The impact of cash transfers on social determinants of health and health inequalities in Sub-Saharan Africa: a systematic review protocol Tackling inequalities in obesity: a protocol for a systematic review of the effectiveness of public health interventions at reducing socioeconomic inequalities in obesity amongst children Tackling inequalities in obesity: a protocol for a systematic review of the effectiveness of public health interventions at reducing socioeconomic inequalities in obesity among adults Defining and measuring health equity effects in research on task shifting interventions in high-income countries: a systematic review protocol Systematic reviews in public health: old chestnuts and new challenges. Improving mental health among people living with HIV: a review of intervention trials in low- and middle-income countries CenteringPregnancy-Africa: a pilot of group antenatal care to address Millennium Development Goals. Improving the reporting of public health intervention research: advancing TREND and CONSORT. The Government of Kenya's Cash Transfer Program Reduces the Risk of Sexual Debut among Young People Age 15-25 Thirty years after Alma-Ata: a systematic review of the impact of community health workers delivering curative interventions against malaria, pneumonia and diarrhoea on child mortality and morbidity in sub-Saharan Africa Tensions in public health policy: patient engagement, evidence-based public health and health inequalities CONSORT-Equity 2017 extension and elaboration for better reporting of health equity in randomised trials Cash for Women’s Empowerment? A Mixed-Methods Evaluation of the Government of Zambia’s Child Grant Program Public views on determinants of health, interventions to improve health, and priorities for government. 'More research needed': plugging gaps in the evidence base on health inequalities. Mexico's conditional cash transfer programme increases cesarean section rates among the rural poor. Exploring antiretroviral treatment adherence in an urban setting in South Africa What impact does contact with the prenatal care system have on women's use of facility delivery? Evidence from low-income countries. Next steps for meeting the needs of people with severe mental illness in low- and middle-income countries.
Background There is increasing pressure to address the social determinants of health ( SDoH ) and health inequities through the implementation of culturally acceptable interventions particularly in Sub-Saharan Africa ( SSA ) where health outcomes are generally poor . Available evaluation research on cash transfers ( CTs ) suggests that the programs may influence the wider determinants of health in SSA ; yet , there has been no attempt to synthesize the evidence regarding their contribution to tackling the SDoH and health inequalities . To date , nearly all the review s on CTs ' impact on health have predominantly featured evidence from Latin America with limited transferability to the social , cultural , and political environments in SSA . Therefore , the aim of this study is to undertake a systematic review to assess the role of CTs in tackling the wider determinants of health and health inequalities in SSA . Methods / design A systematic review of published and unpublished literature on CTs ’ impact on health and health determinants covering the period 2000–2016 will be undertaken . Studies will be considered for inclusion if they present quantitative or qualitative data , including all relevant study design s. The SDoH conceptual framework will be used to guide the data extraction process . EPPI Review er software will be used for data management and analysis . Studies included in the review will be analyzed by narrative synthesis and /or meta- analysis as appropriate for the nature of the data retrieved . Discussion This review will provide empirical evidence on the impact of CTs on SDoH to inform CT policy , implementation , and research in SSA . The protocol follows the Preferred Reporting Items for Systematic Review and Meta- Analysis Protocol s ( PRISMA -P ) . Systematic review registration This protocol has been registered with the PROSPERO international prospect i ve register of systematic review s , reference CRD42015025015 Background There is growing evidence of the impact of overweight and obesity on short- and long-term functioning , health and well-being . Internationally , childhood obesity rates continue to rise in some countries ( for example , Mexico , India , China and Canada ) , although there is emerging evidence of a slowing of this increase or a plateauing in some age groups . In most European countries , the United States and Australia , however , socioeconomic inequalities in relation to obesity and risk factors for obesity are widening . Addressing inequalities in obesity , therefore , has a very high profile on the public health and health services agendas . However , there is a lack of accessible policy-ready evidence on what works in terms of interventions to reduce inequalities in obesity . Methods and design This article describes the protocol for a National Health Service Trust ( NHS ) National Institute for Health Research -funded systematic review of public health interventions at the individual , community and societal levels which might reduce socioeconomic inequalities in relation to obesity amongst children ages 0 to 18 years . The studies will be selected only if ( 1 ) they included a primary outcome that is a proxy for body fatness and ( 2 ) examined differential effects with regard to socioeconomic