Intracluster Correlation Research Articles

Concurrent anemia and stunting among schoolchildren in Wonago district in southern Ethiopia: a cross-sectional multilevel analysis.

BackgroundEven if many schoolchildren in Ethiopia are anemic and stunted, few have studied the co-existence of anemia and stunting among schoolchildren in Ethiopia. In addition, multilevel analysis to explore the variation in prevalence of concurrent anemia and stunting (CAS) across schools and classes is rarely applied. Thus, we aimed to assess the prevalence and risk factors of CAS at the individual, household, and school level among schoolchildren in southern Ethiopia.MethodsWe recruited 864 students aged 7–14 years from the Wonago district in southern Ethiopia using a three-stage random sampling, assigning four schools to level one, 24 classes to level two. We then randomly selected 36 children from each class, and recorded their weight, height, haemoglobin, intestinal helminthic infections, hygienic practices, dietary practices, household food insecurity, and socio-demographic information. A multivariate, multilevel logistic regression model was applied to detect potential risk factors for CAS.ResultsThe prevalence of CAS was 10.5% (85/810) among schoolchildren, which increased with age in years (adjusted odds ratio [aOR] 1.39 [95% confidence interval 1.13, 1.71, P = 0.002]) and among children who always did not wash their hands with soap after use of latrine (aOR 4.30 [1.21, 15.3, P = 0.02]). Children who walked barefoot (aOR 10.4 [2.77, 39.1, P = 0.001]), were infected with Trichuris trichiura (aOR 1.74 [1.05, 2.88, P = 0.03]), or had head lice infestation (aOR 1.71 [1.01, 2.92, P = 0.04]) had higher CAS prevalence. Prevalence rates of CAS were low in those using treated drinking water (aOR 0.32 [95% CI 0.11, 0.97, P = 0.04]). Most of the risk factors for CAS were identified at the individual level. The clustering effect measured by the intra-cluster correlation coefficient was 6.8% at school level and 19% at class.ConclusionCAS prevalence is a moderate public health problem among schoolchildren in southern Ethiopia and varies across classes and schools. After controlling for clustering effects at the school and class levels, we found an association between CAS and increasing age, not always washing hands with soap after using latrine, walking barefoot, and T. trichiura infection. Using treated water for drinking was found to have a protective effect against CAS. Thus, educating children on personal hygiene and provision of safe drinking water could reduce the CAS burden in schoolchildren in rural areas of southern Ethiopia.

RETRACTED ARTICLE: Individual level and community level factors affecting exclusive breast feeding among infants under-six months in Ethiopia using multilevel analysis

BackgroundExclusive breastfeeding (EBF) is the safest and healthiest option of feeding among infants in the first 6 months throughout the world. Thus, promotion of EBF is essential to prevent complex infant health problems even at the adulthood level. But majority of previous studies focused on individual level determinants of EBF by using basic regression models in localized areas. This study aims to identify individual level and community level determinants of EBF which would be helpful to design appropriate strategies in reducing infant mortality and morbidity.MethodsIt is a secondary data analysis using the 2016 Ethiopian Demographic and Health Survey (EDHS) data. A total of 1185 infants under 6 months of age were included in the analysis. Multilevel logistic regression model was employed to investigate factors significantly associated with EBF among under-six month’s infants in Ethiopia. Adjusted odds ratio (AOR) with 95% confidence interval (CI) was used to measure the association of variables whereas Intra cluster correlation (ICC), median odds ratio (MOR), and proportional change in variance (PCV) were used to measure random effects (variation).ResultIn multilevel logistic regression; 4–5 months age infant (AOR = 0.04, 95%CI:0.02–0.07), female infants (AOR = 2.51, 95%CI:1.61–3.91), infant comorbidities (AOR = 0.35, 95%CI: 0.21–0.57), household wealth index (AOR = 10.34, 95%CI: 3.14–34.03) and antenatal care (AOR = 2.25, 95%CI:1.32–3.82) were determinants of EBF at individual level. Whereas, contextual region (AOR = 0.30, 95% CI: 0.10–0.87), community level of postnatal visit (AOR = 2.77, 95% CI: 1.26–6.58) and community level of maternal employment (AOR = 2.8, 95% CI: 1.21–6.47) were determinants of EBF at community level. The full model showed up with higher PCV; that is, 46.8% of variation of exclusive breastfeeding was explained by the combined factors at the individual and community levels. Similarly, it showed that the variation in EBF across communities remained statistically significant (ICC = 8.77% and variance = 0.32 with P < 0.001). The MOR at final model indicates there was significant cluster difference for EBF indicating the heterogeneity was explained by both individual and community level factors.Conclusion and recommendationOur study showed that both individual and community level determinants were significantly associated with EBF practice. Based on our findings it is strongly recommended to promote and enhance antenatal and postnatal care services utilization of mothers and more emphasis should be given for infants with comorbid conditions and those who live in the pastoralist regions.

