Examining the characteristics of social and behavior change communication intervention costs in low- and middle-income countries: A hedonic method approach.

Understanding the costs of health interventions is critical for generating budgets, planning and managing programs, and conducting economic evaluations to use when allocating scarce resources. Here, we utilize techniques from the hedonic pricing literature to estimate the characteristics of the costs of social and behavior change communication (SBCC) interventions, which aim to improve health-seeking behaviors and important intermediate determinants to behavior change. SBCC encompasses a wide range of interventions including mass media (e.g., radio, television), mid media (e.g., community announcements, live dramas), digital media (e.g., short message service/phone reminders, social media), interpersonal communication (e.g., individual or group counseling), and provider-based SBCC interventions focused on improving provider attitudes and provider-client communication. While studies have reported on the costs of specific SBCC interventions in low- and middle-income countries, little has been done to examine SBCC costs across multiple studies and interventions. We use compiled data across multiple SBCC intervention types, health areas, and low- and middle-income countries to explore the characteristics of the costs of SBCC interventions. Despite the wide variation seen in the unit cost data, we can explain between 63 and 97 percent of total variance and identify a statistically significant set of characteristics (e.g., health area) for media and interpersonal communication interventions. Intervention intensity is an important determinant for both media and interpersonal communication, with costs increasing as intervention intensity increases; other important characteristics for media interventions include intervention subtype, target population group, and country income as measured by per capita Gross National Income. Important characteristics for interpersonal communication interventions include health area, intervention subtype, target population group and geographic scope.

Creating Reproductive Health Behavioral Profiles for Women of Reproductive Age in Niger Using Cross-Sectional Survey Data: A Latent Class Analysis.

Objectives: To identify health behavioral profiles for women of reproductive age in Niger. Methods: We interviewed married women of reproductive age in Niger in April 2021 (N = 2,709). Latent class analysis based on sociodemographic and behavioral determinants was used to identify classes of women related to use of antenatal care, facility delivery, and modern family planning (FP) use. Results: We found similar classes between the use of antenatal care and facility-based delivery classes with the first class composed of less educated and poor women with weaker behavioral determinants while the second class was more educated and had stronger behavioral determinants. In the facility-based delivery class was the presence of a third class that was poor and uneducated with low levels of knowledge and social norms, but in contrast had much higher levels of positive attitudes, self-efficacy, and partner communication than the first class. A fourth class of younger, more educated women with strong behavioral determinants emerged related to FP. Conclusion: The application of empirical subgrouping analysis permits an informed approach to targeted interventions and resource allocation for optimizing maternal and reproductive health.

Estimating the Cost of the Design, Production, and Dissemination of Social Media Videos for Social and Behavioral Change: Evidence From Merci Mon Héros in Niger and Côte d'Ivoire.

Merci Mon Héros (MMH) is a youth-led multi-media campaign in Francophone West Africa seeking to improve reproductive health and family planning outcomes using radio, television, social media, and community events. One component to this project is the development of a series of youth-driven videos created to encourage both youth and adults to break taboos by talking to each other about reproductive health and family planning. A costing study was conducted to capture costs associated with the design, production, and dissemination of 11 MMH videos (in French) on social media in Côte d'Ivoire and Niger. The total costs to design, produce and disseminate 11 of the campaign videos for MMH in both Côte d'Ivoire and Niger were $44,981. Unit costs were calculated using three different denominators, resulting in average unit costs of $0.16 per reach, $1.29 per engagement, and $4.27 per video view. These findings can be useful for future studies of SBC interventions using social media for framing the analysis and selecting the appropriate metrics for the denominator, as well as for budgeting and planning SBC programs using social media.

Estimating private sector out-of-pocket expenditures on family planning commodities in low-and-middle-income countries.

