Clostridioides difficile infection, recurrence and the associated healthcare consumption in Sweden between 2006 and 2019: a population-based cohort study.

BACKGROUND: Clostridioides difficile infection (CDI) causes a major burden to individuals and society, yet the impact may vary depending on age, sex, underlying comorbidities and where CDI was acquired (hospital or community). METHODS: This Swedish nationwide population-based cohort study (2006-2019) compared all 43,150 individuals with CDI to their 355,172 matched controls (first year and entire follow-up). Negative binomial regression models compared the cumulated length of stay, number of in-hospital admissions, outpatient visits and prescriptions after the first CDI episode expressed as incidence rate ratios (IRR) and 95% confidence intervals for the entire follow-up. RESULTS: Overall, 91.6% of CDI cases were hospital acquired, and 16.8% presented with recurrence(s); 74.8%of cases were ≥ 65 years and 54.2% were women. Compared to individuals without CDI, in-hospital stay rates were 18.01 times higher after CDI (95% CI 17.40-18.63, first-year: 27.4 versus 1.6 days), 9.45 times higher in-hospital admission (95% CI 9.16-9.76, first-year: 2.6 versus 1.3 hospitalisations), 3.94 times higher outpatient visit (95% CI 3.84-4.05, first-year: 4.0 versus 1.9 visits) and 3.39 times higher dispensed prescriptions rates (95% CI 3.31-3.48, first-year: 25.5 versus 13.7 prescriptions). For all outcomes, relative risks were higher among the younger (< 65 years) than the older (≥ 65 years), and in those with fewer comorbidities, but similar between sexes. Compared to those without recurrence, individuals with recurrence particularly showed a higher rate of hospital admissions (IRR = 1.18, 95% 1.12-1.24). Compared to community-acquired CDI, those with hospital-acquired CDI presented with a higher rate of hospital admissions (IRR = 7.29, 95% CI 6.68-7.96) and a longer length of stay (IRR = 7.64, 95% CI 7.07-8.26). CONCLUSION: CDI was associated with increased health consumption in all affected patient groups. The majority of the CDI burden could be contributed to hospital-acquired CDI (~ 9/10), older patients (~ 3/4) and those with multiple comorbidities (~ 6/10 Charlson score ≥ 3), with 1/5 of the total CDI burden contributed to individuals with recurrence. Yet, relatively speaking the burden was higher among the younger and those with fewer comorbidities, compared to their peers without CDI.

Prevalence and risk factors of metabolic dysfunction-associated steatotic liver disease in south Central Uganda: A cross-sectional survey.

BACKGROUND: Despite numerous risk factors and serious consequences, little is known about metabolic dysfunction-associated steatotic liver disease (MASLD) at population level in Africa. AIM: The aim of the study was to estimate the prevalence and risk factors of MASLD in people living with and without HIV in Uganda. METHODS: We collected data from 37 communities in South Central Uganda between May 2016 and May 2018. We estimated MASLD prevalence using the fatty liver index and advanced liver fibrosis using the dynamic aspartate-to-alanine aminotransferase ratio. We collected additional data on sociodemographics, HIV and cardiovascular disease (CVD) risk factors. We used multivariable logistic regression to determine the association between HIV, CVD risk factors and MASLD. RESULTS: We included 759 people with HIV and 704 HIV-negative participants aged 35-49. MASLD prevalence was 14% in women and 8% in men; advanced liver fibrosis prevalence was estimated to be <1%. MASLD prevalence was more common in women (15% vs. 13%) and men (9% vs. 6%) with HIV. Being female (odds ratio [OR] = 2.1; 95% confidence interval [CI] = 1.4-3.3) was associated with a higher odds of MASLD after adjustment for confounders; HIV infection was borderline associated with MASLD (OR = 1.4; 95% CI: 1.0-2.0). CONCLUSIONS: In a relatively young cohort in Uganda, 14% of women and 8% of men had MASLD. There was an indication of an association between HIV and MASLD in multivariable analysis. These data are the first to describe the population-level burden of MASLD in sub-Saharan Africa using data from a population-based cohort.

Long-term retention on antiretroviral treatment after enrolment in prevention of vertical HIV transmission services: a prospective cohort study in Dar es Salaam, Tanzania.

