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Fraser HL, Feldhaus I, Edoka IP, Wade AN, Kohli-Lynch CN, Hofman K, Verguet S. Extended cost-effectiveness analysis of interventions to improve uptake of diabetes services in South Africa. Health Policy Plan 2024; 39:253-267. [PMID: 38252592 DOI: 10.1093/heapol/czae001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 12/07/2023] [Accepted: 01/16/2024] [Indexed: 01/24/2024] Open
Abstract
The rising prevalence of diabetes in South Africa (SA), coupled with significant levels of unmet need for diagnosis and treatment, results in high rates of diabetes-associated complications. Income status is a determinant of utilization of diagnosis and treatment services, with transport costs and loss of wages being key barriers to care. A conditional cash transfer (CCT) programme, targeted to compensate for such costs, may improve service utilization. We applied extended cost-effectiveness analysis (ECEA) methods and used a Markov model to compare the costs, health benefits and financial risk protection (FRP) attributes of a CCT programme. A population was simulated, drawing from SA-specific data, which transitioned yearly through various health states, based on specific probabilities obtained from local data, over a 45-year time horizon. Costs and disability-adjusted life years (DALYs) were applied to each health state. Three CCT programme strategies were simulated and compared to a 'no programme' scenario: (1) covering diagnosis services only; (2) covering treatment services only; (3) covering both diagnosis and treatment services. Cost-effectiveness was reported as incremental net monetary benefit (INMB) using a cost-effectiveness threshold of USD3015 per DALY for SA, while FRP outcomes were reported as catastrophic health expenditure (CHE) cases averted. Distributions of the outcomes were reported by income quintile and sex. Covering both diagnosis and treatment services for the bottom two quintiles resulted in the greatest INMB (USD22 per person) and the greatest CHE cases averted. There were greater FRP benefits for women compared to men. A CCT programme covering diabetes diagnosis and treatment services was found to be cost-effective, when provided to the poorest 40% of the SA population. ECEA provides a useful platform for including equity considerations to inform priority setting and implementation policies in SA.
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Affiliation(s)
- Heather L Fraser
- Health Economics and Health Technology Assessment, School of Health and Wellbeing, University of Glasgow, Clarice Pears Building (Level 3), 90 Byres Road, United Kingdom
- SA MRC/Centre for Health Economics and Decision Science-PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 27 St Andrews Road, Johannesburg 2193, South Africa
| | - Isabelle Feldhaus
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Ijeoma P Edoka
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, 32 Princess of Wales Terrace, Johannesburg 2193, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 27 St Andrews Road, Johannesburg 2193, South Africa
| | - Alisha N Wade
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 27 St Andrews Road, Johannesburg 2193, South Africa
- Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, United States
| | - Ciaran N Kohli-Lynch
- SA MRC/Centre for Health Economics and Decision Science-PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 27 St Andrews Road, Johannesburg 2193, South Africa
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, 680 N. Lake Shore Drive, Chicago, IL 60611, United States
| | - Karen Hofman
- SA MRC/Centre for Health Economics and Decision Science-PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 27 St Andrews Road, Johannesburg 2193, South Africa
| | - Stéphane Verguet
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
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Yoshino CA, Sidney-Annerstedt K, Wingfield T, Kirubi B, Viney K, Boccia D, Atkins S. Experiences of conditional and unconditional cash transfers intended for improving health outcomes and health service use: a qualitative evidence synthesis. Cochrane Database Syst Rev 2023; 3:CD013635. [PMID: 36999604 PMCID: PMC10064639 DOI: 10.1002/14651858.cd013635.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Abstract
BACKGROUND It is well known that poverty is associated with ill health and that ill health can result in direct and indirect costs that can perpetuate poverty. Social protection, which includes policies and programmes intended to prevent and reduce poverty in times of ill health, could be one way to break this vicious cycle. Social protection, particularly cash transfers, also has the potential to promote healthier behaviours, including healthcare seeking. Although social protection, particularly conditional and unconditional cash transfers, has been widely studied, it is not well known how recipients experience social protection interventions, and what unintended effects such interventions can cause. OBJECTIVES: The aim of this review was to explore how conditional and unconditional cash transfer social protection interventions with a health outcome are experienced and perceived by their recipients. SEARCH METHODS: We searched Epistemonikos, MEDLINE, CINAHL, Social Services Abstracts, Global Index Medicus, Scopus, AnthroSource and EconLit from the start of the database to 5 June 2020. We combined this with reference checking, citation searching, grey literature and contact with authors to identify additional studies. We reran all strategies in July 2022, and the new studies are awaiting classification. SELECTION CRITERIA We included primary studies, using qualitative methods or mixed-methods studies with qualitative research reporting on recipients' experiences of cash transfer interventions where health outcomes were evaluated. Recipients could be adult patients of healthcare services, the general adult population as recipients of cash targeted at themselves or directed at children. Studies could be evaluated on any mental or physical health condition or cash transfer mechanism. Studies could come from any country and be in any language. Two authors independently selected studies. DATA COLLECTION AND ANALYSIS: We used a multi-step purposive sampling framework for selecting studies, starting with geographical representation, followed by health condition, and richness of data. Key data were extracted by the authors into Excel. Methodological limitations were assessed independently using the Critical Appraisal Skills Programme (CASP) criteria by two authors. Data were synthesised using meta-ethnography, and confidence in findings was assessed using the Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) approach. MAIN RESULTS: We included 127 studies in the review and sampled 41 of these studies for our analysis. Thirty-two further studies were found after the updated search on 5 July 2022 and are awaiting classification. The sampled studies were from 24 different countries: 17 studies were from the African region, seven were from the region of the Americas, seven were from the European region, six were from the South-East Asian region, three from the Western Pacific region and one study was multiregional, covering both the African and the Eastern Mediterranean regions. These studies primarily explored the views and experiences of cash transfer recipients with different health conditions, such as infectious diseases, disabilities and long-term illnesses, sexual and reproductive health, and maternal and child health. Our GRADE-CERQual assessment indicated we had mainly moderate- and high-confidence findings. We found that recipients perceived the cash transfers as necessary and helpful for immediate needs and, in some cases, helpful for longer-term benefits. However, across conditional and unconditional programmes, recipients often felt that the amount given was too little in relation to their total needs. They also felt that the cash alone was not enough to change their behaviour and, to change behaviour, additional types of support would be required. The cash transfer was reported to have important effects on empowerment, autonomy and agency, but also in some settings, recipients experienced pressure from family or programme staff on cash usage. The cash transfer was reported to improve social cohesion and reduce intrahousehold tension. However, in settings where some received the cash and others did not, the lack of an equal approach caused tension, suspicion and conflict. Recipients also reported stigma in terms of cash transfer programme assessment processes and eligibility, as well as inappropriate eligibility processes. Across settings, recipients experienced barriers in accessing the cash transfer programme, and some refused or were hesitant to receive the cash. Some recipients found cash transfer programmes more acceptable when they agreed with the programme's goals and processes. AUTHORS' CONCLUSIONS: Our findings highlight the impact of the sociocultural context on the functioning and interaction between the individual, family and cash transfer programmes. Even where the goals of a cash transfer programme are explicitly health-related, the outcomes may be far broader than health alone and may include, for example, reduced stigma, empowerment and increased agency of the individual. When measuring programme outcomes, therefore, these broader impacts could be considered for understanding the health and well-being benefits of cash transfers.
