| 1. |
- 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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| 2. |
- 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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| 3. |
- Eid, Daniel, et al.
(författare)
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"Cheaper and better" : an economic analysis of changing first line treatment for cutaneous leishmaniasis in Bolivia
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Annan publikation (övrigt vetenskapligt/konstnärligt)abstract
- Introduction: Cutaneous leishmaniasis (CL) is endemic in Bolivia, mostly affecting poor people in rainforest areas. The current first-line treatment consists of systemic pentavalent antimonials (SPA) for 20 days and is paid for by the Ministry of Health (MoH). Long periods of drug shortages, a lack of conditions to deliver treatment safely, treatment interruption are challenges to implementation. Intralesional pentavalent antimonials (ILPA) are an alternative to SPA. This study aims to compare the cost of ILPA and SPA, and to estimate the health and economic impacts of changing the first-line treatment for CL in an endemic area of Bolivia.Methods: The cost per patient treated was estimated for SPA and ILPA from the perspectives of the MoH and society. The quantity and unit costs of medications, staff time, transportation and loss of production were obtained through a health facility survey (N=12), official documents and key informants. A one-way sensitivity analysis was conducted on key parameters to evaluate the robustness of the results. The annual number of patients treated and the budget impact of switching to ILPA as the first-line treatment were estimated under different scenarios of increasing treatment utilization using previous estimates of the extent of underreporting. Costs were reported in 2016 international dollars (1 INT$ = 3.10 BOB).Results: Treating CL using ILPA was associated with a cost saving of $248 per patient treated from the MoH perspective, and $688 per patient treated from the societal perspective. ILPA was cost-saving even under a hypothetical increase of 80% in the number of cases treated. Switching first-line treatment would allow two-and-a-half times the current number of patients to be treated, while maintaining the current budget.Conclusions: The results of this study support a shift to ILPA as the first-line treatment for CL in Bolivia and possibly in other South American countries.
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| 4. |
- Hambraeus, Johan, 1959-
(författare)
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Interventional pain management focused on zygapophysial joint pain : a health-economic evaluation
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The pain-system is a central mechanism in our life. Chronic pain is one of the major causes of impaired health-related quality of life according to the World Health Organization’s “Global Burden of Disease”-studies. Zygapophysial joint pain has been shown to account for the pain in 30% - 50% of patients with chronic pain. There are several well-established, evidence-based methods to treat zygapophysial joint pain in the cervical and lumbar regions.This thesis originates from this and starts by exploring whether the treatment of zygapophysial joint pain can improve health-related quality of life. This thesis describes methods for the diagnosis and treatment of zygapophysial joint pain in the thoracic region that can be applied to the treatment of all pain-foci localized to the zygapophysial joints. I show that the health-related quality of life was significantly improved after treatment, and that the clinical methods used for treating thoracic pain were similar to the methods that have been established previously for cervical and lumbar pain.In order to better understand the patients’ experiences we performed qualitative interviews with patients who underwent diagnostic tests and treatments. The overall theme revealed by these interviews was that of empowerment, in which the patients were empowered by the process of diagnostic tests and treatments.The next question was whether the method was cost-effective or not. In the first cost-effectiveness analysis, the patients served as their own controls and we evaluated the results against the limits set by the Swedish national board of health and welfare. The results showed that it was cost-effective in the moderate to low range.Finally, we compared the treatment to the “gold standard” for pain management in Sweden; i.e.pain rehabilitation. We mimicked a randomized controlled trial by using propensity score weighting to compare 254 patients agains 15,357 patients registered in the Swedish National Register of Pain Rehabilitation. The results showed that interventional pain management was cost-effective in the moderate (12 months after treatment) to low (≥24 months after) range whereas pain rehabilitation was in the very high range (after 12 months) and became cost-effective in the high range after 24 months of treatment. Currently, interventional pain management accounts for just 2% of all specialized pain management procedures in Sweden. If this could be increased to 25%, it may be possible to save 106 million SEK annually, while simultaneously gain 14 quality adjusted life years of health. If an interventional pain assessment is performed early in the process, treatable patients could be directed toward interventional treatment and away from interdisciplinary pain management programs, with the potential for further reductions in costs.
