Interventions In Low-income Countries Research Articles

The effectiveness of interventions to involve men living with HIV positive pregnant women in low-income countries: a systematic review of the literature

BackgroundMale involvement (MI) along the continuum of HIV healthcare services has been promoted as a critical intervention in low-income countries and represents one of the reasons for dropout and low retention of women along the cascade of care. The present review aims to identify interventions adopted to improve MI across Antenatal Clinics (ANCs).MethodsFor this systematic review, we searched electronic databases, including Scopus, PubMed, Web of Science (from 2008 to 2018) in English language. We included all interventions explicitly aimed at involving partners in pregnant women’s HIV continuum of care and we excluded studies performed in developed countries, not involving pregnant women. We followed the PRISMA checklist.ResultsWe identified a total of 1694 records and excluded 1651 after duplicates were removed and abstract eligibility assessments were performed. Forty-three full-text articles were screened, but only 12 studies were included. Recurrent intermediate outcomes were antenatal partner attendance rate and male HIV testing. We subdivided articles according to the type of intervention: single intervention (7) and multiple interventions (5). Among single interventions, two studies evaluated the use of an invitation letter sent via women to encourage male attendance to the ANC. Four Randomized Controlled Trials (RCTs) compared the invitation card (standard of care, SC) to word of mouth, information letter, home visit and invitation card plus partner tracing. The partner attendance rate was lower in SC than in the intervention arm in three RCTs: information letter (14.2% vs 16.2%), home-visit (39% vs 87%) and invitation card plus partner tracing (52% vs 74%). Home visit strategies seemed the most effective. One study evaluated words of encouragement adopted to trigger women to invite their partners.Among multiple interventions, the most effective strategies in terms of male attendance included health promotion through education and healthcare worker development. These interventions were more likely to be effective in promoting MI than single interventions.ConclusionsFrom the review emerges the importance of male involvement in HIV cascade for pregnant women in countries with a significant HIV incidence and the need to define more precise indicators for measuring MI.

‘They Give Him a Chance’- Parents’ Perspectives on Disability and Inclusive Primary Education in Uganda

ABSTRACT Inclusive education interventions in low-income countries are dominated by definitions and frameworks from disability studies and educational research scholars from high-income countries. Disability studies scholars have argued for valuing diverse understandings and a different discourse when studying disability and inclusion in low-income countries. In this paper, we explore the meaning of belonging and inclusion to parents of children with disabilities in central Uganda. Through case study analysis we aim to give alternative starting points for inclusive primary education programmes. We explore the themes ‘missing parts’, the ‘ability to manage’, ‘belonging to a family’, and ‘being given a chance’ as key concepts of disability and inclusion. We argue not to translate parents’ descriptions into international categories and framework, but to reflect on the larger and underlying meaning of the concepts to form a more culturally embedded and relevant starting point of education for all. We propose to address the gaps of the postcolonial education system that has taken teachers’ and families’ away from the concept of ‘obuntu bulamu’, and focus interventions on re-creating this togetherness and value the strength of concepts of belonging and caring for each other.

Toward Linking Clinical and Population Health Interventions in Low-Income Countries

"Toward Linking Clinical and Population Health Interventions in Low-Income Countries." , 109(2), pp. 184–185

Sanitation and child health in India

Our study contributes to the understanding of key drivers of stunted growth, a factor widely recognized as major impediment to human capital development. Specifically, we examine the effects of sanitation coverage and usage on child height for age in a semi-urban setting in Northern India. Although sanitation – broadly defined as hygienic means of promoting health through prevention of human contact with the hazards of wastes, particularly human waste – has long been acknowledged as an indispensable element of disease prevention and primary health care programmes, a large number of recent impact evaluation studies on sanitation interventions in low income countries fail to find any health improvements. We address endogeneity of sanitation coverage through an instrumental variable approach, exploiting variation in raw material construction prices. Doing so, we find that sanitation coverage plays a significant and positive role in height growth during the first years of life and that this causal relationship holds particularly for girls. Our findings suggest that a policy that aims to increase sanitation coverage in a context such as the one studied here, is not only effective in reducing child stunting but also implicitly targets girls.