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Affiliation(s)
- Clara A Yoshino
- World Health Organization Collaborating Centre on Tuberculosis and Social Medicine, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Kristi Sidney-Annerstedt
- World Health Organization Collaborating Centre on Tuberculosis and Social Medicine, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Tom Wingfield
- World Health Organization Collaborating Centre on Tuberculosis and Social Medicine, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Clinical Infection, Microbiology, and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Tropical and Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Beatrice Kirubi
- World Health Organization Collaborating Centre on Tuberculosis and Social Medicine, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre for Public Health Research (CPHR), Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Kerri Viney
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Research School of Population Health, Australian National University, Canberra, Australia
- School of Public Health, University of Sydney, Sydney, Australia
| | - Delia Boccia
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, UK
| | - Salla Atkins
- World Health Organization Collaborating Centre on Tuberculosis and Social Medicine, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Global Health and Development, Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland
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Wollburg C, Steinert JI, Reeves A, Nye E. Do cash transfers alleviate common mental disorders in low- and middle-income countries? A systematic review and meta-analysis. PLoS One 2023; 18:e0281283. [PMID: 36812171 PMCID: PMC9946251 DOI: 10.1371/journal.pone.0281283] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 01/19/2023] [Indexed: 02/24/2023] Open
Abstract
A large literature has demonstrated the link between poverty and mental ill-health. Yet, the potential causal effects of poverty alleviation measures on mental disorders are not well-understood. In this systematic review, we summarize the evidence of the effects of a particular kind of poverty alleviation mechanism on mental health: the provision of cash transfers in low- and middle-income countries. We searched eleven databases and websites and assessed over 4,000 studies for eligibility. Randomized controlled trials evaluating the effects of cash transfers on depression, anxiety, and stress were included. All programs targeted adults or adolescents living in poverty. Overall, 17 studies, comprising 26,794 participants in Sub-Saharan Africa, Latin America, and South Asia, met the inclusion criteria of this review. Studies were critically appraised using Cochrane's Risk of Bias tool and publication bias was tested using funnel plots, egger's regression, and sensitivity analyses. The review was registered in PROSPERO (CRD42020186955). Meta-analysis showed that cash transfers significantly reduced depression and anxiety of recipients (dpooled = -0.10; 95%-CI: -0.15, -0.05; p<0.01). However, improvements may not be sustained 2-9 years after program cessation (dpooled = -0.05; 95%-CI: -0.14, 0.04; ns). Meta-regression indicates that impacts were larger for unconditional transfers (dpooled = -0.14; 95%-CI: -0.17, -0.10; p<0.01) than for conditional programs (dpooled = 0.10; 95%-CI: 0.07, 0.13; p<0.01). Effects on stress were insignificant and confidence intervals include both the possibility of meaningful reductions and small increases in stress (dpooled = -0.10; 95%-CI: -0.32, 0.12; ns). Overall, our findings suggest that cash transfers can play a role in alleviating depression and anxiety disorders. Yet, continued financial support may be necessary to enable longer-term improvements. Impacts are comparable in size to the effects of cash transfers on, e.g., children's test scores and child labor. Our findings further raise caution about potential adverse effects of conditionality on mental health, although more evidence is needed to draw robust conclusions.
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Affiliation(s)
- Clara Wollburg
- Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom
- * E-mail:
| | - Janina Isabel Steinert
- TUM School of Social Sciences and Technology, Technical University Munich, Munich, Germany
| | - Aaron Reeves
- Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom
| | - Elizabeth Nye
- Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom
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Luong H. Business grants following natural disasters and their different impact on the performance of female and male-owned microenterprises: Evidence from Sri Lanka. PLoS One 2022; 17:e0279418. [PMID: 36542653 PMCID: PMC9770362 DOI: 10.1371/journal.pone.0279418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE This paper investigates gender differences in the treatment effects of business grants on firm performance following natural disasters, and seeks to identify the mechanisms underlying the unequal effects. METHOD A panel data-set from an experiment in Sri Lanka is used to measure the difference in the treatment effects of a business grant on the performance of female and male-owned firms following the 2004 Indian Ocean tsunami. The sample of 608 microenterprises includes 297 female-owned firms and 311 male-owned firms. There are 338 firms (Male = 176, Female = 162) in the treatment group that received the grant and 270 firms (Male = 135, Female = 135) in the control group that did not receive the grant. Data on firm performance, firm characteristics and owner characteristics were collected in 13 survey waves from April 2005 to December 2010. Firm performance, which is measured by firm profit, is assessed by employing linear regression with fixed effects in an intention-to-treat analysis. FINDINGS The results suggest that the business grant has a positive impact on the performance of male-owned firms, but zero effect on that of female-owned firms. Several potential mechanisms drive the results, including gender differences in business investment, household expenditure and initial business closures. The results also show a positive treatment effect of the business grant on the psychological recovery of recipients, but there is no evidence supporting gender differences in this dimension. CONTRIBUTION This paper provides new evidence on gender differences in the treatment effects of business grants on firm performance in the context of post-disasters, and has implications for business recovery programs aimed at supporting female microentrepreneurs in the aftermath of large-scale catastrophes.
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Affiliation(s)
- Ha Luong
- Department of Economics, University of Barcelona, Barcelona, Spain
- Barcelona Institute of Economics (IEB), Barcelona, Spain
- * E-mail:
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Adinkrah E, Najand B, Rahmani A, Maharlouei N, Ekwegh T, Cobb S, Zare H. Social Determinants of Mental, Physical, and Oral Health of Middle-Aged and Older African Americans in South Los Angeles. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16765. [PMID: 36554645 PMCID: PMC9779480 DOI: 10.3390/ijerph192416765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 12/10/2022] [Accepted: 12/11/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND A growing body of research suggests that financial difficulties could weaken the protective effects of socioeconomic status (SES) indicators, including education and income, on the health status of marginalized communities, such as African Americans. AIM We investigated the separate and joint effects of education, income, and financial difficulties on mental, physical, and oral self-rated health (SRH) outcomes in African American middle-aged and older adults. METHODS This cross-sectional study enrolled 150 middle-aged and older African Americans residing in South Los Angeles. Data on demographic factors (age and gender), socioeconomic characteristics (education, income, and financial difficulties), and self-rated health (mental, physical, and oral health) were collected. Three linear regression models were used to analyze the data. RESULTS Higher education and income were associated with a lower level of financial strain in a bivariate analysis. However, according to multivariable models, only financial difficulties were associated with poor mental, physical, and oral health. As similar patterns emerged for all three health outcomes, the risk associated with financial difficulties seems robust. CONCLUSIONS According to our multivariable models, financial strain is a more salient social determinant of health within African American communities than education and income in economically constrained urban environments such as South Los Angeles. While education and income lose some protective effects, financial strain continues to deteriorate the health of African American communities across domains.