Effects, trends, costs associated with readmission in early-aged patients with suicidal ideation

ABSTRACT Objective To examine determinants, trends, and costs associated with 30-day all-cause readmission (R) for suicidal ideation (SI) in early–aged patients. Methods This was a retrospective cohort study using the 2010–2014 Nationwide Readmissions Database. Discharge records for those aged 5–24 with an SI diagnosis were analyzed. Hierarchical models (HMs) were used to assess factors of R, length of stay (LOS), and total costs of Rs. Results There were 197,603 SI index admissions (IAs). Of these, 2% had a R. The annualized trend of R rates for all age groups remained constant. Those aged 13–18 had the highest rate of Rs, while IA and R mean total costs were highest for those aged 5–12 (IA, $4,546–$5,822; R, $5,361–$7,113). The strongest risk factors for increasing R included nonelective admission and private hospital ownership. The strongest risk factors for increasing LOS and cost were major/extreme severity of illness and 30-day all–cause R. The intracluster correlation coefficient for the HMs were 0.06, 0.33, and 0.55 for the R, LOS, and cost model, respectively. Conclusions The R rate was highest for those in the 13–18 age group, while the costs were highest for those aged 5–12.

The Effects of Moderate‐to‐Vigorous Physical Activity on Arterial Stiffness during Pregnancy

Moderate-to-vigorous physical activity (MVPA) is associated with lower arterial stiffness in the general population. The objective of the present study was to investigate the relationship between MVPA and arterial stiffness in pregnancy. Thirty-nine women participated in this study resulting in 68 measurements in non-pregnant (NP; n=21), first (TM1; n=8), second (TM2; n=20), and third trimesters (TM3; n=19). Carotid to femoral (central) and carotid to finger (peripheral) pulse wave velocity (PWV) were assessed using finometer (proper digital artery), tonometer (carotid artery), and ultrasound (femoral artery). Carotid artery distensibility, compliance, elasticity, and ß-stiffness were calculated from carotid artery diameters at diastole and systole from three ultrasound images of the right carotid artery assessed using manual digital calipers. MVPA was measured during the waking hours of 7-consecutive days using accelerometry (Actigraph; model wGT3X-BT). Freedson accelerometer counts for MVPA were ≥ 1,952 cmp. Comparisons between pregnant and non-pregnant participants and according to gestational age (in pregnant participants only) were performed using multilevel linear regression models adjusted for multiple tests per participant during the study period (NP, TM1, TM2, or TM3) using random effects for modelling intra-cluster correlation to generate β coefficients and 95% confidence intervals (CI). Carotid artery distensibility, elasticity, and β-stiffness were not statistically different between the NP, TM1, TM2, and TM3 phases. However, carotid compliance was higher in TM2 compared to NP. Central and peripheral PWV did not differ between pregnant and non-pregnant participants. Though, meeting the MVPA guidelines (≥150minutes per week) was associated with a decrease in both central PWV (Adj. β coef.: -0.30; 95% CI: -0.58, -0.02, p=0.04) and peripheral PWV (Adj. β coef.: -0.54; 95% CI: -0.91, -0.16, p=0.005) in pregnant and non-pregnant assessments. Central PWV (β Coef: -0.14, 95% CI: -0.27, -0.02, p=0.024; n=42), varied according to gestational age with a decrease in mid-pregnancy and subsequent increase to late pregnancy while gestational age was not significantly associated with peripheral PWV. Adjustment for meeting the MVPA guidelines (β Coef: -0.34, 95% CI: -0.62, -0.06, p=0.016) reduced the association between gestational age and central-PWV (Figure 1). These results suggest that there is a relationship between MVPA and arterial stiffness throughout pregnancy. This may explain a proportion of the correlation between increased physical activity and a reduced risk of hypertension-related disorders in pregnancy.

