Category Archives: CLAHRC International

The Payback from Improving Availability of Donor Human Milk for Premature Babies

CLAHRC WM is collaborating with the African Population Health Research Centre (APHRC) in the evaluation of donor milk banks in slums (informal settlements) in Kenya. The initiative is led by PATH,[1] which has had considerable success in establishing an altruistic donor service in South Africa. The donor milk is donated to hospital wards caring for premature infants.

There is excellent evidence that donor human milk is superior to ‘formula’ in babies whose mothers are unable to express breast milk. As a result of passive immunity, and also because it has nutritional properties that formula is not able to replicate, donor human milk reduces the risk of neonatal infection.[2] In particular, it reduces the dangerous condition of necrotising enterocolitis (NEC).[3][4] NEC can be fatal and may also require surgery that may have permanent consequences – particularly the ‘short bowel syndrome’. The decreased infection risk resulting from use of donor milk is associated with a measurable decrease in mean length of stay.[5]

One concern is that the mothers of infants who receive donor milk may be less likely to initiate breast feeding at a later date for psychological or physiological reasons. The evidence does not bear out this concern and, if anything, these mothers, perhaps inspired by the altruism of the donors, are more likely to breastfeed.[6][7] If so, this may be expected to augment the benefits of donor milk and also reduce the mother’s risk of developing breast cancer later in life.[8]

The benefits do not seem to end there. There is observational evidence, recently reinforced by a substantial study from Brazil,[9] that cognitive ability in later life is improved by human milk. There is a dose-response effect and the results remain after extensive statistical adjustment for confounders. There is also some experimental (RCT) evidence for a beneficial effect on IQ.[10] Improved IQ is correlated with earning power [11] and, we must assume, payback to society.[12]

To summarise the benefits of breastfeeding we offer the following Influence Diagram (Causal Pathway: Model):

CI - Improving Availability of Donor Human Milk Fig 1

A health economic analysis of promotion of breastfeeding for older children (not premature infants specifically) found that the intervention ‘dominated’ – reduced short-term benefits (less infection) and the contingent cost savings (reduced hospital stays) meant that interventions to promote breastfeeding are cost-saving, not just beneficial for health.[12][13]

There have been two studies of the cost-effectiveness of a donor milk service for premature babies. Both found that the service was cost-effective. The first study was based on a hypothetical baby who was very premature (28 weeks gestational age), rather than an observed mean intervention effect observed at the group level.[14] The calculated benefits might therefore be exaggerated. The second study was based on only 175 propensity scored low birth weight infants.[5] The risk of sepsis decreased with increasing dose of human milk, and total costs obtained from the hospital billing system were lower in proportion to the amount of human milk consumed. However, most infants received some human milk, so the infants could not be divided into a control and intervention population, and the above correlation between outcome and volume of donor milk consumed may have been confounded by factors that determine both access to human milk and sepsis, notwithstanding propensity scoring. Both the above studies were American.

Working with colleagues above, we propose a comprehensive health economic model that takes account of long-term outcomes and that can be populated with country-specific data. The base-case model will be populated with evidence from systematic reviews,[12][13] and we propose to use Bayesian techniques to ‘down weight’ observational evidence using the Turner and Spiegelhalter method.[15]

— Richard Lilford, CLAHRC WM Director
— Celia Taylor, Senior Lecturer


  1. PATH. Models of milk banking in South Africa. Seattle, WA: PATH, 2011.
  2. Arslanoglu S, Ziegler EE, Moro GE. Donor human milk in preterm infant feeding: evidence and recommendations. J Perinat Med. 2010; 38: 347-51.
  3. Lucas A, Cole TJ. Breast milk and neonatal necrotising enterocolitis. Lancet. 1990; 336: 1519-23.
  4. Quigley M, McGuire W. Formula versus donor milk for feeding preterm or low birth weight infants. Cochrane Database Sys Revs. 2014; 4: CD002971.
  5. Patel AL, Johnson TJ, Engstrom JL, Fogg LF, Jegier BJ, Bigger HR, Meier PP. Impact of early human milk on sepsis and health-care costs in very low birth weight infants. J Perinatol. 2013; 33: 514-9.
  6. Arslanoglu S, Moro GE, Bellù R, Turoli D, De Nisi G, Tonetto P, Bertino E. Presence of human milk bank is associated with elevated rate of exclusive breastfeeding in VLBW infants. J Perinat Med. 2013; 41(2): 129-31.
  7. Vázquez-Román S, Bustos-Lozano G, López-Maestro M, et al. Clinical impact of opening a human milk bank in a neonatal unit. An Pediatr (Barc). 2014; 81(3): 155-60.
  8. Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and breastfeeding: collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50 302 women with breast cancer and 96 973 women without the disease. Lancet. 2002; 360: 187-95.
  9. Victora CG, Horta BL, Loret de Mola C, Quevedo L, Pinheiro RT, Gigante DP, Gonçalves H, Barros FC. Association between breastfeeding and intelligence, educational attainment, and income at 30 years of age: a prospective birth cohort study from Brazil. Lancet Glob Health. 2015; 3(4): e199-205.
  10. Horta BL, Victora CG. Long-term effects of breastfeeding: a systematic review. Geneva: World Health Organization. 2013
  11. US Environmental Protection Agency. The benefits and costs of the clean air act, 1970 to 1990, appendix G, lead benefits analysis. Washington, DC: Environmental Protection Agency, 1997.
  12. Renfrew MJ, Pokhrel S, Quigley M, et al. Preventing disease and saving resources: the potential contribution of increasing breastfeeding rates in the UK. UNICEF. 2012.
  13. Kramer MS & Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database Sys Revs. 2012; 8: CD003517.
  14. Arnold LDW. The Cost-effectiveness of Using Banked Donor Milk in the Neonatal Intensive Care Unit: Prevention of Necrotizing Enterocolitis. J Hum Lact. 2002; 18(2): 172-7.
  15. Turner RM, Spiegelhalter DJ, Smith GCS, Thompson SG. Bias modeling in evidence synthesis. J R Stat Soc Ser A. 2009; 172: 21–47.

