Improving outcomes for caregivers through treatment of young people affected by war: a randomized controlled trial in Sierra Leone

ObjectiveTo measure the benefits to household caregivers of a psychotherapeutic intervention for adolescents and young adults living in a war-affected area.MethodsBetween July 2012 and July 2013, we carried out a randomized controlled trial of the Youth Readiness Intervention – a cognitive–behavioural intervention for war-affected young people who exhibit depressive and anxiety symptoms and conduct problems – in Freetown, Sierra Leone. Overall, 436 participants aged 15–24 years were randomized to receive the intervention (n = 222) or care as usual (n = 214). Household caregivers for the participants in the intervention arm (n = 101) or control arm (n = 103) were interviewed during a baseline survey and again, if available (n = 155), 12 weeks later in a follow-up survey. We used a burden assessment scale to evaluate the burden of care placed on caregivers in terms of emotional distress and functional impairment. The caregivers’ mental health – i.e. internalizing, externalizing and prosocial behaviour – was evaluated using the Oxford Measure of Psychosocial Adjustment. Difference-in-differences multiple regression analyses were used, within an intention-to-treat framework, to estimate the treatment effects.FindingsCompared with the caregivers of participants of the control group, the caregivers of participants of the intervention group reported greater reductions in emotional distress (scale difference: 0.252; 95% confidence interval, CI: 0.026–0.4782) and greater improvements in prosocial behaviour (scale difference: 0.249; 95% CI: 0.012–0.486) between the two surveys.ConclusionA psychotherapeutic intervention for war-affected young people can improve the mental health of their caregivers.     

Post-tuberculosis mortality risk among immigrants to British Columbia,Canada, 1985–2015: a time-dependent Cox regression analysis of linked immigration,public health,and vital statistics data

ObjectiveTo compare non-tuberculosis (non-TB)-cause mortality risk overall and cause-specific mortality risks within the immigrant population of British Columbia (BC) with and without TB diagnosis through time-dependent Cox regressions.MethodsAll people immigrating to BC during 1985–2015 (N = 1,030,873) were included with n = 2435 TB patients, and the remaining as non-TB controls. Outcomes were time-to-mortality for all non-TB causes, respiratory diseases, cardiovascular diseases, cancers, and injuries/poisonings, and were ascertained using ICD-coded vital statistics data. Cox regressions were used, with a time-varying exposure variable for TB diagnosis.ResultsThe non-TB-cause mortality hazard ratio (HR) was 4.01 (95% CI 3.57–4.51) with covariate-adjusted HR of 1.69 (95% CI 1.50–1.91). Cause-specific covariate-adjusted mortality risk was elevated for respiratory diseases (aHR = 2.96; 95% CI 2.18–4.00), cardiovascular diseases (aHR = 1.63; 95% CI 1.32–2.02), cancers (aHR = 1.40; 95% CI 1.13–1.75), and injuries/poisonings (aHR = 1.85; 95% CI 1.25–2.72).ConclusionsIn any given year, if an immigrant to BC was diagnosed with TB, their risk of non-TB mortality was 69% higher than if they were not diagnosed with TB. Healthcare providers should consider multiple potential threats to the long-term health of TB patients during and after TB treatment. TB guidelines in high-income settings should address TB survivor health.Electronic supplementary materialThe online version of this article (10.17269/s41997-020-00345-y) contains supplementary material, which is available to authorized users.     

