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This mixed-method quasi-experimental study examined whether metaconceptual grammar teaching impacts on (a) students’ L1 grammatical understanding, (b) their ‘blind’ use of grammatical concepts and (c) their preference of using explicit grammatical concepts over everyday concepts in explaining grammatical problems. Previous research, involving single group pre-postintervention designs, found positive effects for metaconceptual interventions on secondary school students’ grammatical reasoning ability, although a negative side effect seemed to be that some students started using grammatical concepts ‘blindly’ (i.e., in an inaccurate way). While there are thus important clues that metaconceptual grammar teaching may lead to increased grammatical understanding, there is a great need for more robust empirical research. The current study, involving 196 Dutch 14-year old pre-university students, is a methodological improvement of previous work, adopting a switching replications design. Bayesian multivariate analyses indicate medium to large effects from the metaconceptual intervention on students’ grammatical understanding. The study found a similar effect of the intervention on students’ ability to use explicit grammatical concepts over everyday concepts in tackling grammatical problems. No evidence for increased ‘blind’ concept use as a negative byproduct of the intervention was found. Additional qualitative analyses of in-intervention tasks provided further evidence for the effectiveness of metaconceptual interventions, and seemed to indicate that cases of blind concept use, rather than being a negative side effect, might actually be part of a gradual process of students’ growing understanding of grammatical (meta)concepts. We discuss these findings in relation to previous work and conclude that linguistic metaconcepts can improve L1 grammatical understanding.

Background Hypertension is a globally recognized threat to social and economic development with premature morbidity and mortality. In middle and low-income countries hypertension appears to be increasing. However, sufficient data on this silent-killer is not available in Ethiopia. Therefore, this study examined the magnitude and risk factors for hypertension among public servants in Tigray, Ethiopia. Methods We used a cross-sectional survey from May-June 2016 among 1525 public servants in Tigray region. Field workers collected data using a pre-tested, standardized questionnaire. A multivariate logistic regression analysis conducted to identify risk factors for hypertension. Statistical significance was declared using a p-value50years [AOR = 3.61, 95% CI:1.93, 6.69], Body Mass Index(BMI); underweight [AOR = 0.40, 95% CI; 0.20, 0.78], overweight [AOR = 1.70, 95%CI; 1.22, 2.33] and obesity [AOR = 3.20, 95% CI; 1.78, 5.78] were determinants for hypertension. Conclusion The prevalence of hypertension is relatively high in Mekelle city compared with previous reports. This study revealed that male sex, age-group, and BMI were evidenced as risk factors for hypertension. Policy makers need to consider sector wise integrating prevention and control of hypertension. Skilled based information, education and communication strategies should be designed and implemented to avoid unhealthy lifestyles, investing in workforces to eliminate the modifiable risk factors for non-communicable diseases and promote healthy practices.

ObjectivesImplementation of ultrasound in antenatal care (ANC) in low-income countries has been shown to increase pregnant women's compliance with ANC visits, and facilitate detection of high-risk pregnancies. In Rwanda, as in other low-income countries, access to ultrasound has increased significantly, but lack of training is often a barrier to its use. The aim of this study was to investigate Rwandan health professionals' experiences and views of obstetric ultrasound in relation to clinical management, resources and skills.MethodsA cross-sectional questionnaire study was undertaken between November 2016 and March 2017, as part of the CROss Country UltraSound Study (CROCUS). Data were collected at 108 health facilities located in both rural and urban areas of Rwanda, including provincial, referral, district and private hospitals as well as health centres. Participants were obstetricians (n = 29), other physicians (n = 222), midwives (n = 269) and nurses (n = 387).ResultsObstetricians/gynecologists/other physicians commonly performed ultrasound examinations but their self-rated skill levels implied insufficient training. Access to ultrasound when needed was reported as common in hospitals, but available to a very limited extent in health centres. The vast majority of participants, independent of health profession, agreed that maternity care would improve if midwives learned to perform basic ultrasound examinations.ConclusionsBarriers to provision of high quality ultrasound services include variable access to ultrasound depending on health facility level and insufficient skills of ultrasound operators. Physicians in general need more training to perform ultrasound examinations. Implementation of a general dating ultrasound examination seems to be a relevant goal as most health professionals agree that pregnant woman would benefit from this service. To further improve maternity care services, the possibility of educating midwives to perform ultrasound examinations should be further explored.

Background There are few studies about the presence of murine typhus in Greece. Our objective was to conduct a large scale retrospective investigation to determine the clinical and epidemiological features of patients diagnosed with murine typhus in Greece. Methodology/Principal findings From 2012 to 2019 serum samples from hospitalized patients and outpatients throughout Greece suspected for murine typhus infection were tested by immunofluorescence assay for Rickettsia typhi. Immunofluorescence positive samples obtained since 2016 were also tested by qPCR targeting R. typhi. Clinical and epidemiological data were retrospectively collected for the patients with confirmed murine typhus. Overall, we tested 5,365 different patients and, in total, 174 patients from all geographic regions of Greece were diagnosed with murine typhus. The most frequently reported sign or symptom was fever (89%), followed by headache (84%) and rash (81%). The classical triad of fever, headache, and rash was present in 72% of patients during their illness. Severe infections with complications including acute renal failure or septic shock were not recorded. The majority of cases (81%) occurred during May–October and peaked in June and September. Most of patients (81%) infected in Athens, recalled that their only activity the last weeks before symptoms onset was swimming on the beach and 59% of them also reported an insect bite while sunbathing. Conclusions/Significance Our results may reflect the reemergence of murine typhus in Greece and we highlight the importance of awareness of this difficult-to-recognize undifferentiated febrile illness., Author summary Murine typhus, a febrile disease caused by Rickettsia typhi, is often misdiagnosed due to its non-specific presentation. Evidence suggests that murine typhus is more prevalent in Greece than originally believed. We retrospectively collected clinical and epidemiological data for all the patients with confirm and probable murine typhus diagnosed in our laboratory the last eight years and we found evidence of murine typhus throughout Greece. Comparing this evidence to other studies, we found that most of Greek patients presented rash and the typical triad probably due to the awareness of physicians, as during our interrogation, most of physicians mentioned that they considered murine typhus based on rash appearance. Finally, we found that most murine typhus cases in the city of Athens were associated with sunbathing on the beach and we raise the question of beach littering in murine typhus endemic areas.

Background Psychosocial interventions for adolescent mental health problems are effective, but evidence on their longer-term outcomes is scarce, especially in low-resource settings. We report on the 12-month sustained effectiveness and costs of scaling up a lay counselor–delivered, transdiagnostic problem-solving intervention for common adolescent mental health problems in low-income schools in New Delhi, India. Methods and findings Participants in the original trial were 250 school-going adolescents (mean [M] age = 15.61 years, standard deviation [SD] = 1.68), including 174 (69.6%) who identified as male. Participants were recruited from 6 government schools over a period of 4 months (August 20 to December 14, 2018) and were selected on the basis of elevated mental health symptoms and distress/functional impairment. A 2-arm, randomized controlled trial design was used to examine the effectiveness of a lay counselor–delivered, problem-solving intervention (4 to 5 sessions over 3 weeks) with supporting printed booklets (intervention arm) in comparison with problem solving delivered via printed booklets alone (control arm), at the original endpoints of 6 and 12 weeks. The protocol was modified, as per the recommendation of the Trial Steering Committee, to include a post hoc extension of the follow-up period to 12 months. Primary outcomes were adolescent-reported psychosocial problems (Youth Top Problems [YTP]) and mental health symptoms (Strengths and Difficulties Questionnaire [SDQ] Total Difficulties scale). Other self-reported outcomes included SDQ subscales, perceived stress, well-being, and remission. The sustained effects of the intervention were estimated at the 12-month endpoint and over 12 months (the latter assumed a constant effect across 3 follow-up points) using a linear mixed model for repeated measures and involving complete case analysis. Sensitivity analyses examined the effect of missing data using multiple imputations. Costs were estimated for delivering the intervention during the trial and from modeling a scale-up scenario, using a retrospective ingredients approach. Out of the 250 original trial participants, 176 (70.4%) adolescents participated in the 12-month follow-up assessment. One adverse event was identified during follow-up and deemed unrelated to the intervention. Evidence was found for intervention effects on both SDQ Total Difficulties and YTP at 12 months (YTP: adjusted mean difference [AMD] = −0.75, 95% confidence interval [CI] = −1.47, −0.03, p = 0.04; SDQ Total Difficulties: AMD = −1.73, 95% CI = −3.47, 0.02, p = 0.05), with stronger effects over 12 months (YTP: AMD = −0.98, 95% CI = −1.51, −0.45, p < 0.001; SDQ Total Difficulties: AMD = −1.23, 95% CI = −2.37, −0.09; p = 0.03). There was also evidence for intervention effects on internalizing symptoms, impairment, perceived stress, and well-being over 12 months. The intervention effect was stable for most outcomes on sensitivity analyses adjusting for missing data; however, for SDQ Total Difficulties and impairment, the effect was slightly attenuated. The per-student cost of delivering the intervention during the trial was $3 United States dollars (USD; or $158 USD per case) and for scaling up the intervention in the modeled scenario was $4 USD (or $23 USD per case). The scaling up cost accounted for 0.4% of the per-student school budget in New Delhi. The main limitations of the study’s methodology were the lack of sample size calculations powered for 12-month follow-up and the absence of cost-effectiveness analyses using the primary outcomes. Conclusions In this study, we observed that a lay counselor–delivered, brief transdiagnostic problem-solving intervention had sustained effects on psychosocial problems and mental health symptoms over the 12-month follow-up period. Scaling up this resource-efficient intervention is an affordable policy goal for improving adolescents’ access to mental health care in low-resource settings. The findings need to be interpreted with caution, as this study was a post hoc extension, and thus, the sample size calculations did not take into account the relatively high attrition rate observed during the long-term follow-up. Trial registration ClinicalTrials.gov NCT03630471., Kanika Malik, Daniel Michelson, and colleagues study the sustained effectiveness of a lay counsellor-delivered problem solving intervention to mental health of adolescents enrolled in low-income schools in New Delhi, India., Author summary Why was this study done? The PRemIum for aDolEscents (PRIDE) is a research program that aims to develop a transdiagnostic, stepped care intervention model to address common adolescent mental health problems (anxiety, depression, and conduct difficulties) in low-resource settings. The intervention model comprises a brief problem-solving intervention (“Step 1”), followed by a higher-intensity personalized psychological treatment (“Step 2”) for adolescents with persistent problems. We previously reported on short-term outcomes from a randomized controlled trial of the first-line problem-solving intervention delivered by lay counselors in secondary schools serving low-income communities in New Delhi, India. The current study examined the sustained effectiveness and costs of scaling up the counselor-led problem-solving intervention compared to printed problem-solving materials without counselor input. What did the researchers do and find? We followed up the original trial participants at 12 months after randomization and collected adolescent-reported outcomes, as well as data on intervention costs using a retrospective ingredients approach. The primary analysis showed sustained intervention effects on both psychosocial problems and mental health symptoms. The economic analysis showed that the counselor-led problem-solving intervention can be scaled up at a small percentage of the per-student budgetary allocation in government-run schools in New Delhi, India. What do these findings mean? Despite its brevity and delivery by lay counselors, the problem-solving intervention showed sustained effectiveness. Scaling up this low-cost intervention represents an affordable policy goal for improving access to school-based mental health care for adolescents in India and, potentially, in other low-resource settings.