INTRODUCTION: To prevent vertical HIV transmission and ensure healthy mothers and children, pregnant women with HIV must remain on antiretroviral treatment (ART) for life. However, motivation to remain on ART may decline beyond the standard 2-year breastfeeding/postpartum period. We assessed attrition and retention in ART care among women with HIV up to 6 years since enrolment in vertical transmission prevention services in Dar es Salaam, Tanzania. METHODS: A prospective cohort of 22,631 pregnant women with HIV were enrolled in vertical transmission prevention services between January 2015 and December 2017 in routine healthcare settings and followed-up to July 2021. Kaplan-Meier was used to estimate time to ART attrition (died, stopped ART or was lost to follow-up [no show ≥90 days since scheduled appointment]) and the proportion retained in care. Cox proportional hazard models were used to estimate adjusted hazard ratios (aHR) of ART attrition in relation to predictors. RESULTS: Participants were followed-up to 6 years for a median of 3 years (IQR: 0.1-4). The overall ART attrition rate was 13.8 per 100 person-years (95% CI: 13.5-14.1), highest in the first year of enrolment at 27.1 (26.3-27.9), thereafter declined to 9.5 (8.9-10.1) in year 3 and 2.7 (2.1-3.5) in year 6. The proportion of women retained in care were 78%, 69%, 63%, 60%, 57% and 56% at 1, 2, 3, 4, 5 and 6 years, respectively. ART attrition was higher in young women aged <20 years (aHR 1.63, 95% CI: 1.38-1.92) as compared to 30-39 year-olds and women enrolled late in the third versus first trimester (aHR 1.29, 95% CI: 1.16-1.44). In contrast, attrition was lower in older women ≥40 years, women who initiated ART before versus during the index pregnancy and women attending higher-level health facilities. CONCLUSIONS: ART attrition among women with HIV remains highest in the first year of enrolment in vertical transmission prevention services and declines markedly following a transition to chronic HIV care. Targeted interventions to improve ART continuity among women with HIV during and beyond prevention of vertical transmission are vital to ending paediatric HIV and keeping women and children alive and healthy.

Cognitive social capital as a health-enabling factor for STI testing among young men in Stockholm, Sweden: A cross-sectional population-based study.

Objective: To assess whether different forms of cognitive social capital increased the relative probability of testing for sexually transmitted infections (STIs) among young men living in Stockholm, Sweden. Methods: A population-based cross-sectional study was conducted in 2017 with men aged 20-29 years living in Stockholm County, Sweden (n = 523). The main outcome was STI testing patterns (never tested, tested only within a12-monthperiod, tested only beyond a12-monthperiod, repeatedly tested). The main exposure were two forms of cognitive social capital: social support (having received help, having someone to share inner feelings with) and institutionalized trust (in school, healthcare, media). Data were analyzed using weighted multivariable multinomial logistic regression to obtain adjusted weighted relative probability ratio (aRPR). Results: After adjusting for confounding factors, receiving help (aRPR: 5.2, 95% CI: 1.7-16.2) and having someone to share inner feelings with (aRPR: 3.1, 95% CI: 1.2-7.7) increased the relative probabilities of young men testing for STIs, but only for those testing beyond a 12-month period. Trust in media increased the relative probability of STI testing for those testing only within a 12-month period (aRPR: 2.6, 95% CI: 1.1-6.1) and for those testing repeatedly (aRPR: 3.6, 95% CI: 1.5-8.8). Conclusion: Young men in Stockholm County exhibit distinct STI testing patterns. Social support and trust in media were factors that increased the probability of being tested for STIs, with this effect varying according to the young men's STI testing pattern. Further studies are required to explore how trust in media might promote STI testing in this population.

Associations between psychosocial wellbeing and experience of gender-based violence at community, household, and intimate-partner levels among a cross-sectional cohort of young people living with and without HIV during COVID-19 in Cape Town, South Africa.

