Jill Luoto

End-User Preferences for and Performance of Competing POU Water Treatment Technologies among the Rural Poor of Kenya

Household point-of-use (POU) water treatment technologies targeted at vulnerable populations are microbiologically effective and, in small trials, improve health. We do not understand the factors that influence preference for and adoption of these technologies by target end-users. We cycled 400 rural subsistence farm households in western Kenya through three randomly ordered two-month trials of three POU products: dilute hypochlorite solution, porous ceramic filtration, and a combined flocculant-disinfectant powdered mixture to compare relative end-user preferences and usage. Households reported higher usage of both dilute hypochlorite and filters than the flocculant-disinfectant. Averaged among all participating households, Escherichia coli reductions in treated water were generally higher among those that received dilute hypochlorite solution than among those receiving either of the other two products. Among those households that self-reported product usage, the E. coli reductions achieved by dilute hypochlorite and the flocculant-disinfectant are statistically equivalent to one another and higher than the reductions achieved by filters. At the same time, households ranked filters most frequently as their most preferred product.

Information and Persuasion: Achieving Safe Water Behaviors in Kenya

Convincing people to adopt preventive health behaviors consistently is difficult, yet many lives could be saved if we understood better how to do so. For example, low-cost point-of-use (POU) technologies such as chlorine and filters can substantially reduce diarrheal disease (Clasen et al. 2006). Nonetheless, they are not widely or consistently used anywhere in the developing world, even when widely available. The authors ran a randomized field study in Kenya in which households received free POU products to test the importance of informational and behavioral constraints on usage. Sharing information about local water quality increases water treatment by 7-10 percentage points (11-24%) above that achieved by providing free products. Persuasive social marketing messages that harness findings from behavioral economics increase water treatment by an additional 9-11 percentage points. These results suggest promising avenues for incremental improvements in encouraging water treatment (and possibly other preventive health) behaviors. However, repeated exposures may be necessary to sustain behavior change.

Reporting of context and implementation in studies of global health interventions: a pilot study

BackgroundThere is an increasing push for ‘evidence-based’ decision making in global health policy circles. However, at present there are no agreed upon standards or guidelines for how to evaluate evidence in global health. Recent evaluations of existing evidence frameworks that could serve such a purpose have identified details of program context and project implementation as missing components needed to inform policy. We performed a pilot study to assess the current state of reporting of context and implementation in studies of global health interventions.MethodsWe identified three existing criteria sets for implementation reporting and selected from them 10 criteria potentially relevant to the needs of policy makers in global health contexts. We applied these 10 criteria to 15 articles included in the evidence base for three global health interventions chosen to represent a diverse set of advocated global health programs or interventions: household water chlorination, prevention of mother-to-child transmission of HIV, and lay community health workers to reduce child mortality. We used a good-fair-poor/none scale for the ratings.ResultsThe proportion of criteria for which reporting was poor/none ranged from 11% to 54% with an average of 30%. Eight articles had ‘good’ or ‘fair’ documentation for greater than 75% of criteria, while five articles had ‘poor or none’ documentation for 50% of criteria or more. Examples of good reporting were identified.ConclusionsReporting of context and implementation information in studies of global health interventions is mostly fair or poor, and highly variable. The idiosyncratic variability in reporting indicates that global health investigators need more guidance about what aspects of context and implementation to measure and how to report them. This lack of context and implementation information is a major gap in the evidence needed by global health policy makers to reach decisions.

Text Messaging for Improving Antiretroviral Therapy Adherence: No Effects After 1 Year in a Randomized Controlled Trial Among Adolescents and Young Adults