Using routine health data and intermittent community surveys to assess the impact of maternal and neonatal health interventions in low-income countries: A systematic review

BackgroundThere is a need to provide increased evidence on effective interventions to reduce maternal and neonatal mortality in low- and middle-income countries (LMICs). ObjectivesTo summarize the breadth of knowledge on using routine data (Routine Health Information Systems [RHIS] and Intermittent Community Surveys [ICS]) for well-designed maternal and neonatal health evaluations in LMICs. Search strategyWe searched reports and articles published in Embase, Medline, and Google scholar.Selection criteriaStudies were considered for inclusion if they were carried out in LMICs, using RHIS or ICS data with experimental or quasi-experimental design. Data collection and analysisA form was used to collect information on indicators used for interventions’ impact assessment. Descriptive statistics and multiple correspondence analyses were then performed. Main resultsOf the 1201 publications identified, 46 studies met the inclusion criteria. Most of these were using RHIS data (n=40), mainly extracted from health facility registers (n=34), and non-controlled before and after design (n=30). The indicators, which were mostly reported, were related to the use of healthcare services (n=36) and maternal/neonatal health outcomes (n=31). Few studies used ICS data (n=6) or indicators of severity (n=2). ConclusionRHIS and ICS data should be increasingly used for impact studies on maternal and neonatal health in LMICs.

Measuring What Works: An Impact Evaluation of Women's Groups on Maternal Health Uptake in Rural Nepal.

BackgroundThere is a need for studies evaluating maternal health interventions in low-income countries. This paper evaluates one such intervention designed to promote maternal health among rural women in Nepal.Methods and ResultsThis was a five-year controlled, non-randomised, repeated cross-sectional study (2007, 2010, 2012) of a participatory community-based maternal health promotion intervention focusing on women’s groups to improve maternal health services uptake. In total 1,236 women of childbearing age, who had their last child ≤ two years ago, were interviewed. Difference-in-Difference estimation assessed the effects of the intervention on selected outcome variables while controlling for a constructed wealth index and women’s characteristics. In the first three years (from 2007 to the 2010), the intervention increased women’s likelihood of attending for antenatal care at least once during pregnancy by seven times [OR = 7.0, 95%CI (2.3; 21.4)], of taking iron and folic acid by three times [OR = 3.0, 95%CI (1.2; 7.8)], and of seeking four or more antenatal care visits of two times, although not significantly [OR = 2.2, 95%CI (1.0; 4.7)]. Over five years, women were more likely to seek antenatal care at least once [OR = 3.0, 95%CI (1.5; 5.2)], to take iron/folic acid [OR = 1.9, [95% CI (1.1; 3.2)], and to attend postnatal care [OR = 1.5, [95% CI (1.1; 2.2)]. No improvement was found on attending antenatal care in the first trimester, birthing at an institution or with a skilled birth attendant.ConclusionCommunity-based health promotion has a much stronger effect on the uptake of antenatal care and less on delivery care. Other factors not easily resolved through health promotion interventions may influence these outcomes, such as costs or geographical constraints. The evaluation has implications for policy and practice in public health, especially maternal health promotion.

Identifying Key Drivers of the Impact of an HIV Cure Intervention in Sub-Saharan Africa.

Background. It is unknown what properties would be required to make an intervention in low income countries that can eradicate or control human immunodeficiency virus (HIV) without antiretroviral therapy (ART) cost-effective.Methods. We used a model of HIV and ART to investigate the effect of introducing an ART-free viral suppression intervention in 2022 using Zimbabwe as an example country. We assumed that the intervention (cost: $500) would be accessible for 90% of the population, be given to those receiving effective ART, have sufficient efficacy to allow ART interruption in 95%, with a rate of viral rebound of 5% per year in the first 3 months, and a 50% decline in rate with each successive year.Results. An ART-free viral suppression intervention with these properties would result in >0.53 million disability-adjusted-life-years averted over 2022–2042, with a reduction in HIV program costs of $300 million (8.7% saving). An intervention of this efficacy costing anything up to $1400 is likely to be cost-effective in this setting.Conclusions. Interventions aimed at curing HIV infection have the potential to improve overall disease burden and to reduce costs. Given the effectiveness and cost of ART, such interventions would have to be inexpensive and highly effective.

