Objectives To update a 2004 systematic review of health care service use and health outcomes related to differences in health literacy level and interventions designed to improve these outcomes for individuals with low health literacy. Disparities in health outcomes and effectiveness of interventions among different sociodemographic groups were also examined. Data sources We searched MEDLINE®, the Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, PsychINFO, and the Educational Resources Information Center. For health literacy, we searched using a variety of terms, limited to English and studies published from 2003 to May 25, 2010. For numeracy, we searched from 1966 to May 25, 2010. Review methods We used standard Evidence-based Practice Center methods of dual review of abstracts, full-text articles, abstractions, quality ratings, and strength of evidence grading. We resolved disagreements by consensus. We evaluated whether newer literature was available for answering key questions, so we broadened our definition of health literacy to include numeracy and oral (spoken) health literacy. We excluded intervention studies that did not measure health literacy directly and updated our approach to evaluate individual study risk of bias and to grade strength of evidence. Results We included good- and fair-quality studies: 81 studies addressing health outcomes (reported in 95 articles including 86 measuring health literacy and 16 measuring numeracy, of which 7 measure both) and 42 studies (reported in 45 articles) addressing interventions. Differences in health literacy level were consistently associated with increased hospitalizations, greater emergency care use, lower use of mammography, lower receipt of influenza vaccine, poorer ability to demonstrate taking medications appropriately, poorer ability to interpret labels and health messages, and, among seniors, poorer overall health status and higher mortality. Health literacy level potentially mediates disparities between blacks and whites. The strength of evidence of numeracy studies was insufficient to low, limiting conclusions about the influence of numeracy on health care service use or health outcomes. Two studies suggested numeracy may mediate the effect of disparities on health outcomes. We found no evidence concerning oral health literacy and outcomes. Among intervention studies (27 randomized controlled trials [RCTs], 2 cluster RCTs, and 13 quasi-experimental designs), the strength of evidence for specific design features was low or insufficient. However, several specific features seemed to improve comprehension in one or a few studies. The strength of evidence was moderate for the effect of mixed interventions on health care service use; the effect of intensive self-management inventions on behavior; and the effect of disease-management interventions on disease prevalence/severity. The effects of other mixed interventions on other health outcomes, including knowledge, self-efficacy, adherence, and quality of life, and costs were mixed; thus, the strength of evidence was insufficient. Conclusions The field of health literacy has advanced since the 2004 report. Future research priorities include justifying appropriate cutoffs for health literacy levels prior to conducting studies; developing tools that measure additional related skills, particularly oral (spoken) health literacy; and examining mediators and moderators of the effect of health literacy. Priorities in advancing the design features of interventions include testing novel approaches to increase motivation, techniques for delivering information orally or numerically, "work around" interventions such as patient advocates; determining the effective components of already-tested interventions; determining the cost-effectiveness of programs; and determining the effect of policy and practice interventions.

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Health literacy interventions and outcomes: an updated systematic review.

Quinine remains an important anti-malarial drug almost 400 years after its effectiveness was first documented However, its continued use is challenged by its poor tolerability, poor compliance with complex dosing regimens, and the availability of more efficacious anti-malarial drugs This article reviews the historical role of quinine, considers its current usage and provides insight into its appropriate future use in the treatment of malaria In light of recent research findings intravenous artesunate should be the first-line drug for severe malaria, with quinine as an alternative The role of rectal quinine as pre-referral treatment for severe malaria has not been fully explored, but it remains a promising intervention In pregnancy, quinine continues to play a critical role in the management of malaria, especially in the first trimester, and it will remain a mainstay of treatment until safer alternatives become available For uncomplicated malaria, artemisinin-based combination therapy (ACT) offers a better option than quinine though the difficulty of maintaining a steady supply of ACT in resource-limited settings renders the rapid withdrawal of quinine for uncomplicated malaria cases risky The best approach would be to identify solutions to ACT stock-outs, maintain quinine in case of ACT stock-outs, and evaluate strategies for improving quinine treatment outcomes by combining it with antibiotics In HIV and TB infected populations, concerns about potential interactions between quinine and antiretroviral and anti-tuberculosis drugs exist, and these will need further research and pharmacovigilance

