Residential energy efficiency interventions: A meta-analysis of effectiveness studies.

Background: The residential sector releases around 17% of global greenhouse gas emissions and making residential buildings more energy efficient can help mitigate climate change. Engineering models are often used to predict the effects of residential energy efficiency interventions (REEI) on energy consumption, but empirical studies find that these models often over-estimate the actual impact of REEI installation. Different empirical studies often estimate different impacts for the same REEI, possibly due to variations in implementation, climate and population. Funding for this systematic review was provided by the evaluation function at the European Investment Bank Group. Objectives: The review aims to assess the effectiveness of installing REEIs on the following primary outcomes: energy consumption, energy affordability, CO2 emissions and air quality indices and pollution levels. Search Methods: We searched CAB Abst, Econlit, Greenfile, Repec, Academic Search Complete, WB e-lib, WoS (SCI and SSCI) and other 42 databases in November 2020. In addition, we searched for grey literature on websites, checked the reference lists of included studies and relevant reviews, used Google Scholar to identify studies citing included studies, and contacted the authors of studies for any ongoing and unpublished studies. We retrieved a total of 13,629 studies that we screened at title and abstract level, followed by full-text screening and data extraction. Selection Criteria: We included randomised control trials, and quasi-experimental studies that evaluated the impact of installing REEIs anywhere in the world and with any comparison. Data Collection and Analysis: Two independent reviewers screened studies for eligibility, extracted data and assessed risk of bias. When more than one included study examined the same installation of the same type of REEI for a similar outcome, we conducted a meta-analysis. We also performed subgroup analyses. Main Results: A total of 16 studies were eligible and included in the review: two studies evaluated the installation of efficient lighting, three studies the installation of attic/loft insulation, two studies the installation of efficient heat pumps, eight studies the installation of a bundle of energy efficiency measures (EEMs), and one study evaluated other EEMs. Two studies, neither appraised as having a low risk of bias, find that lighting interventions lead to a significant reduction in electricity energy consumption (Hedges' g = -0.29; 95% confidence interval [CI]: -0.48, -0.10). All the other interventions involved heating or cooling, and effects were synthesizised by warmer or colder climate and then across climates. Four studies examined the impact of attic/loft insulation on energy consumption, and two of these studies were appraised as having a low risk of bias. Three studies took place in colder climates with gas consumption as an outcome, and one study took place in a warmer climate, with the electricity consumption (air conditioning) as the outcome. The average impact across all climates was small (Hedges' g = 0.04; 95% CI: -0.09, 0.01) and statistically insignificant. However, two of the studies appear to have evaluated the effect of installing small amounts (less than 75 mm) of insulation. The other two studies, one of which was appraised as low risk of bias and the other involving air conditioning, found significant reductions in consumption. Two studies examined the impact of installing electric heat pumps. The average impact across studies was not statistically significant (Hedges' g = -0.11; 95% CI: -0.41, 0.20). However, there was substantial variation between the two studies. Replacing older pumps with more efficient versions significantly reduced electricity consumption in a colder climate (Hedges' g = -0.36; 95% CI, -0.57, -0.14) in a high risk of bias study. However, a low risk of bias study found a significant increase in electricity consumption from installing new heat pumps (Hedges' g = 0.09; 95% CI, 0.06, 0.12). Supplemental analyses in the latter study indicate that households also used the heat pumps for cooling and that the installed heat pumps most likely reduced overall energy consumption across all sources-that is, households used more electricity but less gas, wood and coal. Seven studies examined bundled REEIs where the households chose which EEMs to install (in five studies the installation occurred after an energy audit that recommended which EEMs to install). Overall, the studies estimated that installing an REEI bundle is associated with a significant reduction in energy consumption (Hedges' g = -0.36; 95% CI, -0.52, -0.19). In the two low risk of bias studies, conducted with mostly low-income households, installed bundles reduced energy consumption by a statistically significant amount (Hedges' g = -0.16; 95% CI, -0.13, -0.18). Authors' Conclusions: The 16 included studies indicate that installing REEIs can significantly reduce energy consumption. However, the same type of REEI installed in different studies caused different effects, indicating that effects are conditional on implementation and context. Exploring causes of this variation is usually not feasible because existing research often does not clearly report the features of installed interventions. Additional high quality impact evaluations should be commissioned in more diverse contexts (only one study was conducted in either Asia or Africa-both involved lighting interventions-and no studies were conducted in South America or Southern Europe).

