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The Indian state of Odisha has a longstanding battle with forest malaria. Many remote and rural villages have poor access to health care, a problem that is exacerbated during the rainy season when malaria transmission is at its peak. Approximately 62% of the rural population consists of tribal groups who are among the communities most negatively impacted by malaria. To address the persistently high rates of malaria in these remote regions, the Odisha State Malaria Control Program introduced ‘malaria camps’ in 2017 where teams of health workers visit villages to educate the population, enhance vector control methods, and perform village-wide screening and treatment. Malaria rates declined statewide, particularly in forested areas, following the introduction of the malaria camps, but the impact of the intervention is yet to be externally evaluated. This study protocol describes a cluster-assigned quasi-experimental stepped-wedge study with a pretest-posttest control group design that evaluates if malaria camps reduce the prevalence of malaria, compared to control villages which receive the usual malaria control interventions (e.g. IRS, ITNs), as detected by PCR.

Background In South Africa, female sex workers (FSWs) are perceived to play a pivotal role in the country’s HIV epidemic. Understanding their health status and risk factors for adverse health outcomes is foundational for developing evidence-based health care for this population. Objective Describe the methodology used to successfully implement a community-led study of social and employment circumstances, HIV and associated factors amongst FSWs in South Africa. Method A community-centric, cross-sectional, survey of 3,005 adult FSWs was conducted (January–July 2019) on 12 Sex Work (SW) programme sites across nine provinces of South Africa. Sites had existing SW networks and support programmes providing peer education and HIV services. FSWs were involved in the study design, questionnaire development, and data collection. Questions included: demographic, sexual behaviour, HIV testing and treatment/PrEP history, and violence exposure. HIV rapid testing, viral load, CD4 count, HIV recency, and HIV drug resistance genotypic testing were undertaken. Partner organisations provided follow-up services. Results HIV Prevalence was 61.96%, the median length of selling sex was 6 years, and inconsistent condom use was reported by 81.6% of participants, 88.4% reported childhood trauma, 46.2% reported physical or sexual abuse by an intimate partner and 57.4% by a client. More than half of participants had depression and post-traumatic stress disorder (52.7% and 54.1%, respectively). Conclusion This is the first national survey of HIV prevalence amongst FSWs in programmes in South Africa. The data highlight the vulnerability of this population to HIV, violence and mental ill health, suggesting the need for urgent law reform. Based on the unique methodology and the successful implementation alongside study partners, the outcomes will inform tailored interventions. Our rapid rate of enrolment, low rate of screening failure and low proportion of missing data showed the feasibility and importance of community-centric research with marginalised, highly vulnerable populations.

Background Common mental disorders (CMDs) are highly prevalent conditions that constitute a major public health and economic burden on society in low- and middle-income countries (LMICs). Despite the increased demand for economic evidence to support resource allocation for scaled-up implementation of mental health services in these contexts, economic evaluations of psychological treatments for CMDs remain scarce. Objective The proposed systematic review aims to synthesize findings on methods and outcomes of economic evaluations of psychological treatments for CMDs in LMICs and appraise quality. Methods We will identify, select, and extract data from published economic evaluations of psychological interventions for CMDs conducted in LMICs. We will search bibliographic databases (PubMed, EMBASE, CINAHL, Web of Science, EconLit, PsycINFO, Africa-Wide Information, Cochrane library, Centre for Reviews and Dissemination (CRD), Cost Effectiveness Analysis (CEA) Registry), and the African Journals Online (AJOL) and Google Scholar platforms. Only full economic evaluations (Cost-Effectiveness Analysis (CEA), Cost-Utility Analysis (CUA), Cost-Consequence Analysis (CCA), or Cost-Benefit Analysis (CBA)) of psychological treatments for CMDs (defined as depressive, anxiety, and substance use disorders) conducted in LMICs will be included. There will be no restrictions based on date of publication, perspective, follow-up duration or sample size. Data extraction will be guided by the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Results The results presented will be examined using a narrative synthesis approach. The quality of included studies will be assessed using the Drummond & Jefferson checklist. Conclusion The fledgling evidence base in this area provides an opportunity to promote improved economic evaluation methods in line with repeated calls for economic evidence alongside effectiveness evidence in these settings. A rigorously developed economic evaluation evidence base will support resource allocation decisions for scaled up implementation of psychological interventions in LMIC settings. Systematic review registration PROSPERO CRD42020185277.