It has been shown in literature that East Asians are more inclined to process context information than individuals in Western cultures. Using a context memory task that requires studying object images in social contexts (i.e., rating objects in an imagined social or experiential scenario), our recent study revealed an age-invariant advantage for Chinese young and older participants compared to their Canadian counterparts in memory for encoding contexts. To examine whether this cultural difference also occurred during encoding, this follow-up report analyzed encoding performance and its relationship to subsequent memory based on the same data from the same task of the same sample. The results revealed that at encoding, Chinese participants provided higher ratings of objects, took longer to rate, and reported more vivid imagery of encoding contexts relative to their Canadian counterparts. Furthermore, only Chinese participants rated objects with recognized context at retrieval higher and slower relative to those with misrecognized context. For Chinese participants, primarily older adults, slower ratings were only related to better context memory but not item memory. Importantly, Chinese participants’ context memory advantage disappeared after controlling for encoding differences. Taken together, these results suggest that Chinese participants’ memory advantage for social contexts may have its origin in the construction of elaborative and meaningful object-context associations at encoding.

The COVID-19 pandemic continues to impact people worldwide–steadily depleting scarce resources in healthcare. Medical Artificial Intelligence (AI) promises a much-needed relief but only if the technology gets adopted at scale. The present research investigates people’s intention to adopt medical AI as well as the drivers of this adoption in a representative study of two European countries (Denmark and France,N= 1068) during the initial phase of the COVID-19 pandemic. Results reveal AI aversion; only 1 of 10 individuals choose medical AI over human physicians in a hypothetical triage-phase of COVID-19 pre-hospital entrance. Key predictors of medical AI adoption are people’s trust in medical AI and, to a lesser extent, the trait of open-mindedness. More importantly, our results reveal that mistrust and perceived uniqueness neglect from human physicians, as well as a lack of social belonging significantly increase people’s medical AI adoption. These results suggest that for medical AI to be widely adopted, people may need to express less confidence in human physicians and to even feel disconnected from humanity. We discuss the social implications of these findings and propose that successful medical AI adoption policy should focus on trust building measures–without eroding trust in human physicians.

Globally the burden due to mental disorders is continuously increasing. Still, professional help-seeking behavior is not fully understood. To conceive cultural determinants of help-seeking is crucial to reduce personal and social costs of (untreated) mental disorders. The current study investigates mental health stigma and help-seeking attitudes in a Cuban (n = 195) and a German (n = 165) sample. In a questionnaire survey we asked for attitudes towards mental illness and professional help-seeking in the general Cuban and German populations. The cultural context was associated with mental health stigma and professional help-seeking attitudes. Interestingly, Cuban participants reported stronger mental health stigma and more willingness to seek help. In multiple hierarchical regression analyses, community attitudes towards the mentally ill significantly predicted help-seeking attitudes, especially in the Cuban sample. Only in the German sample, more negative individual beliefs about mental illness predicted more self-stigma on help-seeking. Beyond that, cultural context moderated the association between mental health stigma and help-seeking attitudes with a stronger association between the measures in the German sample. However, gender did not predict help-seeking attitudes and self-stigma on help-seeking and no interactions between community attitudes, cultural context, and gender were found in the prediction of help-seeking attitudes. Similarities and differences between the samples are discussed in the light of the cultural contexts and peculiarities of the current samples. Concluding, implications of the current findings are reviewed., Finanziert durch den Open-Access-Publikationsfonds der Westfälischen Wilhelms-Universität Münster (WWU Münster).

Informal learning environments provide the opportunity to study guests’ experiences as they engage with exhibits specifically designed to invoke the emotional experience of awe. The current paper presents insight gained by using both traditional survey measures and innovative mobile eye-tracking technology to examine guests’ experiences of awe in a science museum. We present results for guests’ visual attention in two exhibit spaces, one chosen for its potential to evoke positive awe and one for negative awe, and examine associations between visual attention and survey responses with regard to different facets of awe. In this exploratory study, we find relationships between how guests attend to features within an exhibit space (e.g., signage) and their feelings of awe. We discuss implications of using both methods concurrently to shed new light on exhibit design, and more generally for working in transdisciplinary multimethod teams to move scientific knowledge and application forward.

Enjoyment is one of the most important factors for the maintenance of regular physical activity. The present study investigated if cooperative games in physical education classes (grades 6–9) can increase students’ enjoyment of physical activity. Data were collected in a quasi-experimental study employing a two-group design with repeated measures and randomization of classes to conditions. The total sample consisted of N = 285 students from regular schools in Germany aged 10 to 16 years (Mage = 12.67 years, SD = 1.10; 48.4% female). We found that cooperative games led to a higher perceived enjoyment in physical education classes (F(1) = 3.49, p = .063, ηp2 = .012), increased the feeling of how strong students felt related to each other (F(1) = 4.38, p = .037, ηp2 = .016), and facilitated feelings of perceived competence in physical education class (F(1) = 6.31, p = .013, ηp2 = .022). In addition, social relatedness and perceived competence partly mediated the effect of cooperative games on enjoyment. The findings indicate that systematically designed cooperative games can help foster enjoyment in physical education classes.

Does the experience of childbirth create social bonds among first-time mothers? Previous research suggests that sharing emotionally intense or painful experiences with others leads to "identity fusion," a visceral feeling of oneness with a group that predicts strong forms of prosocial action and self-sacrifice for other group members. This study compared identity fusion with other mothers during pregnancy versus after childbirth in a sample of 164 U.S. women. Eighty-nine mothers in our sample were pregnant with their firstborn, and 75 mothers had given birth to their firstborn up to 6 months prior to the time of data collection. Results demonstrated that identity fusion with other mothers was higher for postpartum mothers than for antenatal mothers. As predicted, among postpartum mothers, those who thought that their childbirth was more painful than a typical childbirth experience reported greater identity fusion with mothers who reported having had a very difficult birth. Postpartum mothers' ruminative thought about the birth mediated the association between level of dysphoria and identity fusion, and identity fusion moderated the association between postpartum mothers' ruminative and reflective thought about the birth and their posttraumatic growth in complex ways. These findings provide evidence that perceived sharedness of the childbirth experience and thoughts about the birth are important to the process of identity fusion with other mothers, and highlight the importance of post-event processing for psychological health.

Children’s movies often provide messages about morally appropriate and inappropriate conduct. In two studies, we draw on Moral Foundations Theory (MFT) to derive predictions about actual depictions of morality, and people’s preferences for different moral depictions, within children’s movies. According to MFT, people’s moral concerns include individualizing foundations of care and fairness and binding foundations of loyalty, authority, and sanctity. Prior work reveals that although there are political differences in the endorsement of these two broad categories—whereby stronger political conservatism predicts stronger binding concerns and weaker individualizing concerns—there nonetheless is broad agreement across political identity in the importance of individualizing concerns. We therefore predicted that heroes would value individualizing foundations more than villains, and that despite political differences in preferences for moral messages, there would be more agreement in the importance of messages promoting individualizing concerns. In Study 1, we coded heroes and villains from popular children’s movies for their valuation of moral foundations. Heroes valued individualizing concerns more, and binding concerns less, than villains did. Participants in Study 2 considered moral dilemmas faced by children’s movie characters, and rated their preferences for resolutions that promoted either individualizing or binding foundations. Although liberals preferred individualizing-promoting resolutions and conservatives preferred binding-promoting resolutions, there was stronger agreement across political identity in the importance of individualizing concerns. Despite political differences in moral preferences, popular depictions of children’s movie characters and people’s self-reported moral endorsement suggest a shared belief in the importance of the individualizing moral virtues of care and fairness.Movies are often infused with moral messages. From their exploration of overarching themes, their ascription of particular traits to heroic and villainous characters, and their resolution of pivotal moral dilemmas, movies provide viewers with depictions of morally virtuous (and morally suspect) behavior. Moral messaging in children’s movies is of particular importance, since it is targeted at an audience for which morality is actively developing. What moral messages do filmmakers (and consumers, including parents) want children’s movies to depict? Are these preferences related to people’s political identity? And what are the actual moral depictions presented in movies? In the present two studies, we draw on an influential theory of moral judgment—Moral Foundations Theory—to develop and test predictions about the depiction of morality in children’s movies.

The purpose of the current study was to examine the relationship between expertise, performance, and gaze behavior in a complex error-detection cockpit task. Twenty-four pilots and 26 non-pilots viewed video-clips from a pilot’s viewpoint and were asked to detect malfunctions in the cockpit instrument panel. Compared to non-pilots, pilots detected more malfunctioning instruments, had shorter dwell times on the instruments, made more transitions, visited task-relevant areas more often, and dwelled longer on the areas between the instruments. These results provide evidence for three theories that explain underlying processes for expert performance: The long-term working memory theory, the information-reduction hypothesis, and the holistic model of image perception. In addition, the results for generic attentional skills indicated a higher capability to switch between global and local information processing in pilots compared to non-pilots. Taken together, the results suggest that gaze behavior as well as other generic skills may provide important information concerning underlying processes that can explain successful performance during flight in expert pilots. ispartof: PLoS One vol:13 issue:11 ispartof: location:United States status: Published online

Background Past works have linked the COVID-19 pandemic and subsequent public health responses such as isolation, quarantine, and lockdown to increased anxiety, sleep disorders, depressive symptoms, and suicidal ideation. Only a few studies, mostly carried out in high-income countries, have investigated the association between the pandemic and suicide rate. We seek to investigate the changes in the monthly suicide rates during the COVID-19 pandemic in Nepal, compared to the pre-pandemic suicide rates. Methods and findings This is a retrospective study investigating the changes in suicide rates in Nepal during the COVID-19 pandemic period (April 2020 to June 2021), compared to the pre-pandemic period (July 2017 to March 2020), adjusted for seasonality and long-term trend in the suicide rate. We performed analysis for the entire country as well as sub-sample analyses stratified by gender and provinces. A total of 24350 suicides deaths during four years of the study window were analyzed. We found an overall increase in the monthly suicide rate in Nepal with an average increase of 0.28 (CI: 0.12,0.45) suicide per 100,000 during the pandemic months. The increase in suicide rate was significant both among males (increase in rate = 0.26, CI: 0.02,0.50) and females (increase in rate = 0.30, CI: 0.18,0.43). The most striking increments in suicide rates were observed in June, July, and August 2020. The pattern of increased suicide rates faded away early on among males, but the effect was sustained for a longer duration among females. Sudurpaschim and Karnali provinces had the highest increase in suicide rates associated with the COVID-19 pandemic. Conclusions The COVID-19 pandemic is associated with an increased suicide rate in Nepal. The findings may inform policymakers in designing appropriate public health responses to the pandemic that are considerate of the potential impact on mental health and suicide.

