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Background: Integrated vaccine delivery – the linkage of routine vaccination with provision of other essential health services – is a hallmark of robust primary care systems that has been linked to equitable improvements in population health outcomes. Methods: We gathered longitudinal data relating to routine immunization coverage and vaccination equity in 78 low- and middle-income countries that have ever received support from Gavi, the Vaccine Alliance, using multiple imputation to handle missing values. We then estimated several group-based trajectory models to describe the relationship between integrated vaccine delivery and vaccination equity in these countries. Finally, we used multinomial logistic regression to identify predictors of group membership. Results: We identified five distinct trajectories of geographic vaccination equity across both the imputed and non-imputed datasets, along with two and four trajectories of socioeconomic vaccination equity in the imputed and non-imputed datasets, respectively. Integration was associated with reductions in the slope index of inequality of measles vaccination in the countries analyzed. Integration was also associated with an increase in the percentage of districts reporting high measles vaccination coverage. Conclusions: Integrated vaccine delivery is most strongly associated with improvements in vaccination equity in settings with high baseline levels of inequity. Continued scholarship is needed to further characterize the relationship between integration and health equity, as well as to improve measurement of vaccination coverage and integration. [ABSTRACT FROM AUTHOR]

Introduction: Although interactive voice response (IVR) is a promising mobile phone survey (MPS) method for public health data collection in low- and middle-income countries (LMICs), participation rates for this method remain lower than traditional methods. This study tested whether using different introductory messages increases the participation rates of IVR surveys in two LMICs, Bangladesh and Uganda. Methods: We conducted two randomized, controlled micro-trials using fully-automated random digit dialing to test the impact of (1) the gender of the speaker recording the survey (i.e., survey voice); and (2) the valence of the invitation to participate in the survey (i.e., survey introduction) on response and cooperation rates. Participants indicated their consent by using the keypad of cellphones. Four study arms were compared: (1) male and informational (MI); (2) female and information (FI); (3) male and motivational (MM); and (4) female and motivational (FM). Results: Bangladesh and Uganda had 1705 and 1732 complete surveys, respectively. In both countries, a majority of the respondents were males, young adults (i.e., 18-29-year-olds), urban residents, and had O-level/above education level. In Bangladesh, the contact rate was higher in FI (48.9%), MM (50.0%), and FM (55.2%) groups than in MI (43.0%); the response rate was higher in FI (32.3%) and FM (33.1%) but not in MM (27.2%) and MI (27.1%). Some differences in cooperation and refusal rates were also observed. In Uganda, MM (65.4%) and FM (67.9%) had higher contact rates than MI (60.8%). The response rate was only higher in MI (52.5%) compared to MI (45.9%). Refusal and cooperation rates were similar. In Bangladesh, after pooling by introductions, female arms had higher contact (52.1% vs 46.5%), response (32.7% vs 27.1%), and cooperation (47.8% vs 40.4%) rates than male arms. Pooling by gender showed higher contact (52.3% vs 45.6%) and refusal (22.5% vs 16.3%) rates but lower cooperation rate (40.0% vs 48.2%) in motivational arms than informational arms. In Uganda, pooling intros did not show any difference in survey rates by gender; however, pooling by intros showed higher contact (66.5% vs 61.5%) and response (50.0% vs 45.2%) rates in motivational arms than informational arms. Conclusion: Overall, we found higher survey rates among female voice and motivational introduction arms compared to male voice and informational introduction arm in Bangladesh. However, Uganda had higher rates for motivational intro arms only compared to informational arms. Gender and valence must be considered for successful IVR surveys. Trial registration: Name of the registry: ClinicalTrials.gov. Trial registration number: NCT03772431. Date of registration: 12/11/2018, Retrospectively Registered. URL of trial registry record: https://clinicaltrials.gov/ct2/show/NCT03772431?term=03772431&cond=Non-Communicable+Disease&draw=2&rank=1. Protocol Availability: https://www.researchprotocols.org/2017/5/e81. [ABSTRACT FROM AUTHOR]