This paper reports on the design of a study to examine the policy landscape relevant to sugar-sweetened beverage taxation in seven sub-Saharan African countries. The study responds to the need for strong policy to address the rising burden of non-communicable diseases in the region. Sugar-sweetened beverage taxation has been widely recommended as a key component of a comprehensive policy approach to NCD prevention. However, it has proved a contentious policy intervention, with industry strongly opposing the introduction of such taxes. The aim was to identify opportunities to strengthen sugar-sweetened beverage taxation-related policy for the prevention of nutrition-related NCDs in a subset of Eastern and Southern African countries: Kenya, Tanzania, Botswana, Rwanda, Namibia, Zambia, Uganda. The study was conducted as a collaboration by researchers from nine institutions; including the seven study countries, South Africa, and Australia. The research protocol was collaboratively developed, drawing on theories of the policy process to examine the existing availability of evidence, policy context, and stakeholder interests and influence. This paper describes the development of a method for a policy landscape analysis to strengthen policies relevant to NCD prevention, and specifically sugar-sweetened beverage taxation. This takes the form of a prospective policy analysis, based on systematic documentary analysis supplemented by consultations with policy actors, that is feasible in low-resource settings. Data were collected from policy documents, government and industry reports, survey documentation, webpages, and academic literature. Consultations were conducted to verify the completeness of the policy-relevant data collection. We analysed the frames and beliefs regarding the policy ‘problems’, the existing policy context and understandings of sugar-sweetened beverage taxation as a potential policy intervention, and the political context across relevant sectors, including industry interests and influence in the policy process. This study design will provide insights to inform public health action to support sugar-sweetened beverage taxation in the region.

Bullying has been described as one of the most tractable risk factors for poor mental health and educational outcomes, yet there is a lack of evidence-based interventions for use in low and middle-income settings. We aimed to develop and assess the feasibility of an adolescent-led school intervention for reducing bullying among adolescents in Indonesian secondary schools. The intervention was developed in iterative stages: identifying promising interventions for the local context; formative participatory action research to contextualize proposed content and delivery; and finally two pilot studies to assess feasibility and acceptability in South Sulawesi and Central Java. The resulting intervention combines two key elements: 1) a student-driven design to influence students pro-social norms and behavior, and 2) a teacher-training component designed to enhance teacher’s knowledge and self-efficacy for using positive discipline practices. In the first pilot study, we collected data from 2,075 students in a waitlist-controlled trial in four schools in South Sulawesi. The pilot study demonstrated good feasibility and acceptability of the intervention. We found reductions in bullying victimization and perpetration when using the Forms of Bullying Scale. In the second pilot study, we conducted a randomised waitlist controlled trial in eight schools in Central Java, involving a total of 5,517 students. The feasibility and acceptability were good. The quantitative findings were more mixed, with bullying perpetration and victimization increasing in both control and intervention schools. We have designed an intervention that is acceptable to various stakeholders, feasible to deliver, is designed to be scalable, and has a clear theory of change in which targeting adolescent social norms drives behavioral change. We observed mixed findings across different sites, indicating that further adaptation to context may be needed. A full-randomized controlled trial is required to examine effectiveness and cost-effectiveness of the program.

Background The 3D Cohort Study (Design, Develop, Discover) was established to help bridge knowledge gaps about the links between various adverse exposures during pregnancy with birth outcomes and later health outcomes in children. Methods Pregnant women and their partners were recruited during the first trimester from nine sites in Quebec and followed along with their children through to 2 years of age. Questionnaires were administered during pregnancy and post‐delivery to collect information on demographics, mental health and life style, medical history, psychosocial measures, diet, infant growth, and neurodevelopment. Information on the delivery and newborn outcomes were abstracted from medical charts. Biological specimens were collected from mothers during each trimester, fathers (once during the pregnancy), and infants (at delivery and 2 years of age) for storage in a biological specimen bank. Results Of the 9864 women screened, 6348 met the eligibility criteria and 2366 women participated in the study (37% of eligible women). Among women in the 3D cohort, 1721 of their partners (1704 biological fathers) agreed to participate (73%). Two thousand two hundred and nineteen participants had a live singleton birth (94%). Prenatal blood and urine samples as well as vaginal secretions were collected for ≥98% of participants, cord blood for 81% of livebirths, and placental tissue for 89% of livebirths. Conclusions The 3D Cohort Study combines a rich bank of multiple biological specimens with extensive clinical, life style, and psychosocial data. This data set is a valuable resource for studying the developmental etiology of birth and early childhood neurodevelopmental outcomes.