status ( education , income , occupation , social class , deprivation and poverty ) or the intervention was targeted specifically at disadvantaged groups ( for example , children of the unemployed , lone parents , low income and so on ) or at people who live in deprived areas . A rigorous and inclusive international literature search will be conducted for r and omised and nonr and omised controlled trials , prospect i ve and retrospective cohort studies ( with and /or without control groups ) and prospect i ve repeat cross-sectional studies ( with and /or without control groups ) . The following electronic data bases will be search ed : MEDLINE , Embase , CINAHL , PsycINFO , Social Science Citation Index , ASSIA , IBSS , Sociological Abstract s and the NHS Economic Evaluation Data base . Data base search es will be supplemented with website and grey literature search es . No studies will be excluded on the basis of language , country of origin or publication date . Study inclusion , data extraction and quality appraisal will be conducted by two review ers . Meta- analysis and narrative synthesis will be conducted . The main analysis will examine the effects of ( 1 ) individual , ( 2 ) community and ( 3 ) societal level public health interventions on socioeconomic inequalities in childhood obesity . Interventions will be characterised by their level of action and their approach to tackling inequalities . Context ual information on how such public health interventions are organised , implemented and delivered will also be examined . Discussion In this review , we consider public health strategies which reduce and prevent inequalities in the prevalence of childhood obesity , highlight any gaps in the evidence base and seek to establish how such public health interventions are organised , implemented and delivered . PROSPERO registration number : Background Socioeconomic inequalities in obesity and associated risk factors for obesity are widening throughout developed countries worldwide . Tackling obesity is high on the public health agenda both in the United Kingdom and internationally . However , what works in terms of interventions that are able to reduce inequalities in obesity is lacking . Methods / Design The review will examine public health interventions at the individual , community and societal level that might reduce inequalities in  obesity among adults aged 18 years and over , in any setting and in any country . The following electronic data bases will be search ed : MEDLINE , EMBASE , CINAHL , PsycINFO , Social Science Citation Index , ASSIA , IBSS , Sociological Abstract s , and the NHS Economic Evaluation Data base . Data base search es will be supplemented with website and gray literature search es . No studies will be excluded based on language , country or publication date . R and omized and non-r and omized controlled trials , prospect i ve and retrospective cohort studies ( with/without control groups ) and prospect i ve repeat cross-sectional studies ( with/without control groups ) that have a primary outcome that is a proxy for body fatness and have examined differential effects with regard to socioeconomic status ( education , income , occupation , social class , deprivation , poverty ) or where the intervention has been targeted specifically at disadvantaged groups or deprived areas will be included . Study inclusion , data extraction and quality appraisal will be conducted by two review ers . Meta- analysis and narrative synthesis will be conducted . The main analysis will examine the effects of 1 ) individual , 2 ) community and 3 ) societal level public health interventions on socioeconomic inequalities in adult obesity . Interventions will be characterized by their level of action and their approach to tackling inequalities . Context ual information on how such public health interventions are organized , implemented and delivered will also be examined . Discussion The review will provide evidence , and reveal any gaps in the evidence base , of public health strategies which reduce and prevent inequalities in the prevalence of obesity in adults and provide information on the organization , implementation and delivery of such interventions . Systematic review registration PROSPERO registration number : Introduction Task shifting interventions are intended to both deliver clinical ly effective treatments to reduce disease burden and address health inequities or population vulnerability . Little is known about how health equity and population vulnerability are defined and measured in research focused on task shifting . This systematic review will address the following questions : Among  task shifting interventions in high-income setting s that have been studied using r and omised controlled trials or variants , how are health inequity or population vulnerability identified and defined ? What methods and indicators are used to describe , characterise and measure the population ’s baseline status and the intervention ’s impacts on inequity and vulnerability ? Methods and analysis Studies were identified through data base search es ( MEDLINE , Embase , CINAHL , PsycINFO and Web of Science ) . Eligible studies will be r and omised controlled trials published since 2004 , conducted in high-income countries , concerning task shifting interventions to treat any disease , in any population that may face health disadvantage as defined by the PROGRESS-Plus framework ( place of residence , race/ethnicity/culture/ language , occupation , gender/sex , religion , social capital , socioeconomic position , age , disability , sexual orientation , other vulnerable groups ) . We will conduct independent and duplicate title and abstract screening , then identify related papers from the same programme of research through further data base and manual search ing . From each programme of research , we will extract study details , and definitions and measures of health equity or population vulnerability based on the PROGRESS-Plus framework . Two investigators will assess the quality of reporting and measurement related to health equity and vulnerability using a scale developed for this study . A narrative synthesis will highlight similarities and differences between the gathered studies and offer critical analyses and implication s. Ethics and dissemination This review does not involve primary data collection , does not constitute research on human subjects and is not subject to additional institutional ethics review or informed consent procedures . Dissemination will include open-access peer- review ed publication and academic conference presentations . PROSPERO Registration Number CRD42017049959 The Bulletin ’s editorial team has decided to encourage systematic review s. This is an important decision and is to be welcomed . However it is possible that it will not be received positively by all . Some may feel that systematic review s are not suitable for answering wider public health questions , and that the new section will simply result in the publication of systematic review s addressing narrowly focused , clinical questions with a focus on r and omized controlled trials alone.1 There is no reason why this should be so , and there are far too many examples of systematic review s of non- clinical interventions ( including government policies ) , which include non-r and omized studies , to list.2 Systematic review s of qualitative research are also becoming more common.3 Nonetheless misconceptions about the scope and flexibility of systematic review s still surface occasionally and it never fails to surprise me when I stumble across one of these hoary old chestnuts . If it really were true that systematic review s were only for simple , individual-level interventions , systematic review ers working in public health would be very concerned . After all , public health problems require us to draw on complex sets of qualitative as well as quantitative evidence ; and some policy interventions have never been subjected to r and omized controlled trials ( RCTs ) but have been evaluated using other approaches ; everything from controlled and uncontrolled before- and -after studies , to time series analyses , to qualitative methods . In such cases , systematic review s that focused on RCTs alone would have little to say and we would end up producing many “ empty review s ” , which contain no studies at all . These would be undoubtedly quicker to do and quicker to read than the typical systematic review , but would be of limited use for making policy . However this is not the case . In public health we already have a wealth of review s that prioritize RCTs where they are available , but which draw upon a range of other evidence where they are appropriate to answering the review question .2 Take , as an example , transport policies , an important social determinant of health.4 Public health decision-makers have been interested in the effects on health of building new roads for decades , but there has never been a r and omized controlled trial , for obvious reasons . Yet it would make no sense to cl aim that there is no evidence to be review ed ; rather , there have been many controlled and uncontrolled studies that have examined the effects of new roads on respiratory symptoms , injuries , community severance , disturbance and a variety of other outcomes of public health importance . These studies have in fact been systematic ally review ed.5 Many other examples of review s of complex interventions that impact on public health could be given , which appear on the Cochrane Data base and elsewhere,6,7 and such review s are the main focus of the recently-established Cochrane Public Health Review Group . It is also worth noting that both the Cochrane and Campbell Collaboration include increasing numbers of review s that are relevant to low- and middle- income countries,8 though there is a particular need for more systematic review s that consider the effects on equity of the interventions that they include.9 Currently systematic review s have a “ utilitarian bias ” – they tend to be concerned more with the effects on population s and average effects than with distributional effects and impacts in disadvantaged subgroups . It is to be hoped that systematic review s su bmi tted to the Bulletin will routinely consider the effects of interventions on health inequities . The Cochrane Health Equity Field ( http://equity.cochrane.org/en/index.html ) was set up explicitly to further this agenda , to encourage systematic review authors to explicitly assess the effects of interventions not only on the whole population , but on the disadvantaged . So where does this leave non- systematic review s ? Should every review be a systematic review ? This is a difficult question to answer in a short editorial . My own view is that not all review s need to be systematic review s ; there is still a place for review papers that provide a broad overview , and that discuss a range of evidence and make a contribution to wider debates about what might work in particular setting s. However , while such discussion