COVID-19 vaccination is a global priority. Latin American countries have some of the highest COVID-19 death rates worldwide with vaccination hampered by a variety of reasons, including mis- and disinformation, vaccine hesitancy, and vaccine supply constraints. Addressing vaccine hesitancy through effective messages has been found to help increase vaccine uptake. Participatory processes could be used to co-design health messages for this purpose. This article describes the methodology used to co-design evidence-based audio messages to be deployed in a cohort of individuals through an interactive voice response (IVR) mobile phone survey intervention, aimed towards increasing vaccination uptake in an adult population in Colombia. Participants of the COVID-19 vaccination message co-design process included a sample of the general population of the country, representatives of the funder organisation, and research team members. The co-design process consisted of four phases: (1) formative quantitative and qualitative research, (2) message drafting based on the results of the formative research, (3) message content evaluation, and (4) evaluation of the voices to deliver the audio messages; and was informed by reflexive meetings. Three categories of evidence-based audio messages were co-designed, each corresponding to an arm of the mHealth intervention: (1) factual messages, (2) narrative messages, and (3) mixed messages. An additional fourth arm with no message was proposed for control. The iterative co-design process ended with a total of 14 audio messages recorded to be deployed via the intervention. Co-developing health messages in response to health emergencies is possible. Adopting more context-relevant, participatory, people-centred, and reflexive multidisciplinary approaches could help develop solutions that are more responsive to the needs of populations and public health priorities. Investing resources in message co-design is deemed to have a greater potential for influencing behaviours and improving health outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Automated mobile phone surveys (MPS) can be used to collect public health data of various types to inform health policy and programs globally. One challenge in administering MPS is identification of an appropriate and effective participant consent process. This study investigated the impact of different survey consent approaches on participant disposition (response characteristics and understanding of the purpose of the survey) within the context of an MPS that measured noncommunicable disease (NCD) risk factors across Colombia and Uganda. Methods: Participants were randomized to one of five consent approaches, with consent modules varying by the consent disclosure and mode of authorization. The control arm consisted of a standard consent disclosure and a combined opt-in/opt-out mode of authorization. The other four arms consist of a modified consent disclosure and one of four different forms of authorization (i.e., opt-in, opt-out, combined opt-in/opt-out, or implied). Data related to respondent disposition and respondent understanding of the survey purpose were analyzed. Results: Among 1889 completed surveys in Colombia, differences in contact, response, refusal, and cooperation rates by study arms were found. About 68% of respondents correctly identified the survey purpose, with no significant difference by study arm. Participants reporting higher levels of education and urban residency were more likely to identify the purpose correctly. Participants were also more likely to accurately identify the survey purpose after completing several survey modules, compared to immediately following the consent disclosure (78.8% vs 54.2% correct, p<0.001). In Uganda, 1890 completed surveys were collected. Though there were differences in contact, refusal, and cooperation rates by study arm, response rates were similar across arms. About 37% of respondents identified the survey purpose correctly, with no difference by arm. Those with higher levels of education and who completed the survey in English were able to more accurately identify the survey purpose. Again, participants were more likely to accurately identify the purpose of the survey after completing several NCD modules, compared to immediately following the consent module (42.0% vs 32.2% correct, p = 0.013). Conclusion: This study contributes to the limited available evidence regarding consent procedures for automated MPS. Future studies should develop and trial additional interventions to enhance consent for automated public health surveys, and measure other dimensions of participant engagement and understanding. [ABSTRACT FROM AUTHOR]

Evidence-based interventions recommended in the Framework Convention on Tobacco Control of the World Health Organization (WHO FCTC) are subject to implementation factors that might affect their actual effectiveness. The Colombian law enacting key commitments from WHO's FCTC was signed in 2009. This study aims at evaluating the potential impact of the enactment and implementation of these WHO FCTC on four outcomes for tobacco consumption (last-year cigarette smoking prevalence, prevalence of heavy smokers, prevalence of lower-intensity smokers and monthly smoking incidence). We used data from the National Psychoactive Substances Consumption Survey (NPSCS) in 2008 (n = 29 164) and 2013 (n = 32 605), and assessed changes in these four outcomes WHO FCTC using propensity score matching (PSM). Propensity scores were obtained using key socio-demographic variables and by matching through a 'Kernel' estimation. Matching quality tests were performed. The common support for both survey samples was 60 793. Sub-analyses were conducted using a governance index to assess the effect of heterogeneous governance levels, proxying implementation, over the country. We found that cigarette year-prevalence and cigarette month-incidence decreased after matching around 8 and 1.2 percentage points between 2008 and 2013, respectively. Consumption might have shifted, at least partially, from heavy smoking towards lower-intensity smoking. Departments with a higher governance index showed larger reductions of tobacco use, possibly associated to a stronger WHO FCTC implementation. This study highlights the impact that the WHO FCTC had on tobacco consumption in a middle-income country and shows the importance of governance strength as a mediating mechanism for WHO FCTC impact. These results advance current knowledge on the effectiveness of WHO FCTC and shed light on the relevance of governance as a key factor in the WHO FCTC implementation. [ABSTRACT FROM AUTHOR]