Health systems worldwide struggle to manage the growing burden of type 2 diabetes and hypertension. Many patients receive suboptimal care, especially those most vulnerable. An evidence-based Integrated Care Package (ICP) with primary care-based diagnosis, treatment, education and self-management support and collaboration, leads to better health outcomes, but there is little knowledge of how to scale-up. The Scale-up integrated care for diabetes and hypertension project (SCUBY) aims to address this problem by roadmaps for scaling-up ICP in different types of health systems: a developing health system in a lower middle-income country (Cambodia); a centrally steered health system in a high-income country (Slovenia); and a publicly funded highly privatised health-care health system in a high-income country (Belgium). In a quasi-experimental multi-case design, country-specific scale-up strategies are developed, implemented and evaluated. A three-dimensional framework assesses scale-up along three axes: (1) increase in population coverage; (2) expansion of the ICP package; and (3) integration into the health system. The study includes a formative, intervention and evaluation phase. The intervention entails the development and implementation of an improved scale-up strategy through a roadmap with a minimum dataset to monitor proximal and distal outcomes. The SCUBY project is expected to result in three different roadmaps, tailored to the specific health system and country context, to progress scale-up of the ICP along three dimensions. These roadmaps can be adapted to other health systems with similar typology. Implementation is expected to increase the number of well-controlled patients with type 2 diabetes and hypertension in Cambodia, to reduce inequities in care and increase patient empowerment in Belgium and Slovenia.

Current recommendations within integrated community case management (iCCM) programmes advise community health workers (CHWs) to refer cases of chest indrawing pneumonia to health facilities for treatment, but many children die due to delays or non-compliance with referral advice. Recent revision of World Health Organization (WHO) pneumonia guidelines and integrated management of childhood illness chart booklet recommend oral amoxicillin for treatment of lower chest indrawing (LCI) pneumonia on an outpatient basis. However, these guidelines did not recommend its use by CHWs as part of iCCM, due to insufficient evidence regarding safety. We present a protocol for a one-arm safety intervention study aimed at increasing access to treatment of pneumonia by training CHWs, locally referred to as Community Oriented Resource Persons (CORPs) in Nigeria. The primary objective was to assess if CORPs could safely and appropriately manage LCI pneumonia in 2–59 month old children, and refer children with danger signs. The primary outcomes were the proportion of children 2–59 months with LCI pneumonia who were managed appropriately by CORPs and the clinical treatment failure within 6 days of LCI pneumonia. Secondary outcomes included proportion of children with LCI followed up by CORPs on day 3; caregiver adherence to treatment for chest indrawing, acceptability and satisfaction of both CORP and caregivers on the mode of treatment, including caregiver adherence to treatment; and clinical relapse of pneumonia between day 7 to 14 among children whose signs of pneumonia disappeared by day 6. Approximately 308 children 2–59 months of age with LCI pneumonia would be needed for this safety intervention study.

A large amount of preparation goes into setting up trials. Different challenges and lessons are experienced. Our trial, testing a treatment for nodding syndrome, an acquired neurological disorder of unknown cause affecting thousands of children in Eastern Africa, provides a unique case study. As part of a study to determine the aetiology, understand pathogenesis and develop specific treatment, we set up a clinical trial in a remote district hospital in Uganda. This paper describes our experiences and documents supportive structures (enablers), challenges faced and lessons learned during set-up of the trial. Protocol development started in September 2015 with phased recruitment of a critical study team. The team spent 12 months preparing trial documents, procurement and training on procedures. Potential recruitment sites were pre-visited, and district and local leaders met as key stakeholders. Key enablers were supportive local leadership and investment by the district and Ministry of Health. The main challenges were community fears about nodding syndrome, adverse experiences of the community during previous research and political involvement. Other challenges included the number and delays in protocol approvals and lengthy procurement processes. This hard-to-reach area has frequent power and Internet fluctuations, which may affect cold chains for study samples, communication and data management. These concerns decreased with a pilot community engagement programme. Experiences and lessons learnt can reduce the duration of processes involved in trial-site set-up. A programme of community engagement and local leader involvement may be key to the success of a trial and in reducing community opposition towards participation in research.

