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Interventions to improve access to cataract surgical services and their impact on equity in low- and middle-income countries
BACKGROUND: Cataract is the leading cause of blindness in low- and middle-income countries (LMICs), and the prevalence is inequitably distributed between and within countries. Interventions have been undertaken to improve cataract surgical services, however, the effectiveness of these interventions on promoting equity is not known. OBJECTIVES: To assess the effects on equity of interventions to improve access to cataract services for populations with cataract blindness (and visual impairment) in LMICs. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2017, Issue 3), MEDLINE Ovid (1946 to 12 April 2017), Embase Ovid (1980 to 12 April 2017), LILACS (Latin American and Caribbean Health Sciences Literature Database) (1982 to 12 April 2017), the ISRCTN registry (www.isrctn.com/editAdvancedSearch); searched 12 April 2017, ClinicalTrials.gov (www.clinicaltrials.gov); searched 12 April 2017 and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en); searched 12 April 2017. We did not use any date or language restrictions in the electronic searches for trials. SELECTION CRITERIA: We included studies that reported on strategies to improve access to cataract services in LMICs using the following study designs: randomised and quasi-randomised controlled trials (RCTs), controlled before-and-after studies, and interrupted time series studies. Included studies were conducted in LMICs, and were targeted at disadvantaged populations, or disaggregated outcome data by 'PROGRESS-Plus' factors (Place of residence; Race/ethnicity/ culture/ language; Occupation; Gender/sex; Religion; Education; Socio-economic status; Social capital/networks. The 'Plus' component includes disability, sexual orientation and age). DATA COLLECTION AND ANALYSIS: Two authors (JR and JP) independently selected studies, extracted data and assessed them for risk of bias. Meta-analysis was not possible, so included studies were synthesised in table and text. MAIN RESULTS: From a total of 2865 studies identified in the search, two met our eligibility criteria, both of which were cluster-RCTs conducted in rural China. The way in which the trials were conducted means that the risk of bias is unclear. In both studies, villages were randomised to be either an intervention or control group. Adults identified with vision-impairing cataract, following village-based vision and eye health assessment, either received an intervention to increase uptake of cataract surgery (if their village was an intervention group), or to receive 'standard care' (if their village was a control group).One study (n = 434), randomly allocated 26 villages or townships to the intervention, which involved watching an informational video and receiving counselling about cataract and cataract surgery, while the control group were advised that they had decreased vision due to cataract and it could be treated, without being shown the video or receiving counselling. There was low-certainty evidence that providing information and counselling had no effect on uptake of referral to the hospital (OR 1.03, 95% CI 0.63 to 1.67, 1 RCT, 434 participants) and little or no effect on the uptake of surgery (OR 1.11, 95% CI 0.67 to 1.84, 1 RCT, 434 participants). We assessed the level of evidence to be of low-certainty for both outcomes, due to indirectness of evidence and imprecision of results.The other study (n = 355, 24 towns randomised) included three intervention arms: free surgery; free surgery plus reimbursement of transport costs; and free surgery plus free transport to and from the hospital. These were compared to the control group, which was reminded to use the 'low-cost' ( USD 38) surgical service. There was low-certainty evidence that surgical fee waiver with/without transport provision or reimbursement increased uptake of surgery (RR 1.94, 95% CI 1.14 to 3.31, 1 RCT, 355 participants). We assessed the level of evidence to be of low-certainty due to indirectness of evidence and imprecision of results.Neither of the studies reported our primary outcome of change in prevalence of cataract blindness, or other outcomes such as cataract surgical coverage, surgical outcome, or adverse effects. Neither study disaggregated outcomes by social subgroups to enable further assessment of equity effects. We sought data from both studies and obtained data from one; the information video and counselling intervention did not have a differential effect across the PROGRESS-Plus categories with available data (place of residence, gender, education level, socioeconomic status and social capital). AUTHORS' CONCLUSIONS: Current evidence on the effect on equity of interventions to improve access to cataract services in LMICs is limited. We identified only two studies, both conducted in rural China. Assessment of equity effects will be improved if future studies disaggregate outcomes by relevant social subgroups. To assist with assessing generalisability of findings to other settings, robust data on contextual factors are also needed.