561 Patient-dermatologist racial/ethnic and gender concordance are associated with higher Press Ganey scores

Racial/ethnic and gender concordance between patients and physicians is suggested to contribute to better patient-physician relationships; this has not been well studied in dermatology. We aimed to evaluate the associations between patient-dermatologist racial/ethnic or gender concordance and the patient experience as measured by the Press Ganey (PG) Outpatient Medical Practice Survey. A cross-sectional analysis of PG surveys returned for adult outpatient dermatology visits within the University of Pennsylvania Health System between 2014 and 2017 was performed. The primary outcome was receipt of the maximum score for the “likelihood of your recommending this care provider to others” question in the PG survey. The primary exposures were patient-dermatologist racial/ethnic or gender concordance. Generalized estimating equations clustering on physicians with exchangeable intracluster correlations and cluster-robust standard errors were used to evaluate the associations between each primary exposure and outcome. We evaluated 16,289 surveys corresponding to 15,172 unique patients (mean [standard deviation, SD] age 57 [16] years, 41% men, 89% White) and 45 unique dermatologists (mean [SD] age 44 [11] years, 54% men, 76% White). Among racially/ethnically concordant vs. discordant visits, mean (SD) PG scores were 4.83 (0.56) vs. 4.76 (0.68), respectively (p<0.001). In adjusted analyses, racial/ethnic discordance was associated with lower odds of dermatologists receiving the maximum score (adjusted odds ratio [aOR] 0.89; 95% confidence interval [CI] 0.69-0.94). Among gender concordant vs. discordant visits, mean (SD) PG scores were 4.82 (0.58) vs. 4.79 (0.63), respectively (p=0.002). In adjusted analyses, male dermatologists were less likely to receive the maximum score from female vs. male patients (aOR 0.55; 95% CI 0.35-0.86). Our results suggest gender differences in the experience of care provided by male dermatologists and support the need for increased racial/ethnic diversity of the dermatology workforce and the delivery of care in a culturally mindful manner.

A method to estimate intra-cluster correlation for clustered categorical data

Correlated categorical data often arise from studies involving cluster randomized trials, a cluster sampling scheme, or repeated measurements. The intra-cluster correlation coefficient (ICC) is used to estimate the average correlation within clusters. There have been numerous methods proposed to estimate ICC for correlated binary data, the ANOVA method for continuous data, and several methods for time-to-event outcomes. However, no method currently exists to estimate ICC for nominal or ordinal categorical responses with more than two categories. We developed a method based on resampling principles to estimate the ICC and its 95% confidence interval for categorical variables. We conducted a simulation study to show how our method estimates the population ICC under varying event rates, numbers of clusters, and cluster sizes. We also used real study datasets to estimate the ICC for ordinal and nominal categorical variables. We observed that the resampling method estimates the population ICC well for moderate to large numbers of clusters and moderate to large cluster sizes.

The Illness Belief Network Questionnaire: Development and Evaluation of a Psychosomatic Assessment Tool.

Objective: Patients’ beliefs and emotions toward an illness can influence their coping responses, illness behaviors, adherence to treatment, quality of life, and even the psychoneuroimmune responses. The aim of present study was to develop and validate a novel questionnaire assessing both rational and irrational beliefs of patients regarding their illness. Method : In a cross sectional methodological study, the items of the Illness Belief Network (IBN) were developed regarding patients and clients’ opinions about and attribution of their disease extracted from 400 clinical interviews and were coded based on Leventhal’s self-regulation model. An expert panel coded the items. A total of 400 patients with different medical conditions completed the questionnaire. Participants additionally rated the Illness Perceptions Questionnaire in its revised form (IPQ-R) to assess convergent validity. Construct validity was examined by conducting exploratory and confirmatory factor analysis. The Cronbach alpha and Intracluster Correlation Coefficient (ICC) were used for examining Internal consistency and test-retest reliability of the IBN. Results: The IBN questionnaire was finalized with 84 items, and the results of factor analysis revealed 5 factors: psychosocial causes, environmental causes, control, meaning, and consequence/timeline; extracted factors were confirmed by confirmatory factor analysis. Cronbach’s α coefficient for scale was 0.92 and it ranged from 0.79 to 0.89 for the subscales. IBN indicated excellent test-retest reliability results based on ICC 0.842(95%CI: 0.798-0.846). The correlation coefficients of all items exceeded the prespecified acceptable value of 0.40, indicating satisfactory item discriminant validity, and correlation between IBN and IPQ-R subscales were statistically significant (all p values < 0.01), indicating acceptable convergent validity. Conclusion: The IBN questionnaire is a valid and reliable phenomenological, non-judging, and clinical tool to assess patient’s rational and irrational or faith-based beliefs about the illness. This tool can be used to improve doctor-patient communication by exploring the complex nature of human thinking.