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Affiliation(s)
- Edward Adinkrah
- Department of Family Medicine, Charles R Drew University of Medicine and Science, Los Angeles, CA 90059, USA
| | - Babak Najand
- Marginalization-Related Diminished Returns (MDRs) Center, Los Angeles, CA 90059, USA
| | - Arash Rahmani
- Marginalization-Related Diminished Returns (MDRs) Center, Los Angeles, CA 90059, USA
| | - Najmeh Maharlouei
- Marginalization-Related Diminished Returns (MDRs) Center, Los Angeles, CA 90059, USA
| | - Tavonia Ekwegh
- Mervyn M. Dymally School of Nursing, Charles R Drew University of Medicine and Science, Los Angeles, CA 90059, USA
| | - Sharon Cobb
- Mervyn M. Dymally School of Nursing, Charles R Drew University of Medicine and Science, Los Angeles, CA 90059, USA
| | - Hossein Zare
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
- School of Business, University of Maryland Global Campus (UMGC), Adelphi, Garden City, NY 20783, USA
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Thomson RM, Igelström E, Purba AK, Shimonovich M, Thomson H, McCartney G, Reeves A, Leyland A, Pearce A, Katikireddi SV. How do income changes impact on mental health and wellbeing for working-age adults? A systematic review and meta-analysis. Lancet Public Health 2022; 7:e515-e528. [PMID: 35660213 PMCID: PMC7614874 DOI: 10.1016/s2468-2667(22)00058-5] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/22/2022] [Accepted: 02/22/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Lower incomes are associated with poorer mental health and wellbeing, but the extent to which income has a causal effect is debated. We aimed to synthesise evidence from studies measuring the impact of changes in individual and household income on mental health and wellbeing outcomes in working-age adults (aged 16-64 years). METHODS For this systematic review and meta-analysis, we searched MEDLINE, Embase, Web of Science, PsycINFO, ASSIA, EconLit, and RePEc on Feb 5, 2020, for randomised controlled trials (RCTs) and quantitative non-randomised studies. We had no date limits for our search. We included English-language studies measuring effects of individual or household income change on any mental health or wellbeing outcome. We used Cochrane risk of bias (RoB) tools. We conducted three-level random-effects meta-analyses, and explored heterogeneity using meta-regression and stratified analyses. Synthesis without meta-analysis was based on effect direction. Critical RoB studies were excluded from primary analyses. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). This study is registered with PROSPERO, CRD42020168379. FINDINGS Of 16 521 citations screened, 136 were narratively synthesised (12·5% RCTs) and 86 meta-analysed. RoB was high: 30·1% were rated critical and 47·1% serious or high. A binary income increase lifting individuals out of poverty was associated with 0·13 SD improvement in mental health measures (95% CI 0·07 to 0·20; n=42 128; 18 studies), considerably larger than other income increases (0·01 SD improvement, 0·002 to 0·019; n=216 509, 14 studies). For wellbeing, increases out of poverty were associated with 0·38 SD improvement (0·09 to 0·66; n=101 350, 8 studies) versus 0·16 for other income increases (0·07 to 0·25; n=62 619, 11 studies). Income decreases from any source were associated with 0·21 SD worsening of mental health measures (-0·30 to -0·13; n=227 804, 11 studies). Effect sizes were larger in low-income and middle-income settings and in higher RoB studies. Heterogeneity was high (I2=79-87%). GRADE certainty was low or very low. INTERPRETATION Income changes probably impact mental health, particularly where they move individuals out of poverty, although effect sizes are modest and certainty low. Effects are larger for wellbeing outcomes, and potentially for income losses. To best support population mental health, welfare policies need to reach the most socioeconomically disadvantaged. FUNDING Wellcome Trust, Medical Research Council, Chief Scientist Office, and European Research Council.
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Affiliation(s)
- Rachel M Thomson
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK.
| | - Erik Igelström
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Amrit Kaur Purba
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Michal Shimonovich
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Hilary Thomson
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Gerry McCartney
- School of Social and Political Sciences, University of Glasgow, Glasgow, UK; Public Health Scotland, Edinburgh, UK
| | - Aaron Reeves
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
| | - Alastair Leyland
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Anna Pearce
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - S Vittal Katikireddi
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK; Public Health Scotland, Edinburgh, UK
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Ohrnberger J, Fichera E, Sutton M, Anselmi L. The worse the better? Quantile treatment effects of a conditional cash transfer programme on mental health. Health Policy Plan 2021; 35:1137-1149. [PMID: 32879960 PMCID: PMC7810405 DOI: 10.1093/heapol/czaa079] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2020] [Indexed: 12/19/2022] Open
Abstract
Poor mental health is a pressing global health problem, with high prevalence among poor populations from low-income countries. Existing studies of conditional cash transfer (CCT) effects on mental health have found positive effects. However, there is a gap in the literature on population-wide effects of cash transfers on mental health and if and how these vary by the severity of mental illness. We use the Malawian Longitudinal Study of Family and Health containing 790 adult participants in the Malawi Incentive Programme, a year-long randomized controlled trial. We estimate average and distributional quantile treatment effects and we examine how these effects vary by gender, HIV status and usage of the cash transfer. We find that the cash transfer improves mental health on average by 0.1 of a standard deviation. The effect varies strongly along the mental health distribution, with a positive effect for individuals with worst mental health of about four times the size of the average effect. These improvements in mental health are associated with increases in consumption expenditures and expenditures related to economic productivity. Our results show that CCTs can improve adult mental health for the poor living in low-income countries, particularly those with the worst mental health.
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Affiliation(s)
- Julius Ohrnberger
- School of Public Health, Department of Infectious Disease Epidemiology, Imperial College London, Medical School Building, St Mary's Campus, Norfolk Place, W2 1PG, London, UK
| | - Eleonora Fichera
- Department of Economics, University of Bath, Claverton Down, Bath BA2 7JP, Bath, UK
| | - Matt Sutton
- Institute for Health Policy and Organisation, University of Manchester, Booth Street West, M15 6PB, Manchester, UK
| | - Laura Anselmi
- Institute for Health Policy and Organisation, University of Manchester, Booth Street West, M15 6PB, Manchester, UK
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Kola L, Kohrt BA, Hanlon C, Naslund JA, Sikander S, Balaji M, Benjet C, Cheung EYL, Eaton J, Gonsalves P, Hailemariam M, Luitel NP, Machado DB, Misganaw E, Omigbodun O, Roberts T, Salisbury TT, Shidhaye R, Sunkel C, Ugo V, van Rensburg AJ, Gureje O, Pathare S, Saxena S, Thornicroft G, Patel V. COVID-19 mental health impact and responses in low-income and middle-income countries: reimagining global mental health. Lancet Psychiatry 2021; 8:535-550. [PMID: 33639109 PMCID: PMC9764935 DOI: 10.1016/s2215-0366(21)00025-0] [Citation(s) in RCA: 332] [Impact Index Per Article: 110.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 01/11/2021] [Accepted: 01/14/2021] [Indexed: 12/30/2022]
Abstract
Most of the global population live in low-income and middle-income countries (LMICs), which have historically received a small fraction of global resources for mental health. The COVID-19 pandemic has spread rapidly in many of these countries. This Review examines the mental health implications of the COVID-19 pandemic in LMICs in four parts. First, we review the emerging literature on the impact of the pandemic on mental health, which shows high rates of psychological distress and early warning signs of an increase in mental health disorders. Second, we assess the responses in different countries, noting the swift and diverse responses to address mental health in some countries, particularly through the development of national COVID-19 response plans for mental health services, implementation of WHO guidance, and deployment of digital platforms, signifying a welcome recognition of the salience of mental health. Third, we consider the opportunity that the pandemic presents to reimagine global mental health, especially through shifting the balance of power from high-income countries to LMICs and from narrow biomedical approaches to community-oriented psychosocial perspectives, in setting priorities for interventions and research. Finally, we present a vision for the concept of building back better the mental health systems in LMICs with a focus on key strategies; notably, fully integrating mental health in plans for universal health coverage, enhancing access to psychosocial interventions through task sharing, leveraging digital technologies for various mental health tasks, eliminating coercion in mental health care, and addressing the needs of neglected populations, such as children and people with substance use disorders. Our recommendations are relevant for the mental health of populations and functioning of health systems in not only LMICs but also high-income countries impacted by the COVID-19 pandemic, with wide disparities in quality of and access to mental health care.
