An Egg Intervention Improves Ponderal But Not Linear Growth Among Infants 6-12 mo of Age in Rural Bangladesh.

BACKGROUND: Animal source foods are rich in multiple nutrients. Regular egg consumption may improve infant growth in low- and middle-income countries. OBJECTIVES: To assess the impact of daily egg consumption on linear growth among 6-12-mo olds in rural Bangladesh. METHODS: We conducted a 2 × 4 factorial cluster-randomized controlled trial allocating clusters (n = 566) to treatment for enteric pathogens or placebo and a daily egg, protein supplement, isocaloric supplement, or control. All arms received nutrition education. Here, we compare the effect of the egg intervention versus control on linear growth, a prespecified aim of the trial. Infants were enrolled at 3 mo. We measured length and weight at 6 and 12 mo and visited households weekly to distribute eggs and monitor compliance. We used linear regression models to compare 12-mo mean length, weight, and z-scores for length-for-age (LAZ), weight-for-length, and weight-for-age (WAZ), and log-binomial or robust Poisson regression to compare prevalence of stunting, wasting, and underweight between arms. We used generalized estimating equations to account for clustering and adjusted models for baseline measures of outcomes. RESULTS: We enrolled 3051 infants (n = 283 clusters) across arms, with complete 6 and 12 mo anthropometry data from 1228 infants (n = 142 clusters) in the egg arm and 1109 infants (n = 141 clusters) in the control. At baseline, 18.5%, 6.0%, and 16.4% were stunted, wasted, and underweight, respectively. The intervention did not have a statistically significant effect on mean LAZ (ß: 0.05, 95% confidence interval [CI]: -0.01, 0.10) or stunting prevalence (ß: 0.98, 95% CI: 0.89, 1.13) at 12 mo. Mean weight (ß: 0.07 kg, 95% CI: 0.02, 0.11) and WAZ (ß: 0.06, 95% CI: 0.02, 0.11) were significantly higher in the egg compared with control arms. CONCLUSIONS: Provision of a daily egg for 6 mo to infants in rural Bangladesh improved ponderal but not linear growth. TRIAL REGISTRATION NUMBER: NCT03683667, https://clinicaltrials.gov/ct2/show/NCT03683667.

An Egg Intervention Improves Dietary Intakes but Does Not Fill Intake Gaps for Multiple Micronutrients among Infants in Rural Bangladesh.

BACKGROUND: Eggs are nutrient-rich. Strengthening evidence of the impact of egg consumption on dietary quality can inform complementary feeding guidance. OBJECTIVES: We aimed to assess the effect of an egg intervention on dietary intakes among infants aged 6-12 mo in rural Bangladesh. METHODS: We conducted a cluster-randomized controlled trial allocating clusters (n = 566) to enteric pathogen control or placebo treatment, with daily provision of a protein-rich meal, isocaloric meal, egg, or control. Nutrition education was provided to all arms. Our focus here is on the egg and control arms. Infants were enrolled at 3 mo. From 6 mo, we visited households weekly to distribute eggs and measure compliance. A semistructured feeding questionnaire assessed 24-h intake at 6, 9, and 12 mo. Assessments were repeated in ∼10% of subjects 2-29 d later. Using NCI SAS macros, we estimated usual intake distributions for energy, protein, fat, and 18 micronutrients and the proportion meeting intake recommendations. We compared the outcomes between the arms using clustered bootstrapping. RESULTS: Data were available from 757 infants (137 clusters) and 943 infants (141 clusters) in the egg and control arms, respectively. In the egg arm compared with the control arm, the mean usual intakes were higher for energy (610 compared with 602 kcal/d, 9 mo; 669 compared with 658 kcal/d, 12 mo), crude protein (2.2 compared with 1.7 g/(kg·d), 9 mo; 2.4 compared with 1.9 g/(kg·d), 12 mo), available protein (2.0 compared with 1.6 g/(kg·d), 9 mo; 2.1 compared with 1.8 g/(kg·d), 12 mo), and for 13 and 14 micronutrients at 9 and 12 mo, respectively. The proportion meeting intake recommendations for most micronutrients was higher in the egg arm but remained <50% for 15 and 13 micronutrients at 9 and 12 mo, respectively. CONCLUSIONS: Daily egg consumption improved dietary intakes among Bangladeshi infants, but was insufficient to meet multiple micronutrient intake recommendations, demonstrating the need to be coupled with other strategies.

The Pregnancy, Arsenic, and Immune Response (PAIR) Study in rural northern Bangladesh.

