Search

Background: Cross-country comparisons of unofficial payments in the health sector are sparse. In 2002 we conducted a social audit of the health sector of the three Baltic States.Methods: Some 10,320 household interviews from a stratified, last-stage-random, sample of 30 clusters per country, together with institutional reviews, produced preliminary results. Separate focus groups of service users, nurses and doctors interpreted these findings. Stakeholder workshops in each country discussed the survey and focus group results.Results: Nearly one half of the respondents did not consider unofficial payments to health workers to be corruption, yet one half (Estonia 43%, Latvia 45%, Lithuania 64%) thought the level of corruption in government health services was high. Very few (Estonia 1%, Latvia 3%, Lithuania 8%) admitted to making unofficial payments in their last contact with the services. Around 14% of household members across the three countries gave gifts in their last contact with government services.Conclusion: This social audit allowed comparison of perceptions, attitudes and experience regarding unofficial payments in the health services of the three Baltic States. Estonia showed least corruption. Latvia was in the middle. Lithuania evidenced the most unofficial payments, the greatest mistrust towards the system. These findings can serve as a baseline for interventions, and to compare each country's approach to health service reform in relation to unofficial payments. [ABSTRACT FROM AUTHOR]

Background: Gender inequities remain critical determinants influencing maternal health. Harmful gender norms and gender-based violence adversely affect maternal health. Gendered division of labour, lack of access to and control of resources, and limited women's decision-making autonomy impede women's access to maternal healthcare services. We undertook a cluster randomized controlled trial of universal home visits to pregnant women and their spouses in one local government area in Bauchi State, North-Eastern Nigeria. The trial demonstrated a significant improvement in maternal and child health outcomes and male knowledge, attitudes and behaviours. This paper qualitatively evaluates gender equity in the home visits programme., Methods: The research team explored participants' views about gender equity in the home visits programme. We conducted nine key informant interviews with policymakers and 14 gender and age-stratified focus group discussions with men and women from visited households, with women and men home visitors and supervisors, and with men and women community leaders. Analysis used an adapted conceptual framework exploring gender equity in mainstream health. A deductive thematic analysis of interviews and focus group reports looked for patterns and meanings., Results: All respondents considered the home visits programme to have a positive impact on gender equity, as they perceived gender equity. Visited women and men and home visitors reported increased male support for household chores, with men doing heavy work traditionally pre-assigned to women. Men increased their support for women's maternal health by paying for healthcare and providing nutritious food. Households and community members confirmed that women no longer needed their spouses' permission to use health services for their own healthcare. Households and home visitors reported an improvement in spousal communication. They perceived a significant reduction in domestic violence, which they attributed to the changing attitudes of both women and men due to the home visits. All stakeholder groups stressed the importance of engaging male spouses in the home visits programme., Conclusion: The home visits programme, as implemented, contributed to gender equity., (© 2024. The Author(s).)

Background: Fuzzy cognitive mapping (FCM) is a graphic technique to describe causal understanding in a wide range of applications. This practice review summarises the experience of a group of participatory research specialists and trainees who used FCM to include stakeholder views in addressing health challenges. From a meeting of the research group, this practice review reports 25 experiences with FCM in nine countries between 2016 and 2023., Results: The methods, challenges and adjustments focus on participatory research practice. FCM portrayed multiple sources of knowledge: stakeholder knowledge, systematic reviews of literature, and survey data. Methodological advances included techniques to contrast and combine maps from different sources using Bayesian procedures, protocols to enhance the quality of data collection, and tools to facilitate analysis. Summary graphs communicating FCM findings sacrificed detail but facilitated stakeholder discussion of the most important relationships. We used maps not as predictive models but to surface and share perspectives of how change could happen and to inform dialogue. Analysis included simple manual techniques and sophisticated computer-based solutions. A wide range of experience in initiating, drawing, analysing, and communicating the maps illustrates FCM flexibility for different contexts and skill bases., Conclusions: A strong core procedure can contribute to more robust applications of the technique while adapting FCM for different research settings. Decision-making often involves choices between plausible interventions in a context of uncertainty and multiple possible answers to the same question. FCM offers systematic and traceable ways to document, contrast and sometimes to combine perspectives, incorporating stakeholder experience and causal models to inform decision-making. Different depths of FCM analysis open opportunities for applying the technique in skill-limited settings., (© 2024. The Author(s).)