Policy analysis for deciding on a malaria vaccine RTS,S in Tanzania.

BackgroundTraditionally, it has taken decades to introduce new interventions in low-income countries. Several factors account for these delays, one of which is the absence of a framework to facilitate comprehensive understanding of policy process to inform policy makers and stimulate the decision-making process. In the case of the proposed introduction of malaria vaccines in Tanzania, a specific framework for decision-making will speed up the administrative process and shorten the time until the vaccine is made available to the target population.MethodsQualitative research was used as a basis for developing the Policy Framework. Interviews were conducted with government officials, bilateral and multilateral partners and other stakeholders in Tanzania to assess malaria treatment policy changes and to draw lessons for malaria vaccine adoption.ResultsThe decision-making process for adopting malaria interventions and new vaccines in general takes years, involving several processes: meetings and presentations of scientific data from different studies with consistent results, packaging and disseminating evidence and getting approval for use by the Ministry of Health and Social Welfare (MOHSW). It is influenced by contextual factors; Promoting factors include; epidemiological and intervention characteristics, country experiences of malaria treatment policy change, presentation and dissemination of evidence, coordination and harmonization of the process, use of international scientific evidence. Barriers factors includes; financial sustainability, competing health and other priorities, political will and bureaucratic procedures, costs related to the adoption and implementations of interventions, supply and distribution and professional compliance with anti-malarial drugs.ConclusionThe framework facilitates the synthesis of information in a coherent way, enabling a clearer understanding of the policy process, thereby speeding up the policy decision-making process and shortening the time for a malaria vaccine to become available.

The Politics of Priority Setting in Health: A Political Economy Perspective

Many health improving interventions in low-income countries are extremely good value for money. So why has it often proven difficult to obtain political backing for highly cost-effective interventions such as vaccinations, treatments against diarrhoeal disease in children, and preventive policies such as improved access to clean water, or policies curtailing tobacco consumption? We use economic models of public choice, supported by examples, to explain how powerful interests groups, politicians or bureaucrats who pursue their own objectives, or voting and institutional arrangements in countries have shaped health priority setting. We show that it may be perfectly rational for policy makers to accommodate these constraints in their decisions, even if it implies departing from welfare maximizing solutions.

The Politics of Priority Setting in Health: A Political Economy Perspective

Many health improving interventions in low-income countries are extremely good value for money. So why has it often proven difficult to obtain political backing for highly cost-effective interventions such as vaccinations, treatments against diarrhoeal disease in children, and preventive policies such as improved access to clean water, or policies curtailing tobacco consumption? We use economic models of public choice, supported by examples, to explain how powerful interest groups, politicians or bureaucrats who pursue their own objectives, or voting and institutional arrangements in countries have shaped health priority setting. We show that it may be perfectly rational for policy makers to accommodate these constraints in their decisions, even if it implies departing from welfare maximizing solutions.

Evaluations of outcomes for children and youth from NGO-supported microeconomic interventions: a research synthesis