s help place evidence in context and suggest how it may be used , they should not be confused with the evidence -based conclusions of a transparent , scientific review , which systematic ally attempts to find all the relevant evidence , appraises its strengths and limitations in a transparent fashion , and draws that evidence together in such a way that the more robust studies are given greater weight . Finally , the challenges are many . Evidence on interventions to improve public health is in short supply , particularly evidence on social determinants . Systematic review ers therefore face a real challenge in making best use of the sometimes poor , often sparse and usually heterogeneous evidence available to them . It is easy to set narrow inclusion criteria for a review and then sift through the evidence before concluding that there is n’t enough – and what there is , is n’t very good anyway . Such “ evidential nihilism ” is probably not helpful to decision-makers , and public health systematic review ers need to continue to develop new methods and better frameworks within which different types of research evidence can be integrated to inform decision-making . Publishing systematic review s in the Bulletin should give an added impetus to this ongoing work . People living with HIV ( PLWH ) experience greater psychological distress than the general population . Evidence from high-incomes countries suggests that psychological interventions for PLWH can improve mental health symptoms , quality of life , and HIV care engagement . However , little is known about the effectiveness of mental health interventions for PLWH in low- and middle-income countries ( LMICs ) , where the large majority of PLWH reside . This systematized review aims to synthesize findings from mental health intervention trials with PLWH in LMICs to inform the delivery of mental health services in these setting s. A systematic search strategy was undertaken to identify peer- review ed published papers of intervention trials addressing negative psychological states or disorders ( e.g. depression , anxiety ) among PLWH in LMIC setting s. Search results were assessed against pre-established inclusion and exclusion criteria . Data from papers meeting criteria were extracted for synthesis . Twenty-six papers , published between 2000 and 2014 , describing 22 unique interventions were identified . Trials were implemented in sub-Saharan Africa ( n = 13 ) , Asia ( n = 7 ) , and the Middle East ( n = 2 ) , and addressed mental health using a variety of approaches , including cognitive-behavioral ( n = 18 ) , family-level ( n = 2 ) , and pharmacological ( n = 2 ) treatments . Four r and omized controlled trials reported significant intervention effects in mental health outcomes , and 11 preliminary studies demonstrated promising findings . Among the limited mental health intervention trials with PLWH in LMICs , few demonstrated efficacy .  Mental health interventions for PLWH in LMICs must be further developed and adapted for re source -limited setting s to improve effectiveness BACKGROUND severe health worker shortages and re source limitations negatively affect quality of antenatal care ( ANC ) throughout sub-Saharan Africa .  Group ANC , specifically CenteringPregnancy ( CP ) , may offer an innovative approach to enable midwives to offer higher quality ANC . OBJECTIVE our overarching goal was to prepare to conduct a clinical trial of CenteringPregnancy-Africa ( CP-Africa ) in Malawi and Tanzania . In Phase 1 , our goal was to determine the acceptability of CP as a model for ANC in both countries . In Phase 2 , our objective was to develop CP-Africa session content consistent with the Essential Elements of CP model and with national st and ards in both Malawi and Tanzania . In Phase 3 , our objective was to pilot  CP-Africa in Malawi to determine whether sessions could be conducted with fidelity to the Centering process . SETTING Phases 1 and 2 took place in Malawi and Tanzania . Phase 3 , the piloting of two sessions of CP-Africa , occurred at two sites in Malawi : a district hospital and a small clinic . DESIGN we used an Action Research approach to promote partnerships among university research ers , the Centering Healthcare Institute , health care administrators , health professionals and women attending ANC to develop CP-Africa session content and pilot this model of group ANC . PARTICIPANTS for Phases 1 and 2 , members of the Ministries of Health , health professionals and pregnant women in Malawi and Tanzania were introduced to and interviewed about CP . In Phase 2 , we finalised CP-Africa content and trained 13 health professionals in the Centering Healthcare model . In Phase 3 , we conducted a small pilot with 24 pregnant women ( 12 at each site ) . MEASUREMENTS AND FINDINGS participants enthusiastically embraced CP-Africa as an acceptable model of ANC health care delivery . The CP-Africa content met both CP and national st and ards . The pilot established that the  CP model  could be implemented with process fidelity to the 13 Essential Elements . Several implementation challenges and strategies to address these challenges were identified . KEY CONCLUSIONS preliminary data suggest that CP-Africa is feasible in re source -constrained , low-literacy , high-HIV setting s in sub-Saharan Africa . By improving the quality of ANC delivery , midwives have an opportunity to make a contribution towards Millennium Development Goals ( MDG ) targeting improvements in child , maternal and HIV-related health outcomes ( MDGs 4 , 5 