| 1. |
- Beeres, Dorien Tecla, et al.
(författare)
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Child–adult contract for prevention of tobacco use : "as-treated" analysis of a cluster randomized controlled trial (the TOPAS study) at 3-year follow-up
- 2024
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Ingår i: Prevention Science. - : Springer Nature. - 1389-4986 .- 1573-6695. ; 25, s. 175-192
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Tidskriftsartikel (refereegranskat)abstract
- To estimate the effect of a 3-year commitment to remain tobacco free on tobacco uptake among high school students in Sweden. The commitment is developed in the form of a contract between a child and a significant adult, constituting the core component of Tobacco-free Duo (T-Duo), a Swedish school-based tobacco prevention program. Secondary analysis of data from a cluster randomized controlled trial. Participants were 586 students in high schools assigned to the intervention arm of T-Duo. At inception, participants attended grade 7 (i.e., age 12–13). Only students who were tobacco naïve at baseline for the respective outcome and participated in all follow-ups were included. The exposure was defined as signing a 3-year contract with a significant adult, categorized as “stable contract” (3 years contract with the same contract partner), “unstable” (signed a contract sometime during follow-up but this was not sustained over time and/or with the same partner), and “no contract” at all during the intervention period. The primary outcome was having never tried cigarette smoking at the end of grade 9. Exposure and outcomes were self-reported in yearly questionnaires. Of 586 students, 321 (55%) held a stable contract, 204 (35%) an unstable contract, and 61 (10%) did not sign a contract at all. At the end of grade 9 (age 15–16), the relative risk (RR) to remain cigarette free was 1.11 (95% CI 1.00–1.22) (Number Needed to Treat = 10) among students in any type of contract compared to students that did not write a contract at all. The RRs for remaining tobacco free (secondary outcomes) ranged from 1.07 (0.98–1.16) for regular snus use to 1.16 (1.00–1.35) for any type of tobacco use. A commitment to remain tobacco free through a child–adult contract seems to exert a preventive effect on the uptake of tobacco use among Swedish adolescents over 3 school years. The current findings apply to a selected sample of both schools and students.Registration: Current Controlled Trials ISRCTN52858080 Date: January 4, 2019, retrospectively registered.
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| 2. |
- Galanti, Maria Rosaria, et al.
(författare)
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Tobacco-Free Duo Adult-Child Contract for Prevention of Tobacco Use Among Adolescents and Parents : Protocol for a Mixed-Design Evaluation
- 2020
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Ingår i: JMIR Research Protocols. - : JMIR Publications Inc.. - 1929-0748. ; 9:10
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Universal tobacco-prevention programs targeting youths usually involve significant adults, who are assumed to be important social influences. Commitment not to use tobacco, or to quit use, as a formal contract between an adolescent and a significant adult is a preventive model that has not been widely practiced or explored and has been formally evaluated even less. In this paper, we present the rationale and protocol for the evaluation of the Swedish Tobacco-free Duo program, a multicomponent school-based program the core of which rests on a formal agreement between an adolescent and an adult. The adolescent's commitment mainly concerns avoiding the onset of any tobacco use while the adult commits to support the adolescent in staying tobacco free, being a role model by not using tobacco themselves.OBJECTIVE: To assess (1) whether Tobacco-free Duo is superior to an education-only program in preventing smoking onset among adolescents and promoting cessation among their parents, (2) whether exposure to core components (adult-child agreement) entails more positive effects than exposure to other components, (3) the impact of the program on whole school tobacco use, (4) potential negative side effects, and (5) school-level factors related to fidelity of the program's implementation.METHODS: A mixed-design approach was developed. First, a cluster randomized controlled trial was designed with schools randomly assigned to either the comprehensive multicomponent program or its educational component only. Primary outcome at the adolescent level was identified as not having tried tobacco during the 3-year junior high school compulsory grades (12-15 years of age). An intention-to-treat cohort-wise approach and an as-treated approach complemented with a whole school repeated cross-sectional approach was devised as analytical methods of the trial data. Second, an observational study was added in order to compare smoking incidence in the schools participating in the experiment with that of a convenience sample of schools that were not part of the experimental study. Diverse secondary outcomes at both adolescent and adult levels were also included.RESULTS: The study was approved by the Umeå Regional Ethics Review Board (registration number 2017/255-31) in 2017. Recruitment of schools started in fall 2017 and continued until June 2018. In total, 43 schools were recruited to the experimental study, and 16 schools were recruited to the observational study. Data collection started in the fall 2018, is ongoing, and is planned to be finished in spring 2021.CONCLUSIONS: Methodological, ethical, and practical implications of the evaluation protocol were discussed, especially the advantage of combining several sources of data, to triangulate the study questions. The results of these studies will help revise the agenda of this program as well as those of similar programs.TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN) 52858080; https://doi.org/10.1186/ISRCTN52858080.INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/21100.