Background: The intended meaning behind responses to standard questions posed in large-scale health surveys are not always well understood. Systematic follow-up studies, particularly those which pose a few repeated questions followed by open-ended discussions, are well positioned to gauge stability and consistency of data and to shed light on the intended meaning behind survey responses. Such follow-up studies require extensive coordination and face challenges in protecting respondent confidentiality during the process of recontacting and reinterviewing participants. Objectives: We describe practical field strategies for undertaking a mixed methods follow-up study during a large-scale health survey. Methods: The study was designed as a mixed methods follow-up study embedded within the 2014 Ghana Demographic and Health Survey (GDHS). The study was implemented in 13 clusters. Android tablets were used to import reference data from the parent survey and to administer the questionnaire, which asked a mixture of closed- and open-ended questions on reproductive intentions, decision-making, and family planning. Results: Despite a number of obstacles related to recontacting respondents and concern about respondent fatigue, over 92 percent of the selected sub-sample were successfully recontacted and reinterviewed; all consented to audio recording. A confidential linkage between GDHS data, follow-up tablet data, and audio transcripts was successfully created for the purpose of analysis. Conclusions: We summarize the challenges in follow-up study design, including ethical considerations, sample size, auditing, filtering, successful use of tablets, and share lessons learned for future such follow-up surveys.

Background : An m-health application has been developed and implemented with community health workers to improve their counseling in a rural area of India. The ultimate aim was to generate demand and improve utilization of key maternal, neonatal, and child health services. The present study aims to assess the impact and cost-effectiveness of this project. Methods/design : A pre–post quasi-experimental design with a control group will be used to undertake difference in differences analysis for assessing the impact of intervention. The Annual Health Survey (2011) will provide pre-intervention data, and a household survey will be carried out to provide post-intervention data. Two community development blocks where the intervention was introduced will be treated as intervention blocks while two controls blocks are selected after matching with intervention blocks on three indicators: average number of antenatal care checkups, percentage of women receiving three or more antenatal checkups, and percentage of institutional deliveries. Two categories of beneficiaries will be interviewed in both areas: women with a child between 29 days and 6 months and women with a child between 12 and 23 months. Propensity score matched samples from intervention and control areas in pre–post periods will be analyzed using the difference in differences method to estimate the impact of intervention in utilization of key services. Bottom-up costing methods will be used to assess the cost of implementing intervention. A decision model will estimate long-term effects of improved health services utilization on mortality, morbidity, and disability. Cost-effectiveness will be assessed in terms of incremental cost per disability-adjusted life year averted and cost per unit increase in composite service coverage in intervention versus control groups. Conclusions : The study will generate significant evidence on impact of the m-health intervention for maternal, neonatal, and child services and on the cost of scaling up m-health technology for accredited social health activists in India. Keywords: m-health; cost-effectiveness analysis; impact assessment; maternal and child health; community health worker; health services research (Published: 13 May 2016) Citation: Glob Health Action 2016, 9 : 31473 - http://dx.doi.org/10.3402/gha.v9.31473 Supplementary files: To access the supplementary material for this article, please see Supplementary files under ‘Article Tools’

Left ventricular hypertrophy (LVH) is an independent risk factor for the development of heart failure, coronary heart disease and stroke. LVH develops in response to haemodynamic overload, e.g. hypertension. LVH was originally thought to start as an adaptive and beneficial response required to normalise wall stress. However, this concept has been challenged by recent animal experiments suggesting that any degree of LVH is detrimental for the preservation of cardiac function and survival. If confirmed in humans, these findings imply that an increase in LV mass should be prevented, e.g. by lifestyle or pharmacological interventions. To facilitate and optimise interventions, the SMART Heart study was recently set up to develop a prediction model, also involving single nucleotide polymorphism data, for the identification of subjects at high risk of developing LVH in hypertension. For this purpose 1000 subjects with chronic hypertension will undergo cardiac MR imaging. In addition, this study allows the extrapolation of animal experimental genetic research into the human situation. (Neth Heart J 2007;15:295-8.18030317).