Assessing Publication Bias in Social Sciences – a Critically Important Paper from Science

Publication bias means that null results do not make it into the public domain. Assessing publication bias is straightforward in subjects where all studies have to be registered in advance – clinical trials for example. But there is little evidence on publication bias in service delivery / health services research. The CLAHRC WM Director suspects that this lack of evidence arises because much social science literature is observational rather than experimental, and it is so hard to collect convincing evidence on publication bias among such studies. There is no registry of studies; the original hypothesis may not correspond to comparisons reported; many studies might not be written up; and the investigators may evaluate a large number of associations so that results do not neatly dichotomise into significant or null. In addition, the famous funnel plot may be less likely to signal bias than is the case for much clinical research. This is because the association between sample size and risk of publication bias is less likely to hold when the size of the sample is limited more by the size of the database than the cost of recruiting individual participants. These problems were overcome in an interesting article that studied the destiny of 249 grant-funded (peer review) studies conducted within a single ongoing data collection survey over a ten year period.[1] Most of the studies consisted of an evaluation of modifications of the survey instrument (questionnaire) used to populate the survey database. The results show a massive effect. Studies with a positive result (as judged by the author) were much more likely to be written up and, if written up, much more likely to be published. The fact that the source studies were all based on a single database removes (or at least strongly mitigates) bias due to interaction between study topic and probability of a positive result.

These results reinforce the CLAHRC WM Director’s weariness to accept positive results of association studies, such as those that relate patient perception of care to standardised morality rates. Such results feed into the prevailing meta-narrative, in this case that organisational culture determines the quality of the full range of front line services. A null result is less likely to survive peer review under such circumstances. The paper cited here interviewed holders of grants based in the database, and found that they were disheartened by null results and often did not bother to submit them, anticipating that they would be rejected. They are right to be pessimistic since null results were less likely to be accepted when submitted, in keeping with the natural human tendency to reject studies that do not fit with prevailing or preconceived ideas.[2] [3]

What do we recommend? Only studies where the protocol has been published should be considered for publication, and they should all be published provided the protocol was adhered to. The clinical research world has tightened up its act. It is high time for the service delivery world to stop claiming scientific exceptionalism and adhere to the standard tenets of good scientific practice that hark back to Francis Bacon.[4]

— Richard Lilford, CLAHRC WM Director


  1. Franco A, Malhotra N, Simonovits G. Publication bias in the social science. Science. 2014; 345(6203): 1502-5.
  2. Lord CG, Ross L, Lepper MR. Biased Assimilation and Attitude Polarization: The Effects of Prior Theories on Subsequently Considered Evidence. J Pers Soc Psychol. 1979; 37(11): 2098-109.
  3. Kaptchuk TJ. Effect of interpretive bias on research evidence. BMJ. 2003; 326: 1453-5.
  4. Bacon F. Novum Organum. 1620.

Paying or Charging Patients?

Paying or Charging Patients?

