Department Of International Development Research Articles

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

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

The benefits and burden of health financing in Indonesia: analyses of nationally representative cross-sectional data

Indonesia has committed to deliver universal health coverage by 2024. Reforming the country's health-financing system is key to achieving this commitment. We aimed to evaluate how the benefits and burden of health financing are distributed across income groups and the extent to which Indonesia has achieved equity in the funding and delivery of health care after financing reforms. We conducted benefit incidence analyses (BIA) and financing incidence analyses (FIA) using cross-sectional nationally representative data from several datasets. Two waves (Feb 1 to April 30, 2018, and Aug 1 to Oct 31, 2019) of the Equity and Health Care Financing in Indonesia (ENHANCE) study household survey involving 7500 households from ten of the 34 provinces in Indonesia were used to obtain health and socioeconomic status data for the BIA. Two waves (2018 and 2019) of the National Socioeconomic Survey (SUSENAS), the most recent wave (2014) of the Indonesian Family Life Survey, and the 2017 and 2018 National Health Accounts were used to obtain data for the FIA. In the BIA, we calculated a concentration index to assess the distribution of health-care benefits (-1·0 [pro-poor] to 1·0 [pro-rich]), considering potential differences in health-care need. In the FIA, we evaluated the equity of health-financing contributions by socioeconomic quintiles by calculating the Kakwani index to assess the relative progressivity of each financing source. Both the BIA and FIA compared results from early 2018 (baseline) with results from late 2019. There were 31 864 participants in the ENHANCE survey in 2018 compared with 31 215 in 2019. Women constituted 50·5% and men constituted 49·5% of the total participants for each year. SUSENAS had 1 131 825 participants in 2018 compared with 1 204 466 in 2019. Women constituted 49·9% of the participants for each year, whereas men constituted 51·1%. The distribution of health-care benefits in the public sector was marginally pro-poor; people with low income received a greater proportion of benefits from health services than people with high income between 2018 (concentration index -0·008, 95% CI -0·075 to 0·059) and 2019 (-0·060, -0·139 to 0·019). The benefit incidence in the private health sector was significantly pro-rich in 2018 (0·134, 0·065 to 0·203, p=0·0010) and 2019 (0·190, -0·192 to 0·572, p=0·0070). Health-financing incidence changed from being moderately progressive in 2018 (Kakwani index 0·034, 95% CI 0·030 to 0·038) to mildly regressive in 2019 (-0·030, -0·034 to -0·025). Although Indonesia has made substantial progress in expanding health-care coverage, a lot remains to be done to improve equity in financing and spending. Improving comprehensiveness of benefits will reduce out-of-pocket spending and allocating more funding to primary care would improve access to health-care services for people with low income. UK Health Systems Research Initiative, UK Department of International Development, UK Economic and Social Research Council, UK Medical Research Council, and Wellcome Trust.

Equity of health financing in Indonesia: A 5-year financing incidence analysis (2015–2019)

SummaryBackgroundIn 2014, Indonesia launched a single payer national health insurance scheme with the aim of covering the entire population by 2024. The objective of this paper is to assess the equity with which contributions to the health financing system were distributed in Indonesia over 2015 – 2019.MethodsThis study is a secondary analysis of nationally representative data from the National Socioeconomic Survey of Indonesia (2015 – 2019). The relative progressivity of each health financing source and overall health financing was determined using a summary score, the Kakwani index.FindingsAround a third of health financing was sourced from out-of-pocket (OOP) payments each year, with direct taxes, indirect taxes and social health insurance (SHI) each taking up 15 – 20%. Direct taxes and OOP payments were progressive sources of health financing, and indirect tax payments regressive, for all of 2015 – 2019. SHI contributions were regressive except in 2017 and 2018. The overall health financing system was progressive from 2015 to 2018, but this declined year by year and became mildly regressive in 2019.InterpretationThe declining progressivity of the overall health financing system between 2015 – 2019 suggests that Indonesia still has a way to go in developing a fair and equitable health financing system that ensures the poor are financially protected.FundingThis study is supported through the Health Systems Research Initiative in the UK, and is jointly funded by the Department of International Development, the Economic and Social Research Council, the Medical Research Council and the Wellcome Trust.