Optimal design of cluster randomised trials with continuous recruitment and prospective baseline period.

Background:Cluster randomised trials, like individually randomised trials, may benefit from a baseline period of data collection. We consider trials in which clusters prospectively recruit or identify participants as a continuous process over a given calendar period, and ask whether and for how long investigators should collect baseline data as part of the trial, in order to maximise precision.Methods:We show how to calculate and plot the variance of the treatment effect estimator for different lengths of baseline period in a range of scenarios, and offer general advice.Results:In some circumstances it is optimal not to include a baseline, while in others there is an optimal duration for the baseline. All other things being equal, the circumstances where it is preferable not to include a baseline period are those with a smaller recruitment rate, smaller intracluster correlation, greater decay in the intracluster correlation over time, or wider transition period between recruitment under control and intervention conditions.Conclusion:The variance of the treatment effect estimator can be calculated numerically, and plotted against the duration of baseline to inform design. It would be of interest to extend these investigations to cluster randomised trial designs with more than two randomised sequences of control and intervention condition, including stepped wedge designs.

Novel Deterministic Angular Sampling Methods for 3D Channel Models

For the purpose of emulating realistic ray-based channels more exactly, two novel sum-of-cisoids (SOC) channel simulator parameters computation strategies, i.e., the bidirectional allocation (BA) and the simplified forward allocation (FA) methods, are proposed in this letter. Compared with the classical equal power method, the asymmetric computing property of these two methods further improves the spatial correlation emulation accuracy and significantly mitigates the intra-cluster correlation of sub-paths. As shown in the simulation results, both BA and FA methods enable the statistical spatial-temporal characteristics of emulated channel match extremely well with that of the target channel. More important, the proposed processes are deterministic, and will not introduce randomness in different realizations. Hence the proposed methods are always ergodic with arbitrary angle spreads.

Spatial distribution and determinants of intimate partner violence among reproductive-age women in Ethiopia: Spatial and Multilevel analysis

BackgroundIntimate partner violence is a serious global public health problem particularly in low-and middle-income countries such as Ethiopia where women's empowerment is limited. Despite the high prevalence of intimate partner violence in Ethiopia, there is limited evidence on the spatial distribution and determinants of intimate partner violence among reproductive-age women. Exploring the spatial distribution of intimate partner violence is crucial to identify hotspot areas of intimate partner violence to design targeted health care interventions. Therefore, this study aimed to investigate the spatial distribution and determinants of intimate partner violence among reproductive-age women in Ethiopia.MethodsA secondary data analysis was done based on the 2016 Ethiopian Demographic and Health Survey (EDHS) data. A total weighted sample of 6090 reproductive-age women were included in the study. The spatial scan statistical analysis was done to identify the significant hotspot areas of intimate partner violence. A multilevel binary logistic regression analysis was fitted to identify significant determinants of intimate partner violence. Deviance, Intra-cluster Correlation Coefficient (ICC), Median Odds Ratio, and Proportional Change in Variance (PCV) were used for model comparison as well as for checking model fitness. Variables with a p-value less than 0.2 were considered in the multivariable analysis. In the multivariable multilevel analysis, the Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) were reported to declare statistical significance and strength of association between intimate partner violence and independent variables.ResultsThe spatial analysis revealed that the spatial distribution of intimate partner violence was significantly varied across the country (Moran’s I = 0.1007, p-value < 0.0001). The SaTScan analysis identified a total of 192 significant clusters, of these 181 were primary clusters located in the Benishangul-Gumuz, Gambella, northwest Amhara, and west Oromia regions. In the multivariable multilevel analysis; women aged 45–49 years (AOR = 2.79, 95% CI 1.52–5.10), women attained secondary education (AOR = 0.61, 95% CI 0.38–0.98), women in the richest household (AOR = 0.58, 95% CI 0.35–0.97), > 10 family size (AOR = 3.85, 95% CI 1.41–10.54), and high community women empowerment (AOR = 0.66, 95% CI 0.49–0.8)) were significantly associated with intimate partner violence.ConclusionsIntimate partner violence among reproductive-age women had significant spatial variation across the country. Women's age, education status, family size, community women empowerment, and wealth status were found significant determinants of intimate partner violence. Therefore, public health programs should design targeted interventions in identified hot spot areas to reduce the incidence of intimate partner violence. Besides, health programmers should scale up public health programs designed to enhance women's autonomy to reduce the incidence of intimate partner violence and its consequences.