Background : Malaria control is based on early treatment of cases and on vector control. The current measures for malaria vector control in Africa are mainly based on long-lasting insecticide treated nets (LLINs) and to a much smaller extent on indoor residual spraying (IRS). A third pillar in the fight against the malaria vector, larval source management (LSM), has virtually not been used in Africa since the ban of DDT in the 1960s. Within the light of recent WHO recommendations for Bacillus thuringiensis israelensis ( Bti ) use against malaria and other vector species, larval source management could see a revival in the upcoming years. In this project we analyze the ecologic and health impacts as well as the cost effectiveness of larval source management under different larviciding scenarios in a health district in Burkina Faso. Methods : The project is designed as prospective intervention study with duration of three years (2013–2015). Its spatial scale includes three arms of interventions and control, comprising a total of 127 villages and the district capital Nouna in the extended HDSS (Health Demographic Surveillance System) of the Kossi province. Baseline data on mosquito abundance, parasitemia in U5 children, and malaria related morbidity and mortality are gathered over the project duration. Besides the outcome on ecologic and health parameters, the economic costs are seized and valued against the achieved health benefits. Conclusions : Risk map based, guided larvicide application might be a possibility to further decrease economic cost of LSM and facilitate its faster incorporation to integrated malaria control programs. Given the limited resources in many malaria endemic countries, it is of utmost importance to relate the costs of novel strategies for malaria prevention to their effect on the burden of the disease. Occurring costs and the impact on the health situation will be made comparable to other, existing intervention strategies, allowing stakeholders and policymakers decision making. Keywords : Malaria; Bacillus thuringiensis israelensis; vector control; study design; larval source management; Burkina Faso (Published: 5 November 2014) Citation : Glob Health Action 2014, 7 : 25908 - http://dx.doi.org/10.3402/gha.v7.25908

Introduction : Cardiovascular disease (CVD) is a leading cause of death in sub-Saharan Africa (SSA), with annual deaths expected to increase to 2 million by 2030. Currently, most national health systems in SSA are not adequately prepared for this epidemic. This is especially so in slum settlementswhere access to formal healthcare and resources is limited. Objecti v e : To develop and introduce a model of cardiovascular prevention in the slums of Nairobi by integrating public health and private sector approaches. Study design : Two non-profit organizations that conduct public health research, Amsterdam Institute for Global Health and Development (AIGHD) and African Population and Health Research Center (APHRC), collaborated with private-sector Boston Consulting Group (BCG) to develop a service delivery package for CVD prevention in slum settings. Atheoretic model was designed based on the integration of public and private sector approaches with the focus on costs and feasibility. Results : The final model includes components that aim to improve community awareness, a home-based screening service, patient and provider incentives to seek and deliver treatment specifically for hypertension, and adherence support. The expected outcomes projected by this model could prove potentially cost effective and affordable (1 USD/person/year). The model is currently being implemented in a Nairobi slum and is closely followed by key stakeholders in Kenya including the Ministry of Health, the World Health Organization (WHO), and leading non-governmental organizations (NGOs). Conclusion : Through the collaboration of public health and private sectors, a theoretically cost-effective model was developed for the prevention of CVD and is currently being implemented in the slums of Nairobi. If results are in line with the theoretical projections and first impressions on the ground, scale-up of the service delivery package could be planned in other poor urban areas in Kenya by relevant policymakers and NGOs. Keywords : hypertension; cardio v ascular diseases; pre v ention; health system; slums; Africa (Published: 21 October 2013) Citation : Glob Health Action 2013, 6 : 22510 - http://dx.doi.org/10.3402/gha.v6i0.22510 To access the supplementary material for this article, please see Supplementary files in the column to the right (under Article Tools).

Ghana is classified as being in the malaria control phase, according to the global malaria elimination program. With many years of policy development and control interventions, malaria specific mortality among children less than 5 years old has declined from 14.4% in 2000 to 0.6% in 2012. However, the same level of success has not been achieved with malaria morbidity. The recently adopted 2015–2020 Ghana strategic action plan aims to reduce the burden of malaria by 75.0%. Planning and policy development has always been guided by evidence from field studies, and mathematical models that are able to investigate malaria transmission dynamics have not played a significant role in supporting policy development. The objectives of this study are to describe the malaria situation in Ghana and give a brief account of how mathematical modelling techniques could support a more informed malaria control effort in the Ghanaian context. A review is carried out of some mathematical models investigating the dynamics of malaria transmission in sub-Saharan African countries, including Ghana. The applications of these models are then discussed, considering the gaps that still remain in Ghana for which further mathematical model development could be supportive. Because of the collaborative approach adopted in their development, some model examples Ghana could benefit from are also discussed. Collaboration between malaria control experts and modellers will allow for more appropriate mathematical models to be developed. Packaging these models with user-friendly interfaces and making them available at various levels of malaria control management could help provide the decision making tools needed for planning and a platform for monitoring and evaluation of interventions in Ghana.