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| 5. |
- Hitimana, Regis, 1982-
(författare)
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Health economic evaluation for evidence-informed decisions in low-resource settings : the case of Antenatal care policy in Rwanda
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Introduction: The general aim of this thesis is to contribute to the use of health economic evidence for informed health care decisions in low-resource settings, using antenatal care (ANC) policy in Rwanda as a case study. Despite impressive and sustained progress over the last 15 years, Rwanda’s maternal mortality ratio is still among the highest in the world. Persistent gaps in health care during pregnancy make ANC a good candidate among interventions that can, if improved, contribute to better health and well-being of mothers and newborns in Rwanda.Methods: Data used in this thesis were gathered from primary and secondary data collections. The primary data sources included a cross-sectional household survey (N=922) and a health facility survey (N=6) conducted in Kigali city and the Northern Province, as well as expert elicitation with Rwandan specialists (N=8). Health-related quality of life (HRQoL) for women during the first-year post-partum was measured using the EQ-5D-3L instrument. The association between HRQoL and adequacy of ANC utilization and socioeconomic and demographic predictors was tested through bivariate and linear regression analyses (Paper I). The costs of current ANC practices in Rwanda for both the health sector and households were estimated through analysis of primary data (Paper II). Incremental cost associated with the implementation of the 2016 World Health Organization (WHO) ANC recommendations compared to current practice in Rwanda was estimated through simulation of attendance and adaptation of the unit cost estimates (Paper III). Incremental health outcomes of the 2016 WHO ANC recommendations were estimated as life-years saved from perinatal and maternal mortality reduction obtained from the expert elicitation (Paper III). Lastly, a systematic review of the evidence base for the cost and cost-effectiveness of routine ultrasound during pregnancy was conducted (Paper IV). The review included 606 studies published between January 1999 and April 2018 and retrieved from PubMed, Scopus, and the Cochrane database.Results: Sixty one percent of women had not adequately attended ANC according to the Rwandan guidelines during their last pregnancy; either attending late or fewer than four times. Adequate utilization of ANC was significantly associated with better HRQoL after delivery measured using EQ-VAS, as were good social support and household wealth. The most prevalent health problems were anxiety or depression and pain or discomfort. The first ANC visit accounted for about half the societal cost of ANC, which was $44 per woman (2015 USD) in public/faith-based facilities and $160 in the surveyed private facility. Implementing the 2016 WHO recommendations in Rwanda would have an incremental national annual cost between $5.8 million and $11 million across different attendance scenarios. The estimated reduction in perinatal mortality would be between 22.5% and 55%, while maternal mortality reduction would range from 7% to 52.5%. Out of six combinations of attendance and health outcome scenarios, four were below the GDP-based cost-effectiveness threshold. Out of the 606 studies on cost and cost-effectiveness of ultrasound during pregnancy retrieved from the databases, only nine reached the data extraction stage. Routine ultrasound screening was reported to be a cost-effective intervention for screening pregnant women for cervical length, for vasa previa, and congenital heart disease, and cost-saving when used for screening for fetal malformations.Conclusions: The use of health economic evidence in decision making for low-income countries should be promoted. It is currently among the least used types of evidence, yet there is a huge potential of gaining many QALYs given persistent and avoidable morbidity and mortality. In this thesis, ANC policy in Rwanda was used as a case to contribute to evidence informed decision-making using health economic evaluation methods. Low-income countries, particularly those that that still have a high burden of maternal and perinatal mortality should consider implementing the 2016 WHO ANC recommendations.
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| 6. |
- Hitimana, Regis, et al.