Economic strengthening (ES) approaches are increasingly applied in resource-poor environments, including in humanitarian crisis settings, in order to achieve a wide variety of socio-economic goals. At the same time, randomized control trial (RCT) methodology has become more prevalent in evaluations of ES and other microeconomic interventions. This review is a systematic research synthesis of randomized impact evaluations of NGO-implemented interventions in low-income countries that work to build income and/or economic assets either of the caregiver, the household, or the individual child, adolescent, or youth, where the evaluation looked at any child-level or youth-level outcomes. The papers evaluate interventions that work to build household or individual income and/or assets, such as conditional and unconditional cash and asset transfers, savings, and training. We find a wide variety of direct and indirect interventions that can potentially affect children. Most of the statistically significant findings from these studies are good for children across a range of outcome measures; however among the studies included here, there is no discernible pattern of any particular intervention category (skills training, savings, etc.) being more effective than any other at achieving better outcomes for children. In many outcome categories, researchers could find no short-term impact on children from ES programming at all. Unintended negative effects for children were found in over 20 per cent of the studies in our document set. By focusing on RCT evaluations of non-governmental programmes, we provide information about the highest quality evaluations of interventions that may be feasible to implement for programmers interested in this topic.

Cost-effectiveness of invitation to food supplementation early in pregnancy combined with multiple micronutrients on infant survival: analysis of data from MINIMat randomized trial, Bangladesh.

BackgroundAbsence of cost-effectiveness (CE) analyses limits the relevance of large-scale nutrition interventions in low-income countries. We analyzed if the effect of invitation to food supplementation early in pregnancy combined with multiple micronutrient supplements (MMS) on infant survival represented value for money compared to invitation to food supplementation at usual time in pregnancy combined with iron-folic acid.MethodsOutcome data, infant mortality (IM) rates, came from MINIMat trial (Maternal and Infant Nutrition Interventions, Matlab, ISRCTN16581394). In MINIMat, women were randomized to early (E around 9 weeks of pregnancy) or usual invitation (U around 20 weeks) to food supplementation and daily doses of 30 mg, or 60 mg iron with 400 μgm of folic acid, or MMS with 15 micronutrients including 30 mg iron and 400 μgm of folic acid. In MINIMat, EMMS significantly reduced IM compared to UFe60F (U plus 60 mg iron 400 μgm Folic acid). We present incremental CE ratios for incrementing UFe60F to EMMS. Costing data came mainly from a published study.ResultsBy incrementing UFe60F to EMMS, one extra IM could be averted at a cost of US$907 and US$797 for NGO run and government run CNCs, respectively, and at US$1024 for a hypothetical scenario of highest cost. These comparisons generated one extra life year (LY) saved at US$30, US$27, and US$34, respectively.ConclusionsIncrementing UFe60F to EMMS in pregnancy seems worthwhile from health economic and public health standpoints.Trial registrationMaternal and Infant Nutrition Interventions, Matlab; ISRCTN16581394; Date of registration: Feb 16, 2009.

Effects of dietary interventions on neonatal and infant outcomes: a systematic review and meta-analysis

Nutrition plays a fundamental role in fetal growth and birth outcomes. We synthesized effects of dietary interventions before or during pregnancy on neonatal and infant outcomes. Randomized controlled trials that assessed the whole diet or dietary components and neonatal or infant outcomes were included. Two authors independently identified articles to be included and assessed the methodologic quality. A meta-analysis was conducted separately for each outcome by using a random-effects model. Results were reported by dietary intervention as follows: 1) counseling, 2) food and fortified food products, or 3) a combination (counseling plus food) intervention, and 4) collectively for all dietary interventions. Results were subanalyzed by the nutrient of interest, country income, and BMI. Of 2326 abstracts screened, a total of 29 randomized controlled trials (31 publications) were included in this review. Food and fortified food products were effective in increasing birth weight [standardized mean difference (SMD): 0.27; 95% CI: 0.14, 0.40; P < 0.01] and reducing the incidence of low birth weight (SMD: -0.22; 95% CI: -0.37, -0.06; P < 0.01). All dietary interventions and those focused on macronutrient intake also increased birth weight (P < 0.01) and length (P < 0.05) and reduced the incidence of low birth weight (P < 0.01). Dietary interventions in low-income countries and underweight or nutritionally at-risk populations increased birth weight (P < 0.05) and reduced the incidence of low birth weight (P = 0.01). No effects were seen for the following other outcomes: placental weight, head circumference, macrosomia, Apgar score, small for gestational age, large for gestational age, and perinatal mortality. Additional high-quality randomized controlled trials that test different dietary interventions are required to identify maternal diet intakes that optimize neonatal and infant outcomes.