and 6 ) . A clinical trial is needed to establish efficacy . IMPLICATION S FOR PRACTICE CP-Africa also has the potential to reduce job-related stress and enhance job satisfaction for midwives in low income countries . If CP can be transferred with fidelity to process in sub-Saharan Africa and retain similar results to those reported in clinical trials , it has the potential to benefit pregnant women and their infants and could make a positive contribution to MGDs 4 , 5 and 6 BACKGROUND Evidence -based public health decision-making depends on high quality and transparent accounts of what interventions are effective , for whom , how and at what cost . Improving the quality of reporting of r and omized and non-r and omized study design s through the CONSORT and TREND statements has had a marked impact on the quality of study design s. However , public health users of systematic review s have been concerned with the paucity of synthesized information on context , development and rationale , implementation processes and sustainability factors . METHODS This paper examines the existing reporting frameworks for research against information sought by users of systematic review s of public health interventions and suggests additional items that should be considered in future recommendations on the reporting of public health interventions . RESULTS Intervention model , theoretical and ethical considerations , study design choice , integrity of intervention/process evaluation , context , differential effects and inequalities and sustainability are often overlooked in reports of public health interventions . CONCLUSION Population health policy makers need synthesized , detailed and high quality a priori accounts of effective interventions in order to make better progress in tackling population morbidities and inequalities . Adding simple criteria to reporting st and ards will significantly improve the quality and usefulness of published evidence and increase its impact on public health program planning The aim of this study is to assess whether the Government of Kenya 's Cash Transfer for Orphans and Vulnerable Children ( Kenya CT-OVC ) can reduce the risk of HIV among young people by postponing sexual debut . The program provides an unconditional transfer of US$ 20 per month directly to the main caregiver in the household . An evaluation of the program was implemented in 2007–2009 in seven districts . Fourteen Locations were r and omly assigned to receive the program and fourteen were assigned to a control arm . A sample of households was enrolled in the evaluation in 2007 . We revisited these households in 2011 and collected information on sexual activity among individuals between 15–25 years of age . We used logistic regression , adjusted for the respondent 's age , sex and relationship to caregiver , the age , sex and schooling of the caregiver and whether or not the household lived in Nairobi at baseline , to compare rates of sexual debut among young people living in program households with those living in control households who had not yet entered the program . Our results , adjusted for these covariates , show that the program reduced the odds of sexual debut by 31 percent . There were no statistically significant effects on secondary outcomes of behavioral risk such as condom use , number of partners and transactional sex . Since the CT-OVC provides cash to the caregiver and not to the child , and there are no explicit conditions associated with receipt , these impacts are indirect , and may have been achieved by keeping young people in school . Our results suggest that large-scale national social cash transfer programs with poverty alleviation objectives may have potential positive spillover benefits in terms of reducing HIV risk among young people in Eastern and Southern Africa Background Over thirty years have passed since the Alma-Ata Declaration on primary health care in 1978 . Many governments in the first decade following the declaration responded by developing national programmes of community health workers ( CHWs ) , but evaluations of these often demonstrated poor outcomes . As many CHW programmes have responded to the HIV/AIDS p and emic , international interest in them has returned and their role in the response to other diseases should be examined carefully so that lessons can be applied to their new roles . Over half of the deaths in African children under five years of age are due to malaria , diarrhoea and pneumonia - a situation which could be addressed through the use of cheap and effective interventions delivered by CHWs . However , to date there is very little evidence from r and omised controlled trials of the impacts of CHW programmes on child mortality in Africa . Evidence from non-r and omised controlled studies has not previously been review ed systematic ally . Methods We search ed data bases of published and unpublished studies for RCTs and non-r and omised studies evaluating  CHW programmes delivering curative treatments , with or without preventive components , for malaria , diarrhoea or pneumonia , in children in sub-Saharan Africa from 1987 to 2007 . The impact of these programmes on morbidity or mortality in children under six years of age was review ed . A descriptive analysis of interventional and context ual factors associated with these impacts was attempted . Results The review identified seven studies evaluating CHWs , delivering a range of interventions . Limited descriptive data on programmes , context s or process outcomes for these CHW programmes were