HIV prevalence. Wellcome Trust, Médecins Sans Frontières Foundation, and the UK Department for International Development.

An evolving migration-development nexus: DfID and British politics of race and belonging

The last three decades have witnessed increasing interest in the connections between migration and development. Within this body of work less attention has been paid to the ways in which ideas of race and racialised histories and geographies shape the migration-development nexus. Focusing on diasporic communities as key actors within this nexus and using empirical material from Great Britain’s Department for International Development (DfID), this paper explores the shifting constructions of ‘the diaspora’ within the global development context from DfID’s inception in 1997 to its demise in 2020. Constructions of the diaspora-development nexus can be framed as a (shifting) assemblage, bringing together contemporary post-colonial politics of belonging, the racialised histories and geographies of development and the changing (neoliberal) architectures and cultures of development. The paper concludes that in this context, diasporic-centred development can be considered a racialised socio-political mechanism, shaped by the shifting politics of race and belonging, which are themselves bound to colonial pasts and contemporary colonialities. This attends to processes of inclusion (and exclusion) in the global development sphere in contemporary Britain and speaks to the need to think more widely about how race intersects with the migration-development nexus.

Flood vulnerability analysis using different aggregation frameworks across watersheds of Ardabil province, northwestern Iran

Flood-vulnerable-area selection could be interpreted as an intricate multiple-criteria decision-making (MCDM) problem. Lacking systematic flood vulnerability maps in Iran usually leaves the National Disaster Management Organization and provincial authorities to rely on limited knowledge to inform their emergency actions. Therefore, the present study was conducted as pioneer research in flood problematization for solving disaster issues that have not been adequately considered in the country. To obtain a more trustworthy and safer decision, a complex set of multivariate flood vulnerability assessments was done for 26 watersheds of Ardabil province using the novel-ensemble MCDM frameworks. Towards this, the complex proportional assessment of alternatives (COPRAS) and the UK Department for International Development (DFID) approach was integrated with widely used weighting methods of Shannon's entropy (Entropy) and analytical hierarchy process (AHP). Finally, four different aggregation frameworks of COPRAS-Entropy, COPRAS-AHP, DFID-Entropy, and DFID-AHP were developed and compared based on 19 criteria and three factors (exposure, sensitivity, and resilience). The flood vulnerability was obtained as 0.70 ± 0.13, 0.66 ± 0.18, 0.17 ± 0.10, and 0.20 ± 0.15, respectively, based on COPRAS-Entropy, COPRAS-AHP, DFID-Entropy, and DFID-AHP. As can be seen, higher values were estimated according to COPRAS-based frameworks rather than DFID-based frameworks, except for resilience. The top-ranked watersheds in terms of exposure (i.e., Mashiran) and sensitivity (i.e., Samian) produced by aggregation frameworks match entirely. However, the top-ranked watersheds based on resilience and flood vulnerability slightly mismatch among the used aggregation's frameworks. These findings help the responsible authorities for natural disaster risk reduction to promote sustainable development processes and equitable access to financial resources.

Trial-of-antibiotics to assist tuberculosis diagnosis in symptomatic adults in Malawi (ACT-TB study): a randomised controlled trial

Clinical practice and diagnostic algorithms often assume that tuberculosis can be ruled out in mycobacteriology-negative individuals whose symptoms improve with a trial-of-antibiotics. We aimed to investigate diagnostic performance, clinical benefit, and antimicrobial resistance using a randomised controlled trial. In this three-arm, individually randomised, open-label, controlled trial, we enrolled Malawian adults (aged ≥18 years) attending primary care who reported being unwell for at least 14 days (including cough) with no immediate indication for hospitalisation at Limbe and Ndirande Health Centres in Blantyre. Participants were randomly allocated (1:1:1) to azithromycin (500 mg taken once per day for 3 days), amoxicillin (1 g taken three times per day for 5 days), or standard of care with no immediate antibiotics, stratified by study site. Sputum at enrolment and day 8 was tested for tuberculosis (microscopy, Xpert MTB/RIF, and culture). The primary efficacy outcome was day 8 specificity (percentage with symptom improvement among mycobacteriology-negative participants), and day 29 clinical outcome (death, hospitalisation, or missed tuberculosis diagnosis) among all randomised participants. This study is registered with ClinicalTrials.gov, NCT03545373. Between Feb 25, 2019, and March 14, 2020, 5825 adults were screened and 1583 (mean age 36 years; 236 [14·9%] HIV positive) were randomly assigned to standard of care (530 participants), azithromycin (527 participants), or amoxicillin (526 participants) groups. Overall, 6·3% (100 of 1583 participants) had positive baseline sputum mycobacteriology. 310 (79·1%) of 392 patients receiving standard of care reported symptom improvement at day 8, compared with 340 (88·7%) of 383 patients receiving azithromycin (adjusted difference 8·6%, 95% CI 3·9-13·3%; p<0·0004) and 346 (89·4%) of 387 receiving amoxicillin (adjusted difference 8·8%, 4·0-13·6%; p=0·0003). The proportion of participants with day 29 composite clinical outcomes was similar between groups (standard of care 1% [7 of 530 participants], azithromycin 1% [6 of 527 participants], amoxicillin 2% [12 of 526 participants]). Routine outpatient trial-of-antibiotics during tuberculosis investigations modestly improved diagnostic specificity for mycobacteriologically confirmed tuberculosis but had no appreciable effect on death, hospitalisation, and missed tuberculosis diagnosis. These results confirm the limited benefit of trial-of-antibiotics, presenting an opportunity for discontinuation of trial-of-antibiotics and improved antimicrobial stewardship during tuberculosis screening, without affecting clinical outcomes. Northern Norway Regional Health Authority (Helse Nord RHF), Commonwealth Scholarship Commission in the UK, Wellcome Trust, UK Medical Research Council, and the UK Department for International Development.

