Ryota Nakamura

Background: Community-based health insurance (CBHI) aims to extend health coverage to informal-sector and vulnerable populations in low- and middle-income countries, but greater enrolment might not translate into effective and equitable coverage. We examined how subsidies and CBHI operational capacity were associated with enrolment, healthcare use, catastrophic health expenditure (CHE), and socioeconomic equity. Methods: We linked representative household surveys from 2019 and 2022 with census surveys of CBHI schemes from 2017 and 2020 across three regions of Senegal. We compared partially and fully subsidised CBHI models on enrolment, healthcare utilization, and CHE, examined associations with scheme operational capacity, and assessed socioeconomic inequalities using slope and relative inequality indices. Findings: The surveys included 1,767 households in 2019 and 2,160 households in 2022. Enrolment among those eligible for fully subsidised CBHI increased from 17·4% to 38·5%, while enrolment in the partially subsidised population remained below 3%. Enrolment was associated with greater healthcare utilization in the partially subsidised population (OR 1·63, 95% CI 1·25-2·13), but not among those eligible for full subsidies (1·19, 0·82–1·74), and was not associated with lower CHE in either population. Associations between scheme operational-capacity indicators and outcomes were heterogeneous. Enrolment was pro-rich under both models; among those eligible for full subsidies, the slope index of inequality was 10·3 percentage points (95% CI 2·9-17·7) in 2019 and 13·4 (4·2-22·6) in 2022. Interpretation: Enrolment expanded substantially among those eligible for fully subsidised CBHI, but this expansion was not accompanied by consistent evidence of greater healthcare use or financial risk protection, and socioeconomic inequalities in enrolment persisted. Associations with scheme operational capacity were heterogeneous, suggesting that scheme-level strengthening alone might be insufficient. Achieving effective and equitable coverage might require broader financing and risk-pooling reforms alongside interventions addressing non-financial barriers to enrolment and care.

Introduction: Context-specific cost-effectiveness thresholds (CETs) informed by societal willingness to pay (WTP) are crucial for healthcare resource allocation in low- and middle-income countries. This study investigated WTP for health per quality-adjusted life year (QALY) in Bhutan. Methods: A WTP survey was conducted alongside the 2023 National Health Survey in Bhutan, sampling 1869 households. Using contingent valuation, respondents assigned monetary values to three hypothetical scenarios: 1 year of cancer symptom-free life, 1 year of perfect health and 5 years of perfect health. We used generalised linear regression to estimate WTP, controlling for demographic, socioeconomic and health-related factors, as well as elicitation methods. Multilevel analyses examined WTP variations within and between districts. Results: WTP estimates were 76 836 Bhutanese ngultrum (BTN) (0.26 times gross domestic product (GDP) per capita; 95% CI: 71 397 to 82 275) for a year without cancer symptoms, 104 381 BTN (0.35 times GDP per capita; 95% CI: 96 405 to 112 357) for 1 QALY and 235 237 BTN (0.78 times GDP per capita; 95% CI: 218 674 to 251 800) for 5 QALYs. WTP variations were driven by within-district individual characteristics, particularly income and education, rather than between-district differences. Conclusion: Minimal between-district WTP variations support a national-level CET for Bhutan. However, WTP-based CETs would be biased upward by wealthier and more educated groups. This bias could justify expensive technologies that strain public resources in Bhutan’s government-funded healthcare system.

Background: Monitoring progress and inequality in childhood immunization coverage at both national and sub-national levels is essential for refining equity-oriented health programs and ensuring equitable access to care towards achieving global targets in African countries. Methods and Findings: Using approximately 1 million records from 104 nationally representative Demographic and Health Surveys (DHS) conducted in 38 African countries (2000–2019), we estimated childhood immunization coverage for key indicators (BCG, MCV1, DPT3, Polio3, and Full immunization), stratified by socioeconomic status. Variations of Bayesian spatio-temporal analysis using Besag, Besag–York–Mollié (BYM) and BYM2 models were employed to assess and project the trends from 2000 to 2030. We evaluated the probability of achieving Universal Health Coverage (80% coverage) and Immunization Agenda (90% coverage) by 2030, at national and sub-national levels. Finally, we conducted a comprehensive inequality analysis using the Slope Index of Inequality (SII) and Relative Index of Inequality (RII) to assess changes over the study period. Childhood immunization coverage improved significantly across most African countries from 2000 to 2019. However, projections suggest that 12 countries are unlikely to achieve global targets for full immunization by 2030 at the national level if current trends continue. Notably, high-Socio-Demographic Index (SDI) countries such as South Africa, Egypt, and Congo Brazzaville are projected to miss immunization targets across all sub-national regions. While socioeconomic inequalities were widespread in 2000, they are projected to decline or stabilize in 36 countries by 2030, with Eswatini, Morocco, Rwanda, and Burkina Faso expected to eliminate disparities. In contrast, Nigeria and Angola are projected to face increasing inequalities or persistent large gaps. Regional disparities in both coverage and inequality remain pronounced, particularly in Central and Western Africa, where coverage remains low and inequality remains high despite overall national-level improvements. The analysis was limited to DHS surveys 2000–2019, excluding more recent data during the COVID-19 period and potentially overestimating trends in data-sparse settings. Conclusions: This study highlights both progress and persistent challenges in childhood immunization coverage, along with inequalities across 38 African countries. Persistent regional disparities and socioeconomic inequalities require multifaceted strategies that account for demographic, geographic, economic, and political factors to ensure equitable immunization. Greater efforts are needed to close these gaps and support global health goals for the African nations.