Background: The use of temephos, the most common intervention for the chemical control of Aedes aegypti over the last half century, has disappointing results in control of the infection. The footprint of Aedes and the diseases it carries have spread relentlessly despite massive volumes of temephos. Recent advances in community participation show this might be more effective and sustainable for the control of the dengue vector., Methods: Using data from the Camino Verde cluster randomized controlled trial, a compartmental mathematical model examines the dynamics of dengue infection with different levels of community participation, taking account of gender of respondent and exposure to temephos., Results: Simulation of dengue endemicity showed community participation affected the basic reproductive number of infected people. The greatest short-term effect, in terms of people infected with the virus, was the combination of temephos intervention and community participation. There was no evidence of a protective effect of temephos 220 days after the onset of the spread of dengue., Conclusions: Male responses about community participation did not significantly affect modelled numbers of infected people and infectious mosquitoes. Our model suggests that, in the long term, community participation alone may have the best results. Adding temephos to community participation does not improve the effect of community participation alone., (© 2024. The Author(s).)

Background: Parkinson's disease (PD) drastically affects motor and cognitive function, but evidence shows that motor-cognitive training improves disease symptoms. Motor-cognitive training in the home is scarcely investigated and eHealth methods can provide continual support for PD self-management. Feasibility testing is however required., Objective: To assess the feasibility (i) Recruitment capability (ii) Acceptability and Suitability (iii) Demand and Safety of a home-based motor-cognitive eHealth exercise intervention in PD., Methods: The 10-week intervention was delivered using the ExorLive® application and exercises were individually adapted and systematically progressed and targeted functional strength, cardiovascular fitness, flexibility, and motor-cognitive function. People with mild-to moderate PD were assessed before and after the intervention regarding; gait performance in single and dual-task conditions; functional mobility; dual-task performance; balance performance; physical activity level; health related quality of life and perceived balance confidence and walking ability; global cognition and executive function. Feasibility outcomes were continuously measured using a home-exercise diary and contact with a physiotherapist. Changes from pre- and post-intervention are reported descriptively., Results: Fifteen participants (mean age 68.5 years) commenced and 14 completed the 10-week intervention. In relation to intervention Acceptability, 64% of the motor sessions and 52% of motor-cognitive sessions were rated as "enjoyable". Concerning Suitability, the average level of exertion (Borg RPE scale) was light (11-12). Adherence was high, with 86% of all (420) sessions reported as completed. No falls or other adverse events occurred in conjunction with the intervention., Conclusions: This motor-cognitive eHealth home exercise intervention for PD was safe and feasible in terms of Recruitment capability, Acceptability, Safety and Demand. The intensity of physical challenge needs to be increased before testing in an efficacy trial., Trial Registration: This trial is registered at Clinicaltrials.gov (NCT05027620)., (© 2024. The Author(s).)

Background: The COVID-19 pandemic has impacted on public health in several ways. The aim of the study was to investigate changes in lifestyle, adiposity, and cardiometabolic markers among young adults in Sweden during the COVID-19 pandemic and their determinants., Methods: The study included 1 004 participants from the population-based birth cohort BAMSE. Anthropometrics, body composition (bioelectric impedance analyses), pulse, and blood pressure were measured before (December 2016-May 2019; mean age 22.6 years) and during (October 2020-June 2021; mean age 25.7 years) the COVID-19 pandemic. Lifestyle changes during the pandemic were assessed through a questionnaire., Results: All measures of adiposity (weight, BMI, body fat percentage, trunk fat percentage) and cardiometabolic markers (blood pressure, pulse) increased during the study period (e.g., body fat percentage by a median of + 0.8% in females, p < 0.001, and + 1.5% in males, p < 0.001). Male sex, non-Scandinavian ethnicity, BMI status (underweight and obesity), and changes in lifestyle factors, e.g., decreased physical activity during the pandemic, were associated with higher increase in BMI and/or adiposity., Conclusion: Lifestyle factors, adiposity and cardiometabolic markers may have been adversely affected among young adults in Sweden during the COVID-19 pandemic compared with the preceding years. Targeted public health measures to reduce obesity and improve healthy lifestyle are important to prevent future non-communicable diseases., (© 2023. The Author(s).)

