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It is plausible that the relationship between the proximal coverage outcome and the distal coverage outcome would depend upon the system through which the intervention is delivered.
These contextual factors should be described and their effect on the coverage outcome should be assessed where possible.
Rather than using a cross sectional survey pre and post RCT to assess the proximal coverage outcome, cross-sectional surveys pre and post implementation in routine operational conditions with attribution of the proximal coverage outcome to the specific ITN delivery systems would have been sufficient to achieve the objective of this evaluation.
The effect of implementation related factors on the distal coverage outcome may be assessed by measuring the relative dose-response relationship (although care must be taken to assess any selection biases in the dose received) [ 14, 40].
Where more innovation is needed is measuring both coverage (access) and full effective coverage (outcome) of essential health interventions aimed at the key causes of disease and injury burdens, including risk factors.
Where an intervention is delivered through a single system, then the proximal coverage outcomes can be directly attributed to this delivery system and it is appropriate to infer that the delivery system had a causal relationship to the proximal coverage outcome.
Similar(52)
However, we assert that this approach is sufficient for this description of how coverage outcomes differ by equity factors.
Coverage outcomes varied according to population density.
Distal coverage outcomes are measured in the same way as proximal coverage outcomes through RCTs or cross sectional observational studies.
The methodological issues in the internal validity of proximal coverage outcomes mentioned above would therefore apply to that of distal coverage outcomes.
There are factors additional to those confounding proximal coverage outcomes that may confound the relationship between the delivery system and the distal coverage outcomes.
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