Use of verbal autopsy for establishing causes of child mortality in camps for internally displaced people in Mogadishu, Somalia: a population-based, prospective, cohort study

People in humanitarian emergencies are likely to experience excess mortality but information on the causes of death is often unreliable or non-existent. This study aimed to provide evidence on the causes of death among children younger than 5 years in camps for internally displaced people in southern Somalia, during periods of protracted displacement and emergency influx amid the 2017 drought and health emergency. We did a prospective, cohort study in 25 camps in the Afgooye corridor, on the outskirts of Mogadishu, Somalia. All internally displaced children aged 6-59 months were included and followed up with monthly household visits by community health workers. Nutrition, health, and vaccination status were ascertained and verbal autopsy interviews were done with the caregivers of deceased children. We calculated death rates in these children and used verbal autopsy to establish the cause-specific mortality fraction (CSMF). Bayesian InterVA software was used to assign likely causes to each death. Between March, 2016, and March, 2018, 3898 children were followed up. 153 deaths were recorded during 34 746 person-months of observation. The death rate among children younger than 5 years exceeded emergency thresholds (>2 deaths per 10 000 children per day), reaching a peak of seven deaths per 10 000 children per day during the emergency influx. Verbal autopsy data were gathered for 80% of deaths, and the CSMF for the three leading causes of death were diarrhoeal diseases (25·9%), measles (17·8%), and severe malnutrition (8·8%). Coverage of measles vaccination during the first 3 months of the emergency was 42% and the CSMF for measles doubled during the influx. During protracted displacement, symptoms that could be attributable to HIV/AIDS related deaths accounted for 1·6% of the CSMF. It is feasible to establish a health and nutrition surveillance system that ascertains causes of death, using verbal autopsy, in this humanitarian context. These data can inform policy, response planning, and priority setting. The high mortality rate from infectious diseases and malnutrition among children younger than 5 years suggests the need for strengthening a range of public health interventions, including vaccination and provision of water, sanitation, and hygiene. UK Department of International Development.

Prevalence and correlates of common mental health problems and recent suicidal behaviour among female sex workers in Nairobi, Kenya: findings from the Maisha Fiti study

AimsAdverse childhood experiences (ACEs), poverty, violence and harmful alcohol/substance are associated with poor mental health outcomes in the general population. These risks are likely to be exacerbated among Female Sex Workers (FSWs), however there are few studies examining risks factors for mental health problems among FSWs. We examine the prevalence and correlates of common mental health problems including suicidal behaviour among FSWs in Kenya.MethodMaisha Fiti is a longitudinal study among FSWs randomly selected from Sex Worker Outreach Programme (SWOP) clinics across Nairobi. Baseline data were collected from June-December 2019. Mental health problems were assessed using the Patient Health Questionnaire (PHQ-9) for depression, the Generalised Anxiety Disorder tool (GAD-7) for anxiety, and the Harvard Trauma Questionnaire (HTQ-17) for Post-Traumatic Stress Disorder (PTSD). Recent suicidal behaviour was defined as reported suicide attempt or suicidal ideation in the past 30 days. Other measurement tools included the WHO Adverse Childhood Experiences (ACE) score, WHO Violence Against Women questionnaire, and the WHO ASSIST tool (to measure harmful alcohol/substance use in the past 3 months). Descriptive statistics and multivariable logistic regression were conducted in Stata 16.1.ResultOf 1039 eligible FSWs, 1003 FSWs took part in the study (response rate: 96%) with a mean age of 33.7 years. The prevalence of moderate/severe depression was 23.2% (95%CI: 20.7–25.9%), moderate/severe anxiety 11.0% (95%CI: 9.3–13.1%), PTSD 14.0% (95% CI: 12.2–16.5%) and recent suicidal behaviour 10.2% (95%CI: 8.5–12.2%) (2.6% suicide attempt; 10.0% suicidal ideation). Among women with any mental health problem 63.0% also had a harmful alcohol/substance use problem. One in four women (25%; 95%CI: 22.5–27.8%) had depression and/or anxiety and this was independently associated with higher ACE scores, hunger (skipped a meal in last week due to financial difficulties), death of a child, perceived sex work stigma and recent sexual/physical violence. PTSD was associated with higher ACE scores, hunger, increased STI prevalence (chlamydia trachomatis) and recent violence. Recent suicidal behaviour was associated with higher ACE scores, low literacy, hunger, and recent violence. Mental health problems and suicidal behaviour were less prevalent among women reporting social support.ConclusionThe high burden of mental problems among FSWs indicates a need for accessible services tailored for FSWs alongside broader structural interventions addressing poverty, harmful alcohol/substance use and violence. High rates of ACEs among this population indicates the need to consider early childhood and family interventions to prevent poor mental health outcomes.Funding: Medical Research Council and the UK Department of International Development