Missed opportunities for hypertension screening: a cross-sectional study,India

ObjectiveTo assess missed opportunities for hypertension screening at health facilities in India and describe systematic differences in these missed opportunities across states and sociodemographic groups.MethodsWe used nationally representative survey data from the 2017–2018 Longitudinal Ageing Study in India to estimate the proportion of adults aged 45 years or older identified with hypertension and who had not been diagnosed with hypertension despite having visited a health facility during the previous 12 months. We estimated age–sex adjusted proportions of missed opportunities to diagnose hypertension, as well as actual and potential proportions of diagnosis, by sociodemographic characteristics and for each state.FindingsAmong those identified as having hypertension, 22.6% (95% confidence interval, CI: 21.3 to 23.8) had not been diagnosed despite having recently visited a health facility. If these opportunities had been realized, the prevalence of diagnosed hypertension would have increased from 54.8% (95% CI: 53.5 to 56.1) to 77.3% (95% CI: 76.2 to 78.5). Missed opportunities for diagnosis were more common among individuals who were poorer (P = 0.001), less educated (P < 0.001), male (P < 0.001), rural (P < 0.001), Hindu (P = 0.001), living alone (P = 0.028) and working (P < 0.001). Missed opportunities for diagnosis were more common at private than at public health facilities (P < 0.001) and varied widely across states (P < 0.001).ConclusionOpportunistic screening for hypertension has the potential to significantly increase detection of the condition and reduce sociodemographic and geographic inequalities in its diagnosis. Such screening could be a first step towards more effective and equitable hypertension treatment and control.     

Telemedicine to deliver diabetes care in low- and middle-income countries: a systematic review and meta-analysis

ObjectiveTo determine the effectiveness of telemedicine in the delivery of diabetes care in low- and middle-income countries.MethodsWe searched seven databases up to July 2020 for randomized controlled trials investigating the effectiveness of telemedicine in the delivery of diabetes care in low- and middle-income countries. We extracted data on the study characteristics, primary end-points and effect sizes of outcomes. Using random effects analyses, we ran a series of meta-analyses for both biochemical outcomes and related patient properties.FindingsWe included 31 interventions in our meta-analysis. We observed significant standardized mean differences of −0.38 for glycated haemoglobin (95% confidence interval, CI: −0.52 to −0.23; I² = 86.70%), −0.20 for fasting blood sugar (95% CI: −0.32 to −0.08; I² = 64.28%), 0.81 for adherence to treatment (95% CI: 0.19 to 1.42; I² = 93.75%), 0.55 for diabetes knowledge (95% CI: −0.10 to 1.20; I² = 92.65%) and 1.68 for self-efficacy (95% CI: 1.06 to 2.30; I² = 97.15%). We observed no significant treatment effects for other outcomes, with standardized mean differences of −0.04 for body mass index (95% CI: −0.13 to 0.05; I² = 35.94%), −0.06 for total cholesterol (95% CI: −0.16 to 0.04; I² = 59.93%) and −0.02 for triglycerides (95% CI: −0.12 to 0.09; I² = 0%). Interventions via telephone and short message service yielded the highest treatment effects compared with services based on telemetry and smartphone applications.ConclusionAlthough we determined that telemedicine is effective in improving several diabetes-related outcomes, the certainty of evidence was very low due to substantial heterogeneity and risk of bias.     

Delay in childhood vaccinations during the COVID-19 pandemic

ObjectivesIn many jurisdictions, routine medical care was reduced in response to the COVID-19 pandemic. The objective of this study was to determine whether the frequency of on-time routine childhood vaccinations among children age 0–2 years was lower following the COVID-19 declaration of emergency in Ontario, Canada, on March 17, 2020, compared to prior to the pandemic.MethodsWe conducted a longitudinal cohort study of healthy children aged 0–2 years participating in the TARGet Kids! primary care research network in Toronto, Canada. A logistic mixed effects regression model was used to determine odds ratios (ORs) for delayed vaccination (> 30 days vs. ≤ 30 days from the recommended date) before and after the COVID-19 declaration of emergency, adjusted for confounding variables. A Cox proportional hazards model was used to explore the relationship between the declaration of emergency and time to vaccination.ResultsAmong 1277 children, the proportion of on-time vaccinations was 81.8% prior to the COVID-19 declaration of emergency and 62.1% after (p < 0.001). The odds of delayed vaccination increased (odds ratio = 3.77, 95% CI: 2.86–4.96), and the hazard of administration of recommended vaccinations decreased after the declaration of emergency (hazard ratio = 0.75, 95% CI: 0.60–0.92). The median vaccination delay time was 5 days (95% CI: 4–5 days) prior to the declaration of emergency and 17 days (95% CI: 12–22 days) after.ConclusionThe frequency of on-time routine childhood vaccinations was lower during the first wave of the COVID-19 pandemic. Sustained delays in routine vaccinations may lead to an increase in rates of vaccine-preventable diseases.Supplementary InformationThe online version contains supplementary material available at 10.17269/s41997-021-00601-9.     