BACKGROUND: Growing evidence indicates that gender-based violence (GBV) increased during COVID-19. We investigated self-reported impact of the pandemic on GBV at community, household and intimate partner (IPV) levels among young people and its associations with psychosocial wellbeing, i.e., COVID-related stressors and mental health. METHODS: Cross-sectional data were drawn from a survey with young people ages 13-24 (N = 536) living with HIV (YPLWH) and without HIV (YPLWoH), in peri-urban Cape Town, South Africa. The survey, conducted February-October 2021, examined the impact of the initial lockdown on experience and perceived changes in GBV at each level, and pandemic-related psychosocial wellbeing. Descriptive statistics and binomial and multinomial regression analyses were conducted to illustrate exposure and perceived changes in GBV since lockdown, and their association with COVID-related stress factors (e.g., social isolation, anxiety about COVID), mental health (e.g., depression, anxiety), and other risk factors (e.g., age, gender, socioeconomic status) by HIV status. RESULTS: Participants were 70% women with mean age 19 years; 40% were living with HIV. Since lockdown, YPLWoH were significantly more likely than YPLWH to perceive community violence as increasing (45% vs. 28%, p < 0.001), and to report household violence (37% vs. 23%, p = 0.006) and perceive it as increasing (56% vs. 27%, p = 0.002) (ref: decreasing violence). YPLWoH were also more likely to report IPV experience (19% vs. 15%, p = 0.41) and perception of IPV increasing (15% vs. 8%, p = 0.92). In adjusted models, COVID-related stressors and common mental health disorders were only associated with household violence. However, indicators of economic status such as living in informal housing (RRR = 2.07; 95% CI = 1.12-3.83) and food insecurity (Community violence: RRR = 1.79; 95% CI = 1.00-3.20; Household violence: RRR = 1.72; 95% CI = 1.15-2.60) emerged as significant risk factors for exposure to increased GBV particularly among YPLWoH. CONCLUSIONS: Findings suggest that for young people in this setting, GBV at community and household levels was more prevalent during COVID-19 compared to IPV, especially for YPLWoH. While we found limited associations between COVID-related stressors and GBV, the perceived increases in GBV since lockdown in a setting where GBV is endemic, and the association of household violence with mental health, is a concern for future pandemic responses and should be longitudinally assessed.

Drivers of COVID-19 policy stringency in 175 countries and territories: COVID-19 cases and deaths, gross domestic products per capita, and health expenditures.

Background: New data on COVID-19 may influence the stringency of containment policies, but these potential effect are not understood. We aimed to understand the associations of new COVID-19 cases and deaths with policy stringency globally and regionally. Methods: We modelled the marginal effects of new COVID-19 cases and deaths on policy stringency (scored 0-100) in 175 countries and territories, adjusting for gross domestic product (GDP) per capita and health expenditure (% of GDP), and public expenditure on health. The time periods examined were March to August 2020, September 2020 to February 2021, and March to August 2021. Results: Policy response to new cases and deaths was faster and more stringent early in the COVID-19 pandemic (March to August 2020) compared to subsequent periods. New deaths were more strongly associated with stringent policies than new cases. In an average week, one new death per 100 000 people was associated with a stringency increase of 2.1 units in the March to August 2020 period, 1.3 units in the September 2020 to February 2021 period, and 0.7 units in the March to August 2021 period. New deaths in Africa and the Western Pacific were associated with more stringency than in other regions. Higher health expenditure as a percentage of GDP was associated with less stringent policies. Similarly, higher public expenditure on health by governments was mostly associated with less stringency across all three periods. GDP per capita did not have consistent patterns of associations with stringency. Conclusions: The stringency of COVID-19 policies was more strongly associated with new deaths than new cases. Our findings demonstrate the need for enhanced mortality surveillance to ensure policy alignment during health emergencies. Countries that invest less in health or have a lower public expenditure on health may be inclined to enact more stringent policies. This new empirical understanding of COVID-19 policy drivers can help public health officials anticipate and shape policy responses in future health emergencies.

Media use and trust during the COVID-19 pandemic: evidence from eight cross-sectional surveys in Sweden.