PROTOCOL: Evidence and gap map: studies of the effectiveness of transport sector interventions in low- and middle-income countries.

PROTOCOL: Evidence and gap map: studies of the effectiveness of transport sector interventions in low- and middle-income countries.

VULNERABILITY OF MARINE FISHERMEN TO NATURE-DRIVEN STRESSORS

There is an increasing concern over the consequences of global warming and food security. Fishery is one of the worst affected sectors due to the impact of global warming. The livelihood of world’s 36 million fisher folk and nearly 1.5 billion consumers who rely on fish for more than 20% of their dietary animal protein are at risk due to the fact that the global warming make serious impact on the fishery and the livelihood of fishermen (Badjeck, Allison, Hallis, & Dulvy, 2009). As fishermen are often poor, the cash income generated by the sales of fish can give them access to basic goods and services such as education, health, food and other assets (Department of International Development , 2006). Fishery can reduce economic and food vulnerability, but they themselves are vulnerable to external influences such as environmental degradation and climate change (FAO, 2018). These changes influence the coping of fishermen as they want to access the basic goods and services. With the aim of identifying the stressors influencing the fishing occupation of marine fishermen in Kanyakumari district of Tamil Nadu, India, and how these stressors are encountered with various mechanisms (coping strategies) by those fishermen, this study was conducted by involving 308 such fishermen chosen from the area. The study revealed that “higher the nature-driven stress, lower the resilience of fishermen.

Computer-Aided Detection for Tuberculosis and Silicosis in Chest Radiographs of Southern African Gold Miners

Background: The South African gold mining sector has been for over one hundred years a considerable source of tuberculosis and silicosis disease burden across southern Africa. Reading chest radiographs (CXRs) is an expert and time intensive process necessary for the screening and diagnosis of lung disease and the provision of evidence for compensation claims. Our study explores the use of computer-aided detection (CAD) of both tuberculosis (TB) and silicosis in a population with a high incidence of both diseases. Methods: A set of 330 CXRs with human expert-determined classifications of silicosis, tuberculosis, silcotuberculosis, and normal were provided to each of four health technology companies. Ability of each of their respective CAD systems to provide accurate quantitative predictions for each CXR was assessed using receiver operating characteristic (ROC) curve analysis of the under the curve (AUC) metric. Findings Three of the four systems differentiated accurately between TB and normal images (AUCs 0·989 [95% CI 0·975-1·0], 0·963 [0·930-0·996], and 0·980 [0·961-0·998]), while two differentiated accurately between silicosis and normal images (AUCs 0·986 [0·960-1·0], 0·939 [0·901-0·978]). Inclusion of silicotuberculosis images reduced each system's ability to detect either disease from the set of CXRs. In differentiating between any abnormal CXR from normal CXRs, the most accurate system achieved a sensitivity and specificity both of 98·2%. Interpretation: The use of CAD as a tool in mass screening for TB and silicosis in a population with a high burden of both diseases shows considerable promise, but current ability of CAD to differentiate between the two diseases is limited. Retraining of the systems with more silicosis CXRs and adding information about past work exposure into the screening tool may improve accuracy. Funding Statement: Canadian Institutes of Health Research, Canada Research Council, and the Department of International Development, United Kingdom. Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: Ethics approval was provided by the University of British Columbia Behavioural Research Ethics Board (H18-01793) and the University of Cape Town Faculty of Health Sciences Human Research Ethics Committee (HREC REF: 563/2019).