Associations between attainment of incentivised primary care indicators and emergency hospital admissions among type 2 diabetes patients: a population-based historical cohort study

ObjectivesEngland has invested considerably in diabetes care over recent years through programmes such as the Quality and Outcomes Framework and National Diabetes Audit. However, associations between specific programme indicators and key clinical endpoints, such as emergency hospital admissions, remain unclear. We aimed to examine whether attainment of Quality and Outcomes Framework and National Diabetes Audit primary care diabetes indicators is associated with diabetes-related, cardiovascular, and all-cause emergency hospital admissions.DesignHistorical cohort study.SettingA total of 330 English primary care practices, 2010–2017, using UK Clinical Practice Research Datalink.ParticipantsA total of 84,441 adults with type 2 diabetes.Main Outcome MeasuresThe primary outcome was emergency hospital admission for any cause. Secondary outcomes were (1) diabetes-related and (2) cardiovascular-related emergency admission.ResultsThere were 130,709 all-cause emergency admissions, 115,425 diabetes-related admissions and 105,191 cardiovascular admissions, corresponding to unplanned admission rates of 402, 355 and 323 per 1000 patient-years, respectively. All-cause hospital admission rates were lower among those who met HbA1c and cholesterol indicators (incidence rate ratio = 0.91; 95% CI 0.89–0.92; p < 0.001 and 0.87; 95% CI 0.86–0.89; p < 0.001), respectively), with similar findings for diabetes and cardiovascular admissions. Patients who achieved the Quality and Outcomes Framework blood pressure target had lower cardiovascular admission rates (incidence rate ratio = 0.98; 95% CI 0.96–0.99; p = 0.001). Strong associations were found between completing 7–9 (vs. either 4–6 or 0–3) National Diabetes Audit processes and lower rates of all admission outcomes (p-values < 0.001), and meeting all nine National Diabetes Audit processes had significant associations with reductions in all types of emergency admissions by 22% to 26%. Meeting the HbA1c or cholesterol Quality and Outcomes Framework indicators, or completing 7–9 National Diabetes Audit processes, was also associated with longer time-to-unplanned all-cause, diabetes and cardiovascular admissions.ConclusionsAttaining Quality and Outcomes Framework-defined diabetes intermediate outcome thresholds, and comprehensive completion of care processes, may translate into considerable reductions in emergency hospital admissions. Out-of-hospital diabetes care optimisation is needed to improve implementation of core interventions and reduce unplanned admissions.     