Background The current burden of >5 million deaths yearly is the focus of the Sustainable Development Goal (SDG) to end preventable deaths of newborns and children under 5 years old by 2030. To accelerate progression toward this goal, data are needed that accurately quantify the leading causes of death, so that interventions can target the common causes. By adding postmortem pathology and microbiology studies to other available data, the Child Health and Mortality Prevention Surveillance (CHAMPS) network provides comprehensive evaluations of conditions leading to death, in contrast to standard methods that rely on data from medical records and verbal autopsy and report only a single underlying condition. We analyzed CHAMPS data to characterize the value of considering multiple causes of death. Methods and findings We examined deaths identified from December 2016 through November 2020 from 7 CHAMPS sites (in Bangladesh, Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa), including 741 neonatal, 278 infant, and 241 child, In an analysis of data from the Child Health and Mortality Prevention Surveillance (CHAMPS) network, Robert Breiman, Dianna Blau, and colleagues investigate how considering all conditions in the causal chain leading to death informs the identification of deaths attributable to various diagnoses., Author summary Why was this study done? More than 5 million deaths occur annually in children

Background Understanding how knowledge, attitudes and practices regarding leprosy differ in endemic countries can help us develop targeted educational and behavioural change interventions. This study aimed to examine the differences and commonalities in and determinants of knowledge, attitudes, practices and fears regarding leprosy in endemic districts in India and Indonesia. Principle findings A cross-sectional mixed-methods design was used. Persons affected by leprosy, their close contacts, community members and health workers were included. Through interview-administered questionnaires we assessed knowledge, attitudes, practices and fears with the KAP measure, EMIC-CSS and SDS. In addition, semi-structured interviews and focus group discussions were conducted. The quantitative data were analysed using stepwise multivariate regression. Determinants of knowledge and stigma that were examined included age, gender, participant type, education, occupation, knowing someone affected by leprosy and district. The qualitative data were analysed using open, inductive coding and content analysis. We administered questionnaires to 2344 participants (46% from India, 54% from Indonesia) as an interview. In addition, 110 participants were interviewed in-depth and 60 participants were included in focus group discussions. Knowledge levels were low in both countries: 88% of the participants in India and 90% of the participants in Indonesia had inadequate knowledge of leprosy. In both countries, cause, mode of transmission, early symptoms and contagiousness of leprosy was least known, and treatment and treatability of leprosy was best known. In both countries, health workers had the highest leprosy knowledge levels and community members the highest stigma levels (a mean score of up to 17.4 on the EMIC-CSS and 9.1 on the SDS). Data from the interviews indicated that people were afraid of being infected by leprosy. Local beliefs and misconceptions differed, for instance that leprosy is in the family for seven generations (Indonesia) or that leprosy is a result of karma (India). The determinants of leprosy knowledge and stigma explained 10–29% of the variability in level of knowledge and 3–10% of the variability in level of stigma. Conclusion Our findings show the importance of investigating the perceptions regarding leprosy prior to educational interventions in communities: even though knowledge levels were similar, local beliefs and misconceptions differed per setting. The potential determinants we included in our study explained very little of the variability in level of knowledge and stigma and should be explored further. Detailed knowledge of local knowledge gaps, beliefs and fears can help tailor health education to local circumstances., Author summary This study aimed to examine the differences and commonalities in and determinants of knowledge, attitudes, practices and fears regarding leprosy in endemic districts in India and Indonesia. Persons affected by leprosy, their close contacts, community members and health workers were included. We administered questionnaires (the KAP measure, EMIC-CSS and SDS) to 2344 participants. In addition, 110 participants were interviewed in-depth and 60 participants were included in focus group discussions. Knowledge levels were low. In both countries, cause, mode of transmission, early symptoms and contagiousness of leprosy was least known, and treatment and treatability of leprosy was best known. In both countries, health workers had the highest leprosy knowledge levels and community members the highest stigma levels. Data from the interviews indicated that people were afraid of being infected by leprosy. Local beliefs and misconceptions differed. The potential determinants we included in our study explained very little of the variability in level of knowledge and stigma and should be explored further. Our findings show the importance of investigating the perceptions regarding leprosy prior to educational interventions in communities: even though knowledge levels were similar, local beliefs and misconceptions differed per setting.

Introduction Medical personnel is an occupational group that is especially prone to secondary traumatic stress. The factors conditioning its occurrence include organizational and work-related factors, as well as personal features and traits. The aim of this study was to determine Secondary Traumatic Stress (STS) indicators in a group of medical personnel, considering occupational load, job satisfaction, social support, and cognitive processing of trauma. Material and methods Results obtained from 419 medical professionals, paramedics and nurses, were analyzed. The age of study participants ranged from 19 to 65 (M = 39.60, SD = 11.03). A questionnaire developed for this research including questions about occupational indicators as well as four standard evaluation tools: Secondary Traumatic Stress Inventory, Job Satisfaction Scale, Social Support Scale which measures four support sources (supervisors, coworkers, family, friends) and Cognitive Processing of Trauma Scale which allows to evaluate cognitive coping strategies (positive cognitive restructuring, downward comparison, resolution/acceptance, denial, regret) were used in the study. Results The results showed that the main predictor of STS symptoms in the studied group of medical personnel is job satisfaction. Two cognitive strategies also turned out to be predictors of STS, that is regret (positive relation) and resolution/acceptance (negative relation). The contribution of other analyzed variables, i.e., denial, workload and social support to explaining the dependent variable is rather small. Conclusions Paramedics and nurses are at the high risk of indirect traumatic exposure and thus may be more prone to secondary traumatic stress symptoms development. It is important to include the medical personnel in the actions aiming at prevention and reduction of STS symptoms.

Introduction The work environment of healthcare professionals is important for good patient care and is receiving increasing attention in scientific research. A clear and unambiguous understanding of a positive work environment, as perceived by healthcare professionals, is crucial for gaining systematic objective insights into the work environment. The aim of this study was to gain consensus on the concept of a positive work environment in the hospital. Methods This was a three-round Delphi study to establish consensus on what defines a positive work environment. A literature review and 17 semi-structured interviews with experts (transcribed and analyzed by open and thematic coding) were used to generate items for the Delphi study. Results The literature review revealed 228 aspects that were clustered into 48 work environment elements, 38 of which were mentioned in the interviews also. After three Delphi rounds, 36 elements were regarded as belonging to a positive work environment in the hospital. Discussion The work environment is a broad concept with several perspectives. Although all 36 elements are considered important for a positive work environment, they have different perspectives. Mapping the included elements revealed that no one work environment measurement tool includes all the elements. Conclusion We identified 36 elements that are important for a positive work environment. This knowledge can be used to select the right measurement tool or to develop interventions for improving the work environment. However, the different perspectives of the work environment should be considered.

Psychologists have investigated creativity for 70 years, and it is now seen as being an important construct, both scientifically and because of its practical value to society. However, several fundamental unresolved problems persist, including a suitable definition of creativity and the ability of psychometric tests to measure divergent thinking—an important component of creativity—in a way that aligns with theory. It is this latter point that this registered report is designed to address. We administered two divergent thinking tests (the verbal and figural versions of the Torrance Tests of Creative Thinking; TTCT) with an intelligence test (the International Cognitive Ability Resource test; ICAR). We then subjected the subscores from these tests to confirmatory factor analysis to examine which of nine theoretically plausible models best fits the data. Results show that none of the pre-registered models fit the data well, an ambiguous result that leaves unanswered the question of whether intelligence and divergent thinking tests measure the same construct. Exploratory (i.e., not pre-registered) measurement models of each test separately shows that the TTCT-F may not measure a coherent, unitary construct—leading to model misspecification when TTCT-F subtests were included in larger models. This study was conducted in accordance with all open science practices, including pre-registration, open data and syntax, and open materials (with the exception of copyrighted and confidential test stimuli). Materials are available at https://osf.io/8rpfz/.

The growing complexity of cancer care necessitates collaboration among different professionals. This interprofessional collaboration improves cancer care delivery and outcomes. Treatment decision-making within the context of a multidisciplinaire team meeting (MDTMs) may be seen as a particular form of interprofessional collaboration. Various studies on cancer MDTMs highlight a pattern of suboptimal information sharing between attendants. To overcome the lack of non-medical, patient-based information, it might be recommended that non-physician care professionals play a key patient advocacy role within cancer MDTMs. This study aims to explore non-physician care professionals’ current and aspired role within cancer MDTMs. Additionally, the perceived hindering factors for these non-physician care professionals to fulfil their specific role are identified. The analysis focuses on nurses, specialist nurses, head nurses, psychologists, social workers, a head of social workers and data managers. The results show that non-physician care professionals play a limited role during case discussions in MDTMs. Neither do they actively participate in the decision-making process. Barriers perceived by non-physician care professionals are classified on two main levels: 1) team-related barriers (factors internally related to the team) and 2) external barriers (factors related to healthcare management and policy). A group of non-physician care professionals also belief that their information does not add value in the decision-making proces and as such, they underestimate their own role in MDTMs. To conclude, a change of culture is needed towards an interdisciplinary collaboration in which knowledge and expertise of different professions are equally assimilated into an integrated perspective to guarantee a true patient-centred approach for cancer MDTMs.