RubenAnderssonNo Go World: How Fear Is Redrawing Our Maps and Infecting Our PoliticsOakland, CA: University of California Press, 2019. xv + 337p. $29.95.

RubenAnderssonNo Go World: How Fear Is Redrawing Our Maps and Infecting Our PoliticsOakland, CA: University of California Press, 2019. xv + 337p. $29.95.

Policy vs. Practice: Exploring a Mentoring Approach for Building Capacity to Implement Multi-sectoral Nutrition Policies in Tanzania (P22-007-19)

Abstract Objectives Tanzania launched a National Multisectoral Nutrition (MSN) Action Plan and hired Nutrition Officers in all districts and regions. Implementation of multisectoral policies is essential for improving nutrition, yet challenging, particularly for new cadres. We explored mentoring as a novel, low-cost approach to strengthen capacity and engagement in MSN activities in five regions. Methods Regional Nutrition Officers participated in a mentoring workshop, then mentored District Nutrition Officers to form MSN action teams of 2–3 officers from other sectors. Support calls and funding for basic expenses were provided. In-depth interviews with 31 regional and district personnel explored challenges and promising practices over 1 year. Qualitative data were analyzed thematically. Results Regional Officers’ availability and capability varied. Overall, mentoring increased awareness of nutrition as cross-cutting and built collaboration. Nutrition officers were responsible for coordinating MSN, but clinical responsibilities and lack of authority had hindered integration of nutrition across sectors. Other barriers were limited time, resources and conflicting supervisory expectations. Most Nutrition Officers organized action teams across health, agriculture, community development and education departments. Benefits varied by district and sector. For example, learning about national policies and illustrative school- or community-based activities helped officers outside the health sector see the relevance of MSN and encouraged engagement. Agricultural officers already conducting nutrition-sensitive activities welcomed opportunities to share experiences and avoid redundancy. Recommendations to further strengthen MSN mentoring included enhancing collaboration at regional level, involving district personnel in initial workshops and selection of mentors, and sensitizing department heads. Conclusions Implementation of MSN policies requires explicit capacity building. Technical training is insufficient without mobilization across sectors, appropriate workloads, and supervisors who prioritize MSN activities. Mentoring can enhance credibility and capacity of nutrition personnel expected to engage departments outside health in implementing MSN policies. Funding Sources UKAID - Department of International Development.

Effect of a novel vital sign device on maternal mortality and morbidity in low-resource settings: a pragmatic, stepped-wedge, cluster-randomised controlled trial.

SummaryBackgroundIn 2015, an estimated 303 000 women died in pregnancy and childbirth. Obstetric haemorrhage, sepsis, and hypertensive disorders of pregnancy account for more than 50% of maternal deaths worldwide. There are effective treatments for these pregnancy complications, but they require early detection by measurement of vital signs and timely administration to save lives. The primary aim of this trial was to determine whether implementation of the CRADLE Vital Sign Alert and an education package into community and facility maternity care in low-resource settings could reduce a composite of all-cause maternal mortality or major morbidity (eclampsia and hysterectomy).MethodsWe did a pragmatic, stepped-wedge, cluster-randomised controlled trial in ten clusters across Africa, India, and Haiti, introducing the device into routine maternity care. Each cluster contained at least one secondary or tertiary hospital and their main referral facilities. Clusters crossed over from existing routine care to the CRADLE intervention in one of nine steps at 2-monthly intervals, with CRADLE devices replacing existing equipment at the randomly allocated timepoint. A computer-generated randomly allocated sequence determined the order in which the clusters received the intervention. Because of the nature of the intervention, this trial was not masked. Data were gathered monthly, with 20 time periods of 1 month. The primary composite outcome was at least one of eclampsia, emergency hysterectomy, and maternal death. This study is registered with the ISRCTN registry, number ISRCTN41244132.FindingsBetween April 1, 2016, and Nov 30, 2017, among 536 223 deliveries, the primary outcome occurred in 4067 women, with 998 maternal deaths, 2692 eclampsia cases, and 681 hysterectomies. There was an 8% decrease in the primary outcome from 79·4 per 10 000 deliveries pre-intervention to 72·8 per 10 000 deliveries post-intervention (odds ratio [OR] 0·92, 95% CI 0·86–0·97; p=0·0056). After planned adjustments for variation in event rates between and within clusters over time, the unexpected degree of variability meant we were unable to judge the benefit or harms of the intervention (OR 1·22, 95% CI 0·73–2·06; p=0·45).InterpretationThere was an absolute 8% reduction in primary outcome during the trial, with no change in resources or staffing, but this reduction could not be directly attributed to the intervention due to variability. We encountered unanticipated methodological challenges with this trial design, which can provide valuable learning for future research and inform the trial design of future international stepped-wedge trials.FundingNewton Fund Global Research Programme: UK Medical Research Council; Department of Biotechnology, Ministry of Science & Technology, Government of India; and UK Department of International Development.