Tuberculosis treatment outcomes and patient support groups,southern India

ObjectiveTo assess treatment outcomes in tuberculosis patients participating in support group meetings in five districts of Karnataka and Telangana states in southern India.MethodsTuberculosis patients from five selected districts who began treatment in 2019 were offered regular monthly support group meetings, with a focus on patients in urban slum areas with risk factors for adverse outcomes. We tracked the patients’ participation in these meetings and extracted treatment outcomes from the Nikshay national tuberculosis database for the same patients in 2021. We compared treatment outcomes based on attendance of the support groups meetings.FindingsOf 30 706 tuberculosis patients who started treatment in 2019, 3651 (11.9%) attended support groups meetings. Of patients who attended at least one support meeting, 94.1% (3426/3639) had successful treatment outcomes versus 88.2% (23 745/26 922) of patients who did not attend meetings (adjusted odds ratio, aOR: 2.44; 95% confidence interval, CI: 2.10–2.82). The odds of successful treatment outcomes were higher in meeting participants than non-participants for all variables examined including: age ≥ 60 years (aOR: 3.19; 95% CI: 2.26–4.51); female sex (aOR: 3.33; 95% CI: 2.46–4.50); diabetes comorbidity (aOR: 3.03; 95% CI: 1.91–4.81); human immunodeficiency virus infection (aOR: 3.73; 95% CI: 1.76–7.93); tuberculosis retreatment (aOR: 1.69; 1.22–2.33); and drug-resistant tuberculosis (aOR: 1.93; 95% CI: 1.21–3.09).ConclusionParticipation in support groups for tuberculosis patients was significantly associated with successful tuberculosis treatment outcomes, especially among high-risk groups. Expanding access to support groups could improve tuberculosis treatment outcomes at the population level.     

A tuberculosis nationwide prevalence survey in Gambia, 2012

ObjectiveTo estimate the population prevalence of active pulmonary tuberculosis in Gambia.MethodsBetween December 2011 and January 2013, people aged ≥ 15 years participating in a nationwide, multistage cluster survey were screened for active pulmonary tuberculosis with chest radiography and for tuberculosis symptoms. For diagnostic confirmation, sputum samples were collected from those whose screening were positive and subjected to fluorescence microscopy and liquid tuberculosis cultures. Multiple imputation and inverse probability weighting were used to estimate tuberculosis prevalence.FindingsOf 100 678 people enumerated, 55 832 were eligible to participate and 43 100 (77.2%) of those participated. A majority of participants (42 942; 99.6%) were successfully screened for symptoms and by chest X-ray. Only 5948 (13.8%) were eligible for sputum examination, yielding 43 bacteriologically confirmed, 28 definite smear-positive and six probable smear-positive tuberculosis cases. Chest X-ray identified more tuberculosis cases (58/69) than did symptoms alone (43/71). The estimated prevalence of smear-positive and bacteriologically confirmed pulmonary tuberculosis were 90 (95% confidence interval, CI: 53–127) and 212 (95% CI: 152–272) per 100 000 population, respectively. Tuberculosis prevalence was higher in males (333; 95% CI: 233–433) and in the 35–54 year age group (355; 95% CI: 219–490).ConclusionThe burden of tuberculosis remains high in Gambia but lower than earlier estimates of 490 per 100 000 population in 2010. Less than half of all cases would have been identified based on smear microscopy results alone. Successful control efforts will require interventions targeting men, increased access to radiography and more accurate, rapid diagnostic tests.     

Risky Party and Nightclub Attendance during the COVID-19 Nightlife Shutdown in New York City

From March 2020 through May 2021, nightlife venues were shut down and large gatherings were deemed illegal in New York City (NYC) due to COVID-19. This study sought to determine the extent of risky party attendance during the COVID-19 shutdown among people who attend electronic dance music parties in NYC. During the first four months that venues were permitted to reopen (June through September 2021), time–space sampling was used to survey adults (n = 278) about their party attendance during the first year of the shutdown (March 2020–March 2021). We examined prevalence and correlates of attendance and mask-wearing at such parties. A total of 43.9% attended private parties with more than 10 people, 27.3% attended nightclubs, and 20.5% attended other parties such as raves. Among those who attended any, 32.3% never wore a mask and 19.3% reported attending parties in which no one wore a mask. Past-year ecstasy use was associated with increased risk for attending private (aPR = 1.51, 95% CI: 1.00–2.28) or other parties (aPR = 2.75, 95% CI: 1.48–5.13), and use of 2C series drugs was associated with increased risk for attending nightclubs (aPR = 2.67, 95% CI: 1.24–5.77) or other parties (aPR = 2.50, 95% CI: 1.06–5.87). Attending >10 parties was associated with increased risk for never wearing a mask (aPR = 2.74, 95% CI: 1.11–6.75) and for no other attendees wearing masks (aPR = 4.22, 95% CI: 1.26–14.07). Illegal dance parties continued in NYC during the COVID-19 shutdown. Prevention and harm reduction efforts to mitigate risk of COVID-19 transmission during such shutdowns are sorely needed.     