The NHS is constituted to provide care that is free at the point of use. However, even in the NHS, patients sometimes have to contribute (make co-payments) – for example, a prescription charge is levied on patients who do not qualify for exemption. What about the reverse – paying patients to adopt healthy behaviours, such as adhering to recommended treatment? Pregnant women in some parts of France have been incentivised to attend antenatal clinics, for example,[1] while Theresa Marteau’s team has found that financial incentives were superior to other methods in increasing cigarette quit rates.[2] There are many examples of incentive payments in terms of cash or an opportunity to participate in a lottery in low-income countries.[3]

CLAHRC WM is very interested in the effect of individual incentives and co-payments on uptake of services. CLAHRC WM collaborator Ivo Vlaev is co-investigator for a trial on financial incentives for diabetic retinal screening with three arms – control; money payment; and participation in a lottery. We have identified two recent systematic reviews dealing with this topic – one on the effect of co-payments on utilisation of services in high-income countries; and the other on incentive payments in low-income countries. The former study finds that even small co-payments suppress demand. The latter study appears to be a mirror image with the reciprocal finding that small incentive payments stimulate uptake. More data are needed; so far our evidence base is financial flows from patients in high-income settings, and financial flows to patients in low-income countries. However, the evidence suggests that money flow in either direction is associated with high elasticity of demand. This concept of reciprocal responses as money is made available or withdrawn is represented in the figure. The origin is the point where the service is free at the point of use and there is no incentive payment. This origin is represented at around 50% uptake of service, but could lie anywhere between 0% and 100%, depending on the service concerned.

Graph showing Update against Incentive payment / Co-payment, with a  negative Sigmoidal curve passing through the origin at (0,0)
Figure: Representation of change in service utilisation by cost transfers

We would be pleased to hear from other scholars who wish to collaborate with us on populating the above graph. This would answer many questions, for example, is the graph symmetric, or is the graph steeper for incentive payments than for co-payments?

— Richard Lilford, CLAHRC WM Director


  1. McQuide PA, Delvaux T, Buekens P. Prenatal Care Incentives in Europe. J Public Health Policy. 1998; 19: 331-49.
  2. Ierfino D, Mantzari E, Hirst J, Jones T, Aveyard P, Marteau TM. Financial incentives for smoking cessation in pregnancy: a single-arm intervention study assessing cessation and gaming. Addiction. 2015; 110(4): 680-8.
  3. Lagarde M, Haines A, Palmer N. Conditional cash transfers for improving uptake of health interventions in low- and middle-income countries: a systematic review. JAMA. 2007; 298(16): 1900-10.

Areca, the Not So Healthy Nut

The thought of a diet rich in nuts conjures up healthy images, but for the areca nut this could not be further from the truth. Areca catechu, often erroneously referred to as the betel nut as it often consumed with the totally unrelated leaf of the betel piper vine (see Figure 1), is a major public health concern across South and East Asia. Data suggests that the areca nut is consumed by a quarter of the world’s population and is the third most common substance of abuse after tobacco and alcohol. The habit of chewing areca products is steeped and ingrained so deeply in many of the South and East Asian cultures that it has gained immense popularity in these communities. The habit of areca nut chewing has moved with migratory communities and it is not uncommon to see the tell-tale signs of red spittle (produced as a by-product of chewing areca products) in the streets of London, Birmingham, Leicester and Leeds. Unlike tobacco and alcohol, which are forbidden in some Asian cultures, areca nut is well accepted and even encouraged as an aid to promote digestion after a meal. For children it may be given as a sweet after meals, and as a child growing up in London it was not uncommon to go to the local areca nut (paan) shop on a Friday night after dinner for a round of sweet paan (areca nut with coconut and spices, wrapped up in a betel leaf). The adults would have a different variety of paan, consisting of areca nut mixed with raw tobacco, slaked lime and a mixture of spices. Today this is still a common tradition in many households, even though these practices date back thousands of years to the early Vedic scriptures in ancient India.[1] Further, many religious ceremonies will have the areca nut as its centre and it is often used to mark auspicious events and even as dowry in some cultures. So deep is the cultural and societal acceptance of this humble little nut that the deleterious affects from chewing have been grossly understated.

Areca nuts on betel leaves
Figure 1: Areca nuts on betel leaves. (Image by Ananthy94)

The areca nut habit has taken a nasty turn since the development of a commercial product known as pan masala. This consists of plastic-packed powdered areca and tobacco and, despite attempts at legislation, is sold on street corners across Asia for a few Rupees – significantly cheaper than cigarettes.[2] It has caused a massive surge in the popularity of areca products and, as there is poor labelling, the tobacco content.

A report appearing in the Economist found that areca products represented an industry worth 10 billion dollars in India alone in 2012.[3] The global production of areca was estimated to be nearly 0.8 million tonnes in 2009 with over 55% of this production from India, and 25% from China. Furthermore the industry provides employment to many millions, including over 30 million people in India. Despite its harmful effects, the growth in consumption and production are mirrored at a growth rate of about 4% annually, suggesting that the habit is far from being in decline.[4]

So what is it about areca that makes it so popular? Studies have shown that areca is as addictive as heroin and have demonstrated an areca dependency syndrome in chronic chewers.[5] Its stimulant properties make it popular with those who need to stay awake – drivers, labourers and factory workers all use areca in societies where a double espresso or a Red Bull would be an unaffordable luxury. However, the heroin-like dependency is just one of its many dangers. Reports also show that in India there are over 5 million children under the age of eight who are addicted to areca-related products.