Language, NGOs and inclusion: the donor perspective

ABSTRACTListening to communities is valued by UK’s Department of International Development (DFID) for contributing to “beneficiary” empowerment and programme efficiency. This article is based on interviews with elite DFID officials to explore their understandings on how they expect NGOs to engage with local languages and the role of language intermediaries. It uncovers their perceptions of the ways that languages and cultural knowledge shape NGO relationships with communities. It finds that the officials assume that listening is unproblematic for NGOs, and ask few questions about translation and interpretation. The article concludes by reflecting on policy implications and directions for further research.

Water, Infrastructure and Power: Contention and Resistance in Post‐colonial Cities of the South

Water, Infrastructure and Power: Contention and Resistance in Post‐colonial Cities of the South

Antimalarial activity of single-dose DSM265, a novel plasmodium dihydroorotate dehydrogenase inhibitor, in patients with uncomplicated Plasmodium falciparum or Plasmodium vivax malaria infection: a proof-of-concept, open-label, phase 2a study

SummaryBackgroundDSM265 is a novel, long-duration inhibitor of plasmodium dihydroorotate dehydrogenase (DHODH) with excellent selectivity over human DHODH and activity against blood and liver stages of Plasmodium falciparum. This study aimed to assess the efficacy of DSM265 in patients with P falciparum or Plasmodium vivax malaria infection.MethodsThis proof-of-concept, open-label, phase 2a study was conducted at the Asociación Civil Selva Amazónica in Iquitos, Peru. Patients aged 18–70 years, weighing 45–90 kg, who had clinical malaria (P falciparum or P vivax monoinfection) and fever within the previous 24 h were eligible. Exclusion criteria were clinical or laboratory signs of severe malaria, inability to take oral medicine, and use of other antimalarial treatment in the preceding 14 days. Patients were divided into cohorts of those with P falciparum (cohort a) or P vivax (cohort b) infection. Two initial cohorts received single oral doses of 400 mg DSM265. Patients were followed up for efficacy for 28 days and safety for 35 days. Further cohorts received escalated or de-escalated doses of DSM265, after safety and efficacy assessment of the initial dose. The primary endpoints were the proportion of patients achieving PCR-adjusted adequate clinical and parasitological response (ACPR) by day 14 for patients infected with P falciparum and the proportion of patients achieving a crude cure by day 14 for those infected with P vivax. Cohort success, the criteria for dose escalation, was defined as ACPR (P falciparum) or crude cure (P vivax) in at least 80% of patients in the cohort. The primary analysis was done in the intention-to-treat population (ITT) and the per-protocol population, and safety analyses were done in all patients who received the study drug. This study is registered at ClinicalTrials.gov (NCT02123290).FindingsBetween Jan 12, 2015, and Dec 2, 2015, 45 Peruvian patients (24 with P falciparum [cohort a] and 21 with P vivax [cohort b] infection) were sequentially enrolled. For patients with P falciparum malaria in the per-protocol population, all 11 (100%) in the 400 mg group and eight (80%) of ten in the 250 mg group achieved ACPR on day 14. In the ITT analysis, 11 (85%) of 13 in the 400 mg group and eight (73%) of 11 in the 250 mg group achieved ACPR at day 14. For the patients with P vivax malaria, the primary endpoint was not met. In the per-protocol analysis, none of four patients who had 400 mg, three (50%) of six who had 600 mg, and one (25%) of four who had 800 mg DSM265 achieved crude cure at day 14. In the ITT analysis, none of five in the 400 mg group, three (33%) of nine in the 600 mg group, and one (14%) of seven in the 800 mg group achieved crude cure at day 14. During the 28-day extended observation of P falciparum patients, a resistance-associated mutation in the gene encoding the DSM265 target DHODH was observed in two of four recurring patients. DSM265 was well tolerated. The most common adverse events were pyrexia (20 [44%] of 45) and headache (18 [40%] of 45), which are both common symptoms of malaria, and no patients had any treatment-related serious adverse events or adverse events leading to study discontinuation.InterpretationAfter a single dose of DSM265, P falciparum parasitaemia was rapidly cleared, whereas against P vivax, DSM265 showed less effective clearance kinetics. Its long duration of action provides the potential to prevent recurrence of P falciparum after treatment with a single dose, which should be further assessed in future combination studies.FundingThe Global Health Innovative Technology Fund, the Bill & Melinda Gates Foundation, the National Institutes of Health (R01 AI103058), the Wellcome Trust, and the UK Department of International Development.