It Is Time to Go Public

Changes in modern society are rapid and complex and give rise to social problems such as crime. The relevance of community policing is derived from the need to facilitate robust relationships and mutual information flow between the police and the public. A £30 million UK Department for International Development (UK-DFID) overseeing a community policing initiative run in conjunction with the British Council's Security Justice and Growth in Nigeria did not achieve the desired community safety on account of the wide communication gaps between the security providers and the public in Nigeria. In 2004 at the presidential address to the American Sociological Association, Burawoy introduced the concept of public sociology involving taking sociology to the public audience. Adopting the Michael Burawoy's public sociology theoretical perspective, this paper explores the need and possibility of taking ideas of community policing to the public domain in Nigeria.

Analysis of the Sustainability, Vulnerability, and Challenges of Aquaculture Livelihood Projects

Background: Aquaculture is the best source of sustainable livelihood for communities, as long as the technology is in place and environment friendly. The aquaculture in southern Negros Occidental continues to experience a crisis that includes this recent COVID-19 pandemic, in addition to rapid financial and structural changes and awareness of farming's enormous influence on ecosystem health. Oyster and fish cages farmers were familiar with and associated terms such as environmental protection, small-scale aquaculture, profitability, and productivity with sustainable oyster and fish production. Furthermore, the researcher, who has experience in the aquaculture industry, desires to investigate sustainability and recognizes this aquaculture owners/operators' vulnerability and challenges in their livelihood. Thus, the paper analyzed the sustainability, vulnerability, and challenges of aquaculture livelihood projects in Southern Negros. Methods: Using a descriptive quantitative research design, 50 aquaculture operators/owners answered a checklist questionnaire to analyze the sustainability, vulnerability, and challenges of aquaculture livelihood projects. Frequency count and percentage distribution were used in analyzing the quantitative data. Results: In human capital, the operators/owners have at least a high school graduate to engage in aquaculture livelihood and range 0-1 year of experience. They are aware of health and safety practices, and the skills they know are feeding and harvesting. They are sole workers, and the physical skill they perform is swimming. For natural capital, all operators/owners gained access to the Nanunga River permit from the Local Government Unit of Municipality of Hinigaran. The size of the fishing ground and fish pens is at 5x5meters, and they conduct monthly coastal cleaning for the maintenance of the surroundings. The timeline and growth and water sensitivity affect the timeline growth of the oyster shell and fish species, respectively. They are also given an action plan to prepare the climate change and initiate the monthly coastal cleanup to maintain cleanliness in the coastal. In terms of financial capital, the income of operators/owners is higher compared to expenses, debt, and taxes paid per harvest. As a result, they can set aside a net amount for savings. Also, they received support from the government every year. They were given a three-year projected financial statement to know the income, expenses, debt, savings, and taxes. Regarding social capital, the aquaculture livelihood helps their community by providing livelihood to their families, providing food supplies, and contributing to economic gain. The operators/owners are trusted, and they follow norms in the community. They are also involved in the monthly meetings to discuss the concerns about their aquaculture livelihood projects. They also avail of the financial assistance loan from the government through the Department of Labor and Employment (DOLE) Pangkabuhayan Program. These imply scheduling a mandatory monthly meeting for the Aquaculture owners/operators, which is also open to the community. In physical capital, most operators/owners have fish pen infrastructure, fish boats, materials for oyster farming, and fish cage fishing. They also used electricity and fuel as a source of energy. They sent an application for financial aid to the Department of Labor and Employment (DOLE) to purchase new materials for Aquaculture. The major vulnerabilities are the Covid-19 pandemic, climate change, oil spills, seasonality, and technological changes. The major challenges that the Aquaculture operators/owners face are lack of knowledge, high/low tide, no preparation of unforeseen expenses, lack of participation among members in monthly association meetings, and cannot afford to purchase new materials for fish pens and fishing boats. Overall, the findings in the light of the Department for International Development (DFID) Sustainable Livelihood Framework, the results were validated as aquaculture livelihood projects are sustainable in terms of human, natural, financial, social, and physical capital. Conclusion: The aquaculture livelihood projects of aquaculture growers in Southern Negros were sustainable in terms of human, natural, financial, social, and physical capital. It shows that the aquaculture operators/owners have various knowledge and skills in the industry, preservation of water resources and cleanliness of coastal areas, more income and less expenses and debts growers, improve the economy and the people's standard of living and relationships and more fish pens infrastructure and increase of supplies of materials. Notwithstanding the existing vulnerabilities and challenges, the aquaculture livelihood projects were manageable and could easily cope with unforeseen events. Practical Value of the Paper: The local government agency may explore the possibility of assisting aquaculture livelihood projects in gathering information for periodic evaluation and monitoring of the financial status of aquaculture livelihood projects for reporting purposes. It is hoped that future researchers utilize this study as the basis for further research, especially studies focusing on the sustainability, vulnerability, and challenges of other livelihoods like agriculture industries. Also, the Aquaculture owners/operators can use the strategic plan to present to the Department of Labor and Employment (DOLE) and other organizations to avail the financial assistance and funding in the future.