BACKGROUND: Arsenic exposure and micronutrient deficiencies may alter immune reactivity to influenza vaccination in pregnant women, transplacental transfer of maternal antibodies to the foetus, and maternal and infant acute morbidity. OBJECTIVES: The Pregnancy, Arsenic, and Immune Response (PAIR) Study was designed to assess whether arsenic exposure and micronutrient deficiencies alter maternal and newborn immunity and acute morbidity following maternal seasonal influenza vaccination during pregnancy. POPULATION: The PAIR Study recruited pregnant women across a large rural study area in Gaibandha District, northern Bangladesh, 2018-2019. DESIGN: Prospective, longitudinal pregnancy and birth cohort. METHODS: We conducted home visits to enrol pregnant women in the late first or early second trimester (11-17 weeks of gestational age). Women received a quadrivalent seasonal inactivated influenza vaccine at enrolment. Follow-up included up to 13 visits between enrolment and 3 months postpartum. Arsenic was measured in drinking water and maternal urine. Micronutrient deficiencies were assessed using plasma biomarkers. Vaccine-specific antibody titres were measured in maternal and infant serum. Weekly telephone surveillance ascertained acute morbidity symptoms in women and infants. PRELIMINARY RESULTS: We enrolled 784 pregnant women between October 2018 and March 2019. Of 784 women who enrolled, 736 (93.9%) delivered live births and 551 (70.3%) completed follow-up visits to 3 months postpartum. Arsenic was detected (≥0.02 µg/L) in 99.7% of water specimens collected from participants at enrolment. The medians (interquartile ranges) of water and urinary arsenic at enrolment were 5.1 (0.5, 25.1) µg/L and 33.1 (19.6, 56.5) µg/L, respectively. Water and urinary arsenic were strongly correlated (Spearman's ⍴ = 0.72) among women with water arsenic ≥ median but weakly correlated (⍴ = 0.17) among women with water arsenic < median. CONCLUSIONS: The PAIR Study is well positioned to examine the effects of low-moderate arsenic exposure and micronutrient deficiencies on immune outcomes in women and infants. REGISTRATION: NCT03930017.

Telemedicine Referral to Improve Access to Specialty Care for Preschool Children in Rural Alaska: A Cluster-Randomized Controlled Trial.

OBJECTIVES: Preschool programs provide essential preventive services, such as hearing screening, but in rural regions, limited access to specialists and loss to follow-up compound rural health disparities. We conducted a parallel-arm cluster-randomized controlled trial to evaluate telemedicine specialty referral for preschool hearing screening. The goal of this trial was to improve timely identification and treatment of early childhood infection-related hearing loss, a preventable condition with lifelong implications. We hypothesized that telemedicine specialty referral would improve time to follow-up and the number of children receiving follow-up compared with the standard primary care referral. DESIGN: We conducted a cluster-randomized controlled trial in K-12 schools in 15 communities over two academic years. Community randomization occurred within four strata using location and school size. In the second academic year (2018-2019), an ancillary trial was performed in the 14 communities that had preschools to compare telemedicine specialty referral (intervention) to standard primary care referral (comparison) for preschool hearing screening. Randomization of communities from the main trial was used for this ancillary trial. All children enrolled in preschool were eligible. Masking was not possible because of timing in the second year of the main trial, but referral assignment was not openly disclosed. Study team members and school staff were masked throughout data collection, and statisticians were blinded to allocation during analysis. Preschool screening occurred once, and children who were referred for possible hearing loss or ear disease were monitored for follow-up for 9 months from the screening date. The primary outcome was time to ear/hearing-related follow-up from the date of screening. The secondary outcome was any ear/hearing follow-up from screening to 9 months. Analyses were conducted using an intention-to-treat approach. RESULTS: A total of 153 children were screened between September 2018 and March 2019. Of the 14 communities, 8 were assigned to the telemedicine specialty referral pathway (90 children), and 6 to the standard primary care referral pathway (63 children). Seventy-one children (46.4%) were referred for follow-up: 39 (43.3%) in the telemedicine specialty referral communities and 32 (50.8%) in the standard primary care referral communities. Of children referred, 30 (76.9%) children in telemedicine specialty referral communities and 16 (50.0%) children in standard primary care referral communities received follow-up within 9 months (Risk Ratio = 1.57; 95% confidence interval [CI], 1.22 to 2.01). Among children who received follow-up, median time to follow-up was 28 days (interquartile range [IQR]: 15 to 71) in telemedicine specialty referral communities compared with 85 days (IQR: 26 to 129) in standard primary care referral communities. Mean time to follow-up for all referred children was 4.5 (event time ratio = 4.5; 95% CI, 1.8 to 11.4; p = 0.045) times faster in telemedicine specialty referral communities compared with standard primary care referral communities in the 9-month follow-up time frame. CONCLUSIONS: Telemedicine specialty referral significantly improved follow-up and reduced time to follow-up after preschool hearing screening in rural Alaska. Telemedicine referrals could extend to other preventive school-based services to improve access to specialty care for rural preschool children.

Prevalence of Childhood Hearing Loss in Rural Alaska.

