Rationale, conceptual issues, and resultant protocol for a mixed methods Person Trade Off (PTO) and qualitative study to estimate and understand the relative value of gains in health for children and young people compared to adults.

BACKGROUND: Economic evaluation of healthcare typically assumes that an identical health gain to different patients has the same social value. There is some evidence that the public may give greater value to gains for children and young people, although this evidence is not always consistent. We present a mixed methods study protocol where we aim to explore public preferences regarding health gains to children and young people relative to adults, in an Australian setting. METHODS: This study is a Person Trade Off (PTO) choice experiment that incorporates qualitative components. Within the PTO questions, respondents will be asked to choose between treating different groups of patients that may differ in terms of patient characteristics and group size. PTO questions will be included in an online survey to explore respondent views on the relative value of health gains to different age groups in terms of extending life and improving different aspects of quality of life. The survey will also contain attitudinal questions to help understand the impact of question style upon reported preferences. Additionally, the study will test the impact of forcing respondents to express a preference between two groups compared with allowing them to report that the two groups are equivalent. One-to-one 'think aloud', semi-structured interviews will be conducted to explore a sub-sample of respondents' motivations and views in more detail. Focus groups will be conducted with members of the public to discuss the study findings and explore their views on the role of public preferences in health care prioritisation based on patient age. DISCUSSION: Our planned study will provide valuable information to healthcare decision makers in Australia who may need to decide whether to pay more for health gains for children and young people compared with adults. Additionally, the methodological test of forcing respondent choice or allowing them to express equivalence will contribute towards developing best practice methods in PTO studies. The rationale for and advantages of the study approach and potential limitations are discussed in the protocol.

Midday meals as an early childhood nutrition intervention: evidence from plantation communities in Sri Lanka.

BACKGROUND: High rates of child malnutrition are a major public health concern in developing countries, particularly among vulnerable communities. Midday meals programs can be effective for combatting childhood malnutrition among older children. However, their use in early childhood is not well documented, particularly within South Asia. Anthropometric measures and other socioeconomic data were collected for children below the age of 5 years living in selected Sri Lankan tea plantations, to assess the effectiveness of midday meals as a nutrition intervention for improving growth among young children. METHODS: The study exploits a natural experiment whereby the provision of the midday meals program is exogenously determined at the plantation level, resulting in comparable treatment and control groups. Longitudinal data was collected on heights and weights of children, between 2013 and 2015. Standardized weight-for-age, height-for-age and weight-for-height, and binary variables for stunting, wasting and underweight are constructed, following WHO guidelines. All modelling uses STATA SE 15. Random-effects regression with instrumental variables is used for modelling standardized growth while random-effects logistic regression is used for the binary outcomes. Robustness analysis involves different estimation methods and subsamples. RESULTS: The dataset comprises of longitudinal data from a total of 1279 children across three tea plantations in Sri Lanka, with 799 children in the treatment group and 480 in the control group. Results show significant positive effects of access to the midday meals program, on the growth of children. A child with access to the midday meals intervention reports an average standardized weight-for-age 0.03 (±0.01) and height-for-age 0.05 (±0.01) units higher than a similar child without access to the intervention. Importantly, access to the intervention reduces the likelihood of being underweight by 0.45 and the likelihood of wasting by 0.47. The results are robust to different model specifications and across different subsamples by gender, birthweight and birth-year cohort. CONCLUSIONS: Midday meals programs targeting early childhood can be an effective intervention to address high rates of child malnutrition, particularly among vulnerable communities in developing countries like Sri Lanka.

Community-level health programs and child labor: Evidence from Ethiopia.

Many developing countries have adopted community-based primary health-care programs. A vital component of these programs is health literacy, which teaches households to avoid physical harm. Child labor can often result in physical harm through injury. Our hypothesis is that health literacy programs make households aware of previously unknown costs of child labor (i.e., risks of injury), resulting in a reallocation of labor away from children. Using Ethiopian data, we investigate if exposure to a community-level health program delivered by Health Extension Workers (HEWs) lowers child labor. We use panel data comprising 5587 observations from 2255 children over four waves of the Young Lives Project. These data are combined with administrative regional-level data on HEWs over the 2006-2016 period. Our identification strategy exploits variations in the deployment of HEWs across regions and time to investigate a plausibly exogenous effect on child labor. We provide evidence that supports our hypothesis. We posit that the mechanism behind our result is likely behavioral change, and rule out several other potential channels, including public safety net programs and the effect of HEWs on education. Our results point to the role that health programs can play in the fight against child labor.