This research was conducted to explore the nature of multisectoral action for road safety in Brazil. In an effort to improve the implementation of complex interventions, we sought to characterize the relationships and exchange patterns within a network tied to the Bloomberg Initiative for Global Road Safety (BIGRS) in Fortaleza and São Paulo, Brazil. We conducted an organizational social network analysis based on in-person surveys and key informant interviews with 57 individuals across the two cities from August to October 2019. Survey data included network dimensions such as the frequency of interaction, perceived value of interaction, resource sharing, coordination, data/research sharing, practical guidance, and access to decision makers. We coded and analyzed interview transcripts according to network properties of structure, governance, development, and outcomes, as well as in situ codes that emerged from the data. We found differences in all network properties between road safety networks in Fortaleza and São Paulo. Fortaleza was characterized by a centralized, dense, and relatively new network, whereas São Paulo was larger, diffuse, diverse, and established. Government agencies were central in both networks, but an international nongovernmental organization (NGO) was highly central in Fortaleza and a local NGO was highly central in São Paulo. Few actors on the periphery of both networks were connected to one another or decision makers, which revealed sectors to engage for enhancing network connectivity. Finally, politics were understood to be key in facilitating network activity, data (especially their integration and transparency) were considered to be influential for decision making, and strategic planning was acknowledged as a central concern for network expansion and fluidity. Multisectoral action for road safety can be reinforced by carefully disentangling the social dynamics of implementation. Organizational social network analysis, supplemented with interview data, can provide a deeper explanation for how members behave and understand their work. In this way, research can help build a collective identity and impetus to action on road safety, contributing to a healthier and more equitable world. [ABSTRACT FROM AUTHOR]

Background: Healthcare workers are at a higher risk of COVID-19 infection during care encounters compared to the general population. Personal Protective Equipment (PPE) have been shown to protect COVID-19 among healthcare workers, however, Kenya has faced PPE shortages that can adequately protect all healthcare workers. We, therefore, examined the health and economic consequences of investing in PPE for healthcare workers in Kenya. Methods: We conducted a cost-effectiveness and return on investment (ROI) analysis using a decision-analytic model following the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) guidelines. We examined two outcomes: 1) the incremental cost per healthcare worker death averted, and 2) the incremental cost per healthcare worker COVID-19 case averted. We performed a multivariate sensitivity analysis using 10,000 Monte Carlo simulations. Results: Kenya would need to invest $3.12 million (95% CI: 2.65–3.59) to adequately protect healthcare workers against COVID-19. This investment would avert 416 (IQR: 330–517) and 30,041 (IQR: 7243 – 102,480) healthcare worker deaths and COVID-19 cases respectively. Additionally, such an investment would result in a healthcare system ROI of $170.64 million (IQR: 138–209) – equivalent to an 11.04 times return. Conclusion: Despite other nationwide COVID-19 prevention measures such as social distancing, over 70% of healthcare workers will still be infected if the availability of PPE remains scarce. As part of the COVID-19 response strategy, the government should consider adequate investment in PPE for all healthcare workers in the country as it provides a large return on investment and it is value for money. [ABSTRACT FROM AUTHOR]