INTRODUCTION: The role of the private sector in family planning (FP) is well studied; however, few efforts have been made to quantify the role of private out-of-pocket (OOP) expenditures on FP commodities across low-and-middle-income countries (LMICs). Calculating OOP expenditures is important to illuminate the magnitude of these contributions and to inform discussions on how financial burdens can be reduced. METHODS: Estimates of FP users and commodities consumed by women getting their FP methods from the private sector were made for 132 LMICs. Next, unit price data were compiled from to estimate the average price of commodities in the private sector at both a commercial and subsidised price point. These unit prices were applied to commodity consumption estimates to calculate total private OOP expenditures. Sensitivity testing was conducted. RESULTS: Total estimated private OOP expenditures for FP commodities in 2019 was $2.73 billion across 132 LMICs. Spending on contraceptive pills accounted for 80% of this total, and just over three-quarters of expenditure came from upper-middle-income countries. OOP expenditures on subsidised commodities were small but accounted for 20% of expenditures in low-income countries. Non-subsidised unit prices were found to be between 5 and 20 times higher in upper-middle-income countries compared with low-income countries, although wide variation exists. For low-income and lower-middle-income countries, subsidies appear to be greatest for intrauterine devices (IUDs) and pills. CONCLUSION: Large OOP expenditures across all income levels highlight a need for financing approaches that ensure that a wide range of contraceptives are both accessible and affordable.

Using the Demographic Health Survey wealth index to create family planning market segments based on absolute income levels.

Family planning market segmentation approaches typically include analysis by wealth, particularly when considering whether individuals can afford out-of-pocket expenses in the private sector. Most commonly, this is done using the Demographic and Health Survey (DHS) wealth index, which uses a relative approach by summing household asset questions and categorising respondents into five groups from poorest to wealthiest within a country. In addition, the use of absolute measures, such as segmenting populations based on whether one lives below or above the International Poverty line, defined by the World Bank as US$1.90 per person per day, may provide further useful insights when designing strategies to ensure access to family planning. While such measures are not readily available in the DHS, a simple approach can be used to combine the wealth index and World Bank poverty lines to generate an absolute measure for an additional perspective when conducting family planning market segmentation. Family planning market size estimates were made for 24 low-income countries using wealth quintiles and World Bank poverty lines. The results show large variations in market size based on what measure is used, particularly for countries with a high density of poverty. Looking at both types of measures and understanding the reasons for the differences in market size estimates between the approaches can help lend a more nuanced understanding of the distribution of wealth and income in a country, leading to improved family planning market segmentation and ultimately to ensure more women have access to a method of their choice.

Family Planning in Zambia: An Investment Pillar for Economic Development.

Family planning represents a 'best buy' in global efforts to achieve sustainable development and attain improvements in sexual and reproductive health. By meeting contraceptive needs of all women, significant public health impact and development gains accrue. At the same time, governments face the complex challenge of allocating finite resources to competing priorities, each of which presents known and unknown challenges and opportunities. Zambia has experienced a slow but steady increase in contraceptive prevalence, with slight decline in total fertility rate (TFR), over the past 20 years. Drawing from the Zambian context, including a review of current policy solutions, we present a case for making investments in voluntary family planning (FP), underpinned by a human rights framework, as a pillar for accelerating development and socio-economic advancement. Through multilevel interventions aimed at averting unintended pregnancies, Zambia - and other low- and middle-income countries - can reduce their age dependency ratios and harness economic growth opportunities awarded by the demographic dividend while improving the health and quality of life of the population.

Review of performance-based incentives in community-based family planning programmes.

BACKGROUND: One strategy for improving family planning (FP) uptake at the community level is the use of performance-based incentives (PBIs), which offer community distributors financial incentives to recruit more users of FP. This article examines the use of PBIs in community-based FP programmes via a literature search of the peer-reviewed and grey literature conducted in April 2013. RESULTS: A total of 28 community-based FP programmes in 21 countries were identified as having used PBIs. The most common approach was a sales commission model where distributors received commission for FP products sold, while a referral payment model for long-term methods was also used extensively. Six evaluations were identified that specifically examined the impact of the PBI in community-based FP programmes. Overall, the results of the evaluations are mixed and more research is needed; however, the findings suggest that easy-to-understand PBIs can be successful in increasing the use of FP at the community level. CONCLUSION: For future use of PBIs in community-based FP programmes it is important to consider the ethics of incentivising FP and ensuring that PBIs are non-coercive and choice-enhancing.