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Quinine, an old anti-malarial drug in a modern world: role in the treatment of malaria

Over the past half-century, community health workers (CHWs) have been a growing force for extending health care and improving the health of populations. Following their introduction in the 1970s, many large-scale CHW programs declined during the 1980s, but CHW programs throughout the world more recently have seen marked growth. Research and evaluations conducted predominantly during the past two decades offer compelling evidence that CHWs are critical for helping health systems achieve their potential, regardless of a country's level of development. In low-income countries, CHWs can make major improvements in health priority areas, including reducing childhood undernutrition, improving maternal and child health, expanding access to family-planning services, and contributing to the control of HIV, malaria, and tuberculosis infections. In many middle-income countries, most notably Brazil, CHWs are key members of the health team and essential for the provision of primary health care and health promotion. In the United States, evidence indicates that CHWs can contribute to reducing the disease burden by participating in the management of hypertension, in the reduction of cardiovascular risk factors, in diabetes control, in the management of HIV infection, and in cancer screening, particularly with hard-to-reach subpopulations. This review highlights the history of CHW programs around the world and their growing importance in achieving health for all.

Community health workers in low-, middle-, and high-income countries: an overview of their history, recent evolution, and current effectiveness.

Much has been written about the measurement of socio-economic position (SEP) in high-income countries (HIC). Less has been written for an epidemiology, health systems and public health audience about the measurement of SEP in low- and middle-income countries (LMIC). The social stratification processes in many LMIC-and therefore the appropriate measurement tools-differ considerably from those in HIC. Many measures of SEP have been utilized in epidemiological studies; the aspects of SEP captured by these measures and the pathways through which they may affect health are likely to be slightly different but overlapping. No single measure of SEP will be ideal for all studies and contexts; the strengths and limitations of a given indicator are likely to vary according to the specific research question. Understanding the general properties of different indicators, however, is essential for all those involved in the design or interpretation of epidemiological studies. In this article, we describe the measures of SEP used in LMIC. We concentrate on measures of individual or household-level SEP rather than area-based or ecological measures such as gross domestic product. We describe each indicator in terms of its theoretical basis, interpretation, measurement, strengths and limitations. We also provide brief comparisons between LMIC and HIC for each measure.

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Measuring socio-economic position for epidemiological studies in low- and middle-income countries: a methods of measurement in epidemiology paper

Assessment of the nutritional status of the community.

There is little existing knowledge about actual quality of drugs provided by different providers in Nigeria and in many sub-Saharan African countries. Such information is important for improving malaria treatment that will help in the development and implementation of actions designed to improve the quality of treatment. The objective of the study was to determine the quality of drugs used for the treatment of malaria in a broad spectrum of public and private healthcare providers. The study was undertaken in six towns (three urban and three rural) in Anambra state, south-east Nigeria. Anti-malarials (225 samples), which included artesunate, dihydroartemisinin, sulphadoxine-pyrimethamine (SP), quinine, and chloroquine, were either purchased or collected from randomly selected providers. The quality of these drugs was assessed by laboratory analysis of the dissolution profile using published pharmacopoeial monograms and measuring the amount of active ingredient using high performance liquid chromatography (HPLC). It was found that 60 (37%) of the anti-malarials tested did not meet the United States Pharmacopoeia (USP) specifications for the amount of active ingredients, with the suspect drugs either lacking the active ingredients or containing suboptimal quantities of the active ingredients. Quinine (46%) and SP formulations (39%) were among drugs that did not satisfy the tolerance limits published in USP monograms. A total of 78% of the suspect drugs were from private facilities, mostly low-level providers, such as patent medicine dealers (vendors). This study found that there was a high prevalence of poor quality drugs. The findings provide areas for public intervention to improve the quality of malaria treatment services. There should be enforced checks and regulation of drug supply management as well as stiffer penalties for people stocking substandard and counterfeit drugs.