Background: This is the first study to examine the costs of conducting a mobile phone survey (MPS) through interactive voice response (IVR) to collect information on risk factors for noncommunicable diseases (NCD) in three low- and middle-income countries (LMIC); Bangladesh, Colombia, and Uganda. Methods: This is a micro-costing study conducted from the perspective of the payer/funder with a 1-year horizon. The study evaluates the fixed costs and variable costs of implementing one nationally representative MPS for NCD risk factors of the adult population. In this costing study, we estimated the sample size of calls required to achieve a population-representative survey and associated incentives. Cost inputs were obtained from direct economic costs incurred by a central study team, from country-specific collaborators, and from platform developers who participated in the deployment of these MPS during 2017. Costs were reported in US dollars (USD). A sensitivity analysis was conducted assessing different scenarios of pricing and incentive strategies. Also, costs were calculated for a survey deployed targeting only adults younger than 45 years. Results: We estimated the fixed costs ranging between $47,000 USD and $74,000 USD. Variable costs were found to be between $32,000 USD and $129,000 USD per nationally representative survey. The main cost driver was the number of calls required to meet the sample size, and its variability largely depends on the extent of mobile phone coverage and access in the country. Therefore, a larger number of calls were estimated to survey specific harder-to-reach sub-populations. Conclusion: Mobile phone surveys have the potential to be a relatively less expensive and timely method of collecting survey information than face-to-face surveys, allowing decision-makers to deploy survey-based monitoring or evaluation programs more frequently than it would be possible having only face-to-face contact. The main driver of variable costs is survey time, and most of the variability across countries is attributable to the sampling differences associated to reaching out to population subgroups with low mobile phone ownership or access. [ABSTRACT FROM AUTHOR]

Background: Contact tracing is a crucial part of the public health surveillance toolkit. However, it is labor-intensive and costly to carry it out. Some countries have faced challenges implementing contact tracing, and no impact evaluations using empirical data have assessed its impact on COVID-19 mortality. This study assesses the impact of contact tracing in a middle-income country, providing data to support the expansion and optimization of contact tracing strategies to improve infection control. Methods: We obtained publicly available data on all confirmed COVID-19 cases in Colombia between March 2 and June 16, 2020. (N = 54,931 cases over 135 days of observation). As suggested by WHO guidelines, we proxied contact tracing performance as the proportion of cases identified through contact tracing out of all cases identified. We calculated the daily proportion of cases identified through contact tracing across 37 geographical units (32 departments and five districts). Further, we used a sequential log-log fixed-effects model to estimate the 21-days, 28-days, 42-days, and 56-days lagged impact of the proportion of cases identified through contact tracing on daily COVID-19 mortality. Both the proportion of cases identified through contact tracing and the daily number of COVID-19 deaths are smoothed using 7-day moving averages. Models control for the prevalence of active cases, second-degree polynomials, and mobility indices. Robustness checks to include supply-side variables were performed. Results: We found that a 10 percent increase in the proportion of cases identified through contact tracing is related to COVID-19 mortality reductions between 0.8% and 3.4%. Our models explain between 47%-70% of the variance in mortality. Results are robust to changes of specification and inclusion of supply-side variables. Conclusion: Contact tracing is instrumental in containing infectious diseases. Its prioritization as a surveillance strategy will substantially impact reducing deaths while minimizing the impact on the fragile economic systems of lower and middle-income countries. This study provides lessons for other LMIC. [ABSTRACT FROM AUTHOR]

Public health surveys deployed through automated mobile phone calls raise a set of ethical challenges, including succinctly communicating information necessary to obtain respondent informed consent. This study aimed to capture the perspectives of key stakeholders, both experts and community members, on consent processes and preferences for participation in automated mobile phone surveys (MPS) of non-communicable disease risk factors in Colombia. We conducted semi-structured interviews with ethics and digital health experts and focus group discussions with community representatives. There was meaningful disagreement within both groups regarding the necessity of consent, when the purpose of a survey is to contribute to the formulation of public policies. Respondents who favored consent emphasized that consent communications ought to promote understanding and voluntariness, and implicitly suggested that information disclosure conform to a reasonable person standard. Given the automated and unsolicited nature of the phone calls and concerns regarding fraud, trust building was emphasized as important, especially for national MPS deployment. Community sensitization campaigns that provide relevant contextual information (such as the name of the administering institution) were thought to support trust-building. Additional ways to achieve the goals of consent while building trust in automated MPS for disease surveillance should be evaluated in order to inform ethical and effective practice. [ABSTRACT FROM AUTHOR]