Background: During the transition from paediatric to adult healthcare there is a gap between asthma guidelines and actual management with decreased healthcare consultations and dispensations of asthma medications after the transition to adult healthcare among young people with asthma. How health-related quality of life (HRQoL) develops during the transition from adolescence to young adulthood is unclear. Our aim was therefore to investigate HRQoL among young people with asthma during the transition to adulthood. Further, to assess if level of asthma control and physical activity influence any potential association between asthma and HRQoL., Methods: The study population consisted of 2268 participants from the ongoing Swedish population-based prospective birth cohort BAMSE (Barn/Child, Allergy, Milieu, Stockholm, Epidemiology). HRQoL was measured using the instrument EQ-5D-3 L and three general questions. The EQ-5D-3 L consists of the EQ-5D descriptive system and the EQ visual analogue scale (EQ VAS). The EQ-5D-3 L instrument and questions on general health, symptoms and treatment of asthma, and lifestyle factors were based on data from follow-ups at 16 and 24 years. Cross-sectional analyses were made., Results: At the 24-year follow-up, the adjusted median values of EQ VAS were lower compared with at the 16-year follow-up; among both participants with asthma (80 vs. 85, p < 0.01) and those without asthma (80 vs. 87, p < 0.01). At the 24-year follow-up, participants with uncontrolled asthma had a lower adjusted median EQ VAS score than peers with controlled/partly controlled asthma (75 vs. 80, p = 0.03). Further, young adults with asthma who did not fulfil the WHO recommendations on physical activity had lower EQ VAS scores than peers who did (70 vs. 80, p < 0.01)., Conclusion: HRQoL is lower in young adulthood than in adolescence. Young adults with asthma having uncontrolled disease or who are physically inactive appear to be particularly vulnerable., (© 2023. The Author(s).)

Background: Cultural safety training, whereby health professionals learn to reflect on their own culture and to respect the cultural identity of patients, could address intercultural tensions in health care. Given the context of their medical education, however, medical students might perceive such training to be dull or even unnecessary. Game jams, collaborative workshops to create and play games, are a potentially engaging learning environment for medical students today. How medical students learn while making games is poorly documented. This study describes the characteristics of educational games created by participants in a cultural safety game jam and the concepts they used to create games., Methods: As part of a trial, 268 Colombian medical students divided into 48 groups participated in an eight-hour game jam to create a prototype of an educational game on cultural safety. In this qualitative descriptive study, we reviewed the description of the games uploaded by participants, including the name, objective, game narrative, rules, rewards, penalties, and pictures. An inductive thematic analysis collated their descriptions., Results: The game descriptions illustrated the characteristics of the educational games and the aspects of the cultural safety concept that the students used to create games. Medical students situated cultural safety within a continuum with culturally unsafe actions at one end and cultural safety at the other end. Although not familiar with game design, the students designed prototypes of basic educational games including game dynamics, game scenarios, learning objectives, and pedagogical strategies., Conclusion: The findings of this study could help researchers and educators to understand how medical students learn from game design and the kind of games that game jam participants can create without previous game design skills., (© 2022. The Author(s).)

Background: Cultural safety training is not yet standard in Colombian medical education. If incorporated, it could address currently adversarial interactions between health professionals and the 40% of people who use traditional medicine practices. In 2019, a randomised controlled trial tested the impact of cultural safety training for medical students using participatory serious game design. The quantitative evaluation showed improved cultural safety intentions of Colombian medical trainees. We report here a qualitative evaluation of the most significant change perceived by trial participants., Methods: This qualitative descriptive study used the most significant change technique. We invited the trial participants engaged in clinical settings to describe stories of change in their supervised clinical practice that they attributed to the intervention. Using a deductive thematic analysis based on a modified theory of planned behaviour, two independent reviewers coded the stories and, by consensus, created themes and sub-themes., Results: From 27 stories of change, we identified seven themes and 15 subthemes: (a) Conscious knowledge: benefits of cultural safety training, consequences of culturally unsafe behaviour, cultural diversity and cultural practices; (b) Attitudes: respect and appreciation for cultural diversity, openness, and self-awareness; (c) Subjective norms: positive perception of cultural practices and less ethnocentrism; (d) Intention to Change; (e) Agency to accept cultural diversity and to prevent culturally unsafe actions; (f) Discussion; and (g) Action: better communication and relationship with patients and peers, improved outcomes for patients, physicians, and society, investigation about cultural health practices, and efforts to integrate modern medicine and cultural health practices., Conclusion: The narratives illustrated the transformative impact of cultural safety training on a results chain from conscious knowledge through to action. Our results encourage medical educators to report other cultural safety training experiences, ideally using patient-related outcomes or direct observation of medical trainees in clinical practice., Trial Registration: Registered on ISRCTN registry on 18/07/2019., Registration Number: ISRCTN14261595., (© 2022. The Author(s).)