Background : Vulnerability in the past has sometimes been measured and understood in terms of checklists or common understanding. It is argued here that vulnerability is a more complex issue than this. Although checklists of vulnerable groups are important, they do not capture the essence and dynamics of vulnerability. Objective : The case of rural health vulnerability in South Africa is discussed to show that classifying people into vulnerable groups does not portray the complexity and intricacies of what it means to have vulnerability. We also wish to show that there are different kinds of vulnerabilities, and the difference between access vulnerability and illness vulnerability is highlighted. Methods : As part of a larger study, this case study is presented to show how vulnerability in a poor rural community in South Africa has to be understood in a contextual and dynamic manner as opposed to a static manner. Results : Family and social dynamics can influence health. For example, fractured families were seen as a vulnerable issue within the community, while being a person with a disability can lead to isolation and callous attitudes towards them. It is these family and social dynamics that lead proximally to vulnerability to ill health. Conclusions : A contextual approach can assist in giving a more layered understanding of vulnerability than a checklist approach can do. Interventions to change health cannot be addressed simply by medical means. Social conditions need to be changed, and part of changing social conditions is the process of assisting those who are isolated or experience themselves as vulnerable to reconnect with others in the community. Poverty leads to social exclusion; social and family inclusion may be key to well-being. Keywords: Rural; Vulnerability; Health; South Africa; Checklist (Published: 30 November 2016) Citation: Glob Health Action 2016, 9 : 33272 - http://dx.doi.org/10.3402/gha.v9.33272

Background. Sudden cardiac death (SCD) in the young (1-45 years) is a strong risk factor for the presence of inherited cardiac diseases in surviving first-degree relatives. Postmortem investigation of the victim and cardiogenetic evaluation of the first-degree relatives is indicated to detect inherited cardiac diseases and treat relatives at an early stage to prevent SCD. In the Netherlands, postmortem investigation is often not performed and relatives of SCD and sudden unexplained death (SUD) victims are rarely evaluated for inherited cardiac diseases. Methods. A prospective population-based follow-up study carried out in two intervention regions and two control regions. In the intervention regions a comprehensive intervention (stimulate autopsy and storage of victims DNA and the referral of first-degree relatives for cardiogenetic evaluation) is applied in a ‘top down’ and ‘bottom up’ mode. In each region, young sudden death victims are registered and for all cases performance of autopsy and evaluation of relatives in a cardiogenetics outpatient clinic will be determined. Expected results. The study will provide information on the incidence of sudden death in the young and the proportion of diagnosed inherited cardiac diseases. Moreover, the additional value of the introduction of two different preventive strategies directed at early detection of inherited cardiac diseases in first-degree relatives to usual care will be evaluated. Conclusion. The CAREFUL study will help to set a new standard of care in the evaluation of young sudden death victims and their relatives to identify the presence of inherited cardiac diseases, in order to prevent sudden death. (Neth Heart J 2010;18:286-90.)

The Nouna Health and Demographic Surveillance System (HDSS) is located in rural Burkina Faso and has existed since 1992. Currently, it has about 78,000 inhabitants. It is a member of the International Network for the Demographic Evaluation of Populations and Their Health in Developing Countries (INDEPTH), a global network of memberswho conducts longitudinal health and demographic evaluation of populations in low- and middle-income countries. The health facilities consist of one hospital and 13 basic health centres (locally known as CSPS). The Nouna HDSS has been used as a sampling frame for numerous studies in the fields of clinical research, epidemiology, health economics, and health systems research. In this paper we review some of the main findings, and we describe the effects that almost 20 years of health research activities have shown in the population in general and in terms of the perception, economic implications, and other indicators. Longitudinal data analyses show that childhood, as well as overall mortality, has significantly decreased over the observation period 1993-2007. The under-five mortality rate dropped from about 40 per 1,000 person-years in the mid- 1990s to below 30 per 1,000 in 2007. Further efforts are needed to meet goal four of the Millennium Development Goals, which is to reduce the under-five mortality rate by two-thirds between 1990 and 2015. Keywords: epidemiology; Burkina Faso; Africa; INDEPTH network; public health; under-five mortality; malaria; malnutrition; health seeking behavior (Published: 14 September 2010) Citation: Global Health Action 2010, 3: 5284 - DOI: 10.3402/gha.v3i0.5284