Equity monitoring for social marketing: use of wealth quintiles and the concentration index for decision making in HIV prevention, family planning, and malaria programs.

BACKGROUND: The majority of social marketing programs are intended to reach the poor. It is therefore essential that social marketing organizations monitor the health equity of their programs and improve targeting when the poor are not being reached. Current measurement approaches are often insufficient for decision making because they fail to show a program's ability to reach the poor and demonstrate progress over time. Further, effective program equity metrics should be benchmarked against a national reference population and consider exposure, not just health outcomes, to measure direct results of implementation. This study compares two measures of health equity, concentration indices and wealth quintiles, using a defined reference population, and considers benefits of both measures together to inform programmatic decision making. METHODS: Three datasets from recent cross-sectional behavioral surveys on malaria, HIV, and family planning from Nepal and Burkina Faso were used to calculate concentration indices and wealth quintiles. Each sample was standardized to national wealth distributions based on recent Demographic and Health Surveys. Wealth quintiles were generated and concentration indices calculated for health outcomes and program exposure in each sample. Chi-square and t-tests were used to assess statistical significance of results. RESULTS: Reporting wealth quintiles showed that recipients of Population Services International (PSI) interventions were wealthier than national populations. Both measures indicated that desirable health outcomes were usually concentrated among wealthier populations. Positive and significant concentration indices in all three surveys indicated that wealth and program exposure were correlated; however this relationship was not necessarily linear. In analyzing the equity of modern contraceptive use stratified by exposure to family planning messages in Nepal, the outcome was equitable (concentration index = 0.006, p = 0.68) among the exposed, while the wealthy were more likely to use modern contraceptives (concentration index = 0.071, p < 0.01) among the unexposed. CONCLUSIONS: Using wealth quintiles and concentration indices together for equity monitoring improves usability of findings for decision making. Applying both metrics, and analyzing equity of exposure along with health outcomes, provides results that have statistical and programmatic significance. Benchmarking equity data against national data improves generalizability. This approach benefits social marketers and global health implementers to improve strategic decision making and programs' ability to reach the poor.

The impact of vouchers on the use and quality of health care in developing countries: a systematic review.

One approach to delivering healthcare in developing countries is through voucher programmes, where vouchers are distributed to a targeted population for free or subsidised health care. Using inclusion/exclusion criteria, a search of databases, key journals and websites review was conducted in October 2010. A narrative synthesis approach was taken to summarise and analyse five outcome categories: targeting, utilisation, cost efficiency, quality and health outcomes. Sub-group and sensitivity analyses were also performed. A total of 24 studies evaluating 16 health voucher programmes were identified. The findings from 64 outcome variables indicates: modest evidence that vouchers effectively target specific populations; insufficient evidence to determine whether vouchers deliver healthcare efficiently; robust evidence that vouchers increase utilisation; modest evidence that vouchers improve quality; no evidence that vouchers have an impact on health outcomes; however, this last conclusion was found to be unstable in a sensitivity analysis. The results in the areas of targeting, utilisation and quality indicate that vouchers have a positive effect on health service delivery. The subsequent link that they improve health was found to be unstable from the data analysed; another finding of a positive effect would result in robust evidence. Vouchers are still new and the number of published studies is limiting.

Systematic Review: the use of vouchers for reproductive health services in developing countries: systematic review.