BACKGROUND: While a lot has been written about Sweden's COVID-19 control strategy, less is known about Swedish residents' media use during the pandemic and trust in and perceived agreement among key stakeholders commenting in the media. METHODS: Eight online, nationwide surveys were fielded between March and August 2020, during the first wave of the coronavirus pandemic in Sweden, with 8146 responses. Questions were asked on media usage, perceived tone of media, trust in key pandemic stakeholder groups commenting in the media (politicians, journalists, government officials, doctors/healthcare professionals and researchers) and perceived agreement among these key stakeholders about how the pandemic was handled in Sweden. RESULTS: Using five or more information sources was associated with increased perceived alarmism in the media. Women and those with tertiary education were more likely to trust key pandemic actors. Trust in doctors/healthcare professionals and researchers remained high over the course of the study, trust in politicians and journalists was relatively low throughout the study period, with a slight increase in April 2020. Trust in key stakeholders was strongly associated with perceived agreement among the key stakeholders. CONCLUSIONS: Our results show that trust in stakeholders was strongly associated with perceived consistency of messages from those stakeholders. The inverse also holds: perceived conflicting messages among stakeholders was associated with low trust in them. Taken together, this could point to the importance of building trust before a crisis. Trust-building efforts could be targeted to men and those with lower educational attainment, as they had lower trust in key stakeholders.

Debunking highly prevalent health misinformation using audio dramas delivered by WhatsApp: evidence from a randomised controlled trial in Sierra Leone.

INTRODUCTION: Infectious disease misinformation is widespread and poses challenges to disease control. There is limited evidence on how to effectively counter health misinformation in a community setting, particularly in low-income regions, and unsettled scientific debate about whether misinformation should be directly discussed and debunked, or implicitly countered by providing scientifically correct information. METHODS: The Contagious Misinformation Trial developed and tested interventions designed to counter highly prevalent infectious disease misinformation in Sierra Leone, namely the beliefs that (1) mosquitoes cause typhoid and (2) typhoid co-occurs with malaria. The information intervention for group A (n=246) explicitly discussed misinformation and explained why it was incorrect and then provided the scientifically correct information. The intervention for group B (n=245) only focused on providing correct information, without directly discussing related misinformation. Both interventions were delivered via audio dramas on WhatsApp that incorporated local cultural understandings of typhoid. Participants were randomised 1:1:1 to the intervention groups or the control group (n=245), who received two episodes about breast feeding. RESULTS: At baseline 51% believed that typhoid is caused by mosquitoes and 59% believed that typhoid and malaria always co-occur. The endline survey was completed by 91% of participants. Results from the intention-to-treat, per-protocol and as-treated analyses show that both interventions substantially reduced belief in misinformation compared with the control group. Estimates from these analyses, as well as an exploratory dose-response analysis, suggest that direct debunking may be more effective at countering misinformation. Both interventions improved people's knowledge and self-reported behaviour around typhoid risk reduction, and yielded self-reported increases in an important preventive method, drinking treated water. CONCLUSION: These results from a field experiment in a community setting show that highly prevalent health misinformation can be countered, and that direct, detailed debunking may be most effective. TRIAL REGISTRATION NUMBER: NCT04112680.

Engaging religious leaders to promote safe burial practices during the 2014-2016 Ebola virus disease outbreak, Sierra Leone.

OBJECTIVE: To quantify the potential impact of engaging religious leaders in promoting safe burial practices during the 2014-2016 Ebola virus disease outbreak in Sierra Leone. METHODS: We analysed population-based household survey data from 3540 respondents collected around the peak of the outbreak in Sierra Leone, December 2014. Respondents were asked if in the past month they had heard an imam or pastor say that people should not touch or wash a dead body. We used multilevel logistic regression modelling to examine if exposure to religious leaders' messages was associated with protective burial intentions if a family member died at home and other Ebola protective behaviours. FINDINGS: Of the respondents, 3148 (89%) had been exposed to faith-based messages from religious leaders on safe Ebola burials and 369 (10%) were unexposed. Exposure to religious leaders' messages was associated with a nearly twofold increase in the intention to accept safe alternatives to traditional burials and the intention to wait ≥ 2 days for burial teams (adjusted odds ratio, aOR: 1.69; 95% confidence interval, CI: 1.23-2.31 and aOR: 1.84; 95% CI: 1.38-2.44, respectively). Exposure to messages from religious leaders was also associated with avoidance of traditional burials and of contact with suspected Ebola patients (aOR: 1.46; 95% CI: 1.14-1.89 and aOR: 1.65; 95% CI: 1.27-2.13, respectively). CONCLUSION: Public health messages promoted by religious leaders may have influenced safe burial behaviours during the Ebola outbreak in Sierra Leone. Engagement of religious leaders in risk communication should be prioritized during health emergencies in similar settings.