available . CHWs in national programmes achieved large mortality reductions of 63 % and 36 % respectively , when insecticide-treated nets and anti-malarial chemoprophylaxis were delivered , in addition to curative interventions . Conclusions CHW programmes could potentially achieve large gains in  child survival in sub-Saharan Africa if these programmes were implemented at scale . Large-scale rigorous studies , including RCTs , are urgently needed to provide policymakers with more evidence on the effects of CHWs delivering these interventions This paper examines the proposition that there are considerable tensions between key strategies in health policy — namely , evidence -based approaches to population health improvement , reduction of health inequalities , and public and patient engagement — using ( 1 ) a critical analysis of the intersection of evidence -based public health , patient and public engagement , and health inequalities policies from a social constructionist perspective and ( 2 ) mathematical modelling of paternalistic and shared decision making in the management of hypertension in a r and om age and sex stratified community sample of residents of south east Northumberl and , UK . It is concluded that there may be unintended effects on population health of incongruities in major components of public health policy . Greater public and patient engagement may militate against the disease prevention goals of evidence -based policy , and may better engage sections of the population who already benefit from greater access and better health associated with social status and opportunity , serving to increase inequalities by further marginalising those already suffering from relative exclusion We outline CONSORT-Equity 2017 reporting st and ards , an extension to the CONSORT ( Consoli date d St and ards of Reporting Trials ) statement that aims to improve the reporting of intervention effects in r and omised trials where health equity is relevant . Health inequities are unfair differences in health that can be avoided by reasonable action . We defined a r and omised trial where health equity is relevant as one that assesses effects on health equity by evaluating an intervention focused on people experiencing social disadvantage or by exploring the difference in the effect of the intervention between two groups ( or as a gradient across more than two groups ) experiencing different levels of social disadvantage , or both . We held a consensus meeting with diverse potential users from high , middle , and low income countries , including knowledge users such as patients and method ologists . We discussed evidence for each proposed extension item from empirical studies , review s , key informant interviews , and an online survey , aim ing to improve clarity of reporting without imposing undue burden on authors . The new guidance contains equity extensions to 16 items from CONSORT 2010 plus one new item on research ethics reporting , with examples of good practice and a brief explanation and elaboration for each . Widespread uptake of this guidance for the reporting of trials where health equity is relevant will make it easier for decision makers to find and use evidence from r and omised trials to reduce unfair inequalities in health Summary . — The empowerment of women , broadly defined , is an often-cited objective and benefit of social cash transfer programs in developing countries . Despite the promise and potential of cash transfers to empower women , the evidence supporting this outcome is mixed . In addition , there is little evidence from programs at scale in sub-Saharan Africa . We conducted a mixed- methods evaluation of the Government of Zambia ’s Child Grant Program , a poverty-targeted , unconditional transfer given to mothers or primary caregivers of young children aged zero to five . The quantitative component was a four-year longitudinal clustered-r and omized control trial in three rural districts , and the qualitative component was a one-time data collection involving in-depth interviews with women and their partners stratified on marital status and program participation . Our study found that women in beneficiary households were making more sole or joint decisions ( across five out of nine domains ) ; however , impacts translated into relatively modest increases in the number of decision domains a woman is involved in , on average by 0.34 ( or a 6 % increase over a baseline mean of 5.3 ) . Qualitatively , we found that changes in intrahousehold relationships were limited by entrenched gender norms , which indicate men as heads of household and primary decision makers . However , women ’s narratives showed the transfer increased financial empowerment as they were able to retain control over transfers for household investment and savings for emergencies . We highlight method ological challenges in using intrahousehold decision making as the primary indicator to measure empowerment . Results show potential for unconditional cash transfer programs to improve the financial and intrahousehold status of female beneficiaries , however it is likely additional design components are need for transformational change OBJECTIVE There is increasing evidence about the importance of factors that impact health beyond health care and individual behavior , yet there is little public and policy discourse about these things in the United States . We surveyed Wisconsin adults to see what they think are the most important factors that affect health . We also examined which interventions they