OBJECTIVES: To identify where vouchers have been used for reproductive health (RH) services, to what extent RH voucher programmes have been evaluated, and whether the programmes have been effective. METHODS: A systematic search of the peer review and grey literature was conducted to identify RH voucher programmes and evaluation findings. Experts were consulted to verify RH voucher programme information and identify further programmes and studies not found in the literature search. Studies were examined for outcomes regarding targeting, costs, knowledge, utilization, quality, and population health impact. Included studies used cross-sectional, before-and-after and quasi-experimental designs. RESULTS: Thirteen RH voucher programmes fitting established criteria were identified. RH voucher programmes were located in Bangladesh, Cambodia, China, Kenya (2), Korea, India, Indonesia, Nicaragua (3), Taiwan, and Uganda. Among RH voucher programmes, 7 were quantitatively evaluated in 15 studies. All evaluations reported some positive findings, indicating that RH voucher programmes increased utilization of RH services, improved quality of care, and improved population health outcomes. CONCLUSIONS: The potential for RH voucher programmes appears positive; however, more research is needed to examine programme effectiveness using strong study designs. In particular, it is important to see stronger evidence on cost-effectiveness and population health impacts, where the findings can best direct governments and external funders.

Adoption of health promotion practices in a cohort of U.S. physician organizations.

BACKGROUND: Physician organizations such as medical groups and independent practice associations can play a vital role in health promotion through the adoption of effective health promotion practices such as health risk assessments, patient reminder systems, and health promotion education programs. PURPOSE: To examine organizational changes in a cohort of physician organizations and changing health promotion practices. METHODS: Data for a cohort of 369 physician organizations in the U.S. with 20 or more physicians were collected between September 2000 and September 2001 and subsequently from March 2006 to March 2007. Paired-sample t tests were used to identify changes in physician organization characteristics and the use of nine health promotion practices between 2000-2001 and 2006-2007. RESULTS: Compared to 2000-2001, the cohort of physician organizations in 2006-2007 was larger, more likely to be owned by physicians; less likely to be owned by a hospital, health system, or HMO; more profitable; and more likely to use electronic information technology. Between 2000-2001 and 2006-2007, physician organizations increased the use of health risk appraisals to contact high-risk patients and increased the use of reminders for eye exams for diabetic patients. During the same time period, physician organizations decreased the use of nutrition and weight-loss health promotion programs. CONCLUSIONS: The adding and dropping of programs among physician organizations is due to many factors, including changing regulatory environments, market conditions, populations, and new health promotion technologies. In the coming years, incentives and regulatory policy should encourage the adoption of effective health promotion practices by physician organizations.

Adoption of policies to treat tobacco dependence in U.S. medical groups.

BACKGROUND: There remains an ongoing need to reduce tobacco use in the U.S. Physician organizations, such as medical groups, can support healthcare providers to be more effective in their delivery of tobacco cessation by adopting practices recommended in the Public Health Service Clinical Practice Guideline for Treating Tobacco Use and Dependence (PHS Guideline). PURPOSE: To document the extent to which activities to reduce tobacco use, as recommended in the PHS Guideline as system-level interventions, are provided within large medical groups in the U.S. METHODS: During 2006-2007, data were collected on 339 medical groups operating in the U.S., with 20 or more physicians treating at least one of four chronic conditions. Organizations were surveyed regarding activities to reduce tobacco use as recommended in the PHS Guideline as system-level interventions (i.e., tobacco-use status documentation, policies to promote provider interventions, and staff dedicated to treating tobacco dependence). Between 2008 and 2009, bivariate associations and multivariate logistic regression models assessed the relationship of organizational characteristics and external incentives with adoption of systems strategies for treating tobacco dependence. RESULTS: Nearly 83% of medical groups with 20 or more physicians operating in the U.S. in 2006-2007 have adopted one or more strategies recommended as effective to support the treatment of tobacco dependence. However, only 5.6% of medical groups engage in all eight tobacco control activities examined in this study. The two factors that were associated most consistently with medical group policies to treat tobacco dependence were the patient-centeredness of the organization and participation in a quality demonstration program. CONCLUSIONS: There is much room for improvement in increasing medical group adoption of systems strategies to reduce tobacco use. The findings in this paper suggest recommendations to achieve these improvements.