Background : Despite the implementation of various initiatives to address low enrollment in voluntary micro health insurance (MHI) schemes in sub-Saharan Africa, the problem of low enrollment remains unresolved. The lack of process evaluations of such interventions makes it difficult to ascertain whether their poor results are because of design failures or implementation weaknesses. Objective : In this paper, we describe a process evaluation protocol aimed at opening the ‘black box’ to evaluate the implementation processes of the Redesigned Community Health Fund (CHF) program in the Dodoma region of Tanzania. Design : The study employs a cross-sectional mixed methods design and is being carried out 3 years after the launch of the Redesigned CHF program. The study is grounded in a conceptual framework which rests on the Diffusion of Innovation Theory and the Implementation Fidelity Framework. The study utilizes a mixture of quantitative and qualitative data collection tools (questionnaires, focus group discussions, in-depth interviews, and document review), and aligns the evaluation to the Theory of Intervention developed by our team. Quantitative data will be used to measure program adoption, implementation fidelity, and their moderating factors. Qualitative data will be used to explore the responses of stakeholders to the intervention, contextual factors, and moderators of adoption, implementation fidelity, and sustainability. Discussion : This protocol describes a systematic process evaluation in relation to the implementation of a reformed MHI. We trust that the theoretical approaches and methodologies described in our protocol may be useful to inform the design of future process evaluations focused on the assessment of complex interventions, such as MHI schemes. Keywords: micro health insurance; low enrollment; innovations to increase enrollment; Community Health Fund in Tanzania; process evaluation; mixed methods; complex interventions (Published: 15 December 2015) Citation: Glob Health Action 2015, 8 : 29648 - http://dx.doi.org/10.3402/gha.v8.29648 Supplementary material: To access the supplementary material for this article, please see Supplementary files under ‘Article Tools’

Background : Respiratory diseases, namely asthma and chronic obstructive pulmonary disease (COPD), account for one-fourth of the patients at the primary health-care (PHC) facilities in Pakistan. Standard care practices to manage these diseases are necessary to reduce the morbidity and mortality rate associated with non-communicable diseases in developing countries. Objective : To develop and measure the effectiveness of operational guidelines and implementation materials, with sound scientific evidence, for expanding lung health care, especially asthma and COPD through PHC facilities already strengthened for tuberculosis (TB) care in Pakistan. Design : A cluster randomized controlled trial with two arms (intervention and control), with qualitative and costing study components, is being conducted in 34 clusters; 17 clusters per arm (428 asthma and 306 COPD patients), in three districts in Pakistan from October 2014 to December 2016. The intervention consists of enhanced case management of asthma and COPD patients through strengthening of PHC facilities. The main outcomes to be measured are asthma and COPD control among the registered cases at 6 months. Cluster- and individual-level analyses will be done according to intention to treat. Residual confounding will be addressed by multivariable logistic and linear regression models for asthma and COPD control, respectively. The trial is registered with ISRCTN registry (ISRCTN 17409338). Conclusions : Currently, only about 20% of the estimated prevalent asthma and COPD cases are being identified and reported through the respective PHC network. Lung health care and prevention has not been effectively integrated into the core PHC package, although a very well-functioning TB program exists at the PHC level. Inclusion of these diseases in the already existent TB program is expected to increase detection rates and care for asthma and COPD. Keywords: asthma; COPD; primary health care; strengthening; enhanced case management (Published: 16 November 2015) Citation: Glob Health Action 2015, 8 : 28225 - http://dx.doi.org/10.3402/gha.v8.28225

Background : Large prospective epidemiologic studies are vital in determining disease etiology and forming national health policy. Yet, such studies do not exist in sub-Saharan Africa (SSA) notwithstanding the growing burden of chronic diseases. Objective : We explored the feasibility of establishing a large-scale multicountry prospective study at five sites in four sub-Saharan countries. Design : Based on country-specific considerations of feasibility, Nigeria enrolled health care professionals, South Africa and Tanzania enrolled teachers, and Uganda enrolled village residents at one rural and one periurban site each. All sites used a 6-month follow-up period but different approaches for data collection, namely standardized questionnaires filled out by participants or face-to-face interviews. Results : We enrolled 1415 participants from five sites (range 200–489) with a median age of 41 years. Approximately half had access to clean-burning cooking fuel and 70% to piped drinking water, yet 92% had access to a mobile phone. The prevalence of chronic diseases was 49% among 45- to 54-year-olds and was dominated by hypertension (21.7% overall) – ranging from 4.5 to 31.2% across sites – and a serious injury in the past 12 months (12.4% overall). About 80% of participants indicated willingness to provide blood samples. At 6-month follow-up, 68% completed a questionnaire (45 to 96% across sites) with evidence that mobile phones were particularly useful. Conclusions : Our pilot study indicates that a large-scale prospective study in SSA is feasible, and the burden of chronic disease in SSA may already be substantial necessitating urgent etiologic research and primary prevention. Keywords: non-communicable; chronic disease; injury; South Africa; Nigeria; Tanzania; Uganda (Published: 25 May 2015) Citation: Glob Health Action 2015, 8 : 27422 -http://dx.doi.org/10.3402/gha.v8.27422