Risk perception during the 2014-2015 Ebola outbreak in Sierra Leone.

BACKGROUND: Perceived susceptibility to a disease threat (risk perception) can influence protective behaviour. This study aims to determine how exposure to information sources, knowledge and behaviours potentially influenced risk perceptions during the 2014-2015 Ebola Virus Disease outbreak in Sierra Leone. METHODS: The study is based on three cross-sectional, national surveys (August 2014, n = 1413; October 2014, n = 2086; December 2014, n = 3540) that measured Ebola-related knowledge, attitudes, and practices in Sierra Leone. Data were pooled and composite variables were created for knowledge, misconceptions and three Ebola-specific behaviours. Risk perception was measured using a Likert-item and dichotomised into 'no risk perception' and 'some risk perception'. Exposure to five information sources was dichotomised into a binary variable for exposed and unexposed. Multilevel logistic regression models were fitted to examine various associations. RESULTS: Exposure to new media (e.g. internet) and community-level information sources (e.g. religious leaders) were positively associated with expressing risk perception. Ebola-specific knowledge and hand washing were positively associated with expressing risk perception (Adjusted OR [AOR] 1.4, 95% Confidence Interval [CI] 1.2-1.8 and AOR 1.4, 95% CI 1.1-1.7 respectively), whereas misconceptions and avoiding burials were negatively associated with risk perception, (AOR 0.7, 95% CI 0.6-0.8 and AOR 0.8, 95% CI 06-1.0, respectively). CONCLUSIONS: Our results illustrate the complexity of how individuals perceived their Ebola acquisition risk based on the way they received information, what they knew about Ebola, and actions they took to protect themselves. Community-level information sources may help to align the public's perceived risk with their actual epidemiological risk. As part of global health security efforts, increased investments are needed for community-level engagements that allow for two-way communication during health emergencies.

Homecare for sick family members while waiting for medical help during the 2014-2015 Ebola outbreak in Sierra Leone: a mixed methods study.

INTRODUCTION: Caring for an Ebola patient is a known risk factor for disease transmission. In Sierra Leone during the outbreak in 2014/2015, isolation of patients in specialised facilities was not always immediately available and caring for a relative at home was sometimes the only alternative. This study sought to assess population-level protective caregiving intentions, to understand how families cared for their sick and to explore perceived barriers and facilitators influencing caregiving behaviours. METHODS: Data from a nationwide household survey conducted in December 2014 were used to assess intended protective behaviours if caring for a family member with suspected Ebola. Their association with socio-demographic variables, Ebola-specific knowledge and risk perception was analysed using multilevel logistic regression. To put the results into context, semi-structured interviews with caregivers were conducted in Freetown. RESULTS: Ebola-specific knowledge was positively associated with the intention to avoid touching a sick person and their bodily fluids (adjusted OR (AOR) 1.29; 95% CI 1.01 to 1.54) and the intention to take multiple protective measures (AOR 1.38; 95% CI 1.16 to 1.63). Compared with residing in the mostly urban Western Area, respondents from the initial epicentre of the outbreak (Eastern Province) had increased odds to avoid touching a sick person or their body fluids (AOR 4.74; 95% CI 2.55 to 8.81) and to take more than one protective measure (AOR 2.94; 95% CI 1.37 to 6.34). However, interviews revealed that caregivers, who were mostly aware of the risk of transmission and general protective measures, felt constrained by different contextual factors. Withholding care was not seen as an option and there was a perceived lack of practical advice. CONCLUSIONS: Ebola outbreak responses need to take the sociocultural reality of caregiving and the availability of resources into account, offering adapted and acceptable practical advice. The necessity to care for a loved one when no alternatives exist should not be underestimated.