MDS-based state Medicaid reimbursement and the ADL-decline quality indicator.

PURPOSE: We examined the relationship between the quality indicator for decline in activities of daily living (ADL) and the use of the Minimum Data Set (MDS) for determining Medicaid skilled nursing facility reimbursement. DESIGN AND METHODS: We conducted a cross-sectional analysis using the 2004 National MDS Facility Quality Indicator reports as the dependent variable in a multilevel regression model. Our primary explanatory variable was a state-level binary variable distinguishing whether or not the state used an MDS-based Medicaid-reimbursement system in 2004. We obtained control variables through the Online Survey, Certification, and Reporting System. RESULTS: Skilled nursing facilities located in states that used the MDS for Medicaid reimbursement reported more ADL decline than did facilities in states that did not use the MDS for reimbursement. IMPLICATIONS: The finding suggests that the ADL-decline quality indicator captures more than just quality, including state-level policy differences. Therefore, the ADL-decline quality indicator should be investigated and refined prior to being relied on for pay-for-performance initiatives.

Impact of Medicaid reimbursement on mental health quality indicators.

OBJECTIVE: To examine the relationship between the use of the Minimum Data Set (MDS) for determining Medicaid reimbursement to nursing facilities and the MDS Quality Indicators examining nursing facility residents' mental health. DATA SOURCES: The 2004 National MDS facility Quality Indicator reports served as the dependent variables. Explanatory variables were based on the 2004 Online Survey Certification and Reporting system (OSCAR) and an examination of existing reports, a review of the State Medicaid Plans, and State Medicaid personnel. STUDY DESIGN: Multilevel regression models were used to account for the hierarchical structure of the data. DATA COLLECTION: MDS and OSCAR data were linked by facility identifiers and subsequently linked with state-level variables. PRINCIPAL FINDINGS: The use of the MDS for determining Medicaid reimbursement was associated with higher (poorer) quality indicator values for all four mental health quality indicators examined. This effect was not found in four comparison quality indicators. CONCLUSIONS: The findings indicate that documentation of mental health symptoms may be influenced by economic incentives. Policy makers should be cautioned from using these measures as the basis for decision making, such as with pay-for-performance initiatives.

Adoption of system strategies for tobacco cessation by state medicaid programs.

BACKGROUND: The Public Health Service's Clinical Practice Guideline for treating tobacco dependence recommends 6 system-wide strategies for health administrators, insurers, and purchasers to support tobacco cessation. METHODS: A 24-question survey was sent to each state Medicaid program office in the fall of 2005, including questions to assess whether each state Medicaid program adopted 4 of the 6 system strategies most relevant to Medicaid contracting. RESULTS: The number of system strategies adopted by state Medicaid programs in 2005 ranged from 0 to 4 of the 4 strategies examined. Oregon, Pennsylvania, and West Virginia adopted all 4 systems strategies for cessation in their Medicaid programs. Seven states adopted 3 strategies, and 14 states adopted 2. Seventeen states adopted only 1 of the system strategies, and 10 state Medicaid programs had not adopted any of the recommended system strategies for tobacco cessation. The most frequently adopted strategy was Medicaid coverage for tobacco dependence treatments, with 75% of the states covering at least 1 recommended treatment under their Medicaid program. CONCLUSIONS: Although most state Medicaid programs have made efforts to adopt at least one of the recommended system strategies to support tobacco cessation, there remains substantial room for improvement. More research is needed regarding the barriers to Medicaid program adoption of comprehensive system strategies to promote cessation among their enrolled populations.

Knowledge of Medicaid coverage and effectiveness of smoking treatments.