Background: Nurses play an active role in supporting the children with the blood sampling experience. Unfortunately, the blood sampling collection procedure is often affected by pre-analytical errors, leading to consequences such as delayed diagnosis as well as repeated sampling. Moreover, children state that needle procedures are the worst experience of their hospital stay. The nurses' experiences of errors occurring during blood sample collection is unknown. Therefore, the aim of this study therefore was to describe paediatric nurses' experiences of blood sampling collections from children., Method: We used a qualitative study design with a (reflexive) thematic analysis (TA) method described by Braun and Clarke. Three focus group interviews were conducted, with 19 nurses collected by purposeful sampling from Sweden working at two different paediatric hospitals, focusing on their experiences of the blood sample collection procedure., Results: From the three focus group interviews we analysed patterns and meanings of the following main theme Paediatric blood sampling is a challenge for the nurses and the four subthemes Nurses' feelings of frustration with unsuccessful samplings, Nurses believe in team work, Venous blood sampling was experienced as the best option, and Nurses' thoughts and needs regarding skills development in paediatric blood sampling., Conclusion: The narrative results of this study illustrate that nurses working in paediatric hospital care face a big challenge in blood sampling collection from children. The nurses felt frustrated due to unsuccessful blood samplings and frequently could not understand why pre-analytical errors occurred. Nevertheless, they felt strengthened by colleagues in their team and shared feelings of responsibility to help each other with this complex procedure. The implications of this study are that paediatric hospital care needs to focus on improving guidelines for and increasing competence in blood sampling children and helping nurses to understand why samplings may be unsuccessful and how this can be avoided., (© 2022. The Author(s).)

Background: Available research on the contribution of traditional midwifery to safe motherhood focuses on retraining and redefining traditional midwives, assuming cultural prominence of Western ways. Our objective was to test if supporting traditional midwives on their own terms increases cultural safety (respect of Indigenous traditions) without worsening maternal health outcomes., Methods: Pragmatic parallel-group cluster-randomised controlled non-inferiority trial in four municipalities in Guerrero State, southern Mexico, with Nahua, Na savi, Me'phaa and Nancue ñomndaa Indigenous groups. The study included all pregnant women in 80 communities and 30 traditional midwives in 40 intervention communities. Between July 2015 and April 2017, traditional midwives and their apprentices received a monthly stipend and support from a trained intercultural broker, and local official health personnel attended a workshop for improving attitudes towards traditional midwifery. Forty communities in two control municipalities continued with usual health services. Trained Indigenous female interviewers administered a baseline and follow-up household survey, interviewing all women who reported pregnancy or childbirth in all involved municipalities since January 2016. Primary outcomes included childbirth and neonatal complications, perinatal deaths, and postnatal complications, and secondary outcomes were traditional childbirth (at home, in vertical position, with traditional midwife and family), access and experience in Western healthcare, food intake, reduction of heavy work, and cost of health care., Results: Among 872 completed pregnancies, women in intervention communities had lower rates of primary outcomes (perinatal deaths or childbirth or neonatal complications) (RD -0.06 95%CI - 0.09 to - 0.02) and reported more traditional childbirths (RD 0.10 95%CI 0.02 to 0.18). Among institutional childbirths, women from intervention communities reported more traditional management of placenta (RD 0.34 95%CI 0.21 to 0.48) but also more non-traditional cold-water baths (RD 0.10 95%CI 0.02 to 0.19). Among home-based childbirths, women from intervention communities had fewer postpartum complications (RD -0.12 95%CI - 0.27 to 0.01)., Conclusions: Supporting traditional midwifery increased culturally safe childbirth without worsening health outcomes. The fixed population size restricted our confidence for inference of non-inferiority for mortality outcomes. Traditional midwifery could contribute to safer birth among Indigenous communities if, instead of attempting to replace traditional practices, health authorities promoted intercultural dialogue., Trial Registration: Retrospectively registered ISRCTN12397283 . Trial status: concluded., (© 2022. The Author(s).)