Objectives To assess the effectiveness of Short Message Service (SMS) reminder messages on antiretroviral and cotrimoxazole prophylaxis adherence among HIV-positive youths as well as the relative effectiveness of SMS with and without a response option. Methods Eligible HIV-positive patients aged 15 to 22 years at 2 HIV clinics in Kampala, Uganda, participated in a year-long parallel individual-randomized controlled trial and were assigned in a 1-to-1-to-1 ratio to a weekly SMS message group, weekly SMS message with response option group, or a usual-care control group. Results We enrolled 332 participants. Electronically measured mean adherence was 67% in the control group, 64% in the 1-way SMS group (95% confidence interval [CI] = 0.77, 1.14), and 61% in the 2-way SMS group (95% CI = 0.75, 1.12) in an intent-to-treat analysis. Results for secondary outcomes and complete-case analysis were similarly statistically insignificant across groups. Conclusions Despite previous evidence that interventions using SMS reminders can promote antiretroviral therapy adherence, this study shows that they are not always effective in achieving behavior change. More research is needed to find out for whom, and under what conditions, they can be beneficial. Trial registration ClinicalTrials.gov identifier: NCT00830622.

Soft versus Hard Commitments A Test on Savings Behaviors

Many Americans save too little, leaving them vulnerable to unexpected financial shocks. Finding ways to help Americans develop emergency savings funds could greatly improve welfare. A wealth of previous literature has demonstrated the central roles played by patience and self-control in achieving sufficient savings. When people lack patience or self-control, welldesigned interventions may help improve financial stability. Increasingly, interventions intended to improve savings behavior have taken the form of externally restricted accounts such as ‘commitment accounts’ that include hefty fees for early withdrawal or that disallow withdrawals altogether for a pre-specified time. Yet, such hard commitment accounts may not appeal to impatient individuals, those who do not anticipate their own self-control problems, or to the poor for whom restrictions on scarce funds can be particularly painful. We test a new ‘soft’ commitment account that asks borrowers to think about their savings goals, how it would feel to achieve them, and make a pledge to work towards these goals (potentially increasing one’s intrinsic motivation), yet has no external restrictions on savings behavior. In a six-month randomized savings experiment we find that such soft commitments can significantly increase amounts saved on day one relative to either a hard commitment account (with external restrictions on withdrawals) or a traditional savings account. Additionally, the soft commitments significantly increased final savings balances relative to no form of commitment and were particularly effective for impatient individuals. However, despite the inherent illiquidity, the hard commitment account proved most effective in building savings balances amongst our participants at the end of six months. 1 Corresponding Author, email: jluoto@rand.org. We gratefully acknowledge financial support from the Roybal Center for Financial Decisionmaking. All errors are our own.

Explaining low rates of sustained use of siphon water filter: evidence from follow-up of a randomised controlled trial in Bangladesh

To assess sustained siphon filter usage among a low‐income population in Bangladesh and study relevant motivators and barriers.

Blindness, cataract surgery and mortality in Ethiopia

Purpose To examine the relationships between blindness, the intervention of cataract surgery and all-cause mortality in a rural Ethiopian population. Design Population-based, interventional prospective study. Methods Community-based detection methods identified blind Ethiopian persons from two selected kebeles in Amhara region, Ethiopia. Data from 1201 blind patients were collected—628 cataract-blind and 573 blind from other conditions. Free cataract surgery was provided for consenting, cataract-blind patients. Follow-up surveys were conducted after 12 months (±1 month)—the main outcome measure for this report is all-cause mortality at 1 year. Results During the follow-up period, 110 persons died from the selected population (mortality 9.2%), which consisted of those cataract-blind patients who received cataract surgery (N=461), cataract-blind patients who did not receive surgery (N=167) and all non-cataract-blind patients (N=573). Of the 461 patients who received cataract surgery, 44 patients died (9.5%). Of the 740 patients who did not receive surgery, 66 died (8.9%)—28 patients from the cohort of cataract-blind patients who did not receive surgery (16.8%) and 38 patients from the cohort of non-cataract blind (6.6%). Subgroup analysis revealed significantly increased odds of mortality for cataract-blind patients over 75 years of age who did not receive surgery and for unmarried patients of all age groups. Conclusions In this population, mortality risk was significantly elevated for older cataract-blind patients when compared with non-cataract-blind patients—an elevation of risk that was not noted in an age-matched cohort of cataract-blind patients who underwent cataract surgery as early as 1-year follow-up.

Defaulting In and Cashing Out? The Impact of Retirement Plan Design on the Savings Accumulation of Separating Employees

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