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| 3. |
- Pulkki-Brännström, Anni-Maria, et al.
(författare)
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Protocol for the evaluation of cost-effectiveness and health equity impact of a school-based tobacco prevention programme in a cluster randomised controlled trial (the TOPAS study)
- 2021
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Ingår i: BMJ Open. - : BMJ Publishing Group Ltd. - 2044-6055. ; 11:8
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Tidskriftsartikel (refereegranskat)abstract
- Introduction: Despite a long-term downward trend in smoking prevalence, tobacco remains the number one risk factor for death and disability in Sweden. Globally, tobacco use generates a substantial economic burden for health systems and is also a major driver of socioeconomic inequalities in health. This article describes the planned cost-effectiveness and health equity impact evaluation of a multicomponent school-based programme to prevent the onset of tobacco use in adolescents.Methods and analysis: Cost-effectiveness of the multicomponent Tobacco-Free Duo programme will be evaluated against the educational component of the same programme only. An incremental cost-effectiveness ratio (ICER) will be calculated in terms of the cost per case prevented using the trial primary outcome and within-trial payer costs. If the ICER is negative, an incremental net benefit ratio will be calculated. Robustness of the results will be assessed through one-way sensitivity analyses. The slope index of inequality will be computed to assess the potential impact of the Tobacco-free Duo programme on education-related inequalities in the onset of smoking and in adult smoking cessation, comparing the two trial arms.Ethics and dissemination: Ethical approval was obtained from the Regional Ethics Review Board, Umeå (registration number 2017/255-31). The Public Health Agency of Sweden commissioned the study. The findings will be disseminated internationally within academia and to national and local policy-makers.Trial registration number: ISRCTN52858080; Pre-results.
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| 4. |
- Beeres, D., et al.
(författare)
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Evaluation of the Swedish school-based program “tobacco-free DUO” in a cluster randomized controlled trial (TOPAS study). Results at 2-year follow-up
- 2022
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Ingår i: Preventive Medicine. - : Elsevier BV. - 0091-7435 .- 1096-0260. ; 155
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Tidskriftsartikel (refereegranskat)abstract
- Friends' and parents' tobacco use are strong predictors of tobacco uptake among adolescents, however the effectiveness of interventions based on public commitments and agreements to remain tobacco-free are not established. Here, we evaluated the effectiveness of the school-based Swedish program Tobacco-Free Duo (T-Duo) in preventing adolescents from initiating tobacco use (TOPAS study). T-Duo is a multi-component intervention witha formal agreement between a student and an adult partner to remain tobacco-free during the entire 3-year study period as core component. The standardized educational component of the same program was used as comparator (control). Primary outcome was the probability to “remain a non-user” of i) cigarettes and secondary outcomes ii) other types of tobacco at second (21-month) follow-up. Analysis was conducted according to Intention To Treat. In total 1776 adolescents (51% female) aged 12–13 in grade 7 from 34 participating high schools in Sweden were included at baseline in 2018, of which 1489 were retained after 21 months. The Risk Ratio (RR) of not having tried cigarettes 21-months after initiation of the intervention was 1.03(CI 0.98–1.08), Bayes Factor(BF) = 0.93, Absolute Risk Difference(ARD) = 3.1%. Similar associations were found for never smoked a whole cigarette and never use of other tobacco/nicotine products. There was a minimal reduction of tobacco use initiation among Swedish adolescents assigned to a multi-component intervention (T-Duo) compared to those assigned to standardized classroom education after 2 schoolyears. However, for most outcomes' findings were inconclusive and not reliably different from zero. Trial registration: ISRCTN5285808 (doi:https://doi.org/10.1186/ISRCTN52858080); Study protocol: DERR1-https://doi.org/10.2196/21100. Registration: Current Controlled Trials ISRCTN52858080 Date: January 4, 2019, retrospectively registered. Protocol: Galanti, M.R., Pulkki-Brännström, A.-M., Nilsson, M., 2020. Tobacco-free duo adult-child contract for prevention of tobacco use among adolescents and parents: protocol for a mixed-design evaluation. JMIR Res. Protoc. 9, e21100. doi:10.2196/21100. © 2021
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| 5. |
- Nilsson, Maria, 1957-, et al.