Background: In this paper, we predict the health and economic consequences of immediate investment in personal protective equipment (PPE) for health care workers (HCWs) in low- and middle-income countries (LMICs). Methods: To account for health consequences, we estimated mortality for HCWs and present a cost-effectiveness and return on investment (ROI) analysis using a decision-analytic model with Bayesian multivariate sensitivity analysis and Monte Carlo simulation. Data sources included inputs from the World Health Organization Essential Supplies Forecasting Tool and the Imperial College of London epidemiologic model. Results: An investment of $9.6 billion USD would adequately protect HCWs in all LMICs. This intervention would save 2,299,543 lives across LMICs, costing $59 USD per HCW case averted and $4,309 USD per HCW life saved. The societal ROI would be $755.3 billion USD, the equivalent of a 7,932% return. Regional and national estimates are also presented. Discussion: In scenarios where PPE remains scarce, 70–100% of HCWs will get infected, irrespective of nationwide social distancing policies. Maintaining HCW infection rates below 10% and mortality below 1% requires inclusion of a PPE scale-up strategy as part of the pandemic response. In conclusion, wide-scale procurement and distribution of PPE for LMICs is an essential strategy to prevent widespread HCW morbidity and mortality. It is cost-effective and yields a large downstream return on investment. [ABSTRACT FROM AUTHOR]

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Data collection on noncommunicable disease (NCD) behavioral risk factors has traditionally been carried out through face-to-face surveys. However, its high costs and logistical difficulties can lead to lack of timely statistics for planning, particularly in low and middle-income countries. Mobile phone surveys (MPS) have the potential to fill these gaps. This study explores perceptions, feasibility and strategies to increase the acceptability and response rate of health surveys administered through MPS using interactive voice response in Colombia. A sequential multimodal exploratory design was used. We conducted key informant interviews (KII) with stakeholders from government and academia; focus group discussions (FGDs) and user-group tests (UGTs) with young adults and elderly people living in rural and urban settings (men and women). The KII and FGDs explored perceptions of using mobile phones for NCD surveys. In the UGTs, participants were administered an IVR survey, and they provided feedback on its usability and potential improvement. Between February and November 2017, we conducted 7 KII, 6 FGDs (n = 54) and 4 UGTs (n = 34). Most participants consider MPS is a novel way to explore risk factors in NCDs. They also recognize challenges for their implementation including security issues, technological literacy and telecommunications coverage, especially in rural areas. It was recommended to promote the survey using mass media before its deployment and stressing its objectives, responsible institution and data privacy safeguards. The preferences in the survey administration relate to factors such as skills in the use of mobile phones, age, availability of time and educational level. The participants recommend questionnaires shorter than 10 minutes. The possibility of obtaining data through MPS at a population level represents an opportunity to improve the availability of risk-factor data. Steps towards increasing the acceptability and overcoming technological and methodological challenges need to be taken. [ABSTRACT FROM AUTHOR]

Data collection on noncommunicable disease (NCD) behavioral risk factors has traditionally been carried out through face-to-face surveys. However, its high costs and logistical difficulties can lead to lack of timely statistics for planning, particularly in low and middle-income countries. Mobile phone surveys (MPS) have the potential to fill these gaps. This study explores perceptions, feasibility and strategies to increase the acceptability and response rate of health surveys administered through MPS using interactive voice response in Colombia. A sequential multimodal exploratory design was used. We conducted key informant interviews (KII) with stakeholders from government and academia; focus group discussions (FGDs) and user-group tests (UGTs) with young adults and elderly people living in rural and urban settings (men and women). The KII and FGDs explored perceptions of using mobile phones for NCD surveys. In the UGTs, participants were administered an IVR survey, and they provided feedback on its usability and potential improvement. Between February and November 2017, we conducted 7 KII, 6 FGDs (n = 54) and 4 UGTs (n = 34). Most participants consider MPS is a novel way to explore risk factors in NCDs. They also recognize challenges for their implementation including security issues, technological literacy and telecommunications coverage, especially in rural areas. It was recommended to promote the survey using mass media before its deployment and stressing its objectives, responsible institution and data privacy safeguards. The preferences in the survey administration relate to factors such as skills in the use of mobile phones, age, availability of time and educational level. The participants recommend questionnaires shorter than 10 minutes. The possibility of obtaining data through MPS at a population level represents an opportunity to improve the availability of risk-factor data. Steps towards increasing the acceptability and overcoming technological and methodological challenges need to be taken. [ABSTRACT FROM AUTHOR]