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Affiliation(s)
- Lola Kola
- WHO Collaborating Centre for Research and Training in Mental Health, Neurosciences and Drug and Alcohol Abuse, Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria; BRiTE Center, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA.
| | - Brandon A Kohrt
- Division of Global Mental Health, Department of Psychiatry, George Washington University, Washington, DC, USA
| | - Charlotte Hanlon
- Centre for Global Mental Health, Department of Health Service and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-Building, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - John A Naslund
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Siham Sikander
- Global Health Department, Health Services Academy, Islamabad, Pakistan; Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK
| | | | - Corina Benjet
- Division of Epidemiology and Psychosocial Research, National Institute of Psychiatry Ramón de la Fuente Muñiz, Mexico City, Mexico
| | - Eliza Yee Lai Cheung
- The Reference Centre for Psychosocial Support, International Federation of the Red Cross and Red Crescent, Hong Kong Special Administrative Region, China; The Red Cross of the Hong Kong Special Administrative Region of China, Hong Kong Special Administrative Region, China
| | - Julian Eaton
- CBM Global and Centre for Global Mental Health, London, UK
| | - Pattie Gonsalves
- Wellcome-DBT India Alliance, Sangath, New Delhi, India; School of Psychology, University of Sussex, Brighton, UK
| | - Maji Hailemariam
- Department of Obstetrics, Gynecology and Reproductive Biology, College of Human Medicine, Michigan State University, East Lansing, MI, USA
| | | | - Daiane B Machado
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; Centre for Data and Knowledge Integration for Health, CIDACS-FIOCRUZ, Bahia, Brazil
| | - Eleni Misganaw
- Mental Health Service Users Association Ethiopia, Addis Ababa, Ethiopia; Global Mental Health Peer Network, Pretoria, South Africa
| | - Olayinka Omigbodun
- WHO Collaborating Centre for Research and Training in Mental Health, Neurosciences and Drug and Alcohol Abuse, Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria; Centre for Child and Adolescent Mental Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Tessa Roberts
- Centre for Society and Mental Health, Department of Health Service and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Tatiana Taylor Salisbury
- Centre for Global Mental Health, Department of Health Service and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; WHO Collaborating Centre for Research and Training in Mental Health, Department of Health Service and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | | | - Charlene Sunkel
- Global Mental Health Peer Network, Johannesburg, South Africa
| | - Victor Ugo
- Mentally Aware Nigeria Initiative, Lagos, Nigeria; United for Global Mental Health, London, UK
| | - André Janse van Rensburg
- Centre for Rural Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa; Centre for Health Systems Research and Development, Faculty of Humanities, University of the Free State, Bloemfontein, South Africa
| | - Oye Gureje
- WHO Collaborating Centre for Research and Training in Mental Health, Neurosciences and Drug and Alcohol Abuse, Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Soumitra Pathare
- Centre for Mental Health Law and Policy, Indian Law Society, Pune, India
| | - Shekhar Saxena
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Graham Thornicroft
- Centre for Global Mental Health, Department of Health Service and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; Centre for Implementation Science, Department of Health Service and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Vikram Patel
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; Wellcome-DBT India Alliance, Sangath, New Delhi, India
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Assari S, Cobb S, Saqib M, Bazargan M. Economic Strain Deteriorates While Education Fails to Protect Black Older Adults Against Depressive Symptoms, Pain, Self-rated Health, Chronic Disease, and Sick Days. ACTA ACUST UNITED AC 2020; 4:49-62. [PMID: 32724902 DOI: 10.29245/2578-2959/2020/2.1203] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Background A large body of empirical evidence on Minorities' Diminished Returns (MDRs) suggests that educational attainment shows smaller health effects for Blacks compared to Whites. At the same time, economic strain may operate as a risk factor for a wide range of undesired mental and physical health outcomes in Black communities. Aim The current study investigated the combined effects of education and economic strain on the following five health outcomes in Black older adults in underserved areas of South Los Angeles: depressive symptoms, number of chronic diseases, pain intensity, self-rated health, and sick days. Methods This cross-sectional study included 619 Black older adults residing in South Los Angeles. Data on demographic factors (age and gender), socioeconomic characteristics, economic strain, health insurance, living arrangement, marital status, health behaviors, depressive symptoms, pain intensity, number of chronic diseases, sick days, and self-rated health were collected. Five linear regressions were used to analyze the data. Results Although high education was associated with less economic strain, it was the economic strain, not educational attainment, which was universally associated with depressive symptoms, pain intensity, self-rated health, chronic diseases, and sick days, independent of covariates. Similar patterns emerged for all health outcomes suggesting that the risk associated with economic strain and lack of health gain due to educational attainment are both robust and independent of type of health outcome. Conclusion In economically constrained urban environments, economic strain is a more salient social determinant of health of Black older adults than educational attainment. While education loses some of its protective effects, economic strain deteriorates health of Black population across domains. There is a need for bold economic and social policies that increase access of Black communities to cash at times of emergency. There is also a need to improve the education quality in the Black communities.
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Affiliation(s)
- Shervin Assari
- Departments of Family Medicine, Charles R Drew University of Medicine and Science
| | - Sharon Cobb
- School of Nursing, Charles R Drew University of Medicine and Science, Los Angeles, CA, United States
| | - Mohammed Saqib
- University of Michigan School of Public Health, Ann Arbor, MI, United States
| | - Mohsen Bazargan
- Departments of Family Medicine, Charles R Drew University of Medicine and Science.,Departments of Family Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, United States
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Kilburn K, Ferrone L, Pettifor A, Wagner R, Gómez-Olivé FX, Kahn K. The Impact of a Conditional Cash Transfer on Multidimensional Deprivation of Young Women: Evidence from South Africa's HTPN 068. SOCIAL INDICATORS RESEARCH 2020; 151:865-895. [PMID: 33029038 PMCID: PMC7508742 DOI: 10.1007/s11205-020-02367-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/12/2020] [Indexed: 05/16/2023]
Abstract
Despite the growing popularity of multidimensional poverty measurement and analysis, its use to measure the impact of social protection programs remains scarce. Using primary data collected for the evaluation of HIV Prevention Trials Network (HPTN) 068, a randomized, conditional cash transfer intervention for young girls in South Africa that ran from 2011 to 2015, we construct an individual-level measure of multidimensional poverty, a major departure from standard indices that use the household as the unit of analysis. We construct our measure by aggregating multiple deprivation indicators across six dimensions and using a system of nested weights where each domain is weighted equally. Our findings show that the cash transfer consistently reduces deprivations among girls, in particular through the domains of economic agency, violence, and relationships. These results show how social protection interventions can improve the lives of young women beyond single domains and demonstrate the potential for social protection to simultaneously address multiple targets of the SDGs.