Background Pictorial warnings on tobacco products are promising for motivating behavior change, but few studies have examined pictorial warnings for sugary drinks, especially in naturalistic environments. This study aimed to examine the impact of pictorial warnings on parents’ purchases of sugary drinks for their children in a naturalistic store laboratory. Methods and findings Parents of children ages 2 to 12 (n = 325, 25% identifying as Black, 20% Hispanic) completed a shopping task in a naturalistic store laboratory in North Carolina. Participants were randomly assigned to a pictorial warnings arm (sugary drinks displayed pictorial health warnings about type 2 diabetes and heart damage) or a control arm (sugary drinks displayed a barcode label). Parents selected 1 beverage and 1 snack for their child, as well as 1 household good; one of these items was selected for them to purchase and take home. The primary outcome was whether parents purchased a sugary drink for their child. Secondary outcomes included reactions to the trial labels, attitudes toward sugary drinks, and intentions to serve their child sugary drinks. Pictorial warnings led to a 17-percentage point reduction in purchases of sugary drinks (95% CI for reduction: 7% to 27%), with 45% of parents in the control arm buying a sugary drink for their child compared to 28% in the pictorial warning arm (p = 0.002). The impact of pictorial warnings on purchases did not differ by any of the 13 participant characteristics examined (e.g., race/ethnicity, income, education, and age of child). Pictorial warnings also led to lower calories (kcal), purchased from sugary drinks (82 kcal in the control arm versus 52 kcal in the pictorial warnings arm, p = 0.003). Moreover, pictorial warnings led to lower intentions to serve sugary drinks to their child, feeling more in control of healthy eating decisions, greater thinking about the harms of sugary drinks, stronger negative emotional reactions, greater anticipated social interactions, lower perceived healthfulness of sugary drinks for their child, and greater injunctive norms to limit sugary drinks for their child (all p < 0.05). There was no evidence of difference between trial arms on noticing of the labels, appeal of sugary drinks, perceived amount of added sugar in sugary drinks, risk perceptions, or perceived tastiness of sugary drinks (all p > 0.05). Conclusions Pictorial warnings reduced parents’ purchases of sugary drinks for their children in this naturalistic trial. Warnings on sugary drinks are a promising policy approach to reduce sugary drink purchasing in the US. Trial registration The trial design, measures, power calculation, and analytic plan were registered before data collection at www.clinicaltrials.gov NCT04223687., Using a naturalistic store laboratory, Marissa Hall and colleagues examine the impact of pictorial warnings on parents’ purchases of sugary drinks for their children., Author summary Why was this study done? Children in the US consume more than the recommended levels of sugary drinks, increasing their risk of a variety of chronic diseases, including type 2 diabetes and heart disease. Experimental studies of text-only sugary drink warning labels indicate that warnings reduce sugary drink consumption. To our knowledge, studies have not yet examined the effects of pictorial warnings on parents’ purchases of sugary drinks for their children or on purchases in naturalistic settings. What did the researchers do and find? Parents of children aged 2 to 12 years (n = 325) participated in a randomized trial. Participants were randomized to a pictorial warnings arm (sugary drinks displayed pictorial health warnings about type 2 diabetes and heart damage) or a control arm (sugary drinks displayed a barcode label). Participants completed a shopping task in a naturalistic store laboratory, where sugary drinks had the assigned label, and completed a survey. Exposure to pictorial warning labels on sugary drinks led to a 17% absolute reduction in the purchasing of sugary drinks compared to exposure to the barcode control label. What do these findings mean? Pictorial warnings are a promising option for reducing purchases of sugary drinks for children. Implementation of pictorial warning label policies could be an effective strategy for reducing sugary drink purchases and sugary drink–related health outcomes. Future studies should evaluate the long-term effects of warning labels on children’s sugary drink consumption and prevalence of diet-related chronic disease.

Background: Parenting interventions offer an evidence-based method for the prevention and early intervention of child mental health problems, but to-date their population-level effectiveness has been limited by poor reach and engagement, particularly for fathers, working mothers, and disadvantaged families. Internationally, there has been a call for more sensitive intervention frameworks that better recognize parents’ differences and match support accordingly. Tailoring intervention content to parents’ context (i.e., to common parenting situations) offers potential to enhance parent engagement and learning by increasing relevance of content to parents’ daily experiences. However, this approach requires a detailed understanding of the common parenting situations and issues that parents face day-to-day, which is currently lacking.Objective: We sought to identify the most common parenting situations discussed by parents on parenting-specific forums of the free online discussion forum, Reddit, one of the most popular social media platforms in the world. We aimed to understand perspectives from both mothers and fathers, and therefore retrieved publicly available data from two parenting-specific ‘subreddits’ (r/Daddit; r/Mommit).Methods: We used latent Dirichlet allocation (LDA) to identify the most common topics discussed in the Reddit posts. Once topics were identified, we completed a manual text analysis of the 10 posts ranked as most relevant to each topic, and summarized the parenting situations that were described. Our pre-specified definition of a parenting situation required that the post involve a parent and their child aged 0-18 years and describe a potential or actual difficulty or issue.Results: We retrieved 340 (r/Daddit) and 578 (r/Mommit) original posts. A model with 31 LDA topics was found to be the best fitting model. Of these, 24 topics included posts that met our inclusion criteria for manual review. From these, we identified 45 unique but broadly-defined parenting situations. The majority of parenting situations were either focused on basic childcare situations relating to eating, sleeping, routines, sickness and toilet training; or related to how to respond to child negative emotions or difficult behavior. Most situations were discussed in relation to infant or toddler age children, and on the whole, there was a high level of consistency in the themes raised in r/Daddit and r/Mommit.Conclusions: Our text analysis of the r/Daddit and r/Mommit posts highlighted two overarching themes in topics commonly discussed in online parenting forums; basic childcare, and management of child emotions and behavior. Our results offer potential to tailor parenting interventions in a meaningful way, creating opportunities to develop content and resources that are directly relevant to parents’ lived experiences.

Objective The relevance of communication in medical education is continuously increasing. At the Medical Faculty of Hamburg, the communication curriculum was further developed and optimized during this project. This article aims to describe the stakeholders’ perceived challenges and supporting factors in the implementation and optimization processes. Methods The initial communication curriculum and its development after a one-year optimization process were assessed with a curricular mapping. A SWOT analysis and group discussions were carried out to provide information on the need for optimization and on challenges the different stakeholders faced. Results The curricular mapping showed that the communication curriculum is comprehensive, coherent, integrated and longitudinal. In both the implementation and the project-related optimization processes, support from the dean, cooperation among all stakeholders and structural prerequisites were deemed the most critical factors for successfully integrating communication content into the curriculum. Conclusion The initiative and support of all stakeholders, including the dean, teachers and students, were crucial for the project’s success. Practice implications Although the implementation of a communication curriculum is recommended for all medical faculties, their actual implementation processes may differ. In a “top-down” and “bottom-up” approach, all stakeholders should be continuously involved in the process to ensure successful integration.

Adolescence is a period of increased risk-taking behavior, thought to be driven, in part, by heightened reward sensitivity. One challenge of studying reward processing in the field of developmental neuroscience is finding a task that activates reward circuitry, and is short, not too complex, and engaging for youth of a wide variety of ages and socioeconomic backgrounds. In the present study, we tested a brief child-friendly reward task for activating reward circuitry in two independent samples of youth ages 7–19 years old enriched for poverty (study 1: n = 464; study 2: n = 27). The reward task robustly activated the ventral striatum, with activation decreasing from early to mid-adolescence and increasing from mid- to late adolescence in response to reward. This response did not vary by gender, pubertal development, or income-to-needs ratio, making the task applicable for a wide variety of populations. Additionally, ventral striatum activation to the task did not differ between youth who did and did not expect to receive a prize at the end of the task, indicating that an outcome of points alone may be enough to engage reward circuitry. Thus, this reward task is effective for studying reward processing in youth from different socioeconomic backgrounds.

Background The variations in ABO blood groups are reported to be associated with multiple disorders, including ulcerative colitis (UC). We aimed to investigate the distribution of ABO blood groups in UC patients and explore its impact on disease severity. Methods We retrospectively collected 129 UC patients diagnosed at our hospital between January 2000 and November 2019. Clinical characteristics, ABO blood groups, and operation rates were analyzed. Results The mean diagnostic age of patients was 38.97 years. Males accounted for the majority of all patients (62.8%). Of 129 patients, 43 (33.3%) were blood type O, 41 (31.8%) were blood type A, 38 (29.5%) were blood type B, and 7 (5.4%) were blood type AB. Although our patients had higher ratio of blood type A comparing our general population, there was no statistically significant association of ABO blood types distribution between these two groups (p = 0.1906). In the subgroup analysis, there were no significant difference of disease locations and operation rates between different ABO blood groups. Furthermore, blood type A patients had higher serum hemoglobin (Hb) levels compared to blood type O patients (13.31 g/dL vs. 12.30 g/dL, p = 0.0347). Blood type A patients had lower serum erythrocyte sedimentation rate (ESR) levels compared to blood type O patients (12.46 mm/hour vs. 21.5 mm/hour, p = 0.0288). Blood type O had higher serum ESR levels compared to non-O groups (p = 0.0228). In the ABO blood groups and mean diagnostic age (≤ 40 years or > 40 years), there were no statistically significant difference between these two age groups, p = 0.5515. Conclusions Our results showed ABO blood groups are not associated with UC in spite of a higher ratio of blood type A in our patients. Blood type O patients had higher serum ESR levels; however, blood type A patients had higher Hb levels.

Introduction With the emergence of the COVID-19 pandemic, universities immediately responded to protect students’ lives by implementing e-learning in order to stop the spread of the communicable disease within the academic population. This study aimed to describe iranian nursing students’ experiences of e-learning during the COVID-19 pandemic. Materials and methods The current study used a qualitative descriptive study. Ten nursing undergraduate students from a single Iranian university identified using purposive sampling methods. Face-to-face semi-structured interview conducted from May to July 2021 and analyzed through thematic analysis. Lincoln and Goba criteria were used to obtain data validity and reliability. Results Four themes emerged including"novelty of e-learning","advantages of e-learning", "disadvantages of e-learning"and"passage of time and the desire to return to face education". Participants evaluated e-learning as a novel method without proper infrastructure, it was initially confusing but became the new normal as their knowledge of the way to use it improved. Advantages included self-centered flexible learning and reduction in their concerns experienced with face-to-face learning. Disadvantages including changing the way they interact with teachers, decreasing interactions with classmates, problems with education files, superficial learning, hardware problems, family members’ perceptions of the student role, interference of home affairs with e-learning, cheating on exams and assignments and being far away from the clinical context. Conclusion The findings revealed that e-learning has been introduced as a new method for the current research participants and despite the perceived benefits, these students believed that e-learning could supplement face education but not replace it.