Evidence of behaviour change during an Ebola virus disease outbreak, Sierra Leone.

OBJECTIVE: To evaluate changes in Ebola-related knowledge, attitudes and prevention practices during the Sierra Leone outbreak between 2014 and 2015. METHODS: Four cluster surveys were conducted: two before the outbreak peak (3499 participants) and two after (7104 participants). We assessed the effect of temporal and geographical factors on 16 knowledge, attitude and practice outcomes. FINDINGS: Fourteen of 16 knowledge, attitude and prevention practice outcomes improved across all regions from before to after the outbreak peak. The proportion of respondents willing to: (i) welcome Ebola survivors back into the community increased from 60.0% to 89.4% (adjusted odds ratio, aOR: 6.0; 95% confidence interval, CI: 3.9-9.1); and (ii) wait for a burial team following a relative's death increased from 86.0% to 95.9% (aOR: 4.4; 95% CI: 3.2-6.0). The proportion avoiding unsafe traditional burials increased from 27.3% to 48.2% (aOR: 3.1; 95% CI: 2.4-4.2) and the proportion believing spiritual healers can treat Ebola decreased from 15.9% to 5.0% (aOR: 0.2; 95% CI: 0.1-0.3). The likelihood respondents would wait for burial teams increased more in high-transmission (aOR: 6.2; 95% CI: 4.2-9.1) than low-transmission (aOR: 2.3; 95% CI: 1.4-3.8) regions. Self-reported avoidance of physical contact with corpses increased in high but not low-transmission regions, aOR: 1.9 (95% CI: 1.4-2.5) and aOR: 0.8 (95% CI: 0.6-1.2), respectively. CONCLUSION: Ebola knowledge, attitudes and prevention practices improved during the Sierra Leone outbreak, especially in high-transmission regions. Behaviourally-targeted community engagement should be prioritized early during outbreaks.

Ebola vaccine? Family first! Evidence from using a brief measure on Ebola vaccine demand in a national household survey during the outbreak in Sierra Leone.

BACKGROUND: Vaccination against Ebolavirus is an emerging public health tool during Ebola Virus Disease outbreaks. We examined demand issues related to deployment of Ebolavirus vaccine during the 2014-2015 outbreak in Sierra Leone. METHODS: A cluster survey was administered to a population-based sample in December 2014 (N = 3540), before any Ebola vaccine was available to the general public in Sierra Leone. Ebola vaccine demand was captured in this survey by three Likert-scale items that were used to develop a composite score and dichotomized into a binary outcome to define high demand. A multilevel logistic regression model was fitted to assess the associations between perceptions of who should be first to receive an Ebola vaccine and the expression of high demand for an Ebola vaccine. RESULTS: The largest proportion of respondents reported that health workers (35.1%) or their own families (29.5%) should receive the vaccine first if it became available, rather than politicians (13.8%), vaccination teams (9.8%), or people in high risk areas (8.2%). High demand for an Ebola vaccine was expressed by 74.2% of respondents nationally. The odds of expressing high demand were 13 times greater among those who said they or their families should be the first to take the vaccine compared to those who said politicians should be the first recipients (adjusted odds ratio [aOR] 13.0 [95% confidence interval [CI] 7.8-21.6]). The ultra-brief measure of the Ebola vaccine demand demonstrated acceptable scale reliability (Cronbach's α = 0.79) and construct validity (single-factor loadings > 0.50). CONCLUSION: Perceptions of who should be the first to get the vaccine was associated with high demand for Ebola vaccine around the peak of the outbreak in Sierra Leone. Using an ultra-brief measure of Ebola vaccine demand is a feasible solution in outbreak settings and can help inform development of future rapid assessment tools.

Parental support in promoting children's health behaviours and preventing overweight and obesity - a long-term follow-up of the cluster-randomised healthy school start study II trial.