OBJECTIVES: Childhood hearing loss has well-known lifelong consequences. Certain rural populations are at higher risk for infection-related hearing loss. For Alaska Native children, historical data on hearing loss prevalence suggest a higher burden of infection-related hearing loss, but updated prevalence data are urgently needed in this high-risk population. DESIGN: Hearing data were collected as part of two school-based cluster-randomized trials in 15 communities in rural northwest Alaska over two academic years (2017-2019). All enrolled children from preschool to 12th grade were eligible. Pure-tone thresholds were obtained using standard audiometry and conditioned play when indicated. The analysis included the first available audiometric assessment for each child (n = 1634 participants, 3 to 21 years), except for the high-frequency analysis, which was limited to year 2 when higher frequencies were collected. Multiple imputation was used to quantify the prevalence of hearing loss in younger children, where missing data were more frequent due to the need for behavioral responses. Hearing loss in either ear was evaluated using both the former World Health Organization (WHO) definition (pure-tone average [PTA] > 25 dB) and the new WHO definition (PTA ≥ 20 dB), which was published after the study. Analyses with the new definition were limited to children 7 years and older due to incomplete data obtained on younger children at lower thresholds. RESULTS: The overall prevalence of hearing loss (PTA > 25 dB; 0.5, 1, 2, 4 kHz) was 10.5% (95% confidence interval [CI], 8.9 to 12.1). Hearing loss was predominately mild (PTA >25 to 40 dB; 8.9%, 95% CI, 7.4 to 10.5). The prevalence of unilateral hearing loss was 7.7% (95% CI, 6.3 to 9.0). Conductive hearing loss (air-bone gap of ≥ 10 dB) was the most common hearing loss type (9.1%, 95% CI, 7.6 to 10.7). Stratified by age, hearing loss (PTA >25 dB) was more common in children 3 to 6 years (14.9%, 95% CI, 11.4 to 18.5) compared to children 7 years and older (8.7%, 95% CI, 7.1 to 10.4). In children 7 years and older, the new WHO definition increased the prevalence of hearing loss to 23.4% (95% CI, 21.0 to 25.8) compared to the former definition (8.7%, 95% CI, 7.1 to 10.4). Middle ear disease prevalence was 17.6% (95% CI, 15.7 to 19.4) and was higher in younger children (23.6%, 95% CI, 19.7 to 27.6) compared to older children (15.2%, 95% CI, 13.2 to 17.3). High-frequency hearing loss (4, 6, 8kHz) was present in 20.5% (95% CI, 18.4 to 22.7 [PTA >25 dB]) of all children and 22.8% (95% CI, 20.3 to 25.3 [PTA >25 dB]) and 29.7% (95% CI, 27.0 to 32.4 [PTA ≥ 20 dB]) of children 7 years and older (limited to year 2). CONCLUSIONS: This analysis represents the first prevalence study on childhood hearing loss in Alaska in over 60 years and is the largest cohort with hearing data ever collected in rural Alaska. Our results highlight that hearing loss continues to be common in rural Alaska Native children, with middle ear disease more prevalent in younger children and high-frequency hearing loss more prevalent with increasing age. Prevention efforts may benefit from managing hearing loss type by age. Lastly, continued research is needed on the impact of the new WHO definition of hearing loss on field studies.

Changing the Paradigm for School Hearing Screening Globally: Evaluation of Screening Protocols From Two Randomized Trials in Rural Alaska.

OBJECTIVES: Diagnostic accuracy was evaluated for various screening tools, including mobile health (mHealth) pure-tone screening, tympanometry, distortion product otoacoustic emissions (DPOAE), and inclusion of high frequencies to determine the most accurate screening protocol for identifying children with hearing loss in rural Alaska where the prevalence of middle ear disease is high. DESIGN: Hearing screening data were collected as part of two cluster randomized trials conducted in 15 communities in rural northwest Alaska. All children enrolled in school from preschool to 12th grade were eligible. Analysis was limited to data collected 2018 to 2019 (n = 1449), when both trials were running and measurement of high frequencies were included in the protocols. Analyses included estimates of diagnostic accuracy for each screening tool, as well as exploring performance by age and grade. Multiple imputation was used to assess diagnostic accuracy in younger children, where missing data were more prevalent due to requirements for conditioned responses. The audiometric reference standard included otoscopy, tympanometry, and high frequencies to ensure detection of infection-related and noise-induced hearing loss. RESULTS: Both the mHealth pure-tone screen and DPOAE screen performed better when tympanometry was added to the protocol (increase in sensitivity of 19.9%, 95% Confidence Interval (CI): 15.9 to 24.1 for mHealth screen, 17.9%, 95% CI: 14.0 to 21.8 for high-frequency mHealth screen, and 10.4%, 95% CI: 7.5 to 13.9 for DPOAE). The addition of 6 kHz to the mHealth pure-tone screen provided an 8.7 percentage point improvement in sensitivity (95% CI: 6.5 to 11.3). Completeness of data for both the reference standard and the mHealth screening tool differed substantially by age, due to difficulty with behavioral testing in young children. By age 7, children were able to complete behavioral testing, and data indicated that high-frequency mHealth pure-tone screen with tympanometry was the superior tool for children 7 years and older. For children 3 to 6 years of age, DPOAE plus tympanometry performed the best, both for complete data and multiply imputed data, which better approximates accuracy for children with missing data. CONCLUSIONS: This study directly evaluated pure-tone, DPOAE, and tympanometry tools as part of school hearing screening in rural Alaskan children (3 to 18+ years). Results from this study indicate that tympanometry is a key component in the hearing screening protocol, particularly in environments with higher prevalence of infection-related hearing loss. DPOAE is the preferred hearing screening tool when evaluating children younger than 7 years of age (below 2nd grade in the United States) due to the frequency of missing data with behavioral testing in this age group. For children 7 years and older, the addition of high frequencies to pure-tone screening increased the accuracy of screening, likely due to improved identification of hearing loss from noise exposure. The lack of a consistent reference standard in the literature makes comparing across studies challenging. In our study with a reference standard inclusive of otoscopy, tympanometry, and high frequencies, less than ideal sensitivities were found even for the most sensitive screening protocols, suggesting more investigation is necessary to ensure screening programs are appropriately identifying noise- and infection-related hearing loss in rural, low-resource settings.

Anthropometric measures and arsenic methylation among pregnant women in rural northern Bangladesh.