Bullying constitutes a serious risk factor for the psychosocial adjustment of young people in both the general population and minority groups. Among minorities, international adoptees are likely to show a specific vulnerability to the experience of being bullied, moderated by specific risk and protective factors. This study aimed to investigate the association between adoptees’ experience of bullying victimization and their psychosocial adjustment, and to explore the moderating role of adoptive identity and reflected minority categorization. An online, anonymous self-report questionnaire was completed by 140 adolescents (13–17 years), who were internationally adopted by Italian families. Findings showed that being victimized was associated with higher levels of emotional and behavioral difficulties, but that the strength of this relation varied according to the levels of adoptive identity and reflected minority categorization. Specifically, victimization was found to have a more detrimental and negative impact on psychological adjustment for adoptees who were highly identified with the adoptive group, and reported to be less perceived by others as members of the minority group. Results are discussed in relation to recommendations for further research as well as for professionals working with internationally adopted adolescents.

Preprints allow researchers to make their findings available to the scientific community before they have undergone peer review. Studies on preprints within bioRxiv have been largely focused on article metadata and how often these preprints are downloaded, cited, published, and discussed online. A missing element that has yet to be examined is the language contained within the bioRxiv preprint repository. We sought to compare and contrast linguistic features within bioRxiv preprints to published biomedical text as a whole as this is an excellent opportunity to examine how peer review changes these documents. The most prevalent features that changed appear to be associated with typesetting and mentions of supporting information sections or additional files. In addition to text comparison, we created document embeddings derived from a preprint-trained word2vec model. We found that these embeddings are able to parse out different scientific approaches and concepts, link unannotated preprint–peer-reviewed article pairs, and identify journals that publish linguistically similar papers to a given preprint. We also used these embeddings to examine factors associated with the time elapsed between the posting of a first preprint and the appearance of a peer-reviewed publication. We found that preprints with more versions posted and more textual changes took longer to publish. Lastly, we constructed a web application (https://greenelab.github.io/preprint-similarity-search/) that allows users to identify which journals and articles that are most linguistically similar to a bioRxiv or medRxiv preprint as well as observe where the preprint would be positioned within a published article landscape., Preprints allow researchers to make their findings available to the scientific community before they have undergone peer review This study analyzes the full text content of the bioRxiv preprint repository, identifying field-specific patterns and changes that occur during publication, and providing a search tool that can identify the published papers that are most similar to a given bioRxiv or medRxiv preprint.

Background Substance use among adolescents in the U.S. is associated with adverse physical and mental health outcomes in the long-term. Universal youth-focused substance use prevention programs have demonstrated effectiveness but are often not sustainable due to the significant amount of time, effort, and resources required. We describe a trial protocol for a brief, low-participant-burden intervention to improve substance use-specific parent-child communication through the promotion of family meals and increased parental engagement. Methods This study is a parallel-group randomized controlled trial designed to assess the efficacy of a 13-week intervention. A total of 500 dyads of parents and their 5th-7th grade children are recruited from across Massachusetts. Dyads are randomized to the intervention or attention-control condition using block urn randomization, based on child grade, gender, and school. Parents/guardians in the substance use preventive intervention arm receive a short handbook, attend two meetings with an interventionist, and receive two SMS messages per week. Parents/guardians in the control arm receive the same dose but with content focused on nutrition, physical activity, and weight stigma. Participant dyads submit videos of family meals, audio recordings of prompted conversations, and quantitative surveys over an 18-month period (baseline, 3, 6, 12, 18 months post-intervention). The primary outcomes measure the quantity and quality of parent-child substance use conversations and proximal child indicators (i.e., substance use attitudes and expectancies, affiliation with substance-using peers, and intentions and willingness to use substances). The secondary outcome is child substance use initiation. Discussion This is a novel, brief, communication-focused intervention for parents/guardians that was designed to reduce participant burden. The intervention has the potential to improve parent-child engagement and communication and conversations about substance use specifically and decrease child substance use risk factors and substance use initiation. Trial registration ClinicalTrials.gov NCT03925220. Registered on 24 April 2019.

Age-related physiological changes are most notable and best-studied late in life, while the nature of aging in early- or middle-aged individuals has not been explored as thoroughly. In C. elegans, many studies of movement vs. age generally focus on three distinct phases: sustained, youthful movement; onset of rapidly progressing impairment; and gross immobility. We investigated whether this first period of early-life adult movement is a sustained “healthy” level of high function followed by a discrete “movement catastrophe”—or whether there are early-life changes in movement that precede future physiological declines. To determine how movement varies during early adult life, we followed isolated individuals throughout life with a previously unachieved combination of duration and temporal resolution. By tracking individuals across the first six days of adulthood, we observed declines in movement starting as early as the first two days of adult life, as well as high interindividual variability in total daily movement. These findings suggest that movement is a highly dynamic behavior early in life, and that factors driving movement decline may begin acting as early as the first day of adulthood. Using simulation studies based on acquired data, we suggest that too-infrequent sampling in common movement assays limits observation of early-adult changes in motility, and we propose feasible strategies and a framework for designing assays with increased sensitivity for early movement declines.

Long-acting injectable (LAI) antiretroviral therapy (ART) is a novel HIV treatment option for people with HIV. The first LAI ART regimen for HIV treatment received regulatory approval in the United States in January 2021. In February 2020, we collected qualitative data from 18 consumers and 23 clinical and non-clinical stakeholders to catalog anticipated individual-consumer, healthcare system, and structural levels barriers and facilitators to LAI ART implementation in Los Angeles County, California. Thematic analysis was guided by the CFIR implementation science model. CFIR constructs of intervention characteristics, individual characteristics, outer and inner setting, intervention characteristics, and implementation process emerged in analysis. Under intervention characteristics, anticipated facilitators included the relative advantage of LAI ART over pills for adherence and reduced treatment management burden and related anxiety; anticipated barriers included non-adherence to injection appointments, concerns of developing HIV resistance, discomfort with injection and cost. Anticipated facilitators based on individual characteristics included overall acceptability based on knowledge and positive beliefs about LAI ART. Participant noted several characteristics of the outer setting that could negatively impact implementation, such as medical mistrust, external policies, and LAI ART eligibility (i.e., to be virally suppressed prior to initiation). Participants were optimistic about the potential to decrease stigma but expressed that provider willingness for adoption could be hindered by challenges in organizational inner setting related to payment authorizations, increased staffing needs, medication procurement and storage, and provider and healthcare system readiness. Results from this pre-implementation study may inform rollout and scale-up of LAI ART in Los Angeles County.

This paper explores the potential of combining different isotope systems from different tissues to improve resolution when reconstructing breastfeeding and weaning practices (BWP) in archaeology. Additionally, we tested whether changes in diet can be detected in deciduous teeth. Rib collagen samples from 22 infants/children from the archaeological site of Bacuranao I (Mayabeque, Cuba) were processed for nitrogen (δ15N) and carbon (δ13Cco) stable isotopes and assessed using a Bayesian model (WARN). In addition, enamel of 48 teeth from 30 infants/children were analyzed for oxygen (δ18Oen) and carbon (δ13Cen) stable isotopes. Data revealed that the timing of weaning cannot be characterized precisely by analyzing either δ18O or δ15N. While a depletion in both δ15N and δ13Cco is only evident after one year, the WARN model suggested that the weaning process started at around 3 months and ended around 1.7 years. Most teeth were enriched in δ18Oen compared to deciduous incisors, suggesting a breastfeeding signal. However, a high variability in δ18O was found between similar teeth from the same individuals. Higher enrichment in δ18Oen, and variability, was observed in tissues formed during the first six months of life. A δ13C enrichment of 1.0‰ was observed among deciduous teeth and ribs. While most individuals enriched in δ15N showed enrichment in δ13C, the δ18O values were more variable. Our data suggests that stable isotopes of deciduous teeth, especially δ13Cen, can be used to detect changes in diet during the weaning process. It is also possible that the δ18O enrichment observed in M1 is influenced by the effects of cooking techniques on weaning foods. The combination of multiple isotope systems and tissues overcome some of the limitations posed by single tissue approaches.

Background The vast majority of adolescent births occur in low- and middle-income countries and are associated with negative outcomes for both the mother and her child. A multitude of risk factors may explain why few programs have been successful in delaying childbearing and suggest that multisectoral interventions may be necessary. This study examines the longer-term impact of a two-year (2015–17) multisectoral program on early sexual debut and fertility in an urban informal settlement in Kenya. Methods The study used a randomized trial design, longitudinally following 2,075 girls 11–14 years old in 2015 until 2019. The interventions included community dialogues on unequal gender norms and their consequences (violence prevention), a conditional cash transfer (education), health and life skills training (health), and financial literacy training and savings activities (wealth). Girls were randomized to one of four study arms: 1) violence prevention only (V-only); 2) V-only and education (VE); 3) VE and health (VEH); or 4) all four interventions (VEHW). We used ANCOVA to estimate intent-to-treat (ITT) impacts of each study arm and of pooled study arms VE, VEH, and VEHW relative to the V-only arm, on primary outcomes of fertility and herpes simplex virus-2 (HSV-2) infection, and secondary outcomes of education, health knowledge, and wealth creation. Post-hoc analysis was carried out on older girls who were 13–14-years-old at baseline. In 2018, in the VEHW arm, in-depth qualitative evaluation were carried out with adolescent girls, their parents, school staff, mentors, community conversation facilitators, and community gatekeepers. The trial is registered at ISRCTN: ISRCTN77455458. Results At endline in the V-only study arm, 21.0 percent of girls reported having had sex, 7.7 percent having ever been pregnant and 6.6 percent having ever given birth, with higher rates for the older subsample at 32.5 percent, 11.8 percent, and 10.1 percent, respectively. In the full sample, ever having given birth was reduced by 2.3 percentage points (pp) in the VE and VEHW study arms, significant at 10 percent. For the older subsample there were larger and significant reductions in the percent ever having had sex (8.2 pp), HSV-2 prevalence (7.5 pp) and HSV-2 incidence (5.6 pp) in the VE arm. Two years after the end of the interventions, girls continued to have increased schooling, sexual and reproductive health knowledge, and improved financial savings behaviors. Qualitatively, respondents reported that girls were likely to have sex as a result of child sexual exploitation, peer pressure or influence from the media, as well as for sexual adventure and as a mark of maturity. Conclusion This study demonstrates that multisectoral cash plus interventions targeting the community and household level, combined with interventions in the education, health, and wealth-creation sectors that directly target individual girls in early adolescence, generate protective factors against early pregnancy during adolescence. Such interventions, therefore, potentially have beneficial impacts on the longer-term health and economic outcomes of girls residing in impoverished settings. Clinical trial registration ISRCTN registry: ISRCTN77455458; https://doi.org/10.1186/ISRCTN77455458.