BACKGROUND: Effects of obesity prevention interventions in early childhood are only meaningful if they are sustained over time, but long-term follow-up studies are rare. The school-based cluster-randomised Healthy School Start (HSS) trial aimed at child health promotion and obesity prevention through parental support was carried out in 31 pre-school classes (378 families) in disadvantaged areas in Sweden during 2012-2013. Post-intervention results showed intervention effects on intake of unhealthy foods and drinks, and lower BMI-sds in children with obesity at baseline. This study aimed to evaluate the long-term effectiveness 4 years post-intervention. METHODS: Data were collected from 215 children in March-June 2017. Child dietary intake, screen time, and physical activity were measured through parental-proxy questionnaires. Child height and weight were measured by the research group. Group effects were examined using Poisson, linear, logistic, and quantile regression for data on different levels. Analyses were done by intention to treat, per protocol, and sensitivity analyses using multiple imputation. RESULTS: No between-group effects on dietary intake, screen time, physical activity, or BMI-sds were found for the entire group at the four-year follow-up. In girls, a significant subgroup-effect was found favouring intervention compared to controls with a lower intake of unhealthy foods, but this was not sustained in the sensitivity analysis. In boys, a significant sub-group effect was found where the boys in the intervention group beyond the 95th percentile had significantly higher BMI-sds compared to boys in the control group. This effect was sustained in the sensitivity analysis. Analyses per protocol showed significant intervention effects regarding a lower intake of unhealthy foods and drinks in the children with a high intervention dose compared to controls. CONCLUSIONS: Four years after the intervention, only sub-group effects were found, and it is unlikely that the HSS intervention had clinically meaningful effects on the children. These results suggest that school-based prevention programmes need to be extended for greater long-term effectiveness by e.g. integration into school routine practice. In addition, results showed that children with a high intervention dose had better long-term outcomes compared to controls, which emphasises the need for further work to increase family engagement in interventions. TRIAL REGISTRATION: ISRCTN, ISRCTN39690370, retrospectively registered March 1, 2013, http://www.isrctn.com/ISRCTN39690370 .

Passive and mentally-active sedentary behaviors and incident major depressive disorder: A 13-year cohort study.

BACKGROUND: Regular physical activity reduces the risk of depression onset and is an effective treatment for mood disorders. Recent studies have reported that sedentary behavior (SB) increases the risk of depression in adults, but relationships of different types of SBs with depression have not been examined systematically. We explored longitudinal relationships of passive (e.g. watching TV) and mentally-active (e.g. office-work) SBs with incident major depressive disorder (MDD). METHODS: Self-report questionnaires were completed by 40,569 Swedish adults in 1997; responses were linked to clinician-diagnosed MDD obtained from medical registers until 2010. Relationships between passive, mentally-active and total SBs with incident MDD were explored using survival analysis with Cox proportional hazards regression. Models controlled for leisure time moderate-vigorous physical activity and occupational physical activity. Moderating effects of gender were examined. RESULTS: In fully-adjusted models, including only non-depressed adults at baseline, those reporting ≥ 3 h of mentally-active SBs on a typical day (versus < 3 h) had significant lower hazards of incident MDD at follow-up (HR = 0.74, 95% CI = 0.58-0.94, p = 0.018). There was a non-significant positive relationship of passive SBs with incident MDD (HR = 1.20, 95% CI = 0.96-1.52, p = 0.106). The association between total SBs (passive and mentally-active combined) was not significant (HR = 0.91, 95% CI = 0.75-1.10, p = 0.36). Gender did not moderate these associations. LIMITATIONS: Physical activity and SBs were self-reported. CONCLUSION: Mentally-active SBs may have beneficial effects on adults' mental well-being. These effects are largely independent of habitual physical activity levels.

Risk Communication and Ebola-Specific Knowledge and Behavior during 2014-2015 Outbreak, Sierra Leone.

We assessed the effect of information sources on Ebola-specific knowledge and behavior during the 2014-2015 Ebola virus disease outbreak in Sierra Leone. We pooled data from 4 population-based knowledge, attitude, and practice surveys (August, October, and December 2014 and July 2015), with a total of 10,604 respondents. We created composite variables for exposures (information sources: electronic, print, new media, government, community) and outcomes (knowledge and misconceptions, protective and risk behavior) and tested associations by using logistic regression within multilevel modeling. Exposure to information sources was associated with higher knowledge and protective behaviors. However, apart from print media, exposure to information sources was also linked to misconceptions and risk behavior, but with weaker associations observed. Knowledge and protective behavior were associated with the outbreak level, most strongly after the peak, whereas risk behavior was seen at all levels of the outbreak. In future outbreaks, close attention should be paid to dissemination of information.