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Affiliation(s)
- Kelly Kilburn
- Carolina Population Center, University of North Carolina, Chapel Hill, NC USA
- Duke Global Health Institute, Duke University, Durham, NC USA
| | - Lucia Ferrone
- Department of Economics and Management, University of Florence, via delle Pandette, 9, 50127 Florence, Italy
| | - Audrey Pettifor
- Carolina Population Center, University of North Carolina, Chapel Hill, NC USA
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC USA
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ryan Wagner
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Umeå Centre for Global Health Research, Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - F. Xavier Gómez-Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kathy Kahn
- Umeå Centre for Global Health Research, Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
- INDEPTH Network, Accra, Ghana
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11
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Huo X, Gao Q, Zhai F, Lin M. Effects of welfare entry and exit on adolescent mental health: Evidence from panel data in China. Soc Sci Med 2020; 253:112969. [PMID: 32278237 DOI: 10.1016/j.socscimed.2020.112969] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 02/19/2020] [Accepted: 03/29/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Xuan Huo
- School of Government, Nanjing University, 163 Xianlin Avenue, Nanjing, 210023, China.
| | - Qin Gao
- School of Social Work, Columbia University, 1255 Amsterdam Avenue, New York, NY, 10027, USA.
| | - Fuhua Zhai
- Graduate School of Social Service, Fordham University, 113 West 60(th)Street, New York, NY, 10023, USA.
| | - Mingang Lin
- School of Government, Nanjing University, 163 Xianlin Avenue, Nanjing, 210023, China.
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12
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Ohrnberger J, Fichera E, Sutton M, Anselmi L. The effect of cash transfers on mental health - new evidence from South Africa. BMC Public Health 2020; 20:436. [PMID: 32245377 PMCID: PMC7118950 DOI: 10.1186/s12889-020-08596-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 03/26/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Mental health and poverty are strongly interlinked. There is a gap in the literature on the effects of poverty alleviation programmes on mental health. We aim to fill this gap by studying the effect of an exogenous income shock generated by the Child Support Grant, South Africa's largest Unconditional Cash Transfer (UCT) programme, on mental health. METHODS We use biennial data on 10,925 individuals from the National Income Dynamics Study between 2008 and 2014. We exploit the programme's eligibility criteria to estimate instrumental variable Fixed Effects models. RESULTS We find that receiving the Child Support Grant improves adult mental health by 0.822 points (on a 0-30 scale), 4.1% of the sample mean. CONCLUSION Our findings show that UCT programmes have strong mental health benefits for the poor adult population.
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Affiliation(s)
- Julius Ohrnberger
- Department of Infectious Disease Epidemiology, Faculty of Medicine, Imperial College London, School of Public Health, 47 Praed Street, St Mary's Campus, London, UK.
| | | | - Matt Sutton
- Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, UK
| | - Laura Anselmi
- Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, UK
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Owusu-Addo E, Renzaho AMN, Smith BJ. The impact of cash transfers on social determinants of health and health inequalities in sub-Saharan Africa: a systematic review. Health Policy Plan 2018; 33:675-696. [PMID: 29762708 PMCID: PMC5951115 DOI: 10.1093/heapol/czy020] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2018] [Indexed: 11/14/2022] Open
Abstract
Cash transfers (CTs) are now high on the agenda of most governments in low- and middle-income countries. Within the field of health promotion, CTs constitute a healthy public policy initiative as they have the potential to address the social determinants of health (SDoH) and health inequalities. A systematic review was conducted to synthesise the evidence on CTs' impacts on SDoH and health inequalities in sub-Saharan Africa, and to identify the barriers and facilitators of effective CTs. Twenty-one electronic databases and the websites of 14 key organizations were searched in addition to grey literature and hand searching of selected journals for quantitative and qualitative studies on CTs' impacts on SDoH and health outcomes. Out of 182 full texts screened for eligibility, 79 reports that reported findings from 53 studies were included in the final review. The studies were undertaken within 24 CTs comprising 11 unconditional CTs (UCTs), 8 conditional CTs (CCTs) and 5 combined UCTs and CCTs. The review found that CTs can be effective in tackling structural determinants of health such as financial poverty, education, household resilience, child labour, social capital and social cohesion, civic participation, and birth registration. The review further found that CTs modify intermediate determinants such as nutrition, dietary diversity, child deprivation, sexual risk behaviours, teen pregnancy and early marriage. In conjunction with their influence on SDoH, there is moderate evidence from the review that CTs impact on health and quality of life outcomes. The review also found many factors relating to intervention design features, macro-economic stability, household dynamics and community acceptance of programs that could influence the effectiveness of CTs. The external validity of the review findings is strong as the findings are largely consistent with those from Latin America. The findings thus provide useful insights to policy makers and managers and can be used to optimise CTs to reduce health inequalities.
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Affiliation(s)
- Ebenezer Owusu-Addo
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC 3004, Australia
- Bureau of Integrated Rural Development, Kwame Nkrumah University of Science and Technology, Private Mail Bag, University Post Office, KNUST- Kumasi, Ghana
| | - Andre M N Renzaho
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC 3004, Australia
- School of Social Sciences and Psychology, Western Sydney University, Locked Bag 1797, Penrith 2751 NSW, Australia and
| | - Ben J Smith
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC 3004, Australia
- Sydney School of Public Health, University of Sydney, Sydney, NSW 2006, Australia
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Owusu-Addo E, Renzaho AMN, Smith BJ. Evaluation of cash transfer programs in sub-Saharan Africa: A methodological review. EVALUATION AND PROGRAM PLANNING 2018; 68:47-56. [PMID: 29475057 DOI: 10.1016/j.evalprogplan.2018.02.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 12/19/2017] [Accepted: 02/11/2018] [Indexed: 06/08/2023]
Abstract
Cash transfer programs (CTs) have been rigorously evaluated since their inception in the 1990s. However, to date, there has been no study critically examining the utility of the methodological approaches used to evaluate CTs. This article reviews the approaches used to evaluate CTs in sub-Saharan Africa (SSA) to provide recommendations for improving future CTs evaluations. We conducted searches for CTs evaluation studies in SSA in the peer-reviewed and grey literature using electronic databases, hand searching of selected journals, organisational websites, Google Scholar and Scirus Internet search engines. The review included 53 evaluation studies which were largely outcome-focused evaluations (95%; n = 50). The studies were undertaken within 24 CT programs comprising 11 unconditional CTs (UCTs), eight conditional CTs (CCTs) and five combined UCTs and CCTs. The review finds that while there is evidence of CTs impacts on a broad range of outcomes, the current evaluation approaches have primarily been experimental designs and have largely failed to provide explanations for mechanisms of change. To improve CTs policy and practice, there is the need to consider theory-based evaluation approaches such as realist evaluation that provide insights about the contexts and mechanisms through which programs generate outcomes in different circumstances.
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Affiliation(s)
- Ebenezer Owusu-Addo
- School of Public Hea lth and Preventive Medicine, Monash University, Australia; Bureau of Integrated Rural Development, Kwame Nkrumah University of Science and Technology, Ghana.