The main threat is that areca nut is an independent risk factor for head and neck cancer (see Figure 2).[6] [7] [8]

Oral cancer
Figure 2: Patient with oral cancer. (Image by Welleschik)

Head and neck cancer has been described as an epidemic across South and East Asia (see Figure 3), with approximately 70,000 new cases in India every year. The prognosis is poor, due to late detection, and head and neck cancer is responsible for ~48,000 deaths across India.[6] Rates of oral squamous cell carcinoma in countries such as India are the highest in the world. Oral submucous fibrosis (OSF) is an areca-related pre-cancerous condition that results in patients only being able to open their mouth by a few millimetres. Eight percent of patients undergo malignant transformation.[9] There is still no cure for this condition since its discovery in South Africa in 1952. The author’s discovery over a decade ago that high levels of copper in the nut causes an up-regulation of the enzyme lysyl oxidase is a still a front runner in the race to explain this enigmatic disorder.[10] [11]

Age-standardised death rates from Mouth and oropharynx cancers by country (per 100,000 inhabitants)
Figure 3: Age-standardised death rates from Mouth and oropharynx cancers by country (per 100,000 inhabitants). (Image by Lokal_Profil, CC-BY-SA-2.5)

So what is the future for this not so healthy nut? In many countries in South and East Asia, areca consumption remains a scourge of society and despite attempts to legislate and even ban it, sales continue to surge. Compared to smoking and alcohol, areca has received a fraction of the attention attributed to other public health issues in developing countries and has largely remained under the radar for public health researchers in the West, making this a tough nut to crack!

— Dr Chet Trivedy, NIHR Academic Clinical Lecturer in Emergency Medicine, W-CAHRD


  1. Strickland SS. Anthropological perspectives on use of the areca nut. Addict Biol. 2002;7(1):85-97.
  2. Gupta PC, Warnakulasuriya S. Global epidemiology of area nut usage. Addict Biol. 2002; 7(1): 77-83.
  3. The Economist. Chewed out. Oral cancer in India. 2012.
  4. Prakash Kammardi TN, Raganath L, Ranjith Kumar PS. A report on the areca nut in the national economy. University of Agricultural Science, Bangalore.
  5. Winstock AR, Trivedy CR, Warnakulasuriya S, Peters TJ. A dependency syndrome related to areca nut use: some medical and psychological aspects among areca nut users in the Gujarat community in the UK. Addict Biol. 2000;5(2):173-9.
  6. Gupta B, Ariyawardana A. Johnson NW. Oral cancer in India continues in epidemic proportions evidence base and policy initiatives. Int Dent J.2013;63(1): 12-25.
  7. Trivedy C , Warnakulasuriya S, Peters TJ. Areca nuts can have deleterious effects. BMJ.1999;318:1287.
  8. Warnakulasuriya S , Trivedy C , Peters TJ. Areca nut use: An independent risk factor for oral cancer. BMJ. 2002; 324:799-800.
  9. Trivedy C , Craig G, Warnakulasuriya S. The oral health consequences of chewing area nut. Addict Biol. 2002; 7(1):115-25.
  10. Trivedy C, Baldwin D, Warnakulasuria S, Johnson N, Peters TJ. Copper content in Areca catechu (betel nut) products and oral submucous fibrosis. Lancet.1997;340: 1447.
  11. Trivedy C, Meghil S, Warnakulasuriya S, Johnson NW. Harris M. Copper stimulates human oral fibroblasts in vitro: a role in the pathogenesis of oral submucous fibrosis. J Oral Pathol Med. 2001; 30(8):465-70.

Use of Language: Race is to Ethnicity as Sex is to Gender

The CLAHRC WM Director has often puzzled over the use of “gender” vs. “sex”, and “ethnic group” vs. “race” in scientific writing. They are not synonyms; gender and ethnicity are social constructs, while and sex and race are biological. The former are not “polite” terms for the latter. Philip Steer, Emeritus Editor of an exceptionally lively speciality journal BJOG: An International Journal of Obstetrics and Gynaecology, has written a sure-footed article on this topic.[1] Agreeing that race is the appropriate term to describe groups with a similar place of origin, irrespective of culture, he recommends the National Library of Medicine MeSH groupings. Five continental groupings (African, American, Asian, European, and Oceanic) are broken down by sub-region – for example, European into ‘White European’ and ‘Mediterranean’. Gone is the term Caucasian, which was used to describe broader origins than just the Caucasus area and which, the CLAHRC WM Director learned, has eugenic overtones.