PROTOCOL: Residential energy efficiency interventions: An effectiveness systematic review.

This review aims to identify, appraise and synthesise the evidence available on the effectiveness of energy efficiency measure installations, including those bundled with behavioural interventions. The synthesis will estimate the overall impact of these interventions as well as examine possible causes of variation in impacts. We will also attempt to assess the cost-effectiveness of residential energy efficiency interventions.

Effectiveness and safety of herbal medicines for induction of labour: a systematic review and meta-analysis.

OBJECTIVE: The use of herbal medicines for induction of labour (IOL) is common globally and yet its effects are not well understood. We assessed the efficacy and safety of herbal medicines for IOL. DESIGN: Systematic review and meta-analysis of published literature. DATA SOURCES: We searched in MEDLINE, AMED and CINAHL in April 2017, updated in June 2018. ELIGIBILITY CRITERIA: We considered experimental and non-experimental studies that compared relevant pregnancy outcomes between users and non-user of herbal medicines for IOL. DATA EXTRACTION AND SYNTHESIS: Data were extracted by two reviewers using a standardised form. A random-effects model was used to synthesise effects sizes and heterogeneity was explored through I2 statistic. The risk of bias was assessed using 'John Hopkins Nursing School Critical Appraisal Tool' and 'Cochrane Risk of Bias Tool'. RESULTS: A total of 1421 papers were identified through the searches, but only 10 were retained after eligibility and risk of bias assessments. The users of herbal medicine for IOL were significantly more likely to give birth within 24 hours than non-users (Risk Ratio (RR) 4.48; 95% CI 1.75 to 11.44). No significant difference in the incidence of caesarean section (RR 1.19; 95% CI 0.76 to 1.86), assisted vaginal delivery (RR 0.73; 95% CI 0.47 to 1.14), haemorrhage (RR 0.84; 95% CI 0.44 to 1.60), meconium-stained liquor (RR 1.20; 95% CI 0.65 to 2.23) and admission to nursery (RR 1.08; 95% CI 0.49 to 2.38) was found between users and non-users of herbal medicines for IOL. CONCLUSIONS: The findings suggest that herbal medicines for IOL are effective, but there is inconclusive evidence of safety due to lack of good quality data. Thus, the use of herbal medicines for IOL should be avoided until safety issues are clarified. More studies are recommended to establish the safety of herbal medicines.

Factors associated with contraceptive use among young women in Malawi: analysis of the 2015-16 Malawi demographic and health survey data.

BACKGROUND: Although Malawi is one of the countries with highest Contraceptive Prevalence Rate (CPR) in Sub-Saharan Africa, pregnancies and fertility among young women remain high. This suggests low up take of contraceptives by young women. The aim of this study was to investigate the factors associated with contraceptive use among young women in Malawi. METHODS: This is a secondary analysis of household data for 10,422 young women aged 15-24 years collected during the 2015-16 Malawi Demographic and Health Survey (MDHS). The sample was weighted to ensure representativeness. Descriptive statistics, bivariate and multivariate logistic regressions were performed to assess the demographic, social - economic and other factors that influence contraceptive use among young women. Crude Odds Ratio (COR) and Adjusted Odds Ratio (AOR) with their corresponding 95% confidence intervals (95% CI) were computed using the Statistical Package for the Social Sciences version 22.0. RESULTS: Of the 10,422 young women, 3219 used contraception representing a prevalence of 30.9%. The findings indicate that age, region of residence, marital status, education, religion, work status, a visit to health facility, and knowledge of the ovulatory cycle are significant predictors of contraceptive use among young women in Malawi. Women who were in the age group 20-24 years (AOR = 1.93; 95% CI = 1.73-2.16), working (AOR = 1.26; 95% CI = 1.14-1.39), currently married (AOR = 6.26; 95% CI = 5.46-7.18), knowledgeable about their ovulatory cycle (AOR = 1.75; 95% CI = 1.50-2.05), and those with primary education (AOR = 1.47; 95% CI = 1.18-1.83) were more likely to use contraceptives than their counterparts. CONCLUSION: This study has demonstrated that several social demographic and economic factors are associated with contraceptive use among young women in Malawi. These findings should be considered and reflected in public health policies to address issues that could be barriers to the use of contraception by young women. Strengthening access to family planning information and services for young women is highly recommended to reduce pregnancies among young women in Malawi.