Absent Agroecology Aid: On UK Agricultural Development Assistance Since 2010

Using figures published by the UK Department of International Development (DFID), this study finds that despite overwhelming evidence in favour of agroecology as a mode of agricultural development able to address crucial aspects of the interrelated crises facing human societies, UK development aid barely supports agroecology. Based on the most generous interpretation, this study shows for the first time that aid for agroecological projects is less than 5% of agricultural aid and less than 0.5% of total UK aid budget since 2010. Since 1 January 2010, no funds at all have been directed at or been committed to projects with the main focus on development or promotion of agroecological practices. Minor funds have been directed at projects which include some activities promoting agroecology at the most basic level of resource efficiency (e.g., conservation agriculture). By largely supporting industrial and Green Revolution agriculture, UK Aid priorities contribute very little to the transition towards social-ecological sustainability in Africa, Asia, and Latin America.

About the Contributors

About the Contributors

Effect of a training and educational intervention for physicians and caregivers on antibiotic prescribing for upper respiratory tract infections in children at primary care facilities in rural China: a cluster-randomised controlled trial.

Inappropriate antibiotic prescribing contributes to the generation of drug resistance worldwide, and is particularly common in China. We assessed the effectiveness of an antimicrobial stewardship programme aiming to reduce inappropriate antibiotic prescribing in paediatric outpatients by targeting providers and caregivers in primary care hospitals in rural China. We did a pragmatic, cluster-randomised controlled trial with a 6-month intervention period. Clusters were primary care township hospitals in two counties of Guangxi province in China, which were randomly allocated to the intervention group or the control group (in a 1:1 ratio in Rong county and in a 5:6 ratio in Liujiang county). Randomisation was stratified by county. Eligible participants were children aged 2-14 years who attended a township hospital as an outpatient and were given a prescription following a primary diagnosis of an upper respiratory tract infection. The intervention included clinician guidelines and training on appropriate prescribing, monthly prescribing peer-review meetings, and brief caregiver education. In hospitals allocated to the control group, usual care was provided, with antibiotics prescribed at the individual clinician's discretion. Patients were masked to their allocated treatment group but doctors were not. The primary outcome was the antibiotic prescription rate in children attending the hospitals, defined as the cluster-level proportion of prescriptions for upper respiratory tract infections in 2-14-year-old outpatients, issued during the final 3 months of the 6-month intervention period (endline), that included one or more antibiotics. The outcome was based on prescription records and analysed by modified intention-to-treat. This study is registered with the ISRCTN registry, number ISRCTN14340536. We recruited all 25 eligible township hospitals in the two counties (14 hospitals in Rong county and 11 in Liujiang county), and randomly allocated 12 to the intervention group and 13 to the control group. We implemented the intervention in three internal pilot clusters between July 1, 2015, and Dec 31, 2015, and in the remaining nine intervention clusters between Oct 1, 2016 and March 31, 2016. Between baseline (the 3 months before implementation of the intervention) and endline (the final 3 months of the 6-month intervention period) the antibiotic prescription rate at the individual level decreased from 82% (1936/2349) to 40% (943/2351) in the intervention group, and from 75% (1922/2548) to 70% (1782/2552) in the control group. After adjusting for the baseline antibiotic prescription rate, stratum (county), and potentially confounding patient and prescribing doctor covariates, this endline difference between the groups represented an intervention effect (absolute risk reduction in antibiotic prescribing) of -29% (95% CI -42 to -16; p=0·0002). In China's primary care setting, pragmatic interventions on antimicrobial stewardship targeting providers and caregivers substantially reduced prescribing of antibiotics for childhood upper respiratory tract infections. Department of International Development (UKAID) through Communicable Diseases Health Service Delivery.