The article makes some other interesting points. Africa has the greatest human genetic diversity among the continents, accounting for as much as 80% of all human genetic variation. This is because of the bottleneck created by the exodus from Africa of a relatively small group of Homo sapiens about 70,000 years ago. These migrants mated with Neanderthals and spread out to colonise the rest of the globe. All of this is of interest to CLAHRC Africa, which has an interest in preventing hypertension and stroke. Salt is the prime causal suspect and there is evidence that some African people may be especially prone to salt-induced hypertension as a result of a widespread allele. Since intake of salt has increased rapidly over the past century we are developing protocols to identify the main source of salt in the diet. In due course we will design an intervention to tackle this. We are working closely with colleagues in the African Population Health Research Center (APHRC) and Malawi on this project.

However, the whole question of race will become progressively less important in science and medicine in the future for two reasons. First, gene sequencing will increasingly enable scientists and doctors to hypothecate genetic variation at the individual level, rather than the level of the group/race.[2] [3] The arrival of personalised medicine will reduce the importance of race and it has always been the case that there is far more variation within, than between races. Second, mating across racial boundaries will increasingly dilute correlation between race and genetic configuration and vitiate the effects of Homo sapiens great migration out of Africa.

— Richard Lilford, CLAHRC WM Director


  1. Steer P. Race and Ethnicity in Biomedical Publications. BJOG. 2015: 122(4): 464-7.
  2. Burchard EG, Ziv E, Coyle N, et al. The Importance of Race and Ethnic Background in Biomedical Research and Clinical Practice. New Engl J Med. 2003; 348: 1170-5.
  3. Jeffers C. The Cultural Theory of Race: Yet Another Look at Du Bois’s “The Conservation of Races”. Ethics. 2013; 123(3): 403-26.

Lay Community Health Workers

In discussing possible solutions to health problems in CLAHRC Africa, the role of Lay Community Health Workers (LCHWs) often comes up. In fact, there is seldom a large-scale health problem that someone does not suggest can be laid at the door of LCHWs.

What are LCHWs?

  1. LCHWs (sometimes referred to as Lay Health Workers or Community Health Workers) cover a range of functions. However, LCHWs tend to have the following features:
  2. They are of the community in the sense that they live among the people they serve. They tend to be nominated/selected by their local community.
  3. They have a connection to the health service – for example, they have established lines of communication and can refer.
  4. They are not full-time and generally have other roles/jobs in the community.
  5. They may receive some monetary payment from health services, but this is small in amount relative to substantive health care workers.

What is the history of LCHWs?

The CLAHRC WM Director finds it difficult to follow the evolution of present day LCHWs, but he fancies that some people have differentiated themselves to provide services to their community from the beginning of time, for example, providing birth assistance. The present day CHW:

  1. is differentiated from traditional healers and hews, to some extent at least, to an Enlightenment-based scientific model;
  2. performs a role that forms part of, or complements, the local health service.

Recent examples of initiatives that relied on LCHWs include:

  1. The “barefoot doctor” programme in China.[1]
  2. An extensive reproductive health programme in Iran associated with a steep drop in fertility.[2]
  3. An extensive child health programme in Brazil that was associated with a large (over 50%) and precipitate drop in childhood mortality.[3]
  4. The anti-retroviral programme in Africa where LCHWs played a part in identifying cases and helping clients adhere to exacting treatment regimes. [4]

Lay workers are also found in high-income countries and may even be making something of a come-back. Our CLAHRC, for instance, has evaluated the role of such volunteer support workers in the case of vulnerable women over the perinatal period.[5]

Are LCHWs effective?

This question invites the response “compared to what?” They played a large (arguably essential) part in the above programmes and the programmes were themselves successful. LCHWs make a small call on the public purse and so there are good reasons to think they are cost-effective compared to health service personnel who might be deployed to perform the same function. There is empirical support for the theoretical idea that being part and parcel of the local community and being selected by local people provides credibility and enhances the effectiveness of LCHWs. A collaborator of the CLAHRC WM Director, Dr Alex Plowright, argues that the empathy they display is especially important where health systems are weak and staff are often disaffected. Summative evaluations (82 RCTs) show that LCHWs are effective on average, but the results, as with many service interventions, are heterogeneous.[6] This reflects, at least in part, the fact that LCHWs are deployed in very different social and political environments that might be neutral, supportive, or antipathetic to their efforts.[7] [8] Salient questions include the education of LCHWs (how much, in what form, over what time periods), whether LCHWs should specialise, and what functions they should perform.

Towards a theory of LCHWs deployment

The argument proposed here has two premises:

  1. LCHWs do not tend to have detailed theoretical knowledge, nor a deep understanding of patho-physiological pathways. If they did, they would not be LCHWs.
  2. Most health gains in deprived communities in low- and middle-income countries turn not on intensive medical practice, but on a small number of conceptually straightforward processes – basic nutrition, bed nets, oral rehydration, vaccination, access to contraception, and so on.