INTRODUCTION: Arsenic methylation converts inorganic arsenic (iAs) to monomethyl (MMA) and dimethyl (DMA) arsenic compounds. Body mass index (BMI) has been positively associated with arsenic methylation efficiency (higher DMA%) in adults, but evidence in pregnancy is inconsistent. We estimated associations between anthropometric measures and arsenic methylation among pregnant women in rural northern Bangladesh. METHODS: We enrolled pregnant women (n = 784) (median [IQR] gestational week: 14 [13, 15]) in Gaibandha District, Bangladesh from 2018 to 2019. Anthropometric measures were BMI, subscapular and triceps skinfold thicknesses, and mid-upper arm circumference (MUAC), fat area (MUAFA), and muscle area (MUAMA). Arsenic methylation measures were urinary iAs, MMA, and DMA divided by their sum and multiplied by 100 (iAs%, MMA%, and DMA%), primary methylation index (MMA/iAs; PMI), and secondary methylation index (DMA/MMA; SMI). In complete cases (n = 765 [97.6%]), we fitted linear, beta, and Dirichlet regression models to estimate cross-sectional differences in iAs%, MMA%, DMA%, PMI, and SMI per IQR-unit difference in each anthropometric measure, adjusting for drinking water arsenic, age, gestational age, education, living standards index, and plasma folate, vitamin B12, and homocysteine. RESULTS: Median (IQR) BMI, subscapular skinfold thickness, triceps skinfold thickness, MUAC, MUAFA, and MUAMA were 21.5 (19.4, 23.8) kg/m2, 17.9 (13.2, 24.2) mm, 14.2 (10.2, 18.7) mm, 25.9 (23.8, 28.0) cm, 15.3 (10.5, 20.3) cm2, and 29.9 (25.6, 34.2) cm2, respectively. Median (IQR) iAs%, MMA%, DMA%, PMI, and SMI were 12.0 (9.3, 15.2)%, 6.6 (5.3, 8.3)%, 81.0 (77.1, 84.6)%, 0.6 (0.4, 0.7), and 12.2 (9.3, 15.7), respectively. In both unadjusted and adjusted linear models, all anthropometric measures were negatively associated with iAs%, MMA%, and PMI and positively associated with DMA% and SMI. For example, fully adjusted mean differences (95% CI) in DMA% per IQR-unit difference in BMI, subscapular skinfolds thickness, triceps skinfold thickness, MUAC, MUAFA, and MUAMA were 1.72 (1.16, 2.28), 1.58 (0.95, 2.21), 1.74 (1.11, 2.37), 1.45 (0.85, 2.06), 1.70 (1.08, 2.31), and 0.70 (0.13, 1.27) pp, respectively. CONCLUSIONS: Anthropometric measures were positively associated with arsenic methylation efficiency among pregnant women in the early second trimester.

Household animal ownership is associated with infant animal source food consumption in Bangladesh.

Context-specific research is needed on the relationship between household animal production and nutrition outcomes to inform programmes intervening in small-scale animal production. We examined associations between household animal/fishpond ownership and animal source food (ASF) consumption among 6- to 12-month-old infants enroled in the control arm of a cluster-randomised controlled trial in rural Bangladesh. We measured ASF consumption using a 7-day food frequency questionnaire at 6, 9 and 12 months and assessed household animal/fishpond ownership at 12 months. We developed negative binomial regression models with random intercepts for infant and cluster, controlling for infant age and sex, maternal age, socioeconomic status and season. Models were stratified by a dichotomised maternal decision-making score. Compared with infants in households without each animal type, those with 4-10 and ≥11 poultry consumed eggs 1.3 (95% confidence interval [CI]: 1.1, 1.6) and 1.6 (95% CI: 1.3, 2.0) times more, respectively; 2-3 and ≥4 dairy-producing animals consumed dairy 1.9 (95% CI: 1.3, 2.7) and 2.0 (95% CI: 1.3, 3.1) times more, respectively; and ≥12 meat-producing animals consumed meat 1.4 (95% CI: 1.0, 1.8) times more. It was unclear whether there was an association between fishpond ownership and fish consumption. Our results did not suggest that maternal decision-making power was a modifier in the relationship between animal/fishpond ownership and ASF consumption. In this South Asian context, strategies intervening in household animal production may increase infant consumption of eggs, dairy and meat, but not necessarily fish. Research is needed on the role of market access and other dimensions of women's empowerment.

Digitalization of routine health information systems: Bangladesh, Indonesia, Pakistan.

Objective: To describe a systematic process of transforming paper registers into a digital system optimized to enhance service provision and fulfil reporting requirements. Methods: We designed a formative study around primary health workers providing reproductive, maternal, newborn and child health services in three countries in Bangladesh, Indonesia and Pakistan. The study ran from November 2014 to June 2018. We developed a prototype digital application after conducting a needs assessment of health workers' responsibilities, workflows, routine data requirements and service delivery needs. Methods included desk reviews, focus group discussions, in-depth interviews; data mapping of paper registers; observations of health workers; co-design workshops with health workers; and usability testing. Finally, we conducted an observational feasibility assessment to monitor uptake of the application. Findings: Researchers reviewed a total of 17 paper registers across the sites, which we transformed into seven modules within a digital application running on mobile devices. Modules corresponded to the services provided, including household enumeration, antenatal care, family planning, immunization, nutrition and child health. A total of 65 health workers used the modules during the feasibility assessment, and average weekly form submissions ranged from 8 to 234, depending on the health worker and their responsibilities. We also observed variability in the use of modules, requiring consistent monitoring support for health workers. Conclusion: Lessons learnt from this study shaped key global initiatives and resulted in a software global good. The deployment of digital systems requires well-designed applications, change management and strengthening human resources to realize and sustain health system gains.