Psychosocial Interventions for Perinatal Common Mental Disorders Delivered by Providers Who Are Not Mental Health Specialists in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

Perinatal common mental disorders (PCMDs) are a major cause of disability among women. Psychosocial interventions are one approach to reduce the burden of PCMDs. Working with care providers who are not mental health specialists, in the community or in antenatal health care facilities, can expand access to these interventions in low-resource settings. We assessed effects of such interventions compared to usual perinatal care, as well as effects of interventions based on intervention type, delivery method, and timing. We conducted a systematic review, meta-analysis, and meta-regression. We searched databases including Embase and the Global Health Library (up to 7 July 2013) for randomized and non-randomized trials of psychosocial interventions delivered by non-specialist mental health care providers in community settings and antenatal health care facilities in low- and middle-income countries. We pooled outcomes from ten trials for 18,738 participants. Interventions led to an overall reduction in PCMDs compared to usual care when using continuous data for PCMD symptomatology (effect size [ES] -0.34; 95% CI -0.53, -0.16) but not binary categorizations for presence or absence of PCMDs (OR 0.62, 95% CI 0.35, 1.080 [corrected]. We found a significantly larger ES for psychological interventions (three studies; ES -0.46; 95% CI -0.58, -0.33) than for health promotion interventions (seven studies; ES -0.15; 95% CI -0.27, -0.02). Both individual (five studies; ES -0.18; 95% CI -0.34, -0.01) and group (three studies; ES -0.48; 95% CI -0.85, -0.11) interventions were effective compared to usual care, though delivery method was not associated with ES (meta-regression β coefficient -0.11; 95% CI -0.36, 0.14). Combined group and individual interventions (based on two studies) had no benefit compared to usual care, nor did interventions restricted to pregnancy (three studies). Intervention timing was not associated with ES (β 0.16; 95% CI -0.16, 0.49). The small number of trials and heterogeneity of interventions limit our findings. Psychosocial interventions delivered by non-specialists are beneficial for PCMDs, especially psychological interventions. Research is needed on interventions in low-income countries, treatment versus preventive approaches, and cost-effectiveness. Please see later in the article for the Editors' Summary.