Putting these two ideas together can help shape an answer to the above question relating to role definitions. First, it would suggest that LCHWs should not become a type of “dumping ground” for all ills – mental health, untreated ear disease, skin infections, etc. Rather, they should learn what the red flags are and have a generally low threshold of referral to a health facility. A corollary of this idea is that LCHWs should not be required to specialise, though this is not to say that they should not develop a special interest. Childbearing might be an exception, since a type of CHW called a traditional birth attendant can improve outcomes of labour, at least where trained midwives are not available.[9] Once the above fundamentals are covered, then one can imagine a role in health promotion – for example, discouraging salt and sugar and perhaps checking for the silent killer that is hypertension, as recommended by Margaret Thorogood.[10]

— Richard Lilford, CLAHRC WM Director


  1. Rosenthal MM, & Greiner JR. The Barefoot Doctors of China: From Political Creation to Professionalization. Hum Organ. 1982; 41(4): 330-341.
  2. Hoodfar H, & Assadpour S. The Politics of Population Policy in the Islamic Republic of Iran. Stud Family Plann. 2000; 31(1): 19-34.
  3. UNICEF. The State of the World’s Children 2008. New York, NY: UNICEF. 2007.
  4. Hermann K, Van Damme W, Pariyo GW, Schouten E, Assefa Y, Cirera A, Massovon W. Community health workers for ART in sub-Saharan Africa: learning from experience – capitalizing on new opportunities. Hum Resour Health. 2009; 7: 31.
  5. Lilford R. Improve long-term development of children. 20 Feb 2015. [Online].
  6. Lewin S, Munabi-Babigumira S, Glenton C, et al. Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. Cochrane Database Syst Rev. 2010; 3: CD004015.
  7. Glenton C, Colvin CJ, Carlsen B, Swartz A, Lewin S, Noyes J, Rashidian A. Barriers and facilitators to the implementation of lay health worker programmes to improve access to maternal and child health: qualitative evidence synthesis. Cochrane Database Syst Rev. 2013; 10: CD010414.
  8. Kok MC, Kane SS, Tulloch O, et al. How does context influence performance of community health workers in low- and middle-income countries? Evidence from the literature. Health Res Policy Syst. 2015; 13(1): 1.
  9. Jokhio AH, Winter HR, Chang KK. An intervention involving traditional birth attendants and perinatal and maternal mortality in Pakistan. N Engl J Med. 2005; 352(20): 2091-9.
  10. Thorogood M, Goudge J, Bertram M, et al. The Nkateko health service trial to improve hypertension management in rural South Africa: study protocol for a randomised controlled trial. Trials. 2014; 15: 435.

Slums – Exploding Urban Myths!

The CLAHRC WM Director has recently returned from a two week attachment to the African Population Health Research Center (APHRC) in Nairobi. He stayed in the home of the Director, Dr Alex Ezeh, and his charming wife Nkee, to whom he extends his sincere thanks. APHRC is the foremost African centre for the study of slums*. The APHRC were among the first centres to question the idea (discussed in a previous post) that slums provide a frequent conduit from rural poverty to middle class urban life. In fact, for a large proportion of families, they are a sink; three generations can frequently be seen living in a single dwelling.

The APHRC have also exploded another myth – that while urban poverty appears more extreme than rural poverty to the casual observer, slum dwellers enjoy better health than their rural cousins. Research carried out by the APHRC showed that this was not the case for Kenya,[1] and this finding has since been replicated in Bangladesh.[2]

The Director visited the Viwandani slum in the company of APHRC staff with whom he is collaborating on a project on urban regeneration. Although a cursory inspection would suggest that one slum is much like another, deeper examination shows that this is not the case. Slum populations are more transitory in some places than others, suggesting that for some, slum life really is a step on the path to economic emancipation. There is a pronounced economic gradient within slums, with poverty increasing with distance from centres of employment. One thing that struck the Director was the need to pay for every item of service, including water and even access to the lavatory.

Despite the privations that people live under, and the malodorous crowded conditions outside, many slum dwellers maintain a remarkably high standard of personal hygiene, and the homes we were graciously invited to visit were absolutely spotless. The slum we visited had been exposed to a vigorous programme (in which APHRC is participating) promoting exclusive breast-feeding to the age of six months, and the babies we saw were sleek and healthy. One exception was a toddler with a crusty skin infection on his outer ear. The CLAHRC WM Director, pining after his days as a clinician, diagnosed impetigo and referred the child for urgent antibiotic treatment to reduce the risk of acute glomerulonephritis.