| | - Andre M N Renzaho
- School of Public Hea lth and Preventive Medicine, Monash University, Australia; School of Social Sciences and Psychology, Western Sydney University, Australia
| | - Ben J Smith
- School of Public Hea lth and Preventive Medicine, Monash University, Australia
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Pega F, Liu SY, Walter S, Pabayo R, Saith R, Lhachimi SK. Unconditional cash transfers for reducing poverty and vulnerabilities: effect on use of health services and health outcomes in low- and middle-income countries. Cochrane Database Syst Rev 2017; 11:CD011135. [PMID: 29139110 PMCID: PMC6486161 DOI: 10.1002/14651858.cd011135.pub2] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Unconditional cash transfers (UCTs; provided without obligation) for reducing poverty and vulnerabilities (e.g. orphanhood, old age or HIV infection) are a type of social protection intervention that addresses a key social determinant of health (income) in low- and middle-income countries (LMICs). The relative effectiveness of UCTs compared with conditional cash transfers (CCTs; provided so long as the recipient engages in prescribed behaviours such as using a health service or attending school) is unknown. OBJECTIVES To assess the effects of UCTs for improving health services use and health outcomes in vulnerable children and adults in LMICs. Secondary objectives are to assess the effects of UCTs on social determinants of health and healthcare expenditure and to compare to effects of UCTs versus CCTs. SEARCH METHODS We searched 17 electronic academic databases, including the Cochrane Public Health Group Specialised Register, the Cochrane Database of Systematic Reviews (the Cochrane Library 2017, Issue 5), MEDLINE and Embase, in May 2017. We also searched six electronic grey literature databases and websites of key organisations, handsearched key journals and included records, and sought expert advice. SELECTION CRITERIA We included both parallel group and cluster-randomised controlled trials (RCTs), quasi-RCTs, cohort and controlled before-and-after (CBAs) studies, and interrupted time series studies of UCT interventions in children (0 to 17 years) and adults (18 years or older) in LMICs. Comparison groups received either no UCT or a smaller UCT. Our primary outcomes were any health services use or health outcome. DATA COLLECTION AND ANALYSIS Two reviewers independently screened potentially relevant records for inclusion criteria, extracted data and assessed the risk of bias. We tried to obtain missing data from study authors if feasible. For cluster-RCTs, we generally calculated risk ratios for dichotomous outcomes from crude frequency measures in approximately correct analyses. Meta-analyses applied the inverse variance or Mantel-Haenszel method with random effects. We assessed the quality of evidence using the GRADE approach. MAIN RESULTS We included 21 studies (16 cluster-RCTs, 4 CBAs and 1 cohort study) involving 1,092,877 participants (36,068 children and 1,056,809 adults) and 31,865 households in Africa, the Americas and South-East Asia in our meta-analyses and narrative synthesis. The 17 types of UCTs we identified, including one basic universal income intervention, were pilot or established government programmes or research experiments. The cash value was equivalent to 1.3% to 53.9% of the annualised gross domestic product per capita. All studies compared a UCT with no UCT, and three studies also compared a UCT with a CCT. Most studies carried an overall high risk of bias (i.e. often selection and/or performance bias). Most studies were funded by national governments and/or international organisations.Throughout the review, we use the words 'probably' to indicate moderate-quality evidence, 'may/maybe' for low-quality evidence, and 'uncertain' for very low-quality evidence. UCTs may not have impacted the likelihood of having used any health service in the previous 1 to 12 months, when participants were followed up between 12 and 24 months into the intervention (risk ratio (RR) 1.04, 95% confidence interval (CI) 1.00 to 1.09, P = 0.07, 5 cluster-RCTs, N = 4972, I² = 2%, low-quality evidence). At one to two years, UCTs probably led to a clinically meaningful, very large reduction in the likelihood of having had any illness in the previous two weeks to three months (odds ratio (OR) 0.73, 95% CI 0.57 to 0.93, 5 cluster-RCTs, N = 8446, I² = 57%, moderate-quality evidence). Evidence from five cluster-RCTs on food security was too inconsistent to be combined in a meta-analysis, but it suggested that at 13 to 24 months' follow-up, UCTs could increase the likelihood of having been food secure over the previous month (low-quality evidence). UCTs may have increased participants' level of dietary diversity over the previous week, when assessed with the Household Dietary Diversity Score and followed up 24 months into the intervention (mean difference (MD) 0.59 food categories, 95% CI 0.18 to 1.01, 4 cluster-RCTs, N = 9347, I² = 79%, low-quality evidence). Despite several studies providing relevant evidence, the effects of UCTs on the likelihood of being moderately stunted and on the level of depression remain uncertain. No evidence was available on the effect of a UCT on the likelihood of having died. UCTs probably led to a clinically meaningful, moderate increase in the likelihood of currently attending school, when assessed at 12 to 24 months into the intervention (RR 1.06, 95% CI 1.03 to 1.09, 6 cluster-RCTs, N = 4800, I² = 0%, moderate-quality evidence). The evidence was uncertain for whether UCTs impacted livestock ownership, extreme poverty, participation in child labour, adult employment or parenting quality. Evidence from six cluster-RCTs on healthcare expenditure was too inconsistent to be combined in a meta-analysis, but it suggested that UCTs may have increased the amount of money spent on health care at 7 to 24 months into the intervention (low-quality evidence). The effects of UCTs on health equity (or unfair and remedial health inequalities) were very uncertain. We did not identify any harms from UCTs. Three cluster-RCTs compared UCTs versus CCTs with regard to the likelihood of having used any health services, the likelihood of having had any illness or the level of dietary diversity, but evidence was limited to one study per outcome and was very uncertain for all three. AUTHORS' CONCLUSIONS This body of evidence suggests that unconditional cash transfers (UCTs) may not impact a summary measure of health service use in children and adults in LMICs. However, UCTs probably or may improve some health outcomes (i.e. the likelihood of having had any illness, the likelihood of having been food secure, and the level of dietary diversity), one social determinant of health (i.e. the likelihood of attending school), and healthcare expenditure. The evidence on the relative effectiveness of UCTs and CCTs remains very uncertain.
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Affiliation(s)
- Frank Pega
- University of OtagoPublic Health23A Mein Street, NewtownWellingtonNew Zealand6242
| | - Sze Yan Liu
- Harvard UniversityHarvard Center for Population and Development StudiesCambridgeMAUSA
- Weill Cornell Medical College, Cornell UniversityHealthcare Policy and ResearchNew YorkNYUSA
| | - Stefan Walter
- University of California, San FranciscoEpidemiology and Biostatistics185 Berry StSan FranciscoCAUSA94107
| | - Roman Pabayo
- Harvard TH Chan School of Public HealthSocial and Behavioral Sciences677 Huntington AvenueBostonMAUSA02215
- University of AlbertaSchool of Public HealthEdmontonAlbertaCanada
| | - Ruhi Saith
- New DelhiOxford Policy ManagementNew DelhiIndia
| | - Stefan K Lhachimi
- Leibniz Institute for Prevention Research and EpidemiologyResearch Group for Evidence‐Based Public HealthAchterstr. 30BremenGermany28359
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Maselko J. Social Epidemiology and Global Mental Health: Expanding the Evidence from High-Income to Low- and Middle-Income Countries. CURR EPIDEMIOL REP 2017; 4:166-173. [PMID: 28680795 PMCID: PMC5488107 DOI: 10.1007/s40471-017-0107-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE OF THE REVIEW The vast majority of research on the social determinants of mental health has been generated from high-income country (HIC) populations, even as the greatest health disparities, and greatest disease burden, is observed in lower- and middle-income countries (LMICs). The goal of this review is to examine the evidence base on how key social epidemiology constructs relate to mental health in LMIC contexts. A special focus is on points of departure from the HIC knowledge base, gaps in overall understanding, and opportunities for social epidemiology to make a significant contribution. RECENT FINDINGS A growing body of literature suggests that there is significant heterogeneity, both in the direction and magnitude, of association between factors such as socioeconomic status, income inequality, gender, and social networks/supports and mental health in LMIC. For example, higher levels of education and being married can be risk factors for worse mental health among women in certain contexts. However, many studies have methodological limitations that make causal inference difficult. Poverty alleviation interventions offer a unique opportunity to examine the impact of improving economic resources and mental health. SUMMARY Much remains unknown about the impact of key social factors on mental health in LMIC. Findings from HICs may not apply to LMIC populations, since the meaning and distribution of a given social variable may differ significantly from what is commonly observed in HICs. These points of departure point to opportunities for social epidemiology to make a contribution to the field of global mental health.