Exploring the determinants of exclusive breastfeeding among infants under-six months in Ethiopia using multilevel analysis.

Exclusive breastfeeding (EBF) is the safest and healthiest option of feeding among infants in the first 6 months throughout the world. Thus, the promotion of EBF is essential to prevent complex infant health problems even at the adulthood level. But the majority of previous studies focused on individual- level determinants of EBF by using basic regression models in localized areas. This study aimed to identify the determinants of EBF at the individual and community level which would be helpful to design appropriate strategies for improving the practice of EBF. It is a secondary data analysis using the 2016 Ethiopian Demographic and Health Survey (EDHS) data. A total of 1185 infants under 6 months of age were included in the analysis. A Multilevel logistic regression model was employed to investigate factors significantly associated with EBF among under-six infants in Ethiopia. Adjusted odds ratio (AOR) with 95% confidence interval (CI) was used to measure the association of variables whereas Intracluster correlation (ICC), median odds ratio (MOR), and proportional change in variance (PCV) were used to measure random effects (variation). In multilevel logistic regression; 4-5 months age infant (AOR = 0.04, 95%CI:0.02-0.07), female infants (AOR = 2.51, 95%CI:1.61-3.91), infant comorbidities (AOR = 0.35, 95%CI: 0.21-0.57), richest household wealth index (AOR = 10.34, 95%CI: 3.14-34.03) and antenatal care (AOR = 2.25, 95%CI:1.32-3.82) were individual- level determinants significantly associated with exclusive breastfeeding. Whereas, contextual region (AOR = 0.30, 95%CI: 0.10-0.87), community- level of postnatal visit (AOR = 2.77, 95%CI: 1.26-6.58) and community -level of maternal employment (AOR = 2.8, 95%CI: 1.21-6.47) were community level determinants significantly associated with EBF. The full model showed that46.8% of the variation of exclusive breastfeeding was explained by the combined factors at the individual and community levels. Similarly, it showed that the variation in exclusive breastfeeding across communities remained statistically significant (ICC = 8.77% and variance = 0.32 with P<0.001). Our study showed that both individual and community level determinants were significantly associated with EBF practice among under 6 infants. Based on our findings, it is recommended to promote and enhance antenatal and postnatal care services utilization of mothers to improve exclusive breastfeeding practice and more emphasis should be given to infants with comorbid conditions and those who were living in the pastoralist regions.

Semiparametric regression based on quadratic inference function for multivariate failure time data with auxiliary information

This paper deals with statistical inference procedure of multivariate failure time data when the primary covariate can be measured only on a subset of the full cohort but the auxiliary information is available. To improve efficiency of statistical inference, we use quadratic inference function approach to incorporate the intra-cluster correlation and use kernel smoothing technique to further utilize the auxiliary information. The proposed method is shown to be more efficient than those ignoring the intra-cluster correlation and auxiliary information and is easy to implement. In addition, we develop a chi-squared test for hypothesis testing of hazard ratio parameters. We evaluate the finite-sample performance of the proposed procedure via extensive simulation studies. The proposed approach is illustrated by analysis of a real data set from the study of left ventricular dysfunction.