Background: An increasing number of multicomponent workplace interventions are being developed to reduce sedentary time and promote physical activity among office workers. The Physical Activity at Work (PAW) trial was one of these interventions, but it yielded an inconclusive effect on sedentary time after 6 months, with a low uptake of movement breaks, the main intervention component. Objective: This study investigates the factors contributing to the outcomes of the PAW cluster randomized trial. Methods: Following the Medical Research Council’s guidance for process evaluation of complex interventions, we used a mixed methods study design to evaluate the PAW study’s recruitment and context (how job nature and cluster recruitment affected movement break participation), implementation (dose and fidelity), and mechanisms of impact (assessing how intervention components affected movement break participation and identifying the facilitators and barriers to participation in the movement breaks). Data from accelerometers, pedometers, questionnaires, on-site monitoring, and focus group discussions were used for the evaluation. Linear mixed effects models were used to analyze the effects of different intervention components on the movement breaks. Subsequently, qualitative analysis of the focus group discussions provided additional insights into the relationship between the intervention components. Results: The participation in movement breaks declined after the third week, averaging 12.7 sessions (SD 4.94) per participant per week for the first 3 weeks, and continuing to decrease throughout the intervention. On-site monitoring confirmed high implementation fidelity. Analysis of Fitbit data revealed that each additional movement break was associated with a reduction of 6.20 (95% CI 6.99-5.41) minutes in sedentary time and an increase of 245 (95% CI 222-267) steps. Regarding the mechanisms of impact, clusters with higher baseline sedentary time demonstrated greater participation in movement breaks, while those with frequent out-of-office duties showed minimal engagement. Moreover, clusters with enthusiastic and encouraging movement break leaders were associated with a 24.1% (95% CI 8.88%-39.4%) increase in participation. Environmental and organizational support components using posters and leaders’ messages were ineffective, showing no significant change in percentage participation in movement breaks (4.49%, 95% CI –0.49% to 9.47% and 1.82%, 95% CI –2.25% to 5.9%, respectively). Barriers such as high workloads and meetings further hindered participation, while the facilitators included participants’ motivation to feel active and the perceived health benefits from movement breaks. Conclusions: Despite high fidelity, the PAW trial did not significantly reduce sedentary time, with limited uptake of movement breaks due to context-related challenges, ineffective environmental support, and high workloads during the COVID-19 pandemic.

This preregistered systematic review and meta-analysis (PROSPERO: CRD 42022311392) aimed to synthesize the effectiveness of all available population-level tobacco policies on smoking behaviour. Our search across 5 databases and leading organizational websites resulted in 9,925 records, with 476 studies meeting our inclusion criteria. In our narrative summary and both pairwise and network meta-analyses, we identified anti-smoking campaigns, health warnings and tax increases as the most effective tobacco policies for promoting smoking cessation. Flavour bans and free/discounted nicotine replacement therapy also showed statistically significant positive effects on quit rates. The network meta-analysis results further indicated that smoking bans, anti-tobacco campaigns and tax increases effectively reduced smoking prevalence. In addition, flavour bans significantly reduced e-cigarette consumption. Both the narrative summary and the meta-analyses revealed that smoking bans, tax increases and anti-tobacco campaigns were associated with reductions in tobacco consumption and sales. On the basis of the available evidence, anti-tobacco campaigns, smoking bans, health warnings and tax increases are probably the most effective policies for curbing smoking behaviour.