The health of slum dwellers has received much less attention than rural health – for example, there are upwards of 30 Health and Demographic Surveillance Sites (HDSS) in Africa, but until last year only one (managed by APHRC) in a slum area. You might ask what is different about slum vs. rural health – people in both areas are exposed to parasites, water-borne disease, and other afflictions of poverty. However, the spectrum of conditions differ and so do many of the solutions. Providing safe water and ensuring adequate garbage disposal are particular problems. So is the stress and danger of over-crowding, and the risk of fires and burns is high for many reasons. Slum health is mentioned in the Millennium Development Goal 7, but a recent Lancet editorial stated that this document “underestimated the magnitude of the problem by tenfold”.[3]

* Some people prefer the term “informal settlement”, perhaps because it is seen as less stigmatising or offensive to the people who live there. However, Africans speak of slums and this term is used in the research literature. Perhaps it is felt that a blander term would do more harm than good by ‘sanitising’ a harsh reality and reducing a sense of urgency?

— Richard Lilford, CLAHRC WM Director


  1. African Population and Health Research Center. Population and health dynamics in Nairobi’s informal settlements. Nairobi (Kenya): African Population Health Research Center. 2002.
  2. UNICEF. Understanding urban inequalities in Bangladesh: a prerequisite for achieving vision 2021. A study based on the 2009 multiple indicator cluster survey, 2010. [Online].
  3. The Lancet. Urban health post-2015. Lancet. 2015; 385: 745.

Health Service Research in High- and Low-Income Countries

CLAHRC WM is just over one year old and its associated international centre is almost exactly the same age. An obvious question then is “how does service delivery/health services research differ among high- and low-income countries?” In some ways, they are similar – the rules governing a cluster study and the need to pilot complex interventions apply in both contexts, for example. Some of the issues seem similar, at least at first glance. For example, the effect of skill substitution is of universal interest (clinical officers in low-income countries and physicians assistants here in England). But there is also a fundamental difference across contexts. In high-income countries, the fundamental infrastructure is largely in place, while in low-income countries it is inadequate, often woefully inadequate.

Thus, the most pressing problems in high-income countries seem to concern how to make best use of the established infrastructure, while in low-income countries the most pressing need is establishing such infrastructure in the first place. For example, how processes can be improved to recognise the deteriorating patient, avoid falls and prevent pressure ulcers, are recurring patient safety issues in high-income countries. But at the Kenyatta National Hospital, Nairobi, the need is for more nurses. Introducing a scoring system to identify patients at high-risk of pressure ulcers would be wide of the mark in many parts of Sub-Saharan Africa, where there are issues over availability of gloves or re-use of syringes.

It is not my argument that this distinction is absolute – it is more a question of emphasis. After all, a CLAHRC WM affiliated study is examining the effect of improving consultant cover at weekends in England, while we are proposing efficient routines to improve the recognition of hypertension and diabetes in the course of routine care in three African countries. Nevertheless, the difference in emphasis is supported by three types of argument:

  1. Empirical support. The notion that structural solutions should precede process improvement is supported by an iconic study of service interventions in diabetes care. In an analysis of results from over 120 RCTs of diabetes care pathways, Tricco et al. [1] found that structural solutions yield greatest effect sizes where care is poor at baseline, while process solutions are relatively more effective when care is already of a reasonable standard.
  2. Anecdotal evidence: Lack of infrastructure, especially in terms of clinical staff, is a recurring theme in conversations with managers, clinicians and researchers in low-income countries. In fact, this blog was inspired by a conversation with Nkee Ezeh in Nairobi earlier this month.
  3. Labour economics theory: Labour force productivity demonstrates diminishing returns to labour supply. One must imagine that South Sudan, Botswana and Norway occupy very different positions on the “production curve,” as represented below.

Supply of labour vs. Output for South Sudan, Botswana and Norway

None of this is to say that research methods differ across settings, that knowledge from one context is irrelevant in another and, of course, we can expect economies and their facilities to converge over time. As always, comments are invited from those who can improve or demolish this argument.

— Richard Lilford, CLAHRC WM Director


  1. Tricco AC, Ivers NM, Grimshaw JM, et al. Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis. Lancet. 2012; 379: 2252-61.


Improve Long-Term Development of Children

Readers of this CLAHRC WM News Blog will know that we have an enduring interest in early childhood interventions to improve long-term psychosocial development. First, we have carried out an individually randomised trial of perinatal lay support for over 1,400 women at high social risk.[1] Second, we summarised two recent RCTs of infant support (published almost simultaneously in the BMJ [2] and the Lancet [3]) in a previous post. In that post we suggested that a systematic review of experimental evidence is urgently needed. Now we report a third fascinating study from Science to add to studies for review.[4] This was an RCT of 129 participants conducted back in 1986, of whom 105 were available for interview 20 years later. The participants were growth-stunted children aged 9 to 24 months. As in the trials reported in a previous post, they were randomized to four groups:

  1. Psychosocial intervention given weekly by community health workers to encourage mothers in active play.
  2. A nutritional intervention.
  3. Both.
  4. Neither.