Associations between the use of herbal medicines and adverse pregnancy outcomes in rural Malawi: a secondary analysis of randomised controlled trial data.

BACKGROUND: The use of herbal medicines during pregnancy is very high globally and previous studies have pointed out possible associations with adverse pregnancy outcomes. Nevertheless, the safety of herbal medicines in pregnancy is under-explored in low-income countries experiencing high maternal and neonatal complications. We investigated the associations between self-reported use of Mwanamphepo (a group of herbal medicines commonly used to induce or hasten labour) and adverse maternal and neonatal outcomes in rural Malawi. METHODS: We conducted a cross-sectional analysis of secondary household data relating to 8219 births that occurred between 2005 and 2010 in Mchinji district, Malawi. The data were collected as part of a cluster-randomised controlled trial (RCT) that evaluated community interventions designed to reduce maternal and neonatal mortality. Data were gathered on maternity history, demographic characteristics, pregnancy outcomes and exposure to Mwanamphepo. Associations between self-reported use of Mwanamphepo and maternal morbidity as well as neonatal death or morbidity were examined using mixed-effects models, adjusted for relevant covariates. All analyses were also adjusted for the clustered nature of the survey. RESULTS: Of the 8219 births, Mwanamphepo was used in 2113 pregnancies, representing an estimated prevalence of 25.7%. The self-reported use of Mwanamphepo was significantly associated with increased occurrence of maternal morbidity and neonatal death or morbidity. Specifically, the odds of maternal morbidity were 28% higher among self-reported users than non-users of Mwanamphepo (AOR = 1.28; 95% CI = 1.09-1.50) and the probabilities of neonatal death or morbidity were 22% higher (AOR =1.22; 95% CI = 1.06-1.40) among neonates whose mother reportedly used Mwanamphepo than those who did not. CONCLUSION: The use of Mwanamphepo was associated with adverse pregnancy outcomes in rural Malawi. Thus, herbal medicines may not be safe in pregnancy. Where possible, pregnant women should be discouraged from using herbal medicines of unconfirmed safety and those who report to have used should be closely monitored by health professionals. The study was limited by the self-report of exposure and unavailability of data relating to some possible confounders.

Documentation of the partograph in assessing the progress of labour by health care providers in Malawi's South-West zone.

BACKGROUND: There is some evidence that appropriate use of partograph in monitoring the progress of labour could decrease delivery related complications. The documentation of parameters of partographs is however, poorly understood. The aim of the present study was to determine the extent to which health care workers are making use of the partograph in monitoring the progress of labour through checking the documentation of the parameters of the partographs. METHODS: A hospital-based descriptive study involving retrospective review of partographs for births that occurred in 2016 was conducted in Malawi's South-West zone. A total of 1070 partographs that were used to monitor labour in two public hospitals were reviewed to determine the documentation of the parameters of partographs and descriptive statistics were computed using statistical package for the social science software version 22.0. RESULTS: Of the total 1070 partographs reviewed, 58.6% (n = 627) of the partographs had no recording of maternal blood pressure and 65.3% (n = 699) of the partographs had no temperature documentation. Moulding was not recorded in 25.4% (n = 272) of the partographs, foetal heart rate was not recorded in 14.9% (n = 159) of the partographs and descent of the foetal head was not recorded in 12.0% (n = 128) of the partographs. CONCLUSION: There is poor documentation of vital parameters of the partographs. This suggests insufficient monitoring of the progress of labour, which may lead to adverse pregnancy outcomes. To improve the accurate documentation of parameters of the partograph, there is a need to understand the problem and provide tailor-made solutions to address them and ultimately improve pregnancy outcomes. In the meantime, in-service refresher courses on partograph use to health care workers need to be conducted regularly. Supportive supervision to obstetric care providers and regular partograph audit could also improve documentation.

Effectiveness of Continuum of Care-Linking Pre-Pregnancy Care and Pregnancy Care to Improve Neonatal and Perinatal Mortality: A Systematic Review and Meta-Analysis.