(författare)
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Topas - tobakspreventivt arbete i skolan. Slutrapport : en utvärdering av det ANDT-förebyggande programmet Tobaksfri duo
- 2022
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Rapport (övrigt vetenskapligt/konstnärligt)abstract
- I Sverige har tobaksförebyggande program med ungdomar som målgrupp under många år initierats, utvecklats och drivits av kommuner, regioner, och den ideella sektorn. Antalet vetenskapliga studier om tobaksförebyggande arbete i landet som publicerats i vetenskapliga tidskrifter är mycket få och har främst genomförts med en kvasiexperimentell design. Tobaksfri duo (T-Duo) har spridits i landet och önskemål har uttryckts om en utvärdering med metodik som ger högre evidensgrad jämfört med de studier som genomförts tidigare. Genom Topasprojektet har en sådan utvärdering av användningen av programmets kärnkomponenter möjliggjorts. Studien har genomförts av Umeå universitet och Karolinska Institutet på uppdrag av Folkhälsomyndigheten. Den hade en blandad design: 1) en klusterrandomiserad kontrollerad studie (CRCT) där skolor tilldelades programmet T-Duos sex kärnkomponenter eller en minimal komponent i form av Strukturerad undervisning, 2) en observationsstudie där programskolor jämfördes med skolor i en extern referensgrupp samt 3) en hälsoekonomisk utvärdering av programmets kostnadseffekt.Studiens övergripande syfte var att utvärdera effekterna och kostnaderna av programmet T-Duos sex kärnkomponenter genom att besvara följande specifika frågeställningar:Påverkas ungas tobaksdebut och tobaksanvändning av programmet? - d.v.s. är den förebyggande effekten större om man arbetar med programmet jämfört med en minimal komponent, alternativt ordinarie ANDT-undervisning i skolan?Påverkar deltagande i programmet vårdnadshavares tobaksbruk?Har graden av implementering av programmet betydelse för effekten?Är effekterna sådana att programkostnaderna är motiverade?Resultaten från studien visar att det fullständiga programmet T-Duo förknippas med en måttlig förebyggande effekt på högstadieelevers tobaksdebut (cirka 8 % större sannolikhet att förbli rökfria efter tre år), jämfört med om man enbart bedrev undervisning om tobak enligt programmet som ingick i Topas kontrollgrupp Undervisningsskolor (U-skolor). Resultaten kan dock ha påverkats av vissa systematiska fel, dels bortfall, dels beroende på självrapportering.Kontraktet som skrevs mellan ett barn och en vuxen 18 år eller äldre som barnet själv valde som vuxenpartner i T-Duo visade sig vara en effektiv komponent om kontraktet kunde upprätthållas under samtliga år. Komponenten innehåller tre delar kopplat till kontraktet, i) dels en möjlighet till stöd från en vuxen som barnet själv valt, att barnet ii) vid kontraktsskrivning gör ett åtagande inför andra om att man inte ska använda tobak under de kommande tre åren och slutligen iii) möjligheten för barnet att delta i utlottning av mindre priser och till rabatter (på till exempel skolfiket).Resultaten indikerade också att T-Duo kan påverka tobaksbruk på gruppnivå, det vill säga på skolnivå, på ett positivt sätt över tid. Med andra ord att alla elever på en skola som jobbade med T-Duo påverkades av programmet och inte bara de som deltog.Vad gällde vårdnadshavare (VH) i T-skolor sågs en möjlig effekt avseende tobaksstopp, det vill säga att de få deltagare som använde tobak i början av studien och som var kvar i slutet slutade använda tobak i större utsträckning än föräldrar i skolor lottade till enbart undervisningskomponenten. Dock måste resultaten tolkas med stor försiktighet på grund av det låga antalet VH som svarade på enkäten. Av denna anledning är det inte möjligt att säga om VH som tecknade kontrakt med sina barn hade större sannolikhet att förbli tobaksfria eller inte, eftersom andelen tobaksbrukare i gruppen som tecknade kontraktet med sina barn redan från början var mycket låg och betydligt lägre än bland resterande VH.Mycket få skolor hade implementerat programmet T-Duo helt enligt manualen för studien. Implementeringen var oftast måttlig, dvs att man hade genomfört mer än två kärnkomponenter