There was no selective attrition and the samples were balanced with respect to prognostic factors at baseline. Although multiple outcomes were tested, the authors used a previously published step-down algorithm. The results show that those given the psychosocial intervention did better than controls in terms of completing school and subsequent earnings. In terms of earning capacity, they had caught up with the general population of non-stunted children.

— Richard Lilford, CLAHRC WM Director


  1. Kenyon S, Jolly K, Hemming K, et al. Evaluation of Lay Support in Pregnant women with Social risk (ELSIPS): a randomised controlled trial. BMC Preg Child. 2012; 12: 11.
  2. Attanasio OP, Fernandez C, Fitzsimons EO, Grantham-McGregor SM, Meghir C, Rubio-Codina M. Using the infrastructure of a conditional cash transfer program to deliver a scalable integrated early child development program in Colombia: cluster randomized controlled trialBMJ. 2014; 349: g5785.
  3. Yousafzai AK, Rasheed MA, Rizvi A, Armstrong R, Bhutta ZA.Effect of integrated responsive stimulation and nutrition interventions in the Lady Health Worker programme in Pakistan on child development, growth, and health outcomes: a cluster-randomised factorial effectiveness trialLancet. 2014; 384: 1282-93.
  4. Gertler P, Heckman J, Pinto R, et al. Labor market returns to an early childhood stimulation intervention in Jamaica. Science. 2014; 344: 998-1001.

Je suis Raif: bloggers, freedom of speech, doctors and torture

Recent events have drawn attention to three related issues of interest to this part-time blogger with an interest in health care. One shows the high value that Western democracies place on freedom of speech. Another illustrates a contrasting value system and, in a curious way, highlights the complicity of doctors in torture. Could these events on the world’s stage have any resonance within the microcosm of the NHS?

The attack on the French satirical magazine Charlie Hebdo provoked a robust defence of freedom of speech from nations across the world. Even the Saudi Arabian ambassador took part in a solidarity march in France. Which is ironic – back in Saudi Arabia, Raif Badawi faces 50 lashes a week for 20 weeks outside of al-Jafali mosque in Jeddah. His crime was to write a blog criticising religious authorities in Saudi Arabia. The right to criticise is not universally valued and speaking out can be construed as disloyalty.

Fortunately, the latest instalment of his sentence has been postponed because the prison doctor decided that his wounds had not sufficiently healed.[1] Medical intervention has gained Raif Badawi a week’s respite, but it also raises the question of medical complicity in torture. Interestingly this phenomenon is not confined to Saudi Arabia. Medical complicity in legally sanctioned torture has also occurred in Western democracies. How can this happen?

Over a decade ago in the BMJ I predicted that doctors in Guantanamo Bay risked becoming accessories to torture.[2] Three doctors responded to my letter, vying each other in outrage at my suggestion. Anyone with the tiniest knowledge of social psychology would have made the same prediction. Individuals’ behaviour is constrained by the norms of the organisation. In his famous 1971 Stanford Prison Experiment,[3] Zimbardo demonstrated that given the power over others, some individuals will behave sadistically, while others feel unable to intervene. This was of course exactly what happened in Guantanamo.[4] It had previously happened in Abu Ghraib. It will happen again in similar circumstances unless specific measures are put in place to create an organisational culture where this is unacceptable. This means leadership, clear standards of behaviour, external oversight, and open reporting of lapses in standards of behaviour.

Are there any lessons for health services? Freedom of speech is important. The NHS does not flog whistle-blowers in public places, but they often suffer punishment.[5] [6] Organisational culture shapes behaviour, even among health professionals. Without leadership, transparency and external oversight, any organisation risks slipping into poor practice. Cartoonists, bloggers and whistle-blowers may make us feel uncomfortable. But this is all the more reason not to silence them.

— Tom Marshall, Deputy Director CLAHRC WM, Prevention and Detection of Diseases


  1. Tran M. Saudi blogger Raif Badawi’s case referred to supreme court, says his wife. The Guardian. 2015-01-16. [Online].
  2. Marshall T. Doctors in Guantanamo Bay are at risk of being accessories to torture. BMJ. 2002. 324: 235.
  3. Haney C, Banks C, Zimbardo P. A Study of Prisoners and Guards in a Simulated Prison. Washington, D.C.: Office of Naval Research. 1973.
  4. Nye J. U.S. military doctors broke oath to design new torture techniques to be used at Guantanamo Bay. Daily Mail. 2013-11-04. [Online].
  5. Public Concern at Work. Whistleblowing the inside story – Main report. 2013. [Online].
  6. BBC News. Worcestershire hospitals ban paramedic Stuart Gardner. BBC News. 2015-01-16. [Online].