REVIEW REGISTRATION: PROSPERO International prospective register of systematic reviews (CRD42015023424).

The effectiveness of a nationwide universal coverage campaign of insecticide-treated bed nets on childhood malaria in Malawi.

BACKGROUND: Although the universal coverage campaign of insecticide-treated mosquito bed nets (ITNs) has been associated with improved malaria outcomes, recent reports indicate that the campaign is losing its sparkle in some countries. In Malawi, the universal coverage campaign was implemented in 2012, but its impacts are yet to be ascertained. Thus, this study examined the effects of the campaign on malaria morbidity among children in Malawi. METHODS: This is a repeated cross-sectional study. The study used nationally-representative malaria indicator survey (MIS) data collected in 2012 and 2014. In total, the analysis included 4193 children between the ages of 6 and 59 months (2171 from 2012 MIS and 2022 from 2014 MIS). ITNs coverage and malaria morbidity before (2012 = pre-test/control) and after (2014 = post-test/treated) the universal coverage campaign of ITNs were compared. The treated and control samples were matched on measured relevant covariates using propensity scores. RESULTS: The mean number of ITNs per household improved significantly from 1.1 (SD 1.0) in 2012 to 1.4 (SD 1.1) in 2014 (p < 0.001). Nonetheless, the prevalence of malaria among children increased considerably from 27.7 % (2012) to 32.0 % (2014) (p = 0.002). The risk of malaria was also significantly higher in 2014 compared to 2012 (RR = 1.14; 95 % CI 1.01-1.29). Besides, the use of bed nets was not significantly associated with malaria morbidity in 2014 (RR = 0.92; 95 % CI 0.76-1.12), but it was in 2012 (RR = 0.83; 95 % CI 0.70-1.00). CONCLUSIONS: The universal coverage campaign of ITNs was not associated with a reduced burden of malaria among children in Malawi. This was likely due to increased insecticide resistance, inconsistent use of bed nets and under-utilization of other methods of malaria control. This calls for a multifaceted approach in the fight against malaria instead of simple dependence on ITNs. In particular, local or community level malaria interventions should go hand in hand with the universal coverage campaign.

Understanding the mechanisms through which women's group community participatory intervention improved maternal health outcomes in rural Malawi: was the use of contraceptives the pathway?

BACKGROUND: Women's group intervention is a community based initiative through which rural women form groups, meet regularly to discuss maternal health issues affecting them, and come up with locally available solutions. This intervention has been associated with reduced maternal and neonatal mortality in limited resource settings. Nevertheless, the mechanisms through which women's groups influence maternal health outcomes are uncertain. Because contraception reduces the risk of maternal mortality and women's groups also tackled this issue, we speculated that contraceptive use might be the pathway. Consequently, this study investigated whether participation in women's groups was associated with contraceptive use in Malawi. DESIGN: We examined the use of contraceptives between women who participated in women's groups and those who did not through a community-based cross-sectional study in Mchinji, Malawi. The study involved 3,435 women of reproductive age (15-49 years) who were recruited using a multistage sampling approach. Members (treated) and non-members (control) of women's groups were matched on observed covariates using propensity scores and the counterfactual for the treated individuals was estimated. RESULTS: Crude analysis revealed that women's groups improved uptake of contraceptives by 26% (odds ratio (OR)=1.26; 95% confidence interval (CI)=1.03-1.56; p=0.024). However, using the matched data, uptake of contraceptives was almost the same among members and non-members of women's groups. More precisely, the likelihood of using contraceptives was not significantly different between the members and non-members of women's groups (OR=1.00; 95% CI=0.81-1.24; p=0.991). CONCLUSIONS: There is insufficient evidence of an association between participation in women's groups and contraceptive use among rural Malawian women. The implication is that contraception was not the mechanism through which women's groups contributed to reduced maternal mortality in Malawi. Because the effects of community interventions are usually comprehensive and sometimes difficult to demonstrate, ethnographic studies should be considered in the evaluation of women's groups and other related interventions.

The impact of a community driven mass media campaign on the utilisation of maternal health care services in rural Malawi.