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Quality of anti-malarial drugs provided by public and private healthcare providers in south-east Nigeria.

Influence of education and knowledge on perceptions and practices to control malaria in Southeast Nigeria.

An acetone-water neem leaf extract with antimalarial activity was evaluated in vitro at 5 microg/ml for inhibition of adhesion of malaria parasite-infected erythrocytes and cancer cells to endothelial cells, and at 10 microg/ml for protection of lymphocytes against invasion by HIV. The extract was also evaluated in 10 patients with HIV/AIDS at 1000 mg daily for 30 d. The mean binding of infected erythrocytes and cancer cells per endothelial cell was 15 and 11 respectively in the absence of the extract, and 0 and 2 respectively in with the extract. In the absence and presence of the extract, 0% and 75%, respectively, of lymphocytes were protected. In the treated patients, haemoglobin concentration, mean CD4+ cell count and erythrocyte sedimentation rate, which were initially 9.8 g/dl, 126 cells/microl and 90 mm/h respectively, improved to 12.1 g/dl, 241 cells/microl and 49 mm/h. Mean bodyweight and platelet count, initially 57 kg and 328 x 10(3)/mm3 respectively, increased to 60 kg and 359 x 10(3)/mm3. No adverse effects were observed during the study. The extract showed antiretroviral activity with a mechanism of action that may involve inhibition of cytoadhesion. The results may help in the development of novel antiretroviral and antimalarial drugs.

An antimalarial extract from neem leaves is antiretroviral

OBJECTIVES To determine the hypothetical and actual willingness of households to pay (WTP) for insecticide-treated nets (ITNs), and compare these in areas with and without previous exposure to free ITNs. METHODOLOGY The contingent valuation method was used to determine the willingness of the heads of 1908 randomly selected households from five communities in south-east Nigeria to pay for two sizes of ITNs. Two communities previously had free access to ITNs. Validity was assessed using multiple regression analyses, and by offering ITNs for sale to 200 randomly selected people drawn from the original sample. The data was collected between March and September 1998. FINDINGS Most respondents were willing to pay for ITNs: Mbano (93.26%), Ugwogo (97.69%), Orba (83.24%), Alor-uno (95.37%), and Ibagwa-ani (87.34%). In multivariate analyses, WTP was significantly associated with the number of people living in a household, sex of the respondent, average yearly expenditure on gifts and the type of savings scheme (P < 0.05). Some of the residences were also statistically significant in the two models used, and those with prior exposure to free ITNs were negatively related to WTP. Seventy-six percent of those who were hypothetically willing to pay actually purchased them, and the WTP technique correctly predicted the choices of 80% of the respondents. CONCLUSION There was good evidence that stated WTP could be translated into actual WTP. However, peoples' perception of affordability of the nets and its link to their WTP needs further exploration. The WTP technique is a potentially valid tool for market research in healthcare, as it was able to predict the direction of actual WTP for the ITNs. The hypothetical WTP amounts could be used as guide to know either the optimal price to charge for the ITNs or the level of subsidy to introduce.

Hypothetical and actual willingness to pay for insecticide-treated nets in five Nigerian communities

Background
The coverage of insecticide-treated nets (ITNs) remains low despite existing distribution strategies, hence, it was important to assess consumers' preferences for distribution of ITNs, as well as their perceptions and expenditures for malaria prevention and to examine the implications for scaling-up ITNs in rural Nigeria.

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Increasing coverage of insecticide-treated nets in rural Nigeria: implications of consumer knowledge, preferences and expenditures for malaria prevention

Elvis Shu

Papers

Quality of anti-malarial drugs provided by public and private healthcare providers in south-east Nigeria.

Influence of education and knowledge on perceptions and practices to control malaria in Southeast Nigeria.

An antimalarial extract from neem leaves is antiretroviral

Hypothetical and actual willingness to pay for insecticide-treated nets in five Nigerian communities

Increasing coverage of insecticide-treated nets in rural Nigeria: implications of consumer knowledge, preferences and expenditures for malaria prevention