Background Opioid use is rising in the US and may cause special problems in workers compensation cases, including addiction and preventing a return to work after an injury. Objective This study evaluates a physician-level intervention to curb opioid usage. An insurer identified patients with out-of-guideline opioid utilization and called the prescribing physician to discuss the patient's treatment protocol. Research Design This study uses a differences-in-differences study design with a propensity-score-matched control group. Medical and pharmaceutical claims data from 2005 to 2011 were used for analyses. Results Following the intervention, the use of opioids increased for the intervention group and there is little impact on medical spending. Conclusions Counseling physicians about patients with high opioid utilization may focus more attention on their care, but did not impact short-term outcomes. More robust interventions may be needed to manage opioid use. Perspective While the increasing use of opioids is of growing concern around the world, curbing the utilization of these powerfully addictive narcotics has proved elusive. This study examines a prescribing guidelines intervention designed to reduce the prescription of opioids following an injury. The study finds that there was little change in the opioid utilization after the intervention, suggesting interventions along other parts of the prescribing pathway may be needed. [ABSTRACT FROM AUTHOR]

Road injuries are an important cause of global mortality especially in low- and middle-income countries. While these countries undergo major urban transformations, an integral part of their development has often been the implementation of mass transportation systems, including Bus Rapid Transit (BRT) systems. However, the net effect of BRT systems on road safety is still unclear, and while there is reason to believe that BRT systems improve safety, very few available empirical studies have tested this hypothesis using observational data. Furthermore, the existing evidence is mixed and sparse. This paper reviews the available literature on the links of BRT systems and road safety and calls for more research to strengthen the body of evidence on the effect of BRT systems on road safety  in the future. [ABSTRACT FROM AUTHOR]

Comparability of population surveys across countries is key to appraising trends in population health. Achieving this requires deep understanding of the methods used in these surveys to examine the extent to which the measurements are comparable. In this study, we obtained detailed protocols of 8 nationally representative surveys from 2007-2013 from Brazil, Chile, Colombia, Mexico, the United Kingdom(England and Scotland), and the United States--countries that that differ in economic and inequity indicators. Data were collected on sampling frame, sample selection procedures, recruitment, data collection methods, content of interview and examination modules, and measurement protocols. We also assessed their adherence to the World Health Organization's "STEPwise Approach to Surveillance" framework for population health surveys. The surveys, which included half a million participants, were highly comparable on sampling methodology, survey questions, and anthropometric measurements. Heterogeneity was found for physical activity questionnaires and biological samples collection. The common age range included by the surveys was adults aged 18--64 years. The methods used in these surveys were similar enough to enable comparative analyses of the data across the 7 countries. This comparability is crucial in assessing and comparing national and subgroup population health, and to assisting the transfer of research and policy knowledge across countries. [ABSTRACT FROM AUTHOR]

Background: Cost-benefit analysis is a useful tool for priority setting in road safety. The value of statistical life (VOSL) is a metric used to estimate the benefits of road interventions in cost-benefit analyses. The International Road Assessment Program (iRAP), for example, created a rule-of-thumb to calculate VOSL benefits of road infrastructure when performing cost-benefit assessments in countries where data on VOSL are sparse. Aim: To evaluate the rapid assessment metric developed by iRAP and provide suggestions for improvement in these methods. Methods: We replicated iRAP calculations in order to make a critical assessment of the sources, results and conclusions. Conclusions: We found the iRAP metric a good example for highlighting some relevant aspects that should be considered in any VOSL estimation in order to enhance its use as a guiding principle for assessing road interventions. Specifically, we recommend the explicit disclosure of the assumptions, the use of sensitivity analysis and the avoidance of omitted variables bias. [ABSTRACT FROM AUTHOR]