believe would improve health , and whether government should prioritize such interventions . METHODS A phone survey of a r and om sample of 1459 Wisconsin adults was conducted between September 2006 and February 2007 . RESULTS The Wisconsin public believes that health practice s , access to health care , and health insurance are the most important factors affecting health , and that health insurance is a high government priority . Other broader social and economic determinants of health , such as employment , social support , income , housing , and neighborhood factors are seen as less important to health . Although respondents believe that health practice s are important to health , they are less likely to suggest that government prioritize improving individual health practice s. Although the public believes the government should prioritize access to health care and health insurance , they are not as likely to support government implementing social or economic policies in order to improve health . CONCLUSION In light of research demonstrating the importance of social and economic determinants of health , and of ongoing public forums meant to raise awareness of these determinants of health , it will be important to track whether public opinion of Wisconsin adults changes over time to increase attention to the social and economic determinants of health and related policy initiatives Policymakers and public health research ers have dem and ed better evidence of the effects of interventions on public health and health inequalities and have pointed to the relative absence of rigorous outcome evaluations in this area . While most of these commentators agree that health inequalities are a problem , the means of tackling them often seems to rest on poor evidential foundations . This is no longer surprising , as the problem has been well-documented and the solution probably seems clear : if there is not enough evidence , then obviously we need more ; and if the evidence is ‘ weak ’ , well , then , it just needs to be ‘ stronger ’ in future . The funding environment in the UK , at least , is supportive of the production of this new , stronger evidence , with several new funding initiatives which are aim ing to foster the production of new evaluations of public health interventions . However , it might be useful to consider further what ‘ more evidence ’ might look like ( that is , what sort of evidence is needed ) and how might it be ‘ stronger ’ than in the past and also to consider what additional challenges collecting this new evidence might bring . It is clear that evidence on the effectiveness and cost-effectiveness of public health interventions is often missing . Sometimes this is because policies are insufficiently subjected to outcome evaluation , perhaps because it is assumed that they are mostly beneficial and any positive outcomes can be taken as read . R and omized controlled trials of policies are particularly uncommon and there are a variety of real and perceived barriers to trials . This means that the public are frequently ‘ enrolled ’ in real-life policy ‘ experiments ’ without giving their explicit consent , or indeed without any real prospect of anyone learning anything substantial about the effects of those interventions . Although the experimental nature of most policies is generally unacknowledged , this is not always the BACKGROUND Caesarean section rates are increasing in Mexico and Latin America . This study evaluates the impact of a large-scale , conditional cash transfer programme in Mexico on caesarean section rates . The programme provides cash transfers to participating low income , rural households in Mexico conditional on accepting health care and nutrition supplements . METHODS The primary analyses uses retrospective reports from 979 women in poor rural communities participating in an effectiveness study and r and omly assigned to incorporation into the programme in 1998 or 1999 across seven Mexican states . Using multivariate and instrumental variable analyses , we estimate the impact of the programme on caesarean sections and predict the adjusted mean rates by clinical setting . Programme participation is measured by beneficiary status , programme months and cash transfers . RESULTS More than two-thirds of poor rural women delivered in a health facility . Beneficiary status is associated with a 5.1 percentage point increase in caesarean rates ; this impact increases to 7.5 percentage points for beneficiaries enrolled in the programme for > or=6 months before delivery . Beneficiaries had significantly higher caesarean delivery rates in social security facilities ( 24.0 compared with 5.6 % among non-beneficiaries ) and in other government facilities ( 19.3 compared with 9.5 % ) . CONCLUSION The Oportunidades conditional cash transfer programme is associated with higher caesarean section rates in social security and government health facilities . This effect appears to be driven by the increases in disposable income from the cash transfer . These findings are relevant to other countries implementing conditional cash transfer programmes and health care requirements Antiretroviral treatment requires high levels of adherence to be effective . This qualitative study explores the reasons for poor  adherence among 22 purposively selected poor urban participants in South Africa . Over a 4-month period in 2009 , we prospect ively investigated experiences of HIV diagnosis and treatment , adherence , and withdrawal from  treatment  . Patients with no stable food sources faced