COVID-19 cases,hospitalizations and deaths after vaccination: a cohort event monitoring study,Islamic Republic of Iran

ObjectiveTo investigate the incidence of coronavirus disease 2019 (COVID-19) cases, hospitalizations and deaths in Iranians vaccinated with either AZD1222 Vaxzevria, CovIran® vaccine, SARS-CoV-2 Vaccine (Vero Cell), Inactivated (lnCoV) or Sputnik V.MethodsWe enrolled individuals 18 years or older receiving their first COVID-19 vaccine dose between April 2021 and January 2022 in seven Iranian cities. Participants completed weekly follow-up surveys for 17 weeks (25 weeks for AZD1222) to report their COVID-19 status and hospitalization. We used Cox regression models to assess risk factors for contracting COVID-19, hospitalization and death.FindingsOf 89 783 participants enrolled, incidence rates per 1 000 000 person-days were: 528.2 (95% confidence interval, CI: 514.0–542.7) for contracting COVID-19; 55.8 (95% CI: 51.4–60.5) for hospitalization; and 4.1 (95% CI: 3.0–5.5) for death. Compared with SARS-CoV-2 Vaccine (Vero Cell), hazard ratios (HR) for contracting COVID-19 were: 0.70 (95% CI: 0.61−0.80) with AZD1222; 0.73 (95% CI: 0.62–0.86) with Sputnik V; and 0.73 (95% CI: 0.63–0.86) with CovIran®. For hospitalization and death, all vaccines provided similar protection 14 days after the second dose. History of COVID-19 protected against contracting COVID-19 again (HR: 0.76; 95% CI: 0.69–0.84). Diabetes and respiratory, cardiac and renal disease were associated with higher risks of contracting COVID-19 after vaccination.ConclusionThe rates of contracting COVID-19 after vaccination were relatively high. SARS-CoV-2 Vaccine (Vero Cell) provided lower protection against COVID-19 than other vaccines. People with comorbidities had higher risks of contracting COVID-19 and hospitalization and should be prioritized for preventive interventions.     

Catastrophic health expenditure in sub-Saharan Africa: systematic review and meta-analysis

ObjectiveTo estimate the incidence of, and trends in, catastrophic health expenditure in sub-Saharan Africa.MethodsWe systematically reviewed the scientific and grey literature to identify population-based studies on catastrophic health expenditure in sub-Saharan Africa published between 2000 and 2021. We performed a meta-analysis using two definitions of catastrophic health expenditure: 10% of total household expenditure and 40% of household non-food expenditure. The results of individual studies were pooled by pairwise meta-analysis using the random-effects model.FindingsWe identified 111 publications covering a total of 1 040 620 households across 31 sub-Saharan African countries. Overall, the pooled annual incidence of catastrophic health expenditure was 16.5% (95% confidence interval, CI: 12.9–20.4; 50 datapoints; 462 151 households; I² = 99.9%) for a threshold of 10% of total household expenditure and 8.7% (95% CI: 7.2–10.3; 84 datapoints; 795 355 households; I² = 99.8%) for a threshold of 40% of household non-food expenditure. Countries in central and southern sub-Saharan Africa had the highest and lowest incidence, respectively. A trend analysis found that, after initially declining in the 2000s, the incidence of catastrophic health expenditure in sub-Saharan Africa increased between 2010 and 2020. The incidence among people affected by specific diseases, such as noncommunicable diseases, HIV/AIDS and tuberculosis, was generally higher.ConclusionAlthough data on catastrophic health expenditure for some countries were sparse, the data available suggest that a non-negligible share of households in sub-Saharan Africa experienced catastrophic expenditure when accessing health-care services. Stronger financial protection measures are needed.     