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Affiliation(s)
- Joanna Maselko
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 2105e McGavran-Greenberg Hall, Campus Box 7435, Chapel Hill, NC 27599-7435 USA
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Gibbs A, Govender K, Jewkes R. An exploratory analysis of factors associated with depression in a vulnerable group of young people living in informal settlements in South Africa. Glob Public Health 2016; 13:788-803. [PMID: 27533487 DOI: 10.1080/17441692.2016.1214281] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Depression amongst young people is a major health challenge and is often shaped by social marginalisation. Informal settlements are growing rapidly. There is a need to deepen understandings of depression amongst young people in these contexts. We sought to understand factors associated with depressive symptomology amongst 232 young people (122 women, 110 men) aged 18-30 in urban informal settlements in South Africa. We conducted a cross-sectional analysis of baseline data collected for the Stepping Stones and Creating Futures pilot. Logistic regression modelled relationships between depressive symptomology, livelihoods and violence. Symptomatic depression in this population was 49.5% for men and 57.9% for women. In multiple regression, depression in men was associated with stealing because of hunger (adjusted Odds Ratio (aOR) 5.78, p = .03), being more controlling in relationships (aOR 0.81, p = .008) and being more ashamed about lack of work (aOR 0.75, p = .01). For women, depressive symptoms were associated with greater stress about lack of work (aOR 0.72, p < .0001) and food insecurity (aOR 5.57, p = .039). The study emphasises that socio-economic factors, shaped by local understandings of gender, play a significant role in depressive symptomology. We suggest reducing economic distress may have an important role in reducing depression in this population.
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Affiliation(s)
- Andrew Gibbs
- a Health Economics HIV/AIDS Research Division (HEARD) , University of KwaZulu-Natal , Durban , South Africa
| | - Kaymarlin Govender
- a Health Economics HIV/AIDS Research Division (HEARD) , University of KwaZulu-Natal , Durban , South Africa
| | - Rachel Jewkes
- b Gender and Health Research Unit , South African Medical Research Council , Pretoria , South Africa.,c School of Public Health, University of the Witwatersrand , Johannesburg , South Africa
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Burmaster KB, Landefeld JC, Rehkopf DH, Lahiff M, Sokal-Gutierrez K, Adler-Milstein S, Fernald LCH. Impact of a private sector living wage intervention on depressive symptoms among apparel workers in the Dominican Republic: a quasi-experimental study. BMJ Open 2015; 5:e007336. [PMID: 26238394 PMCID: PMC4538264 DOI: 10.1136/bmjopen-2014-007336] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 04/09/2015] [Accepted: 05/14/2015] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Poverty reduction interventions through cash transfers and microcredit have had mixed effects on mental health. In this quasi-experimental study, we evaluate the effect of a living wage intervention on depressive symptoms of apparel factory workers in the Dominican Republic. SETTING Two apparel factories in the Dominican Republic. PARTICIPANTS The final sample consisted of 204 hourly wage workers from the intervention (99) and comparison (105) factories. INTERVENTIONS In 2010, an apparel factory began a living wage intervention including a 350% wage increase and significant workplace improvements. The wage increase was plausibly exogenous because workers were not aware of the living wage when applying for jobs and expected to be paid the usual minimum wage. These individuals were compared with workers at a similar local factory paying minimum wage, 15-16 months postintervention. PRIMARY OUTCOME MEASURES Workers' depressive symptoms were assessed using the Center for Epidemiologic Studies-Depression Scale (CES-D). Ordinary least squares and Poisson regressions were used to evaluate treatment effect of the intervention, adjusted for covariates. RESULTS Intervention factory workers had fewer depressive symptoms than comparison factory workers (unadjusted mean CES-D scores: 10.6 ± 9.3 vs 14.7 ± 11.6, p = 0.007). These results were sustained when controlling for covariates (β = -5.4, 95% CI -8.5 to -2.3, p = 0.001). In adjusted analyses using the standard CES-D clinical cut-off of 16, workers at the intervention factory had a 47% reduced risk of clinically significant levels of depressive symptoms compared with workers at the comparison factory (23% vs 40%). CONCLUSIONS Policymakers have long grappled with how best to improve mental health among populations in low-income and middle-income countries. We find that providing a living wage and workplace improvements to improve income and well-being in a disadvantaged population is associated with reduced depressive symptoms.
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Affiliation(s)
- Katharine B Burmaster
- University of California Berkeley, University of California San Francisco Joint Medical Program, Berkeley, California, USA
| | - John C Landefeld
- University of California Berkeley, University of California San Francisco Joint Medical Program, Berkeley, California, USA
| | | | - Maureen Lahiff
- University of California Berkeley School of Public Health, Berkeley, California, USA
| | - Karen Sokal-Gutierrez
- University of California Berkeley, University of California San Francisco Joint Medical Program, Berkeley, California, USA
| | | | - Lia C H Fernald
- University of California Berkeley School of Public Health, Berkeley, California, USA
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NYIRENDA M, EVANDROU M, MUTEVEDZI P, HOSEGOOD V, FALKINGHAM J, NEWELL ML. Who cares? Implications of care-giving and -receiving by HIV-infected or -affected older people on functional disability and emotional wellbeing. AGEING & SOCIETY 2015; 35:169-202. [PMID: 25878367 PMCID: PMC4301198 DOI: 10.1017/s0144686x13000615] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2013] [Indexed: 11/06/2022]
Abstract
This paper examines how care-giving to adults and/or children and care-receiving is associated with the health and wellbeing of older people aged 50+ in rural South Africa. Data used are from a cross-sectional survey adapted from World Health Organization's Study on Global Ageing and Adult Health (SAGE) conducted in 2009/10 in rural South Africa. Bivariate statistics and multivariate logistical regression were used to assess the relationship between care-giving and/or care-receiving with functional disability, quality of life or emotional wellbeing, and self-rated health status, adjusted for socio-demographic factors. Sixty-three per cent of 422 older people were care-givers to at least one young adult or child; 27 per cent of older people were care-givers due to HIV-related reasons in young adults; 84 per cent of participants were care-recipients mainly from adult children, grandchildren and spouse. In logistic regressions adjusting for sex, age, marital status, education, receipt of grants, household headship, household wealth and HIV status, care-giving was statistically significantly associated with good functional ability as measured by ability to perform activities of daily living. This relationship was stronger for older people providing care-giving to adults than to children. In contrast, care-givers were less likely to report good emotional wellbeing; again the relationship was stronger for care-givers to adults than children. Simultaneous care-giving and -receiving was likewise associated with good functional ability, but about a 47 per cent lower chance of good emotional wellbeing. Participants who were HIV-infected were more likely to be in better health but less likely to be receiving care than those who were HIV-affected. Our findings suggest a strong relationship between care-giving and poor emotional wellbeing via an economic or psychological stressor pathway. Interventions that improve older people's socio-economic circumstances and reduce financial hardship as well as those that provide social support would go some way towards mitigating this relationship.