Monitoring mortality trends in low-resource settings

Background Recent calls for continuous monitoring of large-scale public health interventions in low-income countries (1) have coincided with the increased use of routine monitoring for outcomes after episodes of care in high-income settings. (2-5) Graphical methods have become available to monitor short-term outcomes adjusted for patients' risk. (2,3) However, there are no documented examples of these tools being used to monitor mortality outcomes in low-income settings. As well as facilitating routine monitoring activities, graphical displays of outcomes with time can also suggest avenues for academic research by enhancing the interpretation of data. (1) This in turn can shed light on the potential mechanisms that underlie the observed effects. Here we discuss the use in a low-income setting of one such graphical method, the variable life adjusted display (VLAD). Its advantages are that the charts are easy to understand and can alert users quickly if the outcomes observed are worse than predicted. We briefly describe this method and its uses, and illustrate how it was used with data from a recent trial that studied neonatal deaths in India. (6) Use of VLAD The VLAD method (4) was devised to present time-ordered peri-operative outcomes after cardiac surgery, adjusted for individual patients' risk and based on an established risk scoring system. It has since been adopted internationally as a standard monitoring tool for mortality after cardiac surgery and in many other contexts. (5) The VLAD method does not provide statistical proof of an effect; however, it does provide an excellent mechanism for rapidly identifying unusually favourable or unfavourable outcomes that might warrant study. VLAD method Here we provide a brief description of the technique. A full description is available at http://www.ucl.ac.uk/ operational-research/Analysis Tools/ VLAD and elsewhere. (4,5) The method is suitable for any binary short-term outcome; here we consider neonatal survival after live birth. A VLAD chart shows the difference between the expected numbers of deaths and the numbers of deaths observed with time. As originally designed, the expected numbers of deaths with time was determined by estimating individual risk, but the same risk of death can be used for all individuals. This latter approach is well suited to monitoring individual-level outcomes after public health interventions. For these contexts risk of death can be an observed or target mortality rate. If the baseline probability of neonatal death is given by P, where P is a number between zero and 1 (e.g. a mortality rate of 20% would yield P = 0.2), then on average every live birth would be expected to result in P neonatal deaths. By assigning a value of 1 to an observed neonatal death and a value of zero to an observed survival, the score associated with each live birth can be calculated as (expected outcome) minus (observed outcome). Thus, if a baby dies, that birth is associated with a score of P - 1 (less than zero), and if a baby survives then that birth is associated with a score of P (greater than zero). The VLAD score is the cumulative total of scores with time and represents the cumulative difference between expected and observed deaths. If this difference is greater than zero there have been fewer deaths than expected, and if it is less than zero then there have been more deaths than expected. A VLAD chart is constructed by plotting the VLAD score with time, which reveals trends in outcomes. Subgroups (e.g. trial arms, different geographical regions or individual hospitals) can be plotted separately, with multiple traces on the same VLAD chart. We illustrate the use of VLAD with data from an intervention that involved local women's groups discussing issues related to maternal and newborn health in eastern India. The intervention was rigorously evaluated in a cluster-randomized controlled trial which ran from 31 July 2005 to 30 July 2008, and resulted in a 32% (odds ratio: 0. …

Quantitative evidence for the benefits of Moving the Goalposts, a Sport for Development project in rural Kenya

Sport for Development has many reported benefits, but quantitative evidence of the impact of these interventions in Low Income Countries remains sparse. A new monitoring and evaluation toolkit was used in a cross-sectional survey at Moving the Goalposts (MTG), a football project aiming to empower young Kenyan women. We wished to determine empirically whether increased membership duration brought increased benefits. MTG selected and translated toolkit items consistent with the organisation's strategic aims. We collected 333 completed questionnaires at 15 sites. Psychometric validation revealed some reliable scales; remaining items were scored separately. Scores were sensitive to differences between members defined by sociodemographic and site characteristics. Bivariate and multiple regression analyses showed that increased membership duration brought increasing benefits across several domains (perceived lifeskills; social life; insights about HIV/AIDS; outcomes related to female empowerment). Improved leadership skills were mainly age-related. Members attending more established sites experienced greater benefits, but members at more and less accessible sites benefitted similarly. Positive thoughts and feelings were related not to membership duration, but to how long a site had been operating. This indicates the importance of creating a positive culture over time. This cross-sectional study provides quantitative evidence for the benefits of Sport for Development initiatives.

P12 Study of reliability of the box and block test for manual dexterity of upper extremity function in patients with rheumatoid arthritis

Our study contributes to the understanding of key drivers of stunted growth, a factor widely recognized as major impediment to human capital development. Specifically, we examine the effects of sanitation coverage and usage on child height for age in a semi-urban setting in Northern India. Although sanitation – broadly defined as hygienic means of promoting health through prevention of human contact with the hazards of wastes, particularly human waste – has long been acknowledged as an indispensable element of disease prevention and primary health care programmes, a large number of recent impact evaluation studies on sanitation interventions in low income countries fail to find any health improvements. We address endogeneity of sanitation coverage through an instrumental variable approach, exploiting variation in raw material construction prices. Doing so, we find that sanitation coverage plays a significant and positive role in height growth during the first years of life and that this causal relationship holds particularly for girls. Our findings suggest that a policy that aims to increase sanitation coverage in a context such as the one studied here, is not only effective in reducing child stunting but also implicitly targets girls.