Seat belt use behavior among teen students: The role of their demographic characteristics and family members' behaviors

Background and Objectives: The lack of seat belt use is considered as one of the most common behavioral factors encountering the life of a driver or an occupant to traffic injury risk. The aim of this study was to determine the relationship between seat belt-wearing behavior among school students and their demographic characteristics and family members' behaviors. Methods: In this cross-sectional study, 942 students (497 girls and 445 boys) were included and randomly selected from junior high schools in Tabriz, Iran. A questionnaire on the seat belt-wearing behavior of students and their parents was used to collect data, followed by applying a generalized estimating equation approach to identify the correlation of pupils' traffic behaviors to account for intra-cluster correlation. Results: The results revealed that seat belt-wearing behaviors among male students were significantly more frequent compared to female students (P < 0.0001). The mother's occupation, the father's age, and the student's educational level had a significant impact on seat belt wearing among the students (P < 0.01). In addition, student's adherence to traffic rules was correlated with their seat belt-wearing behavior. Finally, the seat belt-wearing behavior of parents and siblings had a significant positive effect on students' behaviors (P < 0.01). Conclusion: Male students further demonstrated risky behaviors compared to their female peers, and family has an important role in improving the seat belt-wearing behavior of their children. Therefore, involving adolescents' families including their parents and sibling can be important and helpful in developing preventive programs for promoting the use of seat belts among adolescents.

Association between parental attitudes towards their offspring's diet and children's actual dietary habits - The SENDO project.

Introduction: the preschool stage is a critical period for teaching and modeling healthy habits to positively influence children's health and wellbeing throughout their lifetime. Objectives: to evaluate the association between parental attitudes towards their offspring's dietary habits in Spanish children aged 4 to 7 years participating in the Follow-up of Children for Optimal Development (SENDO) project. Methods: we defined an index to measure information on parental attitudes towards their offspring's diet (0 to 8 points), and another one to measure children's actual dietary habits (0 to 19 points). A higher score meant healthier attitudes and healthier habits, respectively. Information was collected through an online questionnaire completed by parents. We calculated crude and multivariable-adjusted odds ratios (OR) and 95 % confidence intervals (CI) for children's healthy dietary habits associated with parental scores in the parental attitudes index. Generalized estimation equations (GEE) were used to account for intra-cluster correlation between siblings. Results: a total of 423 preschoolers (52.3 % boys, mean age 5.3 years) were included in the analyses. Half of the children (51 %) reported unhealthy dietary habits, whereas 56 % of parents reported high adherence to the healthy eating index. Compared to those in the lowest category, the children whose parents were in the highest category in the parental attitudes index showed significantly higher odds of having healthy dietary habits (OR: 2.91; 95 % CI: 1.30-6.53, p for trend = 0.004). Conclusions: our results support a direct association between parental attitudes and their offspring's dietary habits, suggesting that public health interventions aimed at improving children's dietary habits should shift from the individual- to a family-based approach.

Validity and repeatability of the Pediatric Allergy Questionnaire for Athletes (AQUAped) for the screening of atopy.

High atopy prevalence has been reported in athletes. Having an age-specific questionnaire for predicting atopy is important for an optimal management of young athletes. The study objectives were as follows: (i) developing a scoring system for the Pediatric Allergy Questionnaire for Athletes (AQUAped); (ii) identifying the optimal age target within the range 7-14years; (iii) assessing AQUAped validity and repeatability in the identified target population. A total of 133 young athletes (age 7-14years) were recruited. Following a screening visit, the participants filled AQUAped at baseline (T0) and after 7days (T1), concomitantly undergoing skin prick testing. Using atopy as the gold standard (positivity to ≥1 aeroallergen), the 12 core items were scored based on their likelihood ratios, and a total score was calculated. The optimal cut-off was identified based on the Youden's criterion. The repeatability of AQUAped was assessed through the intra-cluster correlation coefficient (ICC). The optimal age target was identified as the largest age range associated with an acceptable cross-validated area under the receiver operating characteristic curve (AUC≥0.70) and an excellent ICC (≥0.75). Forty (30%) children were atopic; the optimal age target was 10-14years (cross-validated AUC=0.70, ICC=0.81). AQUAped total score ranged from -26 to 75, and only 5% of non-atopic children had AQUAped≥24. AQUAped≥2 had 82% specificity, 60% sensitivity, and 74% overall accuracy. Developing and testing a scoring system for AQUAped showed that it is a valid and reliable tool for the screening of atopy in young athletes aged 10-14years.