Association between antiretroviral therapy adherence and employment status: systematic review and meta-analysis

ObjectiveTo assess the association between the employment status of human immunodeficiency virus (HIV)-infected individuals and adherence to antiretroviral therapy (ART).MethodsWe searched the Medline, Embase and Cochrane Central Register of Controlled Trials databases for studies reporting ART adherence and employment status published between January 1980 and September 2014. Information from a wide range of other sources, including the grey literature, was also analysed. Two independent reviewers extracted data on treatment adherence and study characteristics. Study data on the association between being employed and adhering to ART were pooled using a random-effects model. Between-study heterogeneity and sources of bias were evaluated.FindingsThe meta-analysis included 28 studies published between 1996 and 2014 that together involved 8743 HIV-infected individuals from 14 countries. The overall pooled odds ratio (OR) for the association between being employed and adhering to ART was 1.27 (95% confidence interval, CI: 1.04–1.55). The association was significant for studies from low-income countries (OR: 1.85, 95% CI: 1.58–2.18) and high-income countries (OR: 1.33, 95% CI: 1.02–1.74) but not middle-income countries (OR: 0.94, 95% CI: 0.62–1.42). In addition, studies published after 2011 and larger studies showed less association between employment and adherence than earlier and small studies, respectively.ConclusionEmployed HIV-infected individuals, particularly those in low- and high-income countries, were more likely to adhere to ART than unemployed individuals. Further research is needed on the mechanisms by which employment and ART adherence affect each other and on whether employment-creation interventions can positively influence ART adherence, HIV disease progression and quality of life.     

Associations between single and combined occupational mechanical exposures and surgery for subacromial impingement syndrome: a nationwide Danish cohort study

ObjectiveThis study aimed to evaluate whether the risk of surgery for subacromial impingement syndrome (SIS) increases with the number of combined occupational mechanical exposures compared with single exposure.MethodsWe reanalyzed data from a register-based cohort study of the entire Danish working population (N=2 374 403) with 14 118 events of surgery for SIS (2003–2008). Exposure information in 10-year windows was obtained by combining occupational codes with a job exposure matrix. For single and combined mechanical exposures, we created three exposure variables of the number of years with specific exposure intensities with or without co-existing mechanical exposures. We used logistic regression as survival analysis.ResultsWe found exposure–response relations for duration and intensity of each single mechanical exposure except for repetition. The single effect of arm elevation >90º reached a maximum adjusted odds ratio (OR_adj) of 1.7 [95% confidence interval (CI) 1.5–2.0], which increased to 1.8 (95% CI 1.5–2.0), 2.0 (95% CI 1.9–2.2), and 2.2 (95% CI 2.0–2.5) when combined with repetition, force, and both. When combining repetition with arm elevation >90º, force, and both, OR_adj increased from 1.5 (95% CI 1.3–1.8) to 2.1 (95% CI 1.8–2.4), 2.5 (95% CI 2.4–2.9), and 2.7 (95% CI 2.4–3.0). For force, OR_adj increased from 2.5 (95% CI 2.1–2.9) to 2.6 (95% CI 2.3–2.8), 2.8 (95% CI 2.4–3.2), and 3.0 (95% CI 2.6–3.4).ConclusionWe found an increased risk of surgery for SIS with the number of combined exposures; the risk was especially pronounced when the combined exposures included force.     