enligt manualen, dock inte alla. Graden av implementering påverkade dock inte resultaten.I beräkningen av kostnadseffektivitet relaterades skillnaden i kostnader mellan T-skolor och U-skolor till den beräknade effekten i termer av hur många fler barn som förblev rökfria på grund av programmet. Det treåriga programmet kostade 785 kr per exponerat barn på T-skolorna och endast strukturerad undervisning kostade 491 kr per barn på U-skolorna. T-Duo kostade därmed 294 kr mer per barn jämfört med endast Strukturerad undervisning och kostnadseffektiviteten uppskattades till 5 066 kr för varje ytterligare barn som var rökfri i slutet på årskurs nio. Om effekten kvarstår fram till vuxen ålder representerar T-duo en mycket bra användning av resurserna i förhållande till framtida konsekvenser på hälsan som vuxen. Osäkerheten rörande programeffekten och om effekten kommer att bestå är avgörande för denna slutsats.
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| 6. |
- Pulkki-Brännström, Anni-Maria, et al.
(författare)
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Cost and cost effectiveness of long-lasting insecticide-treated bed nets - a model-based analysis
- 2012
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Ingår i: Cost Effectiveness and Resource Allocation. - : Springer Science and Business Media LLC. - 1478-7547. ; 10, s. 5-
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: The World Health Organization recommends that national malaria programmes universally distribute long-lasting insecticide-treated bed nets (LLINs). LLINs provide effective insecticide protection for at least three years while conventional nets must be retreated every 6-12 months. LLINs may also promise longer physical durability (lifespan), but at a higher unit price. No prospective data currently available is sufficient to calculate the comparative cost effectiveness of different net types. We thus constructed a model to explore the cost effectiveness of LLINs, asking how a longer lifespan affects the relative cost effectiveness of nets, and if, when and why LLINs might be preferred to conventional insecticide-treated nets. An innovation of our model is that we also considered the replenishment need i.e. loss of nets over time.METHODS: We modelled the choice of net over a 10-year period to facilitate the comparison of nets with different lifespan (and/or price) and replenishment need over time. Our base case represents a large-scale programme which achieves high coverage and usage throughout the population by distributing either LLINs or conventional nets through existing health services, and retreats a large proportion of conventional nets regularly at low cost. We identified the determinants of bed net programme cost effectiveness and parameter values for usage rate, delivery and retreatment cost from the literature. One-way sensitivity analysis was conducted to explicitly compare the differential effect of changing parameters such as price, lifespan, usage and replenishment need.RESULTS: If conventional and long-lasting bed nets have the same physical lifespan (3 years), LLINs are more cost effective unless they are priced at more than USD 1.5 above the price of conventional nets. Because a longer lifespan brings delivery cost savings, each one year increase in lifespan can be accompanied by a USD 1 or more increase in price without the cheaper net (of the same type) becoming more cost effective. Distributing replenishment nets each year in addition to the replacement of all nets every 3-4 years increases the number of under-5 deaths averted by 5-14% at a cost of USD 17-25 per additional person protected per annum or USD 1080-1610 per additional under-5 death averted.CONCLUSIONS: Our results support the World Health Organization recommendation to distribute only LLINs, while giving guidance on the price thresholds above which this recommendation will no longer hold. Programme planners should be willing to pay a premium for nets which have a longer physical lifespan, and if planners are willing to pay USD 1600 per under-5 death averted, investing in replenishment is cost effective.