(författare)
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Health related quality of life determinants for Rwandan women after delivery
- 2017
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Ingår i: European Journal of Public Health. - : OXFORD UNIV PRESS. - 1101-1262 .- 1464-360X. ; 27:Suppl_3, s. 436-
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Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)abstract
- Health related quality of life determinants for Rwandan women after delivery. Does Antenatal care utilization matter? Maternal health conditions are still a major problem in most low-income countries. The postpartum health status and the effect of antenatal care utilization on health are relatively under researched. This study aims at (1) assessing whether receipt of antenatal care according to Rwandan guidelines is associated with mother’s health-related quality of life (HRQoL) and (2) exploring determinants associated with mother’s HRQoL in the first year (1-13 months) after delivery in Rwanda. In 2014 a cross-sectional survey was conducted on 922 women from Kigali City and Northern province of Rwanda, who gave birth in the period of 1–13 months prior to survey. The study population was randomly selected and interviewed using a questionnaire. HRQoL was measured using EQ-5D-3L. Average values of HRQoL were computed by demographic and socio-economic characteristics. The effect of adequate antenatal care on HRQoL was tested in two multivariable linear regression models - with EQ-5D weights and the Visual Analogue Scale score as outcomes respectively - with ANC adequacy and socio-demographic and psychosocial variables as predictors. Mean HRQoL was 0.92 using EQ-5D and 69.58 using EQ-VAS. Fifteen per cent reported moderate pain/discomfort and 1% reported extreme pain/discomfort, 16% reported being moderately anxious/depressed and 3% reported being extremely anxious/depressed. Having more than one child and being cohabitant or single/not married was associated with significantly lower HRQoL, while having good social support and belonging to the highest wealth quintile was associated with higher HRQoL. Antenatal care utilization was not associated with HRQoL among postpartum mothers. Policy makers should address the social determinants of health, and promote social networks among women. There is a need to assess the quality of Antenatal care in Rwanda.Key messages:Health related quality of life among postpartum mothers is high. Pain or discomfort and anxiety of depression are most prevalent problems.Antenatal care utilization was not associated with HRQoL among postpartum mothers. Rather social determinants of health are important in determining mother's HRQoL
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| 7. |
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| 8. |
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| 9. |
- Pulkki-Brännström, Anni-Maria, et al.
(författare)
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The equity impact of a universal child health promotion programme
- 2019
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Ingår i: European Journal of Public Health. - : Oxford University Press. - 1101-1262 .- 1464-360X. ; 29:Suppl 4, s. 103-103
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Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)abstract
- Background: We aimed to evaluate whether the Salut Programme, a universal child health promotion intervention, aimed to strengthen healthy lifestyles in northern Sweden, had any effect on income-related inequalities in positive birth outcomes for children and on healthcare use for children and their mothers.Methods: Mother’s residence and child’s date of birth determined whether the child and the mother belonged to the control group (areas that received care-as-usual) or the intervention group (areas with the intervention implemented from 2005), during the pre-measure period (children born 2002-2004) and the post-measure period (children born 2006-2008). The sum of parents’ taxable income was used for socioeconomic ranking. We computed the standard concentration index for six binary indicators of positive birth outcomes, and for inpatient and day patient care for children and mothers during the two years after delivery. Using a difference-in-difference approach, we assessed whether the extent of inequality changed over time between areas.Results: Income-related inequalities in child health status at birth and in child healthcare use were absent, except that full-term pregnancies were concentrated among the poor at pre-measure in the intervention group. However, mothers’ healthcare use was significantly pro-poor in the control group. The extent of inequality changed between pre- and post-measure periods for two outcomes: the pro-poor concentration of full-term pregnancies in the intervention group at pre-measure disappeared at post-measure; and an increase in pro-poor concentration of normal birth weight in the control group was not matched by a similar increase in the intervention group. Inequalities in healthcare use did not change significantly.Conclusions: Birth outcomes and child healthcare use seemed to be equitably distributed. However, the results raise concerns whether the intervention may have reduced the pro-poor concentration of positive birth outcomes.Key messagesThere are concerns that participation in universal health promotion programmes differs by socioeconomic status, although few public health interventions have been evaluated from an equity perspective.Birth outcomes and child healthcare use in Northern Sweden seemed to be equitably distributed across different socioeconomic groups.
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