A preliminary study on designing a cluster randomized control trial of two new mosquito nets to prevent malaria parasite infection

BackgroundAlthough long-lasting insecticidal nets (LLINs) are the most effective tool for preventing malaria parasite transmission, the nets have some limitations. For example, the increase of LLIN use has induced the rapid expansion of mosquito insecticide resistance. More than two persons often share one net, which increases the infection risk. To overcome these problems, two new mosquito nets were developed, one incorporating piperonyl butoxide and another covering ceilings and open eaves. We designed a cluster randomized controlled trial (cRCT) to evaluate these nets based on the information provided in the present preliminary study.ResultsNearly 75% of the anopheline population in the study area in western Kenya was Anopheles gambiae s. l., and the remaining was Anopheles funestus s. l. More female anophelines were recorded in the western part of the study area. The number of anophelines increased with rainfall. We planned to have 80% power to detect a 50% reduction in female anophelines between the control group and each intervention group. The between-cluster coefficient of variance was 0.192. As the number of clusters was limited to 4 due to the size of the study area, the estimated cluster size was 7 spray catches with an alpha of 0.05. Of 1619 children tested, 626 (48%) were Plasmodium falciparum positive using a rapid diagnostic test (RDT). The prevalence was higher in the northwestern part of the study area. The number of children who slept under bed nets was 929 (71%). The P. falciparum RDT-positive prevalence (RDTpfPR) of net users was 45%, and that of non-users was 55% (OR 0.73; 95% CI 0.56, 0.95). Using 45% RDTpfPR of net users, we expected each intervention to reduce prevalence by 50%. The intracluster correlation coefficient was 0.053. With 80% power and an alpha of 0.05, the estimated cluster size was 116 children. Based on the distribution of children, we modified the boundaries of the clusters and established 300-m buffer zones along the boundaries to minimize a spillover effect.ConclusionsThe cRCT study design is feasible. As the number of clusters is limited, we will apply a two-stage procedure with the baseline data to evaluate each intervention.

Birth attendants\u2019 hand hygiene compliance in healthcare facilities in low and middle-income countries: a systematic review

BackgroundWith an increasing number of women delivering in healthcare facilities in Low and Middle Income Countries (LMICs), healthcare workers’ hand hygiene compliance on labour wards is pivotal to preventing infections. Currently there are no estimates of how often birth attendants comply with hand hygiene, or of the factors influencing compliance in healthcare facilities in LMICs.MethodsWe conducted a systematic review to investigate the a) level of compliance, b) determinants of compliance and c) interventions to improve hand hygiene during labour and delivery among birth attendants in healthcare facilities of LMICs. We also aimed to assess the quality of the included studies and to report the intra-cluster correlation for studies conducted in multiple facilities.ResultsWe obtained 797 results across four databases and reviewed 71 full texts. Of these, fifteen met our inclusion criteria. Overall, the quality of the included studies was particularly compromised by poorly described sampling methods and definitions. Hand hygiene compliance varied substantially across studies from 0 to 100%; however, the heterogeneity in definitions of hand hygiene did not allow us to combine or compare these meaningfully. The five studies with larger sample sizes and clearer definitions estimated compliance before aseptic procedures opportunities, to be low (range: 1–38%). Three studies described two multi-component interventions, both were shown to be feasible.ConclusionsHand hygiene compliance was low for studies with larger sample sizes and clear definitions. This poses a substantial challenge to infection prevention during birth in LMICs facilities. We also found that the quality of many studies was suboptimal. Future studies of hand hygiene compliance on the labour ward should be designed with better sampling frames, assess inter-observer agreement, use measures to improve the quality of data collection, and report their hand hygiene definitions clearly.

A cross-sectional study of cardiovascular disease risk clustering at different socio-geographic levels in India

Despite its importance for the targeting of interventions, little is known about the degree to which cardiovascular disease (CVD) risk factors cluster within different socio-geographic levels in South Asia. Using two jointly nationally representative household surveys, which sampled 1,082,100 adults across India, we compute the intra-cluster correlation coefficients (ICCs) of five major CVD risk factors (raised blood glucose, raised blood pressure, smoking, overweight, and obesity) at the household, community, district, and state level. Here we show that except for smoking, the level of clustering is generally highest for households, followed by communities, districts, and then states. On average, more economically developed districts have a higher household ICC in rural areas. These findings provide critical information for sample size calculations of cluster-randomized trials and household surveys, and inform the targeting of policies and prevention programming aimed at reducing CVD in India.