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| 7. |
- Wolff, Claudia Anna, et al.
(författare)
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Cost and cost-effectiveness of bed nets : a model-based analysis of long-lasting insecticide-treated nets (LLINs)
- 2013
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Annan publikation (övrigt vetenskapligt/konstnärligt)abstract
- The World Health Organization recommends that national malaria programs universally distribute long-lasting insecticide-treated bed nets (LLINs). We construct a model to explore the cost effectiveness of LLINs, asking how a longer lifespan affects the relative cost effectiveness of nets, and if, when and why LLINs might be preferred to conventional insecticide-treated nets. We model the choice of net over a 10-year period to facilitate the comparison of nets with different lifespans and replenishment need over time. One-way sensitivity analysis is conducted to explicitly compare the differential effect of changing parameters such as price, lifespan, usage and replenishment need. Our results support the World Health Organization recommendation to distribute only LLINs, while giving guidance on the price thresholds above which this recommendation will no longer hold. Program planners should be willing to pay a premium for nets which have a longer physical lifespan, and if planners are willing to pay USD 1600 per under-5 death averted, investing in replenishment is cost effective.
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| 8. |
- Aweesha, Huzeifa, 1980-, et al.
(författare)
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Sudan's health sector partnership : from confined progression to openness and hope to uncertain demise
- 2024
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Ingår i: Development Policy Review. - : John Wiley & Sons. - 0950-6764 .- 1467-7679. ; 42:2
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Tidskriftsartikel (refereegranskat)abstract
- Motivation: Despite signature of the 2005 Paris Declaration on Aid Effectiveness and subsequent adoption of the effective development cooperation (EDC) principles for better health cooperation, there is a gap in documenting the challenges to implement these commitments at country level. Sudan represents an interesting case study: the country adopted a local health compact in 2014, but for much of the time since the regime was under sanction. Sudan witnessed a revolution in 2018, followed by a counter-coup in 2021.Purpose: We aim to explore the evolution of Sudan health sector partners’ relationships, perspectives, and adherence to EDC principles of ownership, alignment, and harmonization, while accounting for underlying processes and context changes between 2015 and 2022.Methods and approach: We collected data through two rounds of interviews, in 2015 (16) and 2022 (8), with stakeholders within the Sudan Health Sector Partnership. We used the framework method for data analysis where responses are coded then sorted into themes.Findings: Prior to the 2019 revolution cooperation was progressive but restricted, with civil society marginalized and a dominating government. The principles, especially ownership, were misused and misaligned with national priorities driven by donors’ interests and conditions.The transitional (post-revolution) period witnessed partners’ openness and influx, but unstable leadership and subsequent changes in priorities led to wasted opportunities.Following the coup, donors adopted a no-contact policy towards the de facto government. Instead, the expectation was that civil society organizations would replace the government as the main implementers. Overall, limited coordination capacity and no sustainability measures were present throughout.Policy implications: Much of what was observed was down to the often complicated and difficult context of the governance of Sudan. That said, general issues arose including the government's ability to coordinate policy and implementation; the need for stable, legitimate arrangements; and the need to define the role of civil society and to empower civil society organizations. Within a complex and volatile context, revisiting partners’ commitments through joint compact reviews and transparent EDC progress monitoring is crucial.
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| 9. |
- Batura, Neha, et al.