significant barriers in adhering to treatment regimens and staying sufficiently healthy to search for , obtain or retain a job . The narratives also identify the influence on adherence of self-esteem and social support , vulnerability generated by ill health , gendered conflict , social inequities amplified by HIV , and exhaustion due to the social burden of the epidemic . Multi-dimensional , inter-sectoral programs that tackle the social determinants of health , such as food insecurity , poverty , gendered inequities , and treatment adherence are more likely to be successful , than single interventions to support adherence Prenatal and delivery care are critical both for maternal and newborn health . Using the Demographic and Health Surveys ( DHS ) data for thirty-two low-income countries across Asia , sub-Saharan Africa and Latin America , and employing a two-level r and om-intercept model , this paper empirically assesses the influence of prenatal attendance and a wide array of observed individual- , household- and community-level characteristics on a woman 's decision to give birth at a health facility or at home . The results show that  prenatal attendance does appreciably influence the use of facility delivery in all three geographical regions , with women having four visits being 7.3 times more likely than those with no prenatal care to deliver at a health facility . These variations are more pronounced for Sub-Saharan Africa . The influence of the number of prenatal visits , maternal age and education , parity level , and economic status of the  birthing women on the place of delivery is found to vary across the three geographical regions . The results also indicate that obstetrics care is geographically and economically more accessible to urban and rural women from the non-poor households than those from the poor households . The strong influence of number of visits , household wealth , education and regional poverty on the site of delivery setting suggests that policies aim ed at increasing the use of obstetric care programs should be linked with the objectives of social development programs such as poverty reduction , enhancing the status of women , and increasing primary and secondary school enrollment rate among girls The explicit inclusion of mental health within the Sustainable Development Goals is a welcome development , borne out of powerful advocacy using public health , economic and human rights arguments . As funding comes on line for scale-up of evidence -based mental health care by task-sharing with primary care , it is time to take stock about care for people affected by severe mental illness ( SMI ) . The existing evidence base for task shared care for SMI provides an imperative to get started , but is skewed towards relatively more affluent and urban population s in middle-income countries where specialist mental health professionals provide most of the care . R and omised , controlled trials and rigorous implementation research on task shared service models are underway which will go some way to improving underst and ing of the quality , safety , effectiveness and acceptability of more widely generalisable care for people with SMI . A sub-group of people with SMI have more complex and long-term needs for care , with a high risk of homelessness , imprisonment and human rights violations as family and social supports become overwhelmed . Case studies from non-governmental organisations provide examples of holistic approaches to rehabilitation , recovery and empowerment of people with SMI , but rigorous comparative studies are needed to identify the most efficient , effective and scalable approaches to care . Health system constraints are emerging as the over-riding barriers to successful task-sharing , highlighting a need to develop and evaluate chronic care models for people with SMI that succeed in reducing premature mortality , improving wellbeing and achieving better social outcomes . Addressing these evidence gaps is essential if task-sharing mental health care is going to deliver on its promise of promoting recovery for the full range of people affected by SMI
The review found that CTs can be effective in tackling structural determinants of health such as financial poverty , education , household resilience , child labour , social capital and social cohesion , civic participation , and birth registration .
The review further found that CTs modify intermediate determinants such as nutrition , dietary diversity , child deprivation , sexual risk behaviours , teen pregnancy and early marriage .
In conjunction with their influence on SDoH , there is moderate evidence from the review that CTs impact on health and quality of life outcomes .
The review also found many factors relating to intervention design features , macro-economic stability , household dynamics and community acceptance of programs that could influence the effectiveness of CTs .
The external validity of the review findings is strong as the findings are largely consistent with those from Latin America .
Cash transfers ( CTs ) are now high on the agenda of most governments in low- and middle-income countries .
Within the field of health promotion , CTs constitute a healthy public policy initiative as they have the potential to address the social determinants of health ( SDoH ) and health inequalities .
A systematic review was conducted to synthesis e the evidence on CTs ' impacts on SDoH and health inequalities in sub-Saharan Africa , and to identify the barriers and facilitators of effective CTs .