Out-of-home day care for families living in a disadvantaged area of London: economic evaluation alongside a RCT.

BACKGROUND: Children born into poverty have lifelong disadvantages compared with those more fortunate; social interventions seek to break this cycle of poverty and deprivation. Early Years Centres are one such intervention. These were established in deprived areas in the UK to provide high quality out-of-home day care. This paper reports the results of an economic evaluation conducted alongside a randomized controlled trial of one of these centres in the Borough of Hackney, London. METHODS: Participants were randomized to receive either high quality day care as provided by the centre or to other child care that they secured for themselves where they chose to do so. Information on resource use (early years education and care, as well as health and social care) was collected over an 18-month period; this was valued using appropriate unit costs. The cost of education, social and health care together with the value of productivity gains and out-of-pocket costs were then compared with the effectiveness of the intervention, increased labour force participant in mothers. RESULTS: From the societal perspective, the value of employment outweighs the costs of health and social services used, and in both groups there are cost savings. These are greater in the intervention group, therefore Early Years day care is an efficient use of resources. However, there is a net cost to the public sector of providing the intervention. The cost of achieving an additional mother in the labour force at 18 months is pound38 550 (85% CI of -pound1273, pound416 172). CONCLUSION: From the societal perspective, over an 18-month period, all child care is cost saving, but high quality day care provided by the Early Years Centre is a cost-effective alternative to day care provided by other local services in Hackney. The public sector, however, incurs added expense from this intervention.

The impact of day care on socially disadvantaged families: an example of the use of process evaluation within a randomized controlled trial.

AIM: This paper describes a process evaluation that was conducted alongside a randomized controlled trial of out-of-home pre-school day care. The evaluation aimed to: (1) describe the intervention; (2) document the day care received by participating families; (3) describe the social context of the trial; and (4) provide data to assist in the interpretation of trial outcomes. METHODS: The setting for the trial was an out-of-home day care Centre in Hackney, East London. Process data were collected through the use of questionnaires, interviews, and researcher field-notes. Data from questionnaires were collected from 120 mothers and included data on 143 children. Interviews were undertaken with 21 participating mothers. Staff also completed questionnaires and the Head of the Centre was interviewed. The quality of care provided was assessed using the Early Childhood Environment Rating Scale. RESULTS: Process data collected during the trial suggest that the day care provided was education-led, flexible in catering to families' needs, and was of a very high quality. The social context of the trial resulted in financial pressures, which may well have influenced the intervention provided. Data collected through in-depth interviews suggested that it may be the flexibility of day care that is particularly important in allowing women to return to paid employment, but that the loss of benefits when starting work may have meant no increase in household income. CONCLUSION: The paper illustrates the value of conducting a process evaluation alongside a randomized trial, particularly where complex interventions are involved. In this case, where the intervention was not provided by the research team, the evaluation allowed an insight into the content of a multifaceted intervention, which is useful in interpreting the trial's results, and in explaining the possible effects of the social context on the intervention.

Randomisation and resource allocation: a missed opportunity for evaluating health care and social interventions.

Equipoise is widely regarded to be an essential prerequisite for the ethical conduct of a randomised controlled trial. There are some circumstances however, under which it is acceptable to conduct a randomised controlled trial (RCT) in the absence of equipoise. Limited access to the preferred intervention is one such circumstance. In this paper we present an example of a randomised trial in which access to the preferred intervention, preschool education, was severely limited by resource constraints. The ethical issues that arise when conducting randomised trials in health care are considered in the context of trials of social interventions. In health, education and social welfare, effective interventions are frequently limited due to budgetary constraints. Explicit acknowledgement of the need to ration interventions, and the use of random allocation to do this even in the absence of equipoise, would facilitate learning more about the effects of these interventions.

Participation of South african youth in the design and development of AIDS photocomics.

In response to an increasing incidence in HIV prevalence among South Africa's youth, a group of interdisciplinary professionals have developed a series of photocomics to address issues around HIV/AIDS communication and sexually transmitted diseases. This article examines the theory behind the use of photocomics in health, and the way the stories work to influence behavior. Results from evaluation of the comics support their use as tools with which to increase information and knowledge while role modeling desirable behavior. Lastly, the article describes the participatory process by which youth were involved in the process of developing and producing the comics. This method of developing culturally relevant and appealing health media is recommended for use in future health promotion strategies that seek to transcend a narrower approach of provision of health information and work to address the social factors that influence youth's decision making.

Evaluation of a learner-produced photocomic in South Africa.

The use of participatory research in developing culturally appropriate health promotion media is now universally recognized. However, although much has been written with respect to the effects of this process on the participants themselves, little evaluation has been conducted on their effectiveness with the larger target group. The photocomic "Between Us" was produced with South African youth to address the issue of communications as it relates to safe sex and non-violent conflict resolution. This article considers its qualitative evaluation. The article first addresses the theory behind the comic's development, and its objectives. It then examines the qualitative results with respect to these objectives: the evaluation showed the comic to be successful in that it elicited identification among youth with the comic's characters and issues presented. This type of medium offers much potential as a Health Promotion tool to be used in educational settings.

Characterization of the defective beta-glucuronidase activity in canine mucopolysaccharidosis type VII.

Canine mucopolysaccharidosis type VII results from deficient activity of lysosomal beta-glucuronidase. Residual enzymatic activity (0.2-1.7% of normal) was detected in tissue homogenates from affected dogs. In contrast, serum and urine from affected animals had up to 15% residual activity. To further characterize the nature of the defective enzyme, hepatic beta-glucuronidase was partially purified from normal and MPS VII dogs for determination of their physical and kinetic properties. About 65% of the total beta-glucuronidase in normal canine liver required detergent for solubilization (i.e., membrane-associated), whereas only 22% of the residual activity in canine MPS VII liver was membrane-associated. Compared to the normal hepatic enzyme, the Km towards 4-methylumbelliferyl-beta-glucuronide was markedly increased in MPS VII dogs (i.e., 0.48 versus greater than 2.5 mmol/l). In contrast, the thermo-, cryo-, and pH stability properties, as well as the pH optimum (approximately 4.6), were essentially unaffected. In addition, the canine MPS VII hepatic residual activity was unresponsive to sulfhydryl reducing reagents and divalent cations, despite the fact that incubation of normal canine beta-glucuronidase with dithiothreitol and magnesium and/or calcium enhanced the activity more than 15-fold.