(författare)
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Collecting and analysing cost data for complex public health trials : reflections on practice
- 2014
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Ingår i: Global Health Action. - : CoAction Publishing. - 1654-9716 .- 1654-9880. ; 7, s. 23257-
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Current guidelines for the conduct of cost-effectiveness analysis (CEA) are mainly applicable to facility-based interventions in high-income settings. Differences in the unit of analysis and the high cost of data collection can make these guidelines challenging to follow within public health trials in low- and middle- income settings.OBJECTIVE: This paper reflects on the challenges experienced within our own work and proposes solutions that may be useful to others attempting to collect, analyse, and compare cost data between public health research sites in low- and middle- income countries.DESIGN: We describe the generally accepted methods (norms) for collecting and analysing cost data in a single-site trial from the provider perspective. We then describe our own experience applying these methods within eight comparable cluster randomised, controlled, trials. We describe the strategies used to maximise adherence to the norm, highlight ways in which we deviated from the norm, and reflect on the learning and limitations that resulted.RESULTS: When the expenses incurred by a number of small research sites are used to estimate the cost-effectiveness of delivering an intervention on a national scale, then deciding which expenses constitute 'start-up' costs will be a nontrivial decision that may differ among sites. Similarly, the decision to include or exclude research or monitoring and evaluation costs can have a significant impact on the findings. We separated out research costs and argued that monitoring and evaluation costs should be reported as part of the total trial cost. The human resource constraints that we experienced are also likely to be common to other trials. As we did not have an economist in each site, we collaborated with key personnel at each site who were trained to use a standardised cost collection tool. This approach both accommodated our resource constraints and served as a knowledge sharing and capacity building process within the research teams.CONCLUSIONS: Given the practical reality of conducting randomised, controlled trials of public health interventions in low- and middle- income countries, it is not always possible to adhere to prescribed guidelines for the analysis of cost effectiveness. Compromises are frequently required as researchers seek a pragmatic balance between rigor and feasibility. There is no single solution to this tension but researchers are encouraged to be mindful of the limitations that accompany compromise, whilst being reassured that meaningful analyses can still be conducted with the resulting data.
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| 10. |
- Batura, Neha, et al.
(författare)
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Highlighting the evidence gap : how cost-effective are interventions to improve early childhood nutrition and development?
- 2015
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Ingår i: Health Policy and Planning. - : Oxford University Press. - 0268-1080 .- 1460-2237. ; 30:6, s. 813-821
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Forskningsöversikt (refereegranskat)abstract
- There is growing evidence of the effectiveness of early childhood interventions to improve the growth and development of children. Although, historically, nutrition and stimulation interventions may have been delivered separately, they are increasingly being tested as a package of early childhood interventions that synergistically improve outcomes over the life course. However, implementation at scale is seldom possible without first considering the relative cost and cost-effectiveness of these interventions. An evidence gap in this area may deter large-scale implementation, particularly in low- and middle-income countries. We conduct a literature review to establish what is known about the cost-effectiveness of early childhood nutrition and development interventions. A set of predefined search terms and exclusion criteria standardized the search across five databases. The search identified 15 relevant articles. Of these, nine were from studies set in high-income countries and six in low- and middle-income countries. The articles either calculated the cost-effectiveness of nutrition-specific interventions (n = 8) aimed at improving child growth, or parenting interventions (stimulation) to improve early childhood development (n = 7). No articles estimated the cost-effectiveness of combined interventions. Comparing results within nutrition or stimulation interventions, or between nutrition and stimulation interventions was largely prevented by the variety of outcome measures used in these analyses. This article highlights the need for further evidence relevant to low- and middle-income countries. To facilitate comparison of cost-effectiveness between studies, and between contexts where appropriate, a move towards a common outcome measure such as the cost per disability-adjusted life years averted is advocated. Finally, given the increasing number of combined nutrition and stimulation interventions being tested, there is a significant need for evidence of cost-effectiveness for combined programmes. This too would be facilitated by the use of a common outcome measure able to pool the impact of both nutrition and stimulation activities.
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