The results of cardiac surgery during the COVID-19 pandemic compared with previous years: a propensity weighted study of outcomes at six months

ObjectivesIn addition to excess mortality due to COVID-19, the pandemic has been characterised by excess mortality due to non-COVID diagnoses and consistent reports of patients delaying seeking medical treatment. This study seeks to compare the outcomes of cardiac surgery during and before the COVID-19 pandemic.DesignOur institutional database was interrogated retrospectively to identify all patients undergoing one of three index procedures during the first six months of the pandemic and the corresponding epochs of the previous five years.SettingA regional cardiothoracic centre.ParticipantsAll patients undergoing surgery during weeks #13-37, 2015-2020.Main outcome measuresPropensity score weighted analysis was employed to compare the incidence of major complications (stroke, renal failure, re-ventilation), 30-day mortality, six month survival and length of hospital stay between the two groups.ResultsThere was no difference in 30-day mortality (HR = 0.76 [95% CI 0.27-2.20], p = 0.6211), 6-month survival (HR = 0.94 [95% CI 0.44-2.01], p = 0.8809) and duration of stay (SHR = 1.00 (95% CI 0.90-1.12), p = 0.959) between the two eras. There were no differences in the incidence of major complications (weighted chi-square test: renal failure: p = 0.923, stroke: p = 0.991, new respiratory failure: p = 0.856).ConclusionsCardiac surgery is as safe now as in the previous five years. Concerns over the transmission of COVID-19 in hospital are understandable but patients should be encouraged not to delay seeking medical attention. All involved in healthcare and the wider public should be reassured by these findings.     

Estimating the measles effective reproduction number in Australia from routine notification data

Objective

To estimate the measles effective reproduction number (R) in Australia by modelling routinely collected notification data.

Methods

R was estimated for 2009–2011 by means of three methods, using data from Australia’s National Notifiable Disease Surveillance System. Method 1 estimated R as 1 − P, where P equals the proportion of cases that were imported, as determined from data on place of acquisition. The other methods estimated R by fitting a subcritical branching process that modelled the spread of an infection with a given R to the observed distributions of outbreak sizes (method 2) and generations of spread (method 3). Stata version 12 was used for method 2 and Matlab version R2012 was used for method 3. For all methods, calculation of 95% confidence intervals (CIs) was performed using a normal approximation based on estimated standard errors.

Findings

During 2009–2011, 367 notifiable measles cases occurred in Australia (mean annual rate: 5.5 cases per million population). Data were 100% complete for importation status but 77% complete for outbreak reference number. R was estimated as < 1 for all years and data types, with values of 0.65 (95% CI: 0.60–0.70) obtained by method 1, 0.64 (95% CI: 0.56–0.72) by method 2 and 0.47 (95% CI: 0.38–0.57) by method 3.

Conclusion

The fact that consistent estimates of R were obtained from all three methods enhances confidence in the validity of these methods for determining R.     

Changing hygiene behaviours: a cluster-randomized trial,Ethiopia

ObjectiveTo determine whether a water, sanitation and hygiene intervention could change hygiene behaviours thought to be important for trachoma control.MethodsWe conducted a cluster-randomized trial in rural Ethiopia from 9 November 2015 to 5 March 2019. We randomized 20 clusters to an intervention consisting of water and sanitation infrastructure and hygiene promotion and 20 clusters to no intervention. All intervention clusters received a primary-school hygiene curriculum, community water point, household wash station, household soap and home visits from hygiene promotion workers. We assessed intervention fidelity through annual household surveys.FindingsOver the 3 years, more wash stations, soap and latrines were seen at households in the intervention clusters than the control clusters: risk difference 47 percentage points (95% confidence interval, CI: 41–53) for wash stations, 18 percentage points (95% CI: 12–24) for soap and 12 percentage points (95% CI: 5–19) for latrines. A greater proportion of people in intervention clusters reported washing their faces with soap (e.g. risk difference 21 percentage points; 95% CI: 15–27 for 0–5 year-old children) and using a latrine (e.g. risk difference 9 percentage points; 95% CI: 2–15 for 6–9 year-old children). Differences between the intervention and control arms were not statistically significant for many indicators until the programme had been implemented for at least a year; they did not decline during later study visits.ConclusionThe community- and school-based intervention was associated with improved hygiene access and behaviours, although changes in behaviour were slow and required several years of the intervention.