The aim of this multi-country, cluster-randomized trial is to test the impact of pharmacy-based health promotion to reduce the blood pressure of individuals with hypertension over a 12-month period in Bangladesh and Pakistan. The trial will be implemented with two arms. In Bangladesh, the estimated sample size is around 3600 hypertensive patients. In Pakistan, we will select samples equivalent to 10% of the participants from Bangladesh, comprising 360 hypertensive patients from four pharmacies. Community pharmacies will be randomized into one of two parallel groups (allocation ratio 1:1). Pharmacy professionals in the treatment arm will provide their patients with educational training and counseling, as well as phone calls/mobile text messages and care coordination in the health sector, as part of the intervention. The study will be conducted in three phases: a baseline survey with intervention, a midline survey with intervention and follow-up, and an endline survey with impact evaluation. The primary outcome of the study will be BP. The secondary outcomes will be BP controlled to target, treatment adherence, quality of life, mortality or hospital admission rates resulting from hypertension and its related complications, incremental cost per health-related quality of life gained, knowledge on healthy lifestyle and dietary behavior, and change in the prevalence of current smoking status.

BACKGROUND An increasing number of multicomponent workplace interventions are being developed to reduce sedentary time and promote physical activity among office workers. The Physical Activity at Work (PAW) trial was one of these interventions, but it yielded an inconclusive effect on sedentary time after 6 months, with a low uptake of movement breaks, the main intervention component. OBJECTIVE This study investigates the factors contributing to the outcomes of the PAW cluster randomized trial. METHODS Following the Medical Research Council’s guidance for process evaluation of complex interventions, we used a mixed methods study design to evaluate the PAW study’s recruitment and context (how job nature and cluster recruitment affected movement break participation), implementation (dose and fidelity), and mechanisms of impact (assessing how intervention components affected movement break participation and identifying the facilitators and barriers to participation in the movement breaks). Data from accelerometers, pedometers, questionnaires, on-site monitoring, and focus group discussions were used for the evaluation. Linear mixed effects models were used to analyze the effects of different intervention components on the movement breaks. Subsequently, qualitative analysis of the focus group discussions provided additional insights into the relationship between the intervention components. RESULTS The participation in movement breaks declined after the third week, averaging 12.7 sessions (SD 4.94) per participant per week for the first 3 weeks, and continuing to decrease throughout the intervention. On-site monitoring confirmed high implementation fidelity. Analysis of Fitbit data revealed that each additional movement break was associated with a reduction of 6.20 (95% CI 6.99-5.41) minutes in sedentary time and an increase of 245 (95% CI 222-267) steps. Regarding the mechanisms of impact, clusters with higher baseline sedentary time demonstrated greater participation in movement breaks, while those with frequent out-of-office duties showed minimal engagement. Moreover, clusters with enthusiastic and encouraging movement break leaders were associated with a 24.1% (95% CI 8.88%-39.4%) increase in participation. Environmental and organizational support components using posters and leaders’ messages were ineffective, showing no significant change in percentage participation in movement breaks (4.49%, 95% CI –0.49% to 9.47% and 1.82%, 95% CI –2.25% to 5.9%, respectively). Barriers such as high workloads and meetings further hindered participation, while the facilitators included participants’ motivation to feel active and the perceived health benefits from movement breaks. CONCLUSIONS Despite high fidelity, the PAW trial did not significantly reduce sedentary time, with limited uptake of movement breaks due to context-related challenges, ineffective environmental support, and high workloads during the COVID-19 pandemic.

We implemented a clustered randomized controlled trial with 6,963 residents in six rural Ghana districts to estimate the causal impact of financial incentives on coronavirus disease 2019 (COVID-19) vaccination uptake. Villages randomly received one of four video treatment arms: a placebo, a standard health message, a high cash incentive (60 Ghana cedis) and a low cash incentive (20 Ghana cedis). For the first co-primary outcome—COVID-19 vaccination intentions—non-vaccinated participants assigned to the cash incentive treatments had an average rate of 81% (1,733 of 2,168) compared to 71% (1,895 of 2,669) for those in the placebo treatment arm. For the other co-primary outcome of self-reported vaccinations 2 months after the initial intervention, the average rate for participants in the cash treatment was 3.5% higher than for participants in the placebo treatment (95% confidence interval (CI): 0.001, 6.9; P = 0.045): 40% (602 of 1,486) versus 36.3% (672 of 1,850). We also verified vaccination status of participants: in the cash treatment arm, 36.6% (355 of 1,058) of verified participants had at least one dose of the COVID-19 vaccine compared to 30.3% (439 of 1,544) for those in the placebo—a difference of 6.3% (95% CI: 2.4, 10.2; P = 0.001). For the intention and the vaccination outcomes, the low cash incentive (20 Ghana cedis) had a larger positive effect on COVID-19 vaccine uptake than the high cash incentive (60 Ghana cedis). Trial identifier: AEARCTR-0008775.