BACKGROUND: Tobacco dependence has enormous health and financial repercussions in the United States, particularly among Medicaid enrollees, where a disproportionate share of the population smokes (36% compared to 23% in the general population). This paper examines two factors associated with the use of tobacco-dependence treatments (TDTs) in the Medicaid population: knowledge of TDT coverage and perceived effectiveness of TDTs. METHODS: Medicaid-enrolled smokers and recent quitters in four areas in the United States with comprehensive coverage of TDTs were interviewed as part of a random-digit-dial telephone survey in September 2003. Information was collected on demographics, health status, smoking history, knowledge of Medicaid coverage of TDTs (nicotine replacement patch and gum, Zyban, and counseling), and perceived effectiveness of TDTs. Logistic regression models were estimated to explain variation in enrollee use of TDTs as a function of knowledge of covered benefits and perceived effectiveness of the treatments. RESULTS: Both knowledge of TDT coverage and the perceived effectiveness of TDTs are positively associated with the use of TDTs in the Medicaid population. However, a majority of Medicaid smokers do not know that Medicaid covers TDTs, and the perceived effectiveness of TDTs is often at odds with findings from the scientific literature. CONCLUSIONS: Knowledge of Medicaid coverage and the perceived effectiveness of TDTs are associated with increased use of TDTs in the Medicaid population. Additional research is needed to better inform Medicaid smokers of their coverage and the effectiveness of TDTs in ways that encourage them to use these treatments to assist quit attempts.

State-mandated benefit review laws.

OBJECTIVE: To determine which states have laws that require the review of mandated health insurance benefits and describe the various approaches states take in reviewing mandated benefits, as stated in the mandated benefit review (MBR) laws. DATA SOURCES: We queried online databases of the individual state statutes and reviewed the state statutes and state legislative agendas for all 50 states and Washington, DC to identify those states with active MBR laws as of September 2004. STUDY DESIGN: We reviewed the identified MBR laws to catalog their various components. The components chosen for this analysis include: general review strategy, designated reviewers, time frame for conducting reviews, criteria used in the review, requirements to use actuaries, sources of funding, and state data collection systems. Two of the authors independently created analysis categories and coded the MBR laws to document details on the major components of the laws. PRINCIPAL FINDINGS: We identified 26 state MBR laws active as of September 2004. A majority of the MBR laws specified a prospective review approach and only one law used an exclusively retrospective review approach. A substantial amount of variation was found with regards to the designated reviewers, time frames for conducting reviews, and criteria used in the review. Few states specified the use of actuaries, sources of funding, and state data collection systems. CONCLUSIONS: The number of states that have enacted MBR laws has increased substantially in recent years, however, different states have structured the review of mandated benefits differently, according to the values and perceived needs of the state legislatures. It is important that states increasingly consider a broader scope of review criteria so state decision makers can position themselves to mandate only those benefits that add real value to the state's health care system.

Medicaid coverage for tobacco-dependence treatments.

This paper presents an update on the availability of tobacco-dependence treatments in Medicaid benefit packages from 1998 to 2003 and discusses variation in states' approaches for addressing tobacco cessation. In 2003 thirty-seven states had coverage for at least one evidence-based treatment. Since 1998, thirteen Medicaid programs have added coverage for at least one, while five programs have expanded coverage of these treatments. Overall, the coverage increases indicate a growing awareness of the treatments' importance for the health of Medicaid recipients, although further expansions are still needed.

Endangered species? Not-for-profit hospitals face tax-exemption challenge.

The recent decision by the Illinois Department of Revenue to revoke the tax-exempt status of Provena Covenant Medical Center is just one indication of a larger trend in which states are increasingly questioning the exchange of social contributions by not-for-profit hospitals for favorable tax treatment. As yet, there is no consensus on how charity care or community benefits should be measured. Results of a study examining different states' specifications of charity care indicate that alternate definitions of charitable contributions have a material effect on the total dollars recognized as charitable contributions. Such differences could have a bearing on any state's decision regarding whether a hospital should be allowed to retain its tax-exempt status.