Research on the Impact of Livelihood Capital by the Honghu Fishermen's Willingness to Quit Fishing.

Aiming at the livelihood of fishermen under the fishing prohibition policy, quantitative research methods were used to explore the relationship between the willingness to quit fishing and livelihood capital. With reference to 609 survey data from 20 fishing grounds in 2 counties and cities of Hubei Province, this paper explores the necessity of convincing fishermen in the Yangtze River to quit fishing and evaluates the impact of livelihood mode on Honghu fishermen's willingness to quit fishing by means of structural equation model based on the sustainable livelihood framework developed by the UK Department for International Development. The results showed the following conclusions: (1) The proportion of fishermen who are willing to participate in quitting fishing is 66.7%, indicating that fishery production is still the main source of livelihood for many fishermen. The overall willingness of fishermen to quit fishing is strong, and fishermen have realized the importance of protecting fishery resources. (2) There is a strong correlation between the indicators of livelihood capital and the willingness of fishermen to quit fishing. Among them, the human capital has the most significant impact on fishermen's willingness to quit fishing for some compensation from public power. The research conclusion is helpful for the government to improve the fishing prohibition policy in a targeted manner and mobilize the enthusiasm of fishermen to protect fishery resources.

A task-shared, collaborative care psychosocial intervention for improving depressive symptomatology among older adults in a socioeconomically deprived area of Brazil (PROACTIVE): a pragmatic, two-arm, parallel-group, cluster-randomised controlled trial

SummaryBackgroundThere is an urgent need to reduce the burden of depression among older adults in low-income and middle-income countries (LMICs). We aimed to evaluate the efficacy of a task-shared, collaborative care psychosocial intervention for improving recovery from depression in older adults in Brazil.MethodsPROACTIVE was a pragmatic, two-arm, parallel-group, cluster-randomised controlled trial conducted in Guarulhos, Brazil. Primary care clinics (clusters) were stratified by educational level and randomly allocated (1:1) to either enhanced usual care alone (control group) or to enhanced usual care plus the psychosocial intervention (intervention group), which involved a 17-week psychosocial programme based on psychoeducation and behavioural activation approaches. Individuals approached for the initial screening assessment were selected randomly from a list of individuals provided by the Health Secretariat of Guarulhos. Face-to-face baseline assessments were conducted among adults aged 60 years or older registered with one of the primary care clinics and identified with clinically significant depressive symptomatology (9-item Patient Health Questionnaire [PHQ-9] score ≥10). Community health workers delivered the programme through home sessions, supported by a dedicated tablet application. Masking of clinic staff and community health workers who delivered the intervention was not feasible; however, research assistants conducting recruitment and follow-up assessments were masked to trial allocation. The primary outcome was recovery from depression (PHQ-9 score <10) at 8-month follow-up. All primary analyses were performed by intention to treat with imputed data. Adaptations to the protocol were made due to the COVID-19 pandemic; recruitment and intervention home sessions were stopped, and follow-up assessments were conducted by telephone. This trial is registered with the ISRCTN registry, ISRCTN57805470.FindingsWe identified 24 primary care clinics in Guarulhos that were willing to participate, of which 20 were randomly allocated to either the control group (ten [50%] clusters) or to the intervention group (ten [50%] clusters). The four remaining eligible clusters were kept as reserves. Between May 23, 2019, and Feb 21, 2020, 8146 individuals were assessed for eligibility, of whom 715 (8·8%) participants were recruited: 355 (49·7%) in the control group and 360 (50·3%) in the intervention group. 284 (80·0%) participants in the control group and 253 (70·3%) in the intervention group completed follow-up at 8 months. At 8-month follow-up, 158 (62·5%) participants in the intervention group showed recovery from depression (PHQ-9 score <10) compared with 125 (44·0%) in the control group (adjusted odds ratio 2·16 [95% CI 1·47–3·18]; p<0·0001). These findings were maintained in the complete case analysis. No adverse events related to the intervention were observed.InterpretationAlthough the COVID-19 pandemic altered delivery of the intervention, the low-intensity psychosocial intervention delivered mainly by non-mental health professionals was highly efficacious in improving recovery from depression in older adults in Brazil. Our results support a low-resource intervention that could be useful to reduce the treatment gap for depression among older people in other LMICs.FundingSão Paulo Research Foundation and Joint Global Health Trials (UK Department for International Development, Medical Research Council, and the Wellcome Trust).