BDNF Val66Met and childhood adversity on response to physical exercise and internet-based cognitive behavioural therapy in depressed Swedish adults.

The genetic effect of Brain-derived neurotrophic factor (BDNF) on treatment response in depression is not consistent in the literature. Childhood adversity is a known risk factor for depression which has been reported to increase depression susceptibility by interacting with BDNF genetic variation. We aimed to explore whether the BDNF variation Val66Met and childhood adversity (CA) predicted the treatment response to a 12-week intervention with physical exercise (PE) or internet-based cognitive behavioural therapy (ICBT) when compared with treatment as usual (TAU). A prospective cohort study nested within a randomised control trial was conducted using data from 547 participants with mild to moderate depression. Depression severity at baseline and follow-up was measured using the Montgomery-Åsberg Depression Rating Scale. Met allele carriers without exposure to CA and current antidepressant use showed higher treatment response to PE than Val homozygotes. There was no evidence to support that BDNF Val66Met or CA alone predicted treatment response to PE and ICBT. The Met carriers had higher serum mature BDNF level. These data suggest that Met allele carriers benefit more from PE treatment but only if they are not exposed to early adversity.

Are Changes in Alcohol Consumption Among Swedish Youth Really Occurring 'in Concert'? A New Perspective Using Quantile Regression.

AIMS: Recent studies of youth alcohol consumption indicate a collective downward drinking trend at all levels of consumption, i.e. reductions occurring 'in concert'. We re-examine the collectivity of drinking theory by applying quantile regression methods to the analysis and interpretation of Swedish youth alcohol consumption. METHOD: Changes in youth alcohol consumption between 2000 and 2014 were assessed using a school-based survey conducted in Stockholm (n = 86,402). Participants were Swedish youth aged 15-18 years. The rate of change in consumption was examined using quantile regression, and compared to Ordinary Least Squares modelling. The hypothesis of parallelism or 'in concert' changes in consumption was assessed using the test of the equality of linear regression slopes corresponding to different quantiles of log consumption. RESULTS: In both models, changes in consumption over time did not occur in parallel, contrary to the collectivity of drinking theory. Instead, a clear divergence in the rate of drinking was observed, with most adolescent quantiles reducing consumption, while heavy consuming remained stable. CONCLUSIONS: Contrary to previous studies, our findings do not support a collectivity of drinking behaviour among Swedish youth. Quantile regression is a robust and appropriate method for analysing temporal changes in alcohol consumption data.

Exercise and internet-based cognitive-behavioural therapy for depression: multicentre randomised controlled trial with 12-month follow-up.

BACKGROUND: Evidence-based treatment of depression continues to grow, but successful treatment and maintenance of treatment response remains limited. AIMS: To compare the effectiveness of exercise, internet-based cognitive-behavioural therapy (ICBT) and usual care for depression. METHOD: A multicentre, three-group parallel, randomised controlled trial was conducted with assessment at 3 months (post-treatment) and 12 months (primary end-point). Outcome assessors were masked to group allocation. Computer-generated allocation was performed externally in blocks of 36 and the ratio of participants per group was 1:1:1. In total, 945 adults with mild to moderate depression aged 18-71 years were recruited from primary healthcare centres located throughout Sweden. Participants were randomly assigned to one of three 12-week interventions: supervised group exercise, clinician-supported ICBT or usual care by a physician. The primary outcome was depression severity assessed by the Montgomery-Åsberg Depression Rating Scale (MADRS). RESULTS: The response rate at 12-month follow-up was 84%. Depression severity reduced significantly in all three treatment groups in a quadratic trend over time. Mean differences in MADRS score at 12 months were 12.1 (ICBT), 11.4 (exercise) and 9.7 (usual care). At the primary end-point the group × time interaction was significant for both exercise and ICBT. Effect sizes for both interventions were small to moderate. CONCLUSIONS: The long-term treatment effects reported here suggest that prescribed exercise and clinician-supported ICBT should be considered for the treatment of mild to moderate depression in adults.