New Editor for Oxford Development Studies

The Editorial Board of Oxford Development Studies is delighted to announce that the journal has a new Editor, Dr. Cheryl Doss of the Department of International Development at the University of Oxf...

Designing research funding schemes to promote global health equity: An exploration of current practice in health systems research.

International research is an essential means of reducing health disparities between and within countries and should do so as a matter of global justice. Research funders from high-income countries have an obligation of justice to support health research in low and middle-income countries (LMICs) that furthers such objectives. This paper investigates how their current funding schemes are designed to incentivise health systems research in LMICs that promotes health equity. Semi-structured in-depth interviews were performed with 16 grants officers working for 11 funders and organisations that support health systems research: the Alliance for Health Policy and Systems Research, Comic Relief, Doris Duke Foundation, European Commission, International Development Research Centre, Norwegian Agency for Development Cooperation, Research Council of Norway, Rockefeller Foundation, UK Department of International Development, UK Medical Research Council, and Wellcome Trust. Thematic analysis of the data demonstrates their funding schemes promote health systems research with (up to) five key features that advance health equity: being conducted with worst-off populations, focusing on research topics that advance equitable health systems, having LMIC ownership of the research agenda, strengthening LMIC research capacity, and having an impact on health disparities. The different types of incentives that encouraged proposed projects to have these features are identified and classified by their strength (strong, moderate, weak). It is suggested that research funders ought to create and maintain funding schemes with strong incentives for the features identified above in order to more effectively help reduce global health disparities.

A Statistical Framework for Automatic Leakage Detection in Smart Water and Gas Grids

In the last few years, due to the technological improvement of advanced metering infrastructures, water and natural gas grids can be regarded as smart-grids, similarly to power ones. However, considering the number of studies related to the application of computational intelligence to distribution grids, the gap between power grids and water/gas grids is notably wide. For this purpose, in this paper, a framework for leakage identification is presented. The framework is composed of three sections aimed at the extraction and the selection of features and at the detection of leakages. A variation of the Sequential Feature Selection (SFS) algorithm is used to select the best performing features within a set, including, also, innovative temporal ones. The leakage identification is based on novelty detection and exploits the characterization of a normality model. Three statistical approaches, The Gaussian Mixture Model (GMM), Hidden Markov Model (HMM) and One-Class Support Vector Machine (OC-SVM), are adopted, under a comparative perspective. Both residential and office building environments are investigated by means of two datasets. One is the Almanac of Minutely Power dataset (AMPds), and it provides water and gas data consumption at 1, 10 and 30 min of time resolution; the other is the Department of International Development (DFID) dataset, and it provides water and gas data consumption at 30 min of time resolution. The achieved performance, computed by means of the Area Under the Curve (AUC), reaches 90 % in the office building case study, thus confirming the suitability of the proposed approach for applications in smart water and gas grids.