Background: Universal home visits to pregnant women and their spouses in Bauchi State, northern Nigeria, discussed local evidence about maternal and child health risks actionable by households. The expected results chain for improved health behaviours resulting from the visits was based on the CASCADA model, which includes Conscious knowledge, Attitudes, Subjective norms, intention to Change, Agency to change, Discussion of options, and Action to change. Previous quantitative analysis confirmed the impact of the visits on maternal and child outcomes. To explore the mechanisms of the quantitative improvements, we analysed participants' narratives of changes in their lives they attributed to the visits., Methods: Local researchers collected stories of change from 23 women and 21 men in households who had received home visits, from eight male and eight female home visitors, and from four government officers attached to the home visits program. We used a deductive thematic analysis based on the CASCADA results chain to analyze stories from women and men in households, and an inductive thematic approach to analyze stories from home visitors and government officials., Results: The stories from the visited women and men illustrated all steps in the CASCADA results chain. Almost all stories described increases in knowledge. Stories also described marked changes in attitudes and positive deviations from harmful subjective norms. Most stories recounted a change in behaviour attributed to the home visits, and many went on to mention a beneficial outcome of the behaviour change. Men, as well as women, described significant changes. The home visitors' stories described increases in knowledge, increased self-confidence and status in the community, and, among women, financial empowerment., Conclusions: The narratives of change gave insights into likely mechanisms of impact of the home visits, at least in the Bauchi setting. The compatibility of our findings with the CASCADA results chain supports the use of this model in designing and analysing similar interventions in other settings. The indication that the home visits changed male engagement has broader relevance and contributes to the ongoing debate about how to increase male involvement in reproductive health., (© 2021. The Author(s).)

Background: Nigeria is the second biggest contributor to global child mortality. Infectious diseases continue to be major killers. In Bauchi State, Nigeria, a stepped wedge cluster randomised controlled trial tested the health impacts of universal home visits to pregnant women and their spouses. We present here the findings related to early child health., Methods: The home visits took place in eight wards in Toro Local Government Authority, randomly allocated into four waves with a delay of 1 year between waves. Female and male home visitors visited all pregnant women and their spouses every 2 months during pregnancy, with a follow up visit 12-18 months after the birth. They presented and discussed evidence about household prevention and management of diarrhoea and immunisation. We compared outcomes among children 12-18 months old born to mothers visited during the first year of intervention in each wave (intervention group) with those among children 12-18 months old pre-intervention in subsequent waves (control group). Primary outcomes included prevalence and management of childhood diarrhoea and immunisation status, with intermediate outcomes of household knowledge and actions. Generalised Estimating Equations (GEE), with an exchangeable correlation matrix and ward as cluster, tested the significance of differences in outcomes., Results: The analysis included 1796 intervention and 5109 control children. In GEE models including other characteristics of the children, intervention children were less likely to have suffered diarrhoea in the last 15 days (Odds Ratio (OR) 0.40, 95% confidence interval (CI) 0.30-0.53) and more likely to have received increased fluids and continued feeding in their last episode of diarrhoea (OR 6.06, 95% CI 2.58-14.20). Mothers of intervention children were more likely to identify lack of hygiene as a cause of diarrhoea (OR 2.24, 95% CI 1.27-3.95) and their households had better observed hygiene (OR 3.29, 95% CI 1.45-7.45). Intervention children were only slightly more likely to be fully immunised (OR 1.67, 95% CI 0.78-3.57)., Conclusions: Evidence-based home visits to both parents stimulated household actions that improved prevention and management of childhood diarrhoea. Such visits could help to improve child health even in settings with poor access to quality health services., Trial Registration: ISRCTN82954580 . Date: 11/08/2017. Retrospectively registered., (© 2021. The Author(s).)