BACKGROUND: Mass media is critical in disseminating public health information, improving health knowledge and changing health behaviours. However, most of the mass media public health interventions do not sufficiently engage the local people; they are externally determined. Due to this, very little is known about the effects of locally instigated mass media promotion. Therefore, the aim of this study was to examine the impact of a community driven mass media campaign called Phukusi la Moyo (tips of life) on the utilisation of maternal health care services. METHODS: A community-based cross-sectional study involving 3825 women of reproductive age (15-49 years) was conducted in rural Malawi to evaluate the Phukusi la Moyo (PLM) campaign. To do this, we compared the utilisation of maternal health care services between women who were exposed to the PLM campaign and those who were not. Respondents were identified using a multistage cluster sampling method. This involved systematically selecting communities (clusters), households and respondents. Associations were examined using Pearson chi square test and a multivariable logistic regression model. RESULTS: The likelihood of using contraceptives (AOR = 1.61; 95% CI = 1.32-1.96), sleeping under mosquito bed-nets (AOR = 1.65; 95% CI = 1.39-1.97), utilising antenatal care services (AOR = 2.62; 95% CI = 1.45-4.73) and utilising postnatal care services (AOR = 1.59; CI = 1.29-1.95) were significantly higher among women who had exposure to the PLM campaign than those who did not. No significant association was found between health facility delivery and exposure to the PLM campaign. CONCLUSION: Women exposed to a community driven mass media campaign in rural Malawi were more likely to utilise maternal health care services than their unexposed counterparts. Since, the use of maternal health care services reduces the risk of maternal morbidity and mortality, community-led mass media could play a significant role towards improving maternal health outcomes in low-and-middle-income countries. Therefore, we recommend the use of locally driven mass media in disseminating public health information in limited resource settings.

What are the social and individual factors that are associated with undergoing male circumcision as an HIV prevention strategy? A mixed methods study in Malawi.

BACKGROUND: There is compelling evidence that medical male circumcision (MMC) decreases transmission of HIV. Nevertheless, the uptake of MMC is generally very low. Understanding the characteristics of individuals who choose MMC could inform future strategies for scaling-up MMC. The main objective of this study was to explore the social and individual characteristics of men that are associated with the uptake of circumcision as an HIV prevention strategy. METHODS: A mixed-methods study, comprising a cross-sectional survey and an exploratory qualitative study, was conducted in Malawi. A total number of 1644 men, of at least 18 years old, participated in this study. A multistage sampling approach was used in the survey while convenience sampling was adopted in the qualitative study. Descriptive statistics, bivariate analyses and multivariable logistic regression were performed to analyze the cross-sectional data and thematic content approach to analyze the qualitative data. RESULTS: Individuals who chose MMC were more likely to be unemployed (AOR=1.65; 95% CI: 1.30-2.11), to be married (AOR=3.16; 95% CI: 2.21-4.52) and to have had exposure to MMC promotions (AOR=1.81; 95% CI: 1.41-2.33). They were also more likely to reside in rural areas (AOR=1.85; 95% CI: 1.44-2.38), to perceive themselves as more vulnerable to HIV (AOR=1.60; 95% CI: 1.19-2.15) and to be more knowledgeable about the benefits of MMC (AOR=1.51; 95% CI: 1.16-1.97). CONCLUSIONS: The findings suggest that men who had certain social and individual characteristics (for example better knowledge of the benefits of MMC, greater perceived vulnerability to HIV, married and unemployed) were more likely to choose circumcision as a prevention strategy for HIV than those who lacked those characteristics. Strategies for increasing MMC take-up should recognize the current social/individual landscape of MMC uptake and ensure that deliberate efforts targeting marginalized categories of men are available.

The role of the parents' perception of the postpartum period and knowledge of maternal mortality in uptake of postnatal care: a qualitative exploration in Malawi.