Cost–effectiveness of community-based treatment of severe acute malnutrition in children

Severe acute malnutrition affects 20 million children aged under 5 years old worldwide. Medical complications and death are common, but nutritional and medical treatment can result in good outcomes. Randomized trials of treatment after in-patient stabilization have shown community-based treatment to have similar outcomes to hospital-based treatment, at lower cost. Community-based ambulatory treatment, with in-patient care reserved for the most severe cases, is increasingly being implemented in Africa but has not been evaluated in randomized trials. Community-based treatment programs have shown favorable outcomes. Economic evaluations of community-based treatment have included cost analyses, cost and consequence analyses and decision analyses. Treatment costs have been consistently lower than for institution-based treatment. Costs of ambulatory community-based treatment of severe acute malnutrition have ranged between US$46 to $453 per child, depending on the type of care provided and the costing methods used. Recent studies have reported on costs and outcomes of similar large-scale African programs covering geographically defined populations, with ambulatory care for most children, and initial in-patient stabilization for the minority with most severe disease. In these studies the costs ranged from US$129 to $201 per child, and mortality rates ranged from 1.2 to 9.2%, depending on length of follow-up. A decision tree model based on such a program in Zambia estimated that community-based treatment of severe acute malnutrition in primary-care centers, with hospital access, cost US$203 per case treated, US$1760 per life saved, and US$53 per disability-adjusted life year gained, compared with no treatment. This latter cost per disability-adjusted life year gained suggests that community-based treatment of severe acute malnutrition is cost effective compared with other priority health interventions in low-income countries, and compared with such countries’ national incomes.

Translating knowledge into policy and action to promote health equity: The Health Equity Fund policy process in Cambodia 2000–2008

To understand how knowledge is used to inform policy on Health Equity Funds (HEFs) in Cambodia; and to draw lessons for translating knowledge into health policies that promote equity. We used a knowledge translation framework to analyse the HEF policy process between 2000 and 2008. The analysis was based on data from document analysis, key informant interviews and authors' observations. The HEF policy-making process in Cambodia was both innovative and incremental. Insights from pilot projects were gradually translated into national health policy. The uptake of HEF in health policy was determined by three important factors: a policy context conducive to the creation, dissemination and adoption of lessons gained in HEF pilots; the credibility and timeliness of HEF knowledge generated from pilot projects; and strong commitment, relationships and networks among actors. Knowledge locally generated through pilot projects is crucial for innovative health policy. It can help adapt blueprints and best practices to a local context and creates ownership. While international organisations and donors can take a leading role in innovative interventions in low-income countries, the involvement of government policy makers is necessary for their scaling-up.

Factors Responsible for Non-compliance among Tuberculosis Patients in Kailali District, Nepal

Introduction Tuberculosis is an important health problem: it is estimated to be among the leading causes of death and disability among the economically active segment of the world’s population. It primarily impacts low income countries where resources for dealing with health are severely constrained. Even so, tuberculosis control merits priority as an intervention in the health sector, as national tuberculosis programmes are among the most cost-effective of any health intervention in low income countries. Objectives To identify the factors responsible for non-compliance among tuberculosis patients in Kailali district Nepal. Methods A cross-sectional study was conducted between December 2004 to March 2005, among 130 compliant and 25 non-compliant tuberculosis patients, randomly selected four DOTS treatment centres, using a structured questionnaire with face to face interview. Patients were deemed to be non-compliant when they had missed more than 7 consecutive days of treatment. Results About half (48%) of non-compliant were more likely to think that treatment could be stopped once they were free of symptoms and thought they were cured. Adherence proportion was high among the higher education group (p<0.05). The overall knowledge scores (p<0.001) were statistically significant difference between the compliant and non-compliant patients. A significant relationship was found between compliance behavior and availability of health workers at DOTS centre (p<0.05), DOT (p<0.001), mode of transportation, and traveling time (p<0.001). Conclusion Compliance is affected by educational level, knowledge, availability of health workers, DOT, and traveling time. It could be improved by provision of more information about tuberculosis and expansion of DOTS near to the patient’s home.