We examined the potential roles of the athlete’s performance passport (APP) for doping detection by analyzing the relationship between weightlifting performance and sanction status. For the present study, performance data of ‘not-sanctioned’ (26740 datasets) and ‘sanctioned’ (289 datasets) male athletes were acquired from the website of the International Weightlifting Federation (www.iwf.net). One-way ANOVA, correlation analysis, and t-tests were used to analyze the relationship between athletes’ use of doping and their performances across age and body weight. Athletic performance was significantly greater for athletes in the sanctioned group than those of the same age group who were not sanctioned, and this performance difference between the two groups was the greatest in their late thirties at 20.6% (not-sanctioned 292.0kg vs. sanctioned 352.3kg) (p < 0.05). From the age group analysis, out of 289 sanctioned cases, 84 cases, which was the largest proportion, were found within the top 10–25% of their performances. When stratified by body weight, athletic performance was significantly greater for the sanctioned group than the not-sanctioned group, and this performance gap was the greatest in the bodyweight category of 96 at 18.6% (not-sanctioned 310.1kg vs. sanctioned 367.8kg) (p < 0.05). From the body weight category analysis, out of 289 sanctioned cases, 75 cases, which was the largest proportion, were found within the top 10–25% of their performances. Additionally, the mean difference in performance between not-sanctioned and sanctioned groups was the largest in the body weight category of 67kg in the ages of 15–19 at 20% (not-sanctioned 234.6kg vs. sanctioned 281.5kg). These results are interpreted to mean that in male weightlifters 1) sanctioned athletes were detected in all ranges of performances regardless of age and body weight, 2) there were even higher rates of sanctioned athletes who performed within the top 10–25% of each age group and body weight category, 3) there were significant differences in performance between not-sanctioned and sanctioned group for all body weight categories, excluding +109, in the ages of 15–19 and 20–24, 4) therefore, performance data can be effectively used to better target suspected athletes for doping testing.

Introduction Khat is a flowering plant with stimulant effect on the nervous system and produce psychological dependence. Despite its harmful effects, the ingestion of khat has been part of cultural norms and the legality of khat varies by region. Objective This systematic review aimed at critically evaluating the available evidence on the risk factors of khat chewing among adolescents. Methods A systematic review was conducted on published research studies from five databases Scopus, PubMed, Science-direct, Ovid and google scholar using keywords khat chewing OR qat chewing AND associated factors OR risk factors OR contributing factors AND adolescents OR teenagers. Articles included were either cross-sectional, cohort, case-control or qualitative studies which were published between the year 1990 till present. Excluded articles were the non-English written articles, descriptive studies and irrelevant topics being studied. Results Out of 2617 records identified and screened, six were included for the analysis and interpretation of the data. All included studies were cross-sectional study design. All six studies reported having family members who chewed khat significantly predict khat chewing among adolescents, followed by five articles for friends or peers who also chewed khat and four articles for male gender. Smoking was also found to have the highest odds (OR = 18.2; 95% CI: 12.95–25.72) for khat chewing among adolescents. Conclusion The review highlights the crucial role of family members, friends or peers and male gender to predict khat chewing among adolescents. Effectiveness of health promotion programs to educate and reduce khat chewing among adolescents will require active participation of family members and friends.

Introduction The world is awash with claims about the effects of health interventions. Many of these claims are untrustworthy because the bases are unreliable. Acting on unreliable claims can lead to waste of resources and poor health outcomes. Yet, most people lack the necessary skills to appraise the reliability of health claims. The Informed Health Choices (IHC) project aims to equip young people in Ugandan lower secondary schools with skills to think critically about health claims and to make good health choices by developing and evaluating digital learning resources. To ensure that we create resources that are suitable for use in Uganda’s secondary schools and can be scaled up if found effective, we conducted a context analysis. We aimed to better understand opportunities and barriers related to demand for the resources, how the learning content overlaps with existing curriculum and conditions in secondary schools for accessing and using digital resources, in order to inform resource development. Methods We used a mixed methods approach and collected both qualitative and quantitative data. We conducted document analyses, key informant interviews, focus group discussions, school visits, and a telephone survey regarding information communication and technology (ICT). We used a nominal group technique to obtain consensus on the appropriate number and length of IHC lessons that should be planned in a school term. We developed and used a framework from the objectives to code the transcripts and generated summaries of query reports in Atlas.ti version 7. Findings Critical thinking is a key competency in the lower secondary school curriculum. However, the curriculum does not explicitly make provision to teach critical thinking about health, despite a need acknowledged by curriculum developers, teachers and students. Exam oriented teaching and a lack of learning resources are additional important barriers to teaching critical thinking about health. School closures and the subsequent introduction of online learning during the COVID-19 pandemic has accelerated teachers’ use of digital equipment and learning resources for teaching. Although the government is committed to improving access to ICT in schools and teachers are open to using ICT, access to digital equipment, unreliable power and internet connections remain important hinderances to use of digital learning resources. Conclusions There is a recognized need for learning resources to teach critical thinking about health in Ugandan lower secondary schools. Digital learning resources should be designed to be usable even in schools with limited access and equipment. Teacher training on use of ICT for teaching is needed.

Though antimicrobial stewardship (AMS) programmes are the cornerstone of Uganda’s national action plan (NAP) on antimicrobial resistance, there is limited evidence on AMS attitude and practices among healthcare providers in health facilities in Uganda. We determined healthcare providers’ AMS attitudes, practices, and associated factors in selected health facilities in Uganda. We conducted a cross-sectional study among nurses, clinical officers, pharmacy technicians, medical officers, pharmacists, and medical specialists in 32 selected health facilities in Uganda. Data were collected once from each healthcare provider in the period from October 2019 to February 2020. Data were collected using an interview-administered questionnaire. AMS attitude and practice were analysed using descriptive statistics, where scores of AMS attitude and practices for healthcare providers were classified into high, fair, and low using a modified Blooms categorisation. Associations of AMS attitude and practice scores were determined using ordinal logistic regression. This study reported estimates of AMS attitude and practices, and odds ratios with 95% confidence intervals were reported. We adjusted for clustering at the health facility level using clustered robust standard errors. A total of 582 healthcare providers in 32 healthcare facilities were recruited into the study. More than half of the respondents (58%,340/582) had a high AMS attitude. Being a female (aOR: 0.66, 95% CI: 0.47–0.92, P < 0.016), having a bachelor’s degree (aOR: 1.81, 95% CI: 1.24–2.63, P < 0.002) or master’s (aOR: 2.06, 95% CI: 1.13–3.75, P < 0.018) were significant predictors of high AMS attitude. Most (46%, 261/582) healthcare providers had fair AMS practices. Healthcare providers in the western region’s health facilities were less likely to have a high AMS practice (aOR: 0.52, 95% CI 0.34–0.79, P < 0.002). In this study, most healthcare providers in health facilities had a high AMS attitude and fair AMS practice.

Background In France, the number of emergency department (ED) admissions doubled between 1996 and 2016. To cope with the resulting crowding situation, redirecting patients to new healthcare services was considered a viable solution which would spread demand more evenly across available healthcare delivery points and render care more efficient. The objective of this study was to analyze the impact of opening new on-demand care services based on variations in patient flow at a large hospital emergency department. Methods We performed a before-and-after study investigating the use of unscheduled care services in the Aube region in eastern France, that focused on ED attendance at Troyes Hospital. A hierarchical clustering based on co-occurrence of diagnoses was applied which divided the population into different multimorbidity profiles. Temporal trends of the resultant clusters were also studied empirically and using regression models. A multivariate logistic regression model was constructed to adjust the periodic effect for appropriate confounders and therefore confirm its presence. Results In total, 120,722 visits to the ED were recorded over a 24-month period (2018–2019) and 16 clusters were identified, accounting for 94.76% of all visits. There was a decrease of 56.77 visits per week in seven specific clusters and an increase of use of unscheduled health care services by 328.12 visits per week. Conclusions Using an innovative and reliable methodology to evaluate changes in patient flow through the ED, these findings may help inform public health policy experts on the implementation of unscheduled care services to ease pressure on hospital EDs.

Background Cryptosporidiosis outbreaks in South America are poorly documented. In March 2018, 51 cases of cryptosporidiosis were reported in Maripasoula, a village located in a remote forest area along the border between Surinam and French Guiana. Method To identify the origin of the epidemic, we performed epidemiological, microbiological, and environmental investigations. Only the cases involving diarrhoea and Cryptosporidium-positive stool were considered as bona fide, while cases involving diarrhoea and close contact with a confirmed case were classified as “possible”. Results We identified 16 confirmed cases and 35 possible ones. Confirmed cases comprised nine children (median age of 18 months, range: 6–21), one immunocompromised adult and six soldiers. One child required a hospitalisation for rehydration. All 16 Cryptosporidium stools were PCR positive, and sequencing of the gp60 gene confirmed only one Cryptosporidium hominis subtype IbA10G2. Tap water consumption was the only common risk factor identified. Contamination of the water network with Cryptosporidium parvum subtype IIdA19G2 was found. Conclusion Water quality is a major public health issue in Amazonian French Guiana, especially for population at risk (children, people with comorbidity, travelers). For them, alternative water supply or treatment should be implemented.

Aims The aim was to investigate the long-term association between leisure time physical activity and hip areal bone mineral density (aBMD), in addition to change in hip aBMD over time, in 32–86 years old women and men. Methods Data were retrieved from the 2001, 2007–2008, and 2015–2016 surveys of the Tromsø Study, a longitudinal population study in Norway. Leisure time physical activity was assessed by the four-level Saltin-Grimby Physical Activity Level Scale which refers to physical exertion in the past twelve months. Hip aBMD was assessed by Dual-Energy X-ray Absorptiometry. Linear Mixed Model analysis was used to examine long-term associations between physical activity and hip aBMD (n = 6324). In addition, the annual change in hip aBMD was analyzed in a subsample of 3199 participants. Results Physical activity was significantly and positively associated with total hip aBMD in the overall cohort (p2 higher aBMD than those who were inactive (95% CI 14.71; 41.69, controlled for confounders), and even light physical activity was associated with higher aBMD than inactivity (8.32 mg/cm2, 95% CI 4.89; 11.76). Associations between physical activity and femoral neck aBMD yielded similar results. Hip aBMD decreased with age in both sexes, although more prominently in women. From 2001 to 2007–2008, aBMD changed by –5.76 mg/cm2 per year (95% CI –6.08; –5.44) in women, and –2.31 mg/cm2 (95% CI –2.69; –1.93), in men. From 2007–2008 to 2015–2016, the change was –4.45 mg/cm2 per year (95% CI –4.84; –4.06) in women, and –1.45 mg/cm2 (95% CI –1.92; –0.98) in men. Conclusions In this cohort of adult men and women, physical activity levels were positively associated with hip aBMD in a dose-response relationship. Hip aBMD decreased with age, although more pronounced in women than men.