Food Insecurity and Delayed or Forgone Medical Care During the COVID-19 Pandemic.

Objectives. To describe food insecurity in the United States in December 2020 and examine associations with underuse of medical care during the COVID-19 pandemic. Methods. We fielded a nationally representative Web-based survey in December 2020 (n = 8318). Multivariable logistic regression models and predicted probabilities were used to evaluate factors associated with food insecurity and compare the likelihood of delaying or forgoing medical care because of cost concerns by food security status. Results. In December 2020, 18.8% of US adults surveyed reported experiencing food insecurity. Elevated odds of food insecurity were observed among non-Hispanic Black, Hispanic, and low-income respondents. Experiencing food insecurity was significantly associated with a greater likelihood of forgoing any type of medical care as a result of cost concerns. Conclusions. Food insecurity during the COVID-19 pandemic disproportionately affected non-White and low-income individuals. Experiencing food insecurity was a significant risk factor for delaying or forgoing medical care, an association that could have cumulative short- and long-term health effects. Public Health Implications. Comprehensive policies that target the most at-risk groups are needed to address the high rates of food insecurity in the United States and mitigate its adverse health effects. (Am J Public Health. 2022;112(5):776-785. https://doi.org/10.2105/AJPH.2022.306724).

Burden of mental distress in the United States is associated with delayed medical visits and missed prescription refills during the COVID-19 pandemic.

The COVID-19 pandemic has contributed to poor health due to a decrease in healthcare utilization and those with mental health problems may be impacted. For this analysis, data came from a cross-sectional, nationally representative December 2020 survey. Logistic regression analyses examined associations between (1) mental distress and delayed medical visits, (2) mental distress and missed prescription refills, controlling for sociodemographics, pre-existing chronic conditions, and access to health insurance. We found that, compared to those that exhibited normal levels of mental distress, those with mild (aOR = 2.83, 95% CI = 2.47-3.24), moderate (aOR = 3.43, 95% CI = 2.95-3.99), and severe (aOR = 4.96, 95% CI = 4.21-5.84) mental distress showed greater odds of delaying medical visits. Similarly, compared to those that exhibited normal levels of mental distress, those with mild (aOR =3.93, 95% CI = 3.04-5.09), moderate (aOR =6.52, 95% CI = 5.07-8.43), and severe (aOR =8.69, 95% CI = 6.71-11.32) mental distress showed greater odds of missing prescription refills. Our study shows that individuals who showed signs of mental distress had increased odds of delayed medical visits and missed prescription refills, compared to those that showed normal levels of mental distress.

Changes in prenatal care and vaccine willingness among pregnant women during the COVID-19 pandemic.

INTRODUCTION: Concerns about SARS-CoV-2 infection risk in health care settings have resulted in changes in prenatal care and birth plans, such as shifts to in-person visits and increased Cesarean delivery. These changes may affect quality of care and limit opportunities for clinicians to counsel pregnant individuals, who are at higher risk of severe COVID-19 disease and adverse pregnancy outcomes, about prevention and vaccination. METHODS: We conducted a cross-sectional online survey of United States adults on changes in prenatal care, COVID-19 vaccine willingness, and reasons for unwillingness to receive a vaccine. We summarized changes in access to care and examined differences in vaccine willingness between pregnant and propensity-score matched non-pregnant controls using chi-squared tests and multivariable conditional logistic regression. RESULTS: Between December 15-23, 2020, 8481 participants completed the survey, of which 233 were pregnant. Three-quarters of pregnant women (n = 186) experienced a change in prenatal care, including format of care (n = 84, 35%) and reduced visits (n = 69, 24%). Two-thirds experienced a change in birth plans, from a hospital birth to home birth (n = 45, 18%) or vaginal birth to a Cesarean delivery (n = 42, 17%). Although 40% of pregnant women (n = 78) were unwilling to receive COVID-19 vaccination, they had higher, though non-significant, odds of reporting willingness to receive vaccination compared to similar non-pregnant women (aOR 1.38, 95% CI: 0.95, 2.00). CONCLUSION: To support pregnant women through the perinatal care continuum, maternity care teams should develop protocols to foster social support, patient-centered education around infection prevention that focuses on improved risk perception, expected changes in care due to COVID-19, and vaccine effectiveness and safety.

Implementing SMS reminders for routine immunization in Northern Nigeria: a qualitative evaluation using the RE-AIM framework.

