Step-wedge cluster-randomised community-based trials: an application to the study of the impact of community health insurance.
Step-wedge cluster-randomised community-based trials: an application to the study of the impact of community health insurance.
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DOI：
10.1186/1478-4505-6-10
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发表时间：
2008-10-22
影响因子：
4
通讯作者：
Sauerborn, Rainer
中科院分区：
文献类型：
--
作者：
De Allegri, Manuela;Pokhrel, Subhash;Becher, Heiko;Dong, Hengjin;Mansmann, Ulrich;Kouyate, Bocar;Kynast-Wolf, Gisela;Gbangou, Adjima;Sanon, Mamadou;Bridges, John;Sauerborn, Rainer
我们描述了一项基于社区的阶梯楔形整群随机试验，该试验自 2003 年以来一直进行，以配合西非社区健康保险 (CHI) 计划的实施。该试验旨在克服关于 CHI 影响的循证信息的缺乏。影响是根据卫生服务利用和家庭针对疾病成本的保护的变化来定义的。我们专门关注这些方法的描述和讨论是合理的，因为该研究依赖于以前应用于疾病控制领域的方法，但从未应用于卫生筹资领域。首先，我们澄清如何从统计考虑以及当地地理和社会文化方面来定义集群。其次，我们说明如何对集群内的家庭进行抽样。第三，阐述了数据收集过程和调查工具。最后，我们概述了用于估计 CHI 影响的统计工具。我们讨论与方法论考虑以及该领域面临的特定道德和组织问题相关的所有设计选择。根据我们经验的评估，我们假设进行相对复杂的试验（例如我们的阶梯楔形整群随机社区试验），旨在产生可靠的公共卫生证据，在低收入环境中也是可行且有价值的。我们的工作表明，如果与当地卫生当局一起准确设计，此类试验有可能产生可靠的科学证据，并且不会阻碍、有时甚至会促进 CHI 等复杂健康干预措施的实施。
We describe a step-wedge cluster-randomised community-based trial which has been conducted since 2003 to accompany the implementation of a community health insurance (CHI) scheme in West Africa. The trial aims at overcoming the paucity of evidence-based information on the impact of CHI. Impact is defined in terms of changes in health service utilisation and household protection against the cost of illness. Our exclusive focus on the description and discussion of the methods is justified by the fact that the study relies on a methodology previously applied in the field of disease control, but never in the field of health financing. First, we clarify how clusters were defined both in respect of statistical considerations and of local geographical and socio-cultural concerns. Second, we illustrate how households within clusters were sampled. Third, we expound the data collection process and the survey instruments. Finally, we outline the statistical tools to be applied to estimate the impact of CHI. We discuss all design choices both in relation to methodological considerations and to specific ethical and organisational concerns faced in the field. On the basis of the appraisal of our experience, we postulate that conducting relatively sophisticated trials (such as our step-wedge cluster-randomised community-based trial) aimed at generating sound public health evidence, is both feasible and valuable also in low income settings. Our work shows that if accurately designed in conjunction with local health authorities, such trials have the potential to generate sound scientific evidence and do not hinder, but at times even facilitate, the implementation of complex health interventions such as CHI.