Long-term athletic development practices have been recommended for the past two decades. However, limited research exists exploring the knowledge and skills required by practitioners to optimise long-term athletic development. Therefore, this study aimed to evaluate the knowledge, adherence, practices, and challenges of practitioners responsible for delivering long-term athletic development. A mixed methods survey was completed by 236 practitioners (e.g., sport coaches, physical education teachers) consisting of four parts; 1) demographics, 2) knowledge, 3) adherence, and 4) practices and challenges. Quantitative and qualitative data were analysed by Friedman’s analysis of variance and thematic analyses, respectively. Quantitative findings showed practitioners 1) recognised their responsibility for delivering long-term athletic development, 2) have a familiarity with existing developmental models, and 3) had high adherence, focused upon health and wellbeing, to delivering long-term athletic development. However, practices associated with growth and maturity, monitoring and assessment, and the systematic progression and individualisation of training had lower adherence. Qualitative analysis indicated that practitioner’s perceived definitions of athleticism and long-term athletic development were inconsistent, especially according to the psychological components (i.e., confidence). Practitioners’ descriptions of their long-term athletic development practices identified two higher order themes; 1) goals, in which long-term athletic development “is for life” and the importance of “an individual centered journey” highlighted as sub-themes; and 2) realities of delivering long-term athletic development, whereby variety in programme delivery, monitoring development and practical challenges were noted as key priorities. Eight practical challenges were identified including governance and priorities, resources, education, early specialization, high training volumes, staff communication, parents and youth motivation. This mixed method survey highlighted a multitude of knowledge, adherence, practices and challenges towards long-term athletic development. These novel findings can help inform policy to optimise long-term athletic development and to support the complex problem of developing a healthier, fitter and more physically active youth population.

Adults under time pressure share with others generously, but with more time they act more selfishly. In the current study, we investigated whether young children already operate in this same way, and, if so, whether this changes over the preschool and early school age years. We tested 144 children in three age groups (3-, 5-, and 7-year olds) in a one-shot dictator game: Children were given nine stickers and had the possibility to share stickers with another child who was absent. Children in the Time Pressure condition were instructed to share quickly, whereas children in the Delay condition were instructed to take time and consider their decision carefully. Across ages, children in the Time Pressure condition shared significantly more stickers than children in the Delay condition. Moreover, the longer children waited, the less they shared. Thus, children, like adults, are more prosocial when acting spontaneously than after considering their decision more carefully. Publisher PDF

Background The incidence of keratinocyte carcinomas is high and rapidly growing. Approximately 80% of keratinocyte carcinomas consist of basal cell carcinomas (BCC) with 50% of these being considered as low-risk tumors. Nevertheless, 83% of the low-risk BCC patients were found to receive more follow-up care than recommended according to the Dutch BCC guideline, which is one visit post-treatment for this group. More efficient management could reduce unnecessary follow-up care and related costs. Objectives To study the efficacy, cost-utility, and budget impact of a personalized discharge letter for low-risk BCC patients compared with usual care (no personalized letter). Methods In a multi-center intervention study, a personalized discharge letter in addition to usual care was compared to usual care in first-time BCC patients. Model-based cost-utility and budget impact analyses were conducted, using individual patient data gathered via surveys. The outcome measures were number of follow-up visits, costs and quality adjusted life years (QALY) per patient. Results A total of 473 first-time BCC patients were recruited. The personalized discharge letter decreased the number of follow-up visits by 14.8% in the first year. The incremental costs after five years were -€24.45 per patient. The QALYs were 4.12 after five years and very similar in both groups. The national budget impact was -€2,7 million after five years. Conclusions The distribution of a personalized discharge letter decreases the number of unnecessary follow-up visits and implementing the intervention in a large eligible population would results in substantial cost savings, contributing to restraining the growing BCC costs.

The work was supported by the Science and Technology Facilities Council (STFC) under Grants STFC ST/R000328/1 (including salary to S.A.B., D.B., H.P., T.R.M. and non-salary costs) and STFC ST/T000872/1 (including salary to S.A.B., D.B., K.C., T.R.M. and non-salary costs), the Darwin Trust of Edinburgh (https://darwintrust.bio.ed.ac.uk; including salary to S.A.B. and H.P. and non-salary costs), the Wellcome Trust-University of Edinburgh Institutional Strategic Support Fund under Wellcome Trust Grant number 204804/Z/16/Z (salary to H.P.), a Public Engagement with Genetics Tier 2 Grant from the Genetics Society (https://genetics.org.uk; non-salary costs), the Natural Environment Research Council (NERC) under Grant NE/P000592/1 (including salary to N.C. and M.G.R. and non-salary costs), the Biotechnology and Biological Sciences Research Council (BBSRC) under Grant BB/S018506/1 (including salary to F.A. and non-salary costs), the School of Biological Sciences at the University of Edinburgh (https://www.ed.ac.uk/biology; including salary to S.A.B. and H.P. and non-salary costs) and its Institute of Evolutionary Biology (https://www.ed.ac.uk/biology/evolutionary-biology; non-salary costs), the Access for Rural Communities project (ARC) at University of St Andrews (https://www.st-andrews.ac.uk/study/access/projects/arc; non-salary costs) and the Engineering and Physical Sciences Research Council (EPSRC) under Grant EP/V52038X/1 (including salary to S.A.B. and non-salary costs). E.W.J.W. is supported by a Sir Henry Dale Fellowship jointly funded by the Wellcome Trust and the Royal Society [208779/Z/17/Z] (including salary to E.W.J.W.). Over the last few decades, the nature of life sciences research has changed enormously, generating a need for a workforce with a variety of computational skills such as those required to store, manage, and analyse the large biological datasets produced by next-generation sequencing. Those with such expertise are increasingly in demand for employment in both research and industry. Despite this, bioinformatics education has failed to keep pace with advances in research. At secondary school level, computing is often taught in isolation from other sciences, and its importance in biological research is not fully realised, leaving pupils unprepared for the computational component of Higher Education and, subsequently, research in the life sciences. The 4273pi Bioinformatics at School project (https://4273pi.org) aims to address this issue by designing and delivering curriculum-linked, hands-on bioinformatics workshops for secondary school biology pupils, with an emphasis on equitable access. So far, we have reached over 180 schools across Scotland through visits or teacher events, and our open education resources are used internationally. Here, we describe our project, our aims and motivations, and the practical lessons we have learned from implementing a successful bioinformatics education project over the last 5 years. Publisher PDF

The epidemiology of typhoid fever in Lao People`s Democratic Republic is poorly defined. Estimating the burden of typhoid fever in endemic countries is complex due to the cost and limitations of population-based surveillance; serological approaches may be a more cost-effective alternative. ELISAs were performed on 937 serum samples (317 children and 620 adults) from across Lao PDR to measure IgG antibody titers against Vi polysaccharide and the experimental protein antigens, CdtB and HlyE. We measured the significance of the differences between antibody titers in adults and children and fitted models to assess the relationship between age and antibody titers. The median IgG titres of both anti-HylE and CdtB were significantly higher in children compared to adults (anti-HylE; 351.7 ELISA Units (EU) vs 198.1 EU, respectively; p, Author summary Typhoid fever is a serious bloodstream infection caused by the bacterium Salmonella Typhi. Estimating the burden of typhoid fever is complex due to the limitations, cost, and scalability of current diagnostic surveillance methods. The detection of specific antibody responses against the organism may be a more sustainable manner of measuring exposure and disease burden in endemic location. We measured antibody (IgG) in 937 serum samples (317 children and 620 adults) from across the Lao People`s Democratic Republic against a polysaccharide (Vi) and two experimental protein antigens, CdtB and HlyE, that may more appropriate markers of disease exposure. We measured the significance of the differences between antibody titers in adults and children and fitted models to assess the relationship between age and antibody titers. The median IgG titres against HylE and CdtB were significantly higher in children than adults. Conversely, the median IgG titres against Vi was significantly higher in adults than children. We identified a significant association between a peak in IgG titres against CdtB and HlyE in children aged under 5 years. These data are indicative of high level of typhoid fever exposure in children under 5 years of age in Lao PDR and we surmise that IgG titres against HylE and CdtB may be a superior measure of typhoid disease burden than IgG titres against Vi. Our approach is scalable and can be further validated to assess the burden of typhoid fever in countries where the disease may be endemic, and evidence is required for the introduction of typhoid vaccines.

Background and aim For decades, corporations such as the tobacco and fossil fuel industries have used youth education programmes and schools to disseminate discourses, ideas and values favourable to their positions, and to pre-empt regulation that threatens profits. However, there is no systematic research into alcohol industry-funded youth education programmes. This article serves to address this important gap in the literature. Methods Using a discourse theoretical approach informed by poststructural discourse theory and critical discourse analysis, we analysed teaching materials from three school-based youth education initiatives which focus on alcohol consumption and health harms: Drinkaware for Education, The Smashed Project (funded by Diageo), and Talk About Alcohol (Alcohol Education Trust). These materials, some of which are disseminated internationally, are provided to schools through intermediary bodies in receipt of alcohol industry funding. Findings The analysis found that these materials drew from and presented discourses of personal responsibility, moderate alcohol consumption, and involved a narrowing of the problem definition and causes. The locus of the problem is located by the discourses within individuals including youth, with causes of youth alcohol consumption repeatedly presented as peer pressure and ‘poor choices’, with little or no mention of alcohol industry marketing or other practices. All programmes promoted familiarisation and normalisation of alcohol as a ‘normal’ adult consumer product which children must learn about and master how to use responsibly when older. The discourses constructed in these materials closely align with those of other alcohol industry corporate social responsibility discourses which employ selective presentation of harms, including misinformation about cancer, and ambiguous terms such as “responsible drinking”. Furthermore, the role of alcohol price, availability and access, and the impacts of alcohol and the industry on inequities were not articulated within the discourses. The research was limited to an analysis of teaching materials and further research is needed to explore their impact on youth, teachers and wider discourses and social norms. Conclusion Alcohol industry-sponsored youth education programmes serve industry interests and promote moderate consumption while purportedly educating children about harms and influences of alcohol use. There are considerable conflicts of interest in the delivery of alcohol education programmes funded by the alcohol industry and intermediary bodies in receipt of such funding. Alcohol education materials should be developed independent from industry, including funding, and should empower children and young people to understand and think critically about alcohol, including harms and drivers of consumption, and effective interventions needed to protect them and others from alcohol-related harms. Independent organisations can use this analysis to critique their materials to strengthen alignment with meeting student and public health interests. The ongoing exposure of children and young people to such conflicted and misleading materials needs urgent attention from policymakers, practitioners, teachers and parents, and resources dependent on industry support should cease being used in schools.