BACKGROUND: Short Message Service (SMS) reminders have improved vaccine uptake in low- and middle-income countries (LMICs). However, the limited use of SMS reminders in LMICs requires evaluating the intervention's internal and external validity to improve adoption and sustainability. Using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, we qualitatively assessed the impact of a SMS reminder intervention implemented in Kebbi State, Northwest Nigeria between May 20, 2019 and May 31, 2020. This will guide and inform future SMS reminder interventions to improve childhood immunization uptake in LMICs. METHODS: In June 2020, we conducted 14 focus group discussions, 13 in-depth interviews, and 20 key informant interviews among 144 purposively selected participants from five local government areas of Kebbi State. For analysis, we used a deductive approach to develop preliminary codes based on the RE-AIM framework and the inductive approach to generate themes that emerged from the interviews. RESULTS: The perceived importance and impact of the SMS reminder in improving demand and uptake for vaccinations were the consistent contributing factors that encouraged participants' participation. Other facilitators included the involvement of health workers in supporting SMS reminder registration and community gatekeepers using existing structures to convey messages on scheduled immunization services. Policymakers adopted the intervention because it aligns with the state's priority to improve immunization coverage. Similarly, the SMS reminder appealed to health workers and program managers because it reduced their workload and served as a performance monitoring tool to track immunization and intervention defaulters. Despite these, low mobile phone ownership and the inability to read text messages due to the low literacy level were the main barriers during implementation. Finally, data availability on cost-effectiveness and the intervention's impact on improving coverage was critical for scalability. CONCLUSIONS: Our study demonstrated that SMS reminders in local languages could improve vaccination demand and uptake in resource-constrained settings due to their perceived importance and impact. Addressing the cited implementation barriers and promoting the facilitators is critical to its adoption and sustainability. Costing and impact data are needed to collaborate findings on the effectiveness of the SMS reminder to improve childhood vaccination uptake.

A Novel Score for mHealth Apps to Predict and Prevent Mortality: Further Validation and Adaptation to the US Population Using the US National Health and Nutrition Examination Survey Data Set.

BACKGROUND: The C-Score, which is an individual health score, is based on a predictive model validated in the UK and US populations. It was designed to serve as an individualized point-in-time health assessment tool that could be integrated into clinical counseling or consumer-facing digital health tools to encourage lifestyle modifications that reduce the risk of premature death. OBJECTIVE: Our study aimed to conduct an external validation of the C-Score in the US population and expand the original score to improve its predictive capabilities in the US population. The C-Score is intended for mobile health apps on wearable devices. METHODS: We conducted a literature review to identify relevant variables that were missing in the original C-Score. Subsequently, we used data from the 2005 to 2014 US National Health and Nutrition Examination Survey (NHANES; N=21,015) to test the capacity of the model to predict all-cause mortality. We used NHANES III data from 1988 to 1994 (N=1440) to conduct an external validation of the test. Only participants with complete data were included in this study. Discrimination and calibration tests were conducted to assess the operational characteristics of the adapted C-Score from receiver operating curves and a design-based goodness-of-fit test. RESULTS: Higher C-Scores were associated with reduced odds of all-cause mortality (odds ratio 0.96, P<.001). We found a good fit of the C-Score for all-cause mortality with an area under the curve (AUC) of 0.72. Among participants aged between 40 and 69 years, C-Score models had a good fit for all-cause mortality and an AUC >0.72. A sensitivity analysis using NHANES III data (1988-1994) was performed, yielding similar results. The inclusion of sociodemographic and clinical variables in the basic C-Score increased the AUCs from 0.72 (95% CI 0.71-0.73) to 0.87 (95% CI 0.85-0.88). CONCLUSIONS: Our study shows that this digital biomarker, the C-Score, has good capabilities to predict all-cause mortality in the general US population. An expanded health score can predict 87% of the mortality in the US population. This model can be used as an instrument to assess individual mortality risk and as a counseling tool to motivate behavior changes and lifestyle modifications.

Promised and Lottery Airtime Incentives to Improve Interactive Voice Response Survey Participation Among Adults in Bangladesh and Uganda: Randomized Controlled Trial.

BACKGROUND: Increased mobile phone penetration allows the interviewing of respondents using interactive voice response surveys in low- and middle-income countries. However, there has been little investigation of the best type of incentive to obtain data from a representative sample in these countries. OBJECTIVE: We assessed the effect of different airtime incentives options on cooperation and response rates of an interactive voice response survey in Bangladesh and Uganda. METHODS: The open-label randomized controlled trial had three arms: (1) no incentive (control), (2) promised airtime incentive of 50 Bangladeshi Taka (US $0.60; 1 BDT is approximately equivalent to US $0.012) or 5000 Ugandan Shilling (US $1.35; 1 UGX is approximately equivalent to US $0.00028), and (3) lottery incentive (500 BDT and 100,000 UGX), in which the odds of winning were 1:20. Fully automated random-digit dialing was used to sample eligible participants aged ≥18 years. The risk ratios (RRs) with 95% confidence intervals for primary outcomes of response and cooperation rates were obtained using log-binomial regression. RESULTS: Between June 14 and July 14, 2017, a total of 546,746 phone calls were made in Bangladesh, with 1165 complete interviews being conducted. Between March 26 and April 22, 2017, a total of 178,572 phone calls were made in Uganda, with 1248 complete interviews being conducted. Cooperation rates were significantly higher for the promised incentive (Bangladesh: 39.3%; RR 1.38, 95% CI 1.24-1.55, P<.001; Uganda: 59.9%; RR 1.47, 95% CI 1.33-1.62, P<.001) and the lottery incentive arms (Bangladesh: 36.6%; RR 1.28, 95% CI 1.15-1.45, P<.001; Uganda: 54.6%; RR 1.34, 95% CI 1.21-1.48, P<.001) than those for the control arm (Bangladesh: 28.4%; Uganda: 40.9%). Similarly, response rates were significantly higher for the promised incentive (Bangladesh: 26.5%%; RR 1.26, 95% CI 1.14-1.39, P<.001; Uganda: 41.2%; RR 1.27, 95% CI 1.16-1.39, P<.001) and lottery incentive arms (Bangladesh: 24.5%%; RR 1.17, 95% CI 1.06-1.29, P=.002; Uganda: 37.9%%; RR 1.17, 95% CI 1.06-1.29, P=.001) than those for the control arm (Bangladesh: 21.0%; Uganda: 32.4%). CONCLUSIONS: Promised or lottery airtime incentives improved survey participation and facilitated a large sample within a short period in 2 countries. TRIAL REGISTRATION: ClinicalTrials.gov NCT03773146; http://clinicaltrials.gov/ct2/show/NCT03773146.