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Affiliation(s)
- M. NYIRENDA
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa
- Faculty of Social and Human Sciences, University of Southampton, UK
| | - M. EVANDROU
- Faculty of Social and Human Sciences, University of Southampton, UK
| | - P. MUTEVEDZI
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa
- Division of Population Health, University College London, UK
| | - V. HOSEGOOD
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa
- Faculty of Social and Human Sciences, University of Southampton, UK
| | - J. FALKINGHAM
- Faculty of Social and Human Sciences, University of Southampton, UK
| | - M.-L. NEWELL
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa
- Faculty of Medicine and Faculty of Social and Human Sciences, University of Southampton, UK
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Plagerson S. Integrating mental health and social development in theory and practice. Health Policy Plan 2014; 30:163-70. [DOI: 10.1093/heapol/czt107] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Prevalence and correlates of depression among HIV-infected and -affected older people in rural South Africa. J Affect Disord 2013; 151:31-8. [PMID: 23726780 PMCID: PMC3781323 DOI: 10.1016/j.jad.2013.05.005] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Accepted: 05/03/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND Little is known about depression in older people in sub-Saharan Africa, the associated impact of HIV, and the influence on health perceptions. OBJECTIVES Examine the prevalence and correlates of depression; explore the relationship between depression and health perceptions in HIV-infected and -affected older people. METHODS In 2010, 422 HIV-infected and -affected participants aged 50+ were recruited into a cross-sectional study. Nurse professionals interviewed participants and a diagnosis of depressive episode was derived from the Composite International Diagnostic Interview (Depression module) using the International Classification of Diseases diagnostic criteria and categorised as major (MDE) or brief (BDE). RESULTS Overall, 42.4% (n=179) had a depressive episode (MDE: 22.7%, n=96; BDE: 19.7%, n=83). Prevalence of MDE was significantly higher in HIV-affected (30.1%, 95% CI 24.0-36.2%) than HIV-infected (14.8%, 95% CI 9.9-19.7%) participants; BDE was higher in HIV-infected (24.6%, 95% CI 18.7-30.6%) than in HIV-affected (15.1%, 95% CI 10.3-19.8%) participants. Being female (aOR 3.04, 95% CI 1.73-5.36), receiving a government grant (aOR 0.34, 95% CI 0.15-0.75), urban residency (aOR 1.86, 95% CI 1.16-2.96) and adult care-giving (aOR 2.37, 95% CI 1.37-4.12) were significantly associated with any depressive episode. Participants with a depressive episode were 2-3 times more likely to report poor health perceptions. LIMITATIONS Study limitations include the cross-sectional design, limited sample size and possible selection biases. CONCLUSIONS Prevalence of depressive episodes was high. Major depressive episodes were higher in HIV-affected than HIV-infected participants. Psycho-social support similar to that of HIV treatment programmes around HIV-affected older people may be useful in reducing their vulnerability to depression.
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Kuo C, Reddy MK, Operario D, Cluver L, Stein DJ. Posttraumatic stress symptoms among adults caring for orphaned children in HIV-endemic South Africa. AIDS Behav 2013; 17:1755-63. [PMID: 23539187 PMCID: PMC3664126 DOI: 10.1007/s10461-013-0461-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
There is growing evidence that mental health is a significant issue among families affected by AIDS-related parental deaths. The current study examined posttraumatic stress symptoms and identified risk factors among adults caring for AIDS-orphaned and other-orphaned children in an HIV-endemic South African community. A representative community sample of adults caring for children (N = 1,599) was recruited from Umlazi Township. Of the 116 participants who reported that a traumatic event was still bothering them, 19 % reported clinically significant posttraumatic stress symptoms. Of the 116 participants, caregivers of AIDS-orphaned and other-orphaned children were significantly more likely to meet threshold criteria for PTSD (28 %) compared to caregivers of non-orphaned children (10 %). Household receipt of an old age pension was identified as a possible protective factor for PTSD symptoms among caregivers of orphaned children. Services are needed to address PTSD symptoms among caregivers of orphaned children.
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Affiliation(s)
- Caroline Kuo
- Department of Behavioral and Social Sciences, Brown University, 121 South Main Street, Box G-S121-Floor 4, Providence, RI, USA.
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Prioritizing research for "One health - One world". Infect Dis Poverty 2012; 1:1. [PMID: 23849840 PMCID: PMC3710101 DOI: 10.1186/2049-9957-1-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Accepted: 08/30/2012] [Indexed: 12/01/2022] Open
Abstract
Infectious diseases of poverty, a collective term coined for infections known to be particularly prevalent amongst poor populations, is increasingly used for neglected tropical diseases (NTDs) with special transmission routes, such as depending on vectors and/or intermediate hosts. The journal Infectious Diseases of Poverty (IDP) is launched to explore new avenues in research to better understand the relationship between infectious diseases and poverty, and to contribute to priority settings for plans to control them. Introducing the “One health - One world” concept, IDP will publish original and empirical work based on analyses of disease burdens, their distribution and research needs in this area. The new journal will not only bring out research articles but also scoping reviews and highlights of trans-disciplinary work undertaken to combat the infectious diseases of poverty, wherever in the world they exist.
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Petersen I, Bhana A, Baillie K. The feasibility of adapted group-based interpersonal therapy (IPT) for the treatment of depression by community health workers within the context of task shifting in South Africa. Community Ment Health J 2012; 48:336-41. [PMID: 21687982 DOI: 10.1007/s10597-011-9429-2] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Accepted: 06/07/2011] [Indexed: 11/29/2022]
Abstract
Within the context of a large treatment gap for depression and a scarcity of specialist resources, there is a need for task shifting to scale up mental health services to address this gap in South Africa. This study assessed the feasibility of an adapted manualized version of grouped based Interpersonal Therapy (IPT) for use by supervised community health workers through a pilot study on 60 primary health care clinic users screened as having moderate to severe depression. Retention was good and participants in the group-based IPT intervention showed significant reduction in depressive symptoms on completion of the 12-week intervention as well as 24 weeks post baseline compared to the control group. Qualitative process evaluation suggests that improved social support, individual coping skills and improved personal agency assisted in the reduction of depressive symptoms.
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Affiliation(s)
- I Petersen
- School of Psychology, Howard College, University of KwaZulu-Natal, Durban, South Africa.
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Kuo C, Operario D, Cluver L. Depression among carers of AIDS-orphaned and other-orphaned children in Umlazi Township, South Africa. Glob Public Health 2011; 7:253-69. [PMID: 22081931 DOI: 10.1080/17441692.2011.626436] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
South Africa faces the challenge of supporting the well-being of adults caring for growing numbers of AIDS-orphaned children. These adults play a critical role in responses to the epidemic, but little information exists in regard to their mental health needs. This paper reports on findings from n=1599 adults, recruited through representative household sampling, who serve as primary carers for children in Umlazi Township, an HIV-endemic community. Overall, 22% of participants were carers of AIDS-orphaned children, 11% were carers of other-orphaned children and 67% were carers of non-orphaned children. Prevalence of depression was 30.3%. Orphan carers, regardless of whether they cared for AIDS-orphaned or other-orphaned children, were significantly more likely than carers of non-orphaned children to meet the clinical threshold for depression (35.2% vs. 27.9%, p < 0.01). In multivariate logistic regressions, food insecurity and being a female carer were identified as additional risk factors for greater depression. In contrast, households with access to running water and households dependent on salaries as the main source of income were identified as protective factors for disparities in depression. Mental health interventions are urgently needed to address an increased risk for depression among all orphan carers, not just those caring for AIDS-orphaned children.
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Affiliation(s)
- Caroline Kuo
- Division of Child and Adolescent Psychiatry, Rhode Island Hospital and Alpert Medical School, Brown University, Providence, RI, USA.
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Environment and health in South Africa: Gains, losses, and opportunities. J Public Health Policy 2011; 32 Suppl 1:S37-43. [DOI: 10.1057/jphp.2011.21] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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