Association of Racial/Ethnic and Gender Concordance Between Patients and Physicians With Patient Experience Ratings

The Press Ganey Outpatient Medical Practice Survey is used to measure the patient experience. An understanding of the patient- and physician-related determinants of the patient experience may help identify opportunities to improve health care delivery and physician ratings. To evaluate the associations between the patient experience as measured by scores on the Press Ganey survey and patient-physician racial/ethnic and gender concordance. A cross-sectional analysis of Press Ganey surveys returned for outpatient visits within the University of Pennsylvania Health System between 2014 and 2017 was performed. Participants included adult patient and physician dyads for whom surveys were returned. Data analysis was performed from January to June 2019. Patient-physician racial/ethnic and gender concordance. The primary outcome was receipt of the maximum score for the "likelihood of your recommending this care provider to others" question in the Care Provider domain of the Press Ganey survey. Secondary outcomes included each of the remaining 9 questions in the Care Provider domain. Generalized estimating equations clustering on physicians with exchangeable intracluster correlations and cluster-robust standard errors were used to investigate associations between the outcomes and patient-physician racial/ethnic and gender concordance. In total, 117 589 surveys were evaluated, corresponding to 92 238 unique patients (mean [SD] age, 57.7 [15.6] years; 37 002 men [40.1%]; 75 307 White patients [81.6%]) and 747 unique physicians (mean [SD] age 45.5 [10.6] years; 472 men [63.2%]; 533 White physicians [71.4%]). Compared with racially/ethnically concordant patient-physician dyads, discordance was associated with a lower likelihood of physicians receiving the maximum score (adjusted odds ratio [OR], 0.88; 95% CI, 0.82-0.94; P < .001). Black (adjusted OR, 0.73; 95% CI, 0.68-0.78; P < .001) and Asian (adjusted OR, 0.55; 95% CI, 0.50-0.60; P < .001) patient race were both associated with lower patient experience ratings. Patient-physician gender concordance was not associated with Press Ganey scores (adjusted OR, 1.00; 95% CI, 0.96-1.04; P = .90). In this study, higher Press Ganey survey scores were associated with racial/ethnic concordance between patients and their physicians. Efforts to improve physician workforce diversity are imperative. Delivery of health care in a culturally mindful manner between racially/ethnically discordant patient-physician dyads is also essential. Furthermore, Press Ganey scores may differ by a physician's patient demographic mix; thus, care must be taken when publicly reporting or using Press Ganey scores to evaluate physicians on an individual level.

Dockless bike-sharing as a feeder mode of metro commute? The role of the feeder-related built environment: Analytical framework and empirical evidence

The newly prevailing dockless bike-sharing system offers a decent solution to the first- and last-mile problem and connects trip origins/destinations and transit (mostly metro) stations. Few studies, however, have explored the effects of built environment characteristics on the integrated usage of dockless bike-sharing and the metro, especially in different conditions (e.g., access versus egress and morning peak versus evening peak) and using panel data. To fill the gap, this study proposes a people–metro–bike–route–urban space framework to describe the feeder-related built environment from the perspective of the feeder process. Using 3-day data of ofo bikes in Shenzhen, China, this study then develops multilevel negative binomial models that incorporate random effects and address the intracluster correlation attributed to repeated measures to scrutinize the feeder-related built environment effects on the integrated usage. The findings are listed as follows: (1) The majority of access and egress integrated trips have a distance range of 500–2000 m and a duration range of 2.5–10 min; (2) Popular metro stations (with a large ridership) are positively related to the access integrated usage; (3) The number of available shared bikes and the length of bikeway in the catchment areas of the metro are positively related to the integrated usage; and (4) Mixed land use increases the integrated usage, whereas urban villages are places with few demands for the integrated usage. These findings are beneficial in developing a bike-friendly built environment that facilitates the seamless connection between dockless bike-sharing and the metro.