Burden of mental distress in the US associated with trust in media for COVID-19 information.

During the COVID-19 pandemic, news and social media outlets have played a major role in dissemination of information. This analysis aimed to study the association between trust in social and traditional media and experiences of mental distress among a representative sample of US adults. Data for this study came from National Pandemic Pulse, a cross-sectional, nationally representative survey that sampled participants on the Dynata platform. Participants included 6435 adults surveyed between 15-23 December 2020. Ordinal logistic regression analyses examined the associations of trust in (i) social media, (ii) print media, (iii) broadcast TV and (iv) cable TV, for COVID-19-related information with self-reported mental distress (4-item Patient Health Questionnaire), controlling for sociodemographics and census region. Compared with those who distrusted social media, those who trusted social media had 2.09 times (95% CI = 1.84-2.37) greater adjusted odds of being in a more severe category of mental distress. In contrast, compared with those who distrusted print media, those who trusted print media had 0.80 times (95% CI = 0.69-0.93) lower adjusted odds of being in a more severe category of mental distress. No significant associations were found between mental distress and trust in broadcast or cable TV for accessing news about COVID-19. Trust in different news outlets may be associated with mental distress during public health emergencies like the COVID-19 pandemic. Future studies should explore mechanisms behind these associations, including adherence to best practices for crisis reporting among different media sources and exposure of individuals to misinformation.

During the COVID-19 pandemic, both, traditional channels like print, TV and cable news, as well as social media, have been major sources to obtain news about the pandemic. In this manuscript, we study the association between trust in social and traditional media and symptoms of mental distress among a nationally representative sample of 6435 US adults surveyed in December 2020. Our findings show that those who reported trusting traditional print media were less likely to report more severe mental distress. Conversely, those who reported trusting social media were more likely to report more severe levels of mental distress. This highlights the urgent need for understanding the diffusion patterns of misinformation and rumors that circulate on social media, and consumers' reactions to them. It is important that during a public health emergency, we follow best practices for crisis communication to reduce panic, address uncertainty, promote protective behaviors and mental health.

Rapid Real-time Tracking of Nonpharmaceutical Interventions and Their Association With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Positivity: The Coronavirus Disease 2019 (COVID-19) Pandemic Pulse Study.

BACKGROUND: Current mitigation strategies for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) rely on the population-wide adoption of nonpharmaceutical interventions (NPIs). Monitoring the adoption of NPIs and their associations with SARS-CoV-2 infection history can provide key information for public health. METHODS: We sampled 1030 individuals in Maryland from 17-28 June 2020 to capture sociodemographically and geographically resolved information about NPI adoption and access to SARS-CoV-2 testing, and examine associations with self-reported SARS-CoV-2 positivity. RESULTS: Overall, 92% reported traveling for essential services and 66% visited friends/family. Use of public transport was reported by 18%. In total, 68% reported strict social distancing indoors and 53% reported strict masking indoors; indoor social distancing was significantly associated with age, and race/ethnicity and income were associated with masking. Overall, 55 participants (5.3%) self-reported ever testing positive for SARS-CoV-2, with strong dose-response relationships between several forms of movement frequency and SARS-CoV-2 positivity. In a multivariable analysis, a history of SARS-CoV-2 infection was negatively associated with strict social distancing (adjusted odds ratio [aOR] for outdoor social distancing, 0.10; 95% confidence interval, .03-.33). Only public transport use (aOR for >7 times vs never, 4.3) and visiting a place of worship (aOR for ≥3 times vs never, 16.0) remained significantly associated with SARS-CoV-2 infection after adjusting for strict social distancing and demographics. CONCLUSIONS: These results support public health messaging that strict social distancing during most activities can reduce SARS-CoV-2 transmission. Additional considerations are needed for indoor activities with large numbers of persons (places of worship and public transportation), where even NPIs may not be possible or sufficient.

Effects of a Water, Sanitation, and Hygiene Mobile Health Program on Diarrhea and Child Growth in Bangladesh: A Cluster-randomized Controlled Trial of the Cholera Hospital-based Intervention for 7 Days (CHoBI7) Mobile Health Program.