Undesirable behaviours (UBs) in dogs are common and important issues with serious potential welfare consequences for both the dogs and their owners. This study aimed to investigate the usage of drug therapy for UBs in dogs and assess demographic risk factors for drug-prescribed UBs within the dog population under primary-care veterinary care in the UK in 2013. Dogs receiving drug therapy for UB were identified through the retrospective analysis of anonymised electronic patient records in VetCompass™. Risk factor analysis used multivariable logistic regression modelling. The study population comprised 103,597 dogs under veterinary care in the UK during 2013. There were 413 drug-prescribed UBs recorded among 404 dogs. The prevalence of dogs with at least one UB event treated with a drug in 2013 was 0.4%. Multivariable modelling identified 3 breeds with increased odds of drug-prescribed UB compared with crossbred dogs: Toy Poodle (OR 2.75), Tibetan Terrier (OR 2.68) and Shih-tzu (OR 1.95). Increasing age was associated with increased odds of drug-prescribed UB, with dogs ≥ 12 years showing 3.1 times the odds compared with dogs < 3 years. Neutered males (OR 1.82) and entire males (OR 1.50) had increased odds compared with entire females. The relatively low prevalence of dogs with at least one UB event that was treated with a drug in 2013 could suggest that opportunities for useful psychopharmaceutical intervention in UBs may be being missed in first opinion veterinary practice. While bodyweight was not a significant factor, the 3 individual breeds at higher odds of an UB treated with a behaviour modifying drug all have a relatively low average bodyweight. The current results also support previous research of a male predisposition to UBs and it is possible that this higher risk resulted in the increased likelihood of being prescribed a behaviour modifying drug, regardless of neuter status.

Objectives Dental caries is the most common preventable childhood condition. Non-dental professionals and health workers are often well placed to support parents in adopting positive oral health behaviours for their children. The aim of this study was to determine the effectiveness of behaviour change interventions and their individual component behaviour change techniques (BCTs), that were delivered by non-dental professionals and health workers. Methods A systematic search of Ovid MEDLINE, PubMed, CINAHL, Cochrane Library, Web of Science, TRoPHI and PROQUEST from inception until March 2021 was conducted. Randomised controlled trials and quasi-experimental studies for improving oral health outcomes in children were included. Quality assessment was carried out using Cochrane Risk of Bias tool and ROBINS-I tool. Publication bias was assessed using funnel plots and Egger’s regression intercept. Effect sizes were estimated as standardised mean difference (SMD) and odds ratio/risk ratio for proportions. Meta-analyses were performed for studies reporting mean decayed, missing, filled surfaces (dmfs) and mean decayed, missing, filled, teeth (dmft) indices. Behaviour change technique coding was performed using behaviour change technique taxonomy v1 (BCTTv1). Results Out of the 9,101 records retrieved, 36 studies were included with 28 showing a significant effect either in clinical and/or behavioural/knowledge outcomes. Most studies (n = 21) were of poor methodological quality. The pooled SMD for caries experience showed statistically significant result for caries prevention at surface level -0.15 (95% CI -0.25, -0.04) and at the tooth level -0.24 (95% CI -0.42, -0.07). In 28 effective interventions, 27 individual BCTs were identified and the most frequently used were: “Instructions on how to perform the behaviour” and “Information about health consequences”. Conclusion There is low quality of evidence suggesting non-dental professionals and health workers may help improve oral health outcomes for children. To confirm these findings, further high-quality studies incorporating a variety of BCTs in their interventions for adoption of good oral health behaviours are needed.

Objective To evaluate the use of a COVID-19 app containing relevant information for healthcare workers (HCWs) in hospitals and to determine user experience. Methods A smartphone app (Firstline) was adapted to exclusively contain local COVID-19 policy documents and treatment protocols. This COVID-19 app was offered to all HCWs of a 900-bed tertiary care hospital. App use was evaluated with user analytics and user experience in an online questionnaire. Results A total number of 1168 HCWs subscribed to the COVID-19 app which was used 3903 times with an average of 1 minute and 20 seconds per session during a three-month period. The number of active users peaked in April 2020 with 1017 users. Users included medical specialists (22.3%), residents (16.5%), nurses (22.2%), management (6.2%) and other (26.5%). Information for HCWs such as when to test for SARS-CoV-2 (1214), latest updates (1181), the COVID-19 telephone list (418) and the SARS-CoV-2 / COVID-19 guideline (280) were the most frequently accessed advice. Seventy-one users with a mean age of 46.1 years from 19 different departments completed the questionnaire. Respondents considered the COVID-19 app clear (54/59; 92%), easy-to-use (46/55; 84%), fast (46/52; 88%), useful (52/56; 93%), and had faith in the information (58/70; 83%). The COVID-19 app was used to quickly look up something (43/68; 63%), when no computer was available (15/68; 22%), look up / dial COVID-related phone numbers (15/68; 22%) or when walking from A to B (11/68; 16%). Few respondents felt app use cost time (5/68; 7%). Conclusions Our COVID-19 app proved to be a relatively simple yet innovative tool that was used by HCWs from all disciplines involved in taking care of COVID-19 patients. The up-to-date app was used for different topics and had high user satisfaction amongst questionnaire respondents. An app with local hospital policy could be an invaluable tool during a pandemic.

Background Financial incentives and audit/feedback are widely used in primary care to influence clinician behaviour and increase quality of care. While observational data suggest a decline in quality when these interventions are stopped, their removal has not been evaluated in a randomised controlled trial (RCT), to our knowledge. This trial aimed to determine whether chlamydia testing in general practice is sustained when financial incentives and/or audit/feedback are removed. Methods and findings We undertook a 2 × 2 factorial cluster RCT in 60 general practices in 4 Australian states targeting 49,525 patients aged 16–29 years for annual chlamydia testing. Clinics were recruited between July 2014 and September 2015 and were followed for up to 2 years or until 31 December 2016. Clinics were eligible if they were in the intervention group of a previous cluster RCT where general practitioners (GPs) received financial incentives (AU$5–AU$8) for each chlamydia test and quarterly audit/feedback reports of their chlamydia testing rates. Clinics were randomised into 1 of 4 groups: incentives removed but audit/feedback retained (group A), audit/feedback removed but incentives retained (group B), both removed (group C), or both retained (group D). The primary outcome was the annual chlamydia testing rate among 16- to 29-year-old patients, where the numerator was the number who had at least 1 chlamydia test within 12 months and the denominator was the number who had at least 1 consultation during the same 12 months. We undertook a factorial analysis in which we investigated the effects of removal versus retention of incentives (groups A + C versus groups B + D) and the effects of removal versus retention of audit/feedback (group B + C versus groups A + D) separately. Of 60 clinics, 59 were randomised and 55 (91.7%) provided data (group A: 15 clinics, 11,196 patients; group B: 14, 11,944; group C: 13, 11,566; group D: 13, 14,819). Annual testing decreased from 20.2% to 11.7% (difference −8.8%; 95% CI −10.5% to −7.0%) in clinics with incentives removed and decreased from 20.6% to 14.3% (difference −7.1%; 95% CI −9.6% to −4.7%) where incentives were retained. The adjusted absolute difference in treatment effect was −0.9% (95% CI −3.5% to 1.7%; p = 0.2267). Annual testing decreased from 21.0% to 11.6% (difference −9.5%; 95% CI −11.7% to −7.4%) in clinics where audit/feedback was removed and decreased from 19.9% to 14.5% (difference −6.4%; 95% CI −8.6% to −4.2%) where audit/feedback was retained. The adjusted absolute difference in treatment effect was −2.6% (95% CI −5.4% to −0.1%; p = 0.0336). Study limitations included an unexpected reduction in testing across all groups impacting statistical power, loss of 4 clinics after randomisation, and inclusion of rural clinics only. Conclusions Audit/feedback is more effective than financial incentives of AU$5–AU$8 per chlamydia test at sustaining GP chlamydia testing practices over time in Australian general practice. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12614000595617, In a cluster randomized trial, Jane S Hocking and colleagues investigate the impact of removing financial incentives and/or audit and feedback on chlamydia testing in general practice in Australia., Author summary Why was this study done? Financial incentives and audit/feedback are widely used in primary care to influence clinician behaviour and increase quality of care. As healthcare costs continue to increase, governments and funding agencies are reassessing funding models for primary care, with widespread cuts to financial incentives. While observational data suggest a decline in quality when these interventions are stopped, their removal has not been evaluated in a randomised controlled trial (RCT). What did the researchers do and find? We conducted a 2 × 2 factorial cluster RCT in Australian general practices that aimed to determine the impact on chlamydia testing in general practice when incentive payments per activity and/or audit/feedback on activity performance were removed. Clinics were randomised into 1 of 4 groups: incentives removed but audit/feedback retained, audit/feedback removed but incentives retained, both removed, and both retained. The primary outcome was the annual chlamydia testing rate among 16- to 29-year-old patients. We found that removal of incentive payments had little impact on general practice chlamydia testing, but the removal of audit and feedback reduced testing. What do these results mean? Our payments were consistent with other incentives general practitioners (GPs) received at the time, suggesting that in the Australian general practice setting, incentive payments of this amount do not have a substantial impact on influencing GP preventive healthcare activities such as chlamydia testing. The removal of quarterly audit and feedback for GPs had a greater impact on testing rates, reflecting the importance of this strategy in influencing GP preventive healthcare activities. The provision of audit and feedback was costlier than the provision of financial incentives. However, using online video conferencing and fully automating the audit and feedback reports would reduce costs. Our results suggest that, in Australia at least, audit and feedback is more effective than incentive payments of AU$5 to AU$8 per activity at influencing GP behaviour.