Background: Interventions targeting lifestyle-related risk factors and non-communicable diseases have contributed to the mainstream knowledge necessary for action. However, there are gaps in how this knowledge can be translated for practical day-to-day use in complex multicultural settings like that in India. Here, we describe the design of the Behavioural Intervention for Diet study, which was developed as a community-based intervention to change dietary behaviour among middle-income households in rural Kerala. Methods: This was a cluster-randomized controlled trial to assess the effectiveness of a sequential stagematched intervention to bring about dietary behaviour change by targeting the procurement and consumption of five dietary components: fruits, vegetables, salt, sugar, and oil. Following a step-wise process of pairing and exclusion of outliers, six out of 22 administrative units in the northern part of Trivandrum district, Kerala state were randomly selected and allocated to intervention or control arms. Trained community volunteers carried out the data collection and intervention delivery. An innovative tool was developed to assess household readiness-to-change, and a household measurement kit and easy formulas were introduced to facilitate the practical side of behaviour change. The 1-year intervention included a household component with sequential stage-matched intervention strategies at 0, 6, and 12 months along with counselling sessions, telephonic reminders, and home visits and a community component with general awareness sessions in the intervention arm. Households in the control arm received information on recommended levels of intake of the five dietary components and general dietary information leaflets. Discussion: Formative research provided the knowledge to contextualise the design of the study in accordance with socio-cultural aspects, felt needs of the community, and the ground realities associated with existing dietary procurement, preparation, and consumption patterns. The study also addressed two key issues, namely the central role of the household as the decision unit and the long-term sustainability through the use of existing local and administrative networks and community volunteers. Keywords: dietary intervention; non-communicable diseases; stages of change; behavioural intervention; behaviour change; nutrition (Published: 17 July 2013) Citation: Glob Health Action 2013, 6 : 20993 - http://dx.doi.org/10.3402/gha.v6i0.20993

Background: The quality of health care depends on the competence and motivation of the health workers that provide it. In the West, several tools exist to measure worker motivation, and some have been applied to the health sector. However, none have been validated for use in sub-Saharan Africa. The complexity of such tools has also led to concerns about their application at primary care level. Objective: To develop a common instrument to monitor any changes in maternal and neonatal health (MNH) care provider motivation resulting from the introduction of pilot interventions in rural, primary level facilities in Ghana, Burkina Faso, and Tanzania. Design: Initially, a conceptual framework was developed. Based upon this, a literature review and preliminary qualitative research, an English-language instrument was developed and validated in an iterative process with experts from the three countries involved. The instrument was then piloted in Ghana. Reliability testing and exploratory factor analysis were used to produce a final, parsimonious version. Results and discussion: This paper describes the actual process of developing the instrument. Consequently, the concepts and items that did not perform well psychometrically at pre-test are first presented and discussed. The final version of the instrument, which comprises 42 items for self-assessment and eight for peer-assessment, is then shown. This is followed by a presentation and discussion of the findings from first use of the instrument with MNH providers from 12 rural, primary level facilities in each of the three countries. Conclusions: It is possible to undertake work of this nature at primary health care level, particularly if the instruments are kept as straightforward as possible and well introduced. However, their development requires very lengthy preparatory periods. The effort needed to adapt such instruments for use in different countries within the region of sub-Saharan Africa should not be underestimated. Keywords: health personnel; motivation; performance; maternalneonatal health services; developing countries (Published: 1 October 2012) Citation: Glob Health Action 2012, 5 : 19120 - http://dx.doi.org/10.3402/gha.v5i0.19120

The Millennium Declaration, adopted by the United Nations (UN) in 2000, set a series of Millennium Development Goals (MDGs) as priorities for UN member countries, committing governments to realising eight major MDGs and 18 associated targets by 2015. Progress towards these goals is being assessed by tracking a series of 48 technical indicators that have since been unanimously adopted by experts. This concept paper outlines the role member Health and Demographic Surveillance Systems (HDSSs) of the INDEPTH Network could play in monitoring progress towards achieving the MDGs. The unique qualities of the data generated by HDSSs lie in the fact that they provide an opportunity to measure or evaluate interventions longitudinally, through the long-term follow-up of defined populations. Keywords: Health and Demographic Surveillance Systems; Millennium Development Goals; longitudinal data; monitoring MDG progress (Published: 13 September 2010) Citation: Global Health Action 2010, 3: 5517 - DOI: 10.3402/gha.v3i0.5517