BACKGROUND: The Cholera Hospital-Based Intervention for 7 Days (CHoBI7) mobile health (mHealth) program was a cluster-randomized controlled trial of diarrhea patient households conducted in Dhaka, Bangladesh. METHODS: Patients were block-randomized to 3 arms: standard message on oral rehydration solution use; health facility delivery of CHoBI7 plus mHealth (no home visits); and health facility delivery of CHoBI7 plus 2 home visits and mHealth. The primary outcome was reported diarrhea in the past 2 weeks collected monthly for 12 months. The secondary outcomes were stunting, underweight, and wasting at a 12-month follow-up. Analysis was intention-to-treat. RESULTS: Between 4 December 2016 and 26 April 2018, 2626 participants in 769 households were randomly allocated to 3 arms: 849 participants to the standard message arm, 886 to mHealth with no home visits arm, and 891 to the mHealth with 2 home visits. Children <5 years had significantly lower 12-month diarrhea prevalence in both the mHealth with 2 home visits arm (prevalence ratio [PR]: 0.73 [95% confidence interval {CI}, .61-.87]) and the mHealth with no home visits arm (PR: 0.82 [95% CI, .69-.97]). Children <2 years were significantly less likely to be stunted in both the mHealth with 2 home visits arm (33% vs 45%; odds ratio [OR]: 0.55 [95% CI, .31-.97]) and the mHealth with no home visits arm (32% vs 45%; OR: 0.54 [95% CI, .31-.96]) compared with children in the standard message arm. CONCLUSIONS: The CHoBI7 mHealth program lowered pediatric diarrhea and stunting among diarrhea patient households. CLINICAL TRIALS REGISTRATION: NCT04008134.

A cost study for mobile phone health surveys using interactive voice response for assessing risk factors of noncommunicable diseases.

BACKGROUND: This is the first study to examine the costs of conducting a mobile phone survey (MPS) through interactive voice response (IVR) to collect information on risk factors for noncommunicable diseases (NCD) in three low- and middle-income countries (LMIC); Bangladesh, Colombia, and Uganda. METHODS: This is a micro-costing study conducted from the perspective of the payer/funder with a 1-year horizon. The study evaluates the fixed costs and variable costs of implementing one nationally representative MPS for NCD risk factors of the adult population. In this costing study, we estimated the sample size of calls required to achieve a population-representative survey and associated incentives. Cost inputs were obtained from direct economic costs incurred by a central study team, from country-specific collaborators, and from platform developers who participated in the deployment of these MPS during 2017. Costs were reported in US dollars (USD). A sensitivity analysis was conducted assessing different scenarios of pricing and incentive strategies. Also, costs were calculated for a survey deployed targeting only adults younger than 45 years. RESULTS: We estimated the fixed costs ranging between $47,000 USD and $74,000 USD. Variable costs were found to be between $32,000 USD and $129,000 USD per nationally representative survey. The main cost driver was the number of calls required to meet the sample size, and its variability largely depends on the extent of mobile phone coverage and access in the country. Therefore, a larger number of calls were estimated to survey specific harder-to-reach sub-populations. CONCLUSION: Mobile phone surveys have the potential to be a relatively less expensive and timely method of collecting survey information than face-to-face surveys, allowing decision-makers to deploy survey-based monitoring or evaluation programs more frequently than it would be possible having only face-to-face contact. The main driver of variable costs is survey time, and most of the variability across countries is attributable to the sampling differences associated to reaching out to population subgroups with low mobile phone ownership or access.

Designing an SMS reminder intervention to improve vaccination uptake in Northern Nigeria: a qualitative study.

BACKGROUND: Penta3 coverage in Nigeria was low at 33 % in 2017. The most reported reason for non-vaccination was lack of knowledge about the immunization place, time, and need. To address knowledge gaps and improve vaccination uptake, we designed an Immunization Reminder and Information SMS System (IRISS) to educate and remind parents/caregivers about immunization using SMS. A formative study was conducted to understand the contextual and behavioural factors that would inform the IRISS intervention design and implementation. METHODS: We conducted the study in four Local Government Areas (LGAs) of Kebbi State Nigeria in October 2018, amongst a diverse selection of participants. Data on social norms about vaccinations, barriers to immunization uptake, mobile phone use, SMS message testing, and willingness to accept SMS reminders were collected from focus group discussions (N = 11), in-depth interviews (N = 12), and key informant interviews (N = 13). In addition, we assessed 33 messages covering schedule reminders, normative, motivational, educational, and informative contents for clarity, comprehensibility, relevance, cultural appropriateness, and ability to motivate action among community members from Argungu and Fakai LGAs. All interviews were analyzed using a thematic analysis approach. RESULTS: We interviewed 135 people, and 90 % were community members. While we found positive perceptions about immunizations among those interviewed, pockets of misconceptions existed among community members. Lack of awareness on the importance of vaccination was a consistent reason for under-vaccination across the LGAs. In addition, most community members do not own phones, could not read SMS messages, and were unaware of how to check/open text messages received. Despite concerns about low literacy levels and phone ownership, community members still saw a role in SMS reminders when phone owners receive messages. For instance, community leaders can disseminate said messages to community members through existing channels such as town announcers and religious gatherings. Therefore, the SMS becomes a source of information, with phone owners acting as a conduit to community dissemination mechanisms. We generally found the tested messages to be relevant, motivating, and culturally acceptable. CONCLUSIONS: SMS reminders have the potential to bridge the information gap in community awareness for vaccination, which can translate to improved immunization uptake. In rural communities with low literacy levels and phone ownership, immunization information can be disseminated when existing community leadership structures are engaged.