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Strategies to increase the ownership and use of insecticide-treated bednets to prevent malaria: A systematic review
BACKGROUND: Malaria is a life-threatening parasitic disease and 40 percent of the world's population lives in areas affected by malaria. Insecticide-treated bednets (ITNs) effectively prevent malaria, however, barriers to their use have been identified. OBJECTIVES: To assess the evidence on the effectiveness of available strategies that focus on delivery and appropriate use of ITNs. SEARCH METHODS: We searched the EPOC Register of Studies, CENTRAL, MEDLINE, EMBASE, HealthStar, CINAHL, PubMed, Science Citation Index, ProQuest Dissertations and Theses, African Index Medicus (AIM), World Health Organization Library and Information Networks for Knowledge (WHOLIS), LILACS, Virtual Health Library(VHL), and the World Health Organization Library Information System (WHOLIS).Initial searches were conducted in May 2011, updated in March 2012 and February 2013. Authors contacted organizations and individuals involved in ITN distribution programs or research to identify current initiatives, studies or unpublished data, and searched reference lists of relevant reviews and studies. SELECTION CRITERIA: Randomized controlled trials (RCTs), non-randomized controlled trials, controlled before-after (CBA) studies, and interrupted time series evaluating interventions focused on increasing ITN ownership and use were considered. The populations of interest were individuals in malaria-endemic areas. DATA COLLECTION AND ANALYSIS: Two authors independently screened studies to be included. They extracted data from the selected studies and assessed the risk of bias. For RCTs, we used the Cochrane Collaboration's 'Risk of bias' tool and we used the risk of bias criteria suggested by EPOC for other study designs. When consensus was not reached, any disagreements were discussed with a third author. The magnitude of effect and quality of evidence for each outcome was assessed. MAIN RESULTS: Of the 3,032 possibly relevant records identified, 10 studies were included in this review; eight cluster RCTs, one RCT, and one CBA study. Overall, three studies were assessed as having moderate risk of bias and seven studies were assessed as high risk of bias. Effect of ITN cost on ownership:Four studies including 4,566 households and another study comprising 424 participants evaluated the effect of ITN price on ownership. These studies suggest that providing free ITNs probably increases ITN ownership when compared to subsidized ITNs or ITNs offered at full market price.Pooled data for two studies suggested that receiving an ITN at no cost probably increases ITN ownership, compared to purchasing an ITN at the market price (SMD0.69, 95% confidence interval (CI) 0.39 to 0.99, moderate-certainty evidence) or purchasing an ITN using a loan (SMD 0.37, 95% CI 0.27 to 0.47, moderate-certainty evidence). There is probably little to no difference in ITN ownership when comparing groups in which ITNs were purchased using a loan and those in which ITNs were purchased at the market price (SMD 0.29, 95% CI -0.06 to 0.63, moderate-certainty evidence).Effect of ITN cost on appropriate use of ITNs: Three studies including 9,968 households and another study comprising 259 individuals found that there is probably little or no difference in the use of ITNs when they are provided free, compared to providing subsidized ITNs or ITNs offered at full market price.Effect of education interventions on use of ITNs: Five studies, including 12,637 households, assessed educational interventions regarding ITN use and concluded that education may increase the number of adults and children using ITNs (sleeping under ITNs) compared to no education.One study, including 519 households, assessed the effects of providing an incentive (an undisclosed prize) to promote ITN ownership and use, and found that incentives probably lead to little or no difference in ownership or use of ITNs, compared to not receiving an incentive.None of the included studies reported on adverse effects.IMPLICATIONS FOR POLICY AND RESEARCH: Five studies examined the effect of price on ITN ownership and found moderate certainty evidence that ownership was highest among the groups who received the ITN free versus those who purchased the ITN at any cost. In other words, demand for ITNs is elastic with regard to price and hence subsidies (providing full or partial cost recovery) will probably increase ownership. However, once the ITN is supplied, the price paid for the ITN probably has little to no effect on its use; the four studies addressing this outcome failed to confirm the hypothesis that people who purchase nets will use them more than those who receive them at no cost. Educational interventions for promoting ITN use have an additional positive effect. In other words, the evidence suggests that ITN use is highly inelastic with respect to price, and therefore additional encouragement (such as through education) is probably needed to promote appropriate use, over and above any subsidies to increase ownership. However, the impact of different types or intensities of education is unknown.
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Integrating prevention of mother-to-child HIV transmission programs to improve uptake: A systematic review
BACKGROUND: We performed a systematic review to assess the effect of integrated perinatal prevention of mother-to-child transmission of HIV interventions compared to non- or partially integrated services on the uptake in low- and middle-income countries METHODS: We searched for experimental, quasi-experimental and controlled observational studies in any language from 21 databases and grey literature sources RESULTS: Out of 28 654 citations retrieved, five studies met our inclusion criteria. A cluster randomized controlled trial reported higher probability of nevirapine uptake at the labor wards implementing HIV testing and structured nevirapine adherence assessment (RRR 1.37, bootstrapped 95% CI, 1.04-1.77). A stepped wedge design study showed marked improvement in antiretroviral therapy (ART) enrolment (44.4% versus 25.3%, p<0.001) and initiation (32.9% versus 14.4%, p<0.001) in integrated care, but the median gestational age of ART initiation (27.1 versus 27.7 weeks, p = 0.4), ART duration (10.8 versus 10.0 weeks, p = 0.3) or 90 days ART retention (87.8% versus 91.3%, p = 0.3) did not differ significantly. A cohort study reported no significant difference either in the ART coverage (55% versus 48% versus 47%, p = 0.29) or eight weeks of ART duration before the delivery (50% versus 42% versus 52%; p = 0.96) between integrated, proximal and distal partially integrated care. Two before and after studies assessed the impact of integration on HIV testing uptake in antenatal care. The first study reported that significantly more women received information on PMTCT (92% versus 77%, p<0.001), were tested (76% versus 62%, p<0.001) and learned their HIV status (66% versus 55%, p<0.001) after integration. The second study also reported significant increase in HIV testing uptake after integration (98.8% versus 52.6%, p<0.001) CONCLUSION: Limited, non-generalizable evidence supports the effectiveness of integrated PMTCT programs. More research measuring coverage and other relevant outcomes is urgently needed to inform the design of services delivering PMTCT programs
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