BACKGROUND: Postpartum is the most risky period for both mothers and newborn babies. However, existing evidence suggests that utilization of postnatal care is relatively lower when compared to uptake of other similar health care services. Therefore, the aim of this study was to examine the perceptions of parents toward the postpartum period and postnatal care in order to deepen our understanding of the maternal care-seeking practices after childbirth. METHODS: A descriptive qualitative study, comprising four focus group discussions with 50 parents aged between 18 and 35 years, was conducted in Malawi between January and March 2014. Only young men and women who had either given birth or fathered a baby within 12 months prior to the study were eligible to participate in this study. This was to ensure that only participants who had recent first-hand postpartum experience were included. Local leaders purposively identified all parents who met the inclusion criteria and then simple random sampling was used to select participants from this pool of parents. Data analysis followed the six steps of thematic approach developed by Braun and Clarke, and NVivo software aided the process. FINDINGS: The parents interviewed described the various factors relating to pregnancy, childbirth, and postpartum periods that may possibly influence uptake of postnatal care. These factors were categorized into the following three themes: beliefs about the causes of maternal morbidity and mortality; risks associated with the pregnancy, childbirth and postpartum periods; and the importance of and barriers to postnatal care. Most participants perceived pregnancy and childbirth as the most risky periods to women, and their understanding of the causes of maternal death differed considerably from the existing evidence. In addition, segregation of mother and baby care in the clinics was identified as one of the potential barriers to postnatal care. CONCLUSION: The study findings suggest that parents' perception of the postpartum period and postnatal care as well as their knowledge of maternal morbidity and mortality play a vital role in the uptake of postnatal care. The study has also established that lack of knowledge of postnatal care, long waiting time for treatment, and separation of the mother and baby care in clinics are some of the key barriers to postnatal care. We recommend massive maternal health education programs as well as the integration of all postdelivery health care services provided in clinics, so that mothers and neonates receive health care together.

The effect of mass media campaign on Men's participation in maternal health: a cross-sectional study in Malawi.

BACKGROUND: Men's participation in antenatal, childbirth and postnatal care is crucial to the health of the mothers and neonates. Nevertheless, very few men participate in maternal health, especially in developing countries. Mass media is one of the popular and effective tools for health promotion and behavioral change globally. However, this approach is rarely recognized in maternal health literature and its impact on men's participation in maternal health is not thoroughly understood. Therefore, the objective of this study was to assess the effect of mass media campaign on men's involvement in maternal health. METHODS: A cross-sectional study involving 3,825 women of childbearing age (15-49 years) was conducted between July and December 2013 in Malawi's Mchinji district. Our interest was to establish if husbands of the women who were exposed to the maternal health radio program called Phukusi la Moyo (PLM) were significantly different to those of the women who were not exposed, especially in terms of their involvement in maternal health. We collected data on exposure to the radio campaign and men's involvement in maternal health through face-to-face interviews using electronic structured questionnaires. The univariate, bivariate and multiple logistic regression analyses were used during analysis of the data. The level of significance was set at p ≤ 0.05. RESULTS: Husbands of the women who were exposed to the PLM radio program were more likely to participate in antenatal care (OR1.5 [95% confidence interval 1.3-1.8]), to be involved in childbirth (OR 1.7 [95% confidence interval 1.5-2.0]) and to participate in postnatal care (OR 1.9 [95% confidence interval 1.7-22]) than their counterparts. CONCLUSION: The use of mass media in promoting the involvement of men in antenatal care, childbirth and postnatal care is effective. Henceforward, we recommend the inclusion of mass media in projects or interventions designed to promote men's engagement in maternal health.

Fear of oxygen therapy for children in Malawi.

BACKGROUND: Although pneumonia is a common cause of death in children in Malawi, healthcare staff frequently encounter patients or carers who refuse oxygen therapy. This qualitative study documents factors that influence acceptance or refusal of oxygen therapy for children in Malawi. METHODS: Nine group interviews involving 86 participants were held in community and hospital settings in rural and urban Malawi. Eleven in-depth interviews of healthcare staff providing oxygen were held in a central hospital. Thematic analysis of transcripts of the audio recordings was carried out to identify recurring themes. RESULTS: Similar ideas were identified in the group interviews and in-depth staff interviews. Past experiences of oxygen use (direct and indirect, positive and negative) had a strong influence on views of oxygen. A recurrent theme was fear of oxygen, often due to a perceived association between death and recent oxygen use. Fears were intensified by a lack of familiarity with equipment used to deliver oxygen, distrust of medical staff and concerns about cost of oxygen. CONCLUSIONS: This study identifies reasons for refusal of oxygen therapy for children in a low-income country. Findings from the study suggest that training of healthcare staff to address fears of parents, and information, education and communication (IEC) approaches that improve public understanding of oxygen and provide positive examples of its use are likely to be helpful in improving uptake of oxygen therapy in Malawi.