Purpose: This study describes an interdiscursive evidence-based priority setting process with pregnant and parenting adolescents and their services providers., Methods: A mixed methods literature review identified studies reporting on perinatal outcomes and experiences of adolescents during pregnancy to 12 months post-partum published in Canada after 2000. We also calculated relative risks for common perinatal risk factors and outcomes for adolescents compared to adult populations from 2012 to 2017 based on data from a provincial database of maternal and newborn outcomes. Two trained peer researchers identified outcomes most relevant to their peers. We shared syntheses results with four service providers and 13 adolescent mothers accessing services at a community service organization, who identified and prioritized their areas of concern. We repeated the process for the identified priority issue and expanded upon it through semi-structured interviews., Results: Adolescent mothers face higher rates of poverty, abuse, anxiety and depression than do adult mothers. Adolescents prioritized the experience of judgment in perinatal health and social services, particularly as it contributed to them being identified as a child protection risk. Secondary priorities included loss of social support and inaccessibility of community resources. The experience of judgment in adolescent perinatal health literature was summarized around: being invisible, seen as incapable and seen as a risk. Adolescent mothers adapted these categories, emphasizing organizational and social barriers., Conclusions: Young marginalized women are disproportionately affected by inequities in perinatal outcomes, yet their perspectives are rarely centered in efforts to address these inequities. This research addresses health inequities by presenting a robust, transparent and participatory approach to priority setting as a way to better represent the perspectives of those who carry the greatest burden of health inequities in evidence syntheses. In our work, marginalized adolescent parents adapted published literature around the experience and consequences of social stigma on perinatal outcomes, shifting our understanding of root causes and possible solutions.

Background: Short birth interval is associated with adverse perinatal, maternal, and infant outcomes, although evidence on actionable factors underlying short birth interval remains limited. We explored women and community views on short birth intervals to inform potential solutions to promote a culturally safe child spacing in Northern Uganda., Methods: Gendered fuzzy cognitive mapping sessions (n = 21), focus group discussions (n = 12), and an administered survey questionnaire (n = 255) generated evidence on short birth intervals. Deliberative dialogues with women, their communities, and service providers suggested locally relevant actions promote culturally safe child spacing., Results: Women, men, and youth have clear understandings of the benefits of adequate child spacing. This knowledge is difficult to translate into practice as women are disempowered to exercise child spacing. Women who use contraceptives without their husbands' consent risk losing financial and social assets and are likely to be subject to intra-partner violence. Women were not comfortable with available contraceptive methods and reported experiencing well-recognized side effects. They reported anxiety about the impact of contraception on the health of their future children. This fear was fed by rumors in their communities about the effects of contraceptives on congenital diseases. The women and their communities suggested a home-based sensitization program focused on improving marital relationships (spousal communication, mutual understanding, male support, intra-partner violence) and knowledge and side-effects management of contraceptives., Conclusions: The economic context, gender power dynamics, inequality, gender bias in land tenure and ownership regulations, and the limited contraceptive supply reduce women's capacity to practice child spacing.

Background: Short birth intervals, defined by the World Health Organization as less than 33 months, may damage the health and wellbeing of children, mothers, and their families. People in northern Nigeria recognise many adverse effects of short birth interval (kunika in the Hausa language) but it remains common. We used fuzzy cognitive mapping to systematize local knowledge of causes of kunika to inform the co-design of culturally safe strategies to address it., Methods: Male and female groups in twelve communities built 48 maps of causes and protective factors for kunika, and government officers from the Local Government Area (LGA) and State made four maps. Each map showed causes of kunika or no-kunika, with arrows showing relationships with the outcome and between causes. Participants assigned weights for the perceived strength of relationships between 5 (strongest) and 1 (weakest). We combined maps for each group: men, women, and government officers. Fuzzy transitive closure calculated the maximum influence of each factor on the outcome, taking account of all relationships in the map. To condense the maps, we grouped individual factors into broader categories and calculated the cumulative net influence of each category. We made further summarised maps and presented these to the community mapping groups to review., Results: The community maps identified frequent sex, not using modern or traditional contraception, and family dynamics (such as competition between wives) as the most influential causes of kunika. Women identified forced sex and men highlighted lack of awareness about contraception and fear of side effects as important causes of kunika. Lack of male involvement featured in women's maps of causes and in the maps from LGA and State levels. Maps of protective factors largely mirrored those of the causes. Community groups readily appreciated and approved the summary maps resulting from the analysis., Conclusions: The maps showed how kunika results from a complex network of interacting factors, with culture-specific dynamics. Simply promoting contraception alone is unlikely to be enough to reduce kunika. Outputs from transitive closure analysis can be made accessible to ordinary stakeholders, allowing their meaningful participation in interpretation and use of the findings. For people in Bauchi State, northern Nigeria, kunika describes a short interval between successive births, understood as becoming pregnant again before the previous child is weaned. They recognise it is bad for children, mothers and households. We worked with 12 communities in Bauchi to map their knowledge of the causes and protective factors for kunika. Separate groups of men and women built 48 maps, and government officers at local and state level built four maps. Each group drew two maps showing causes of kunika or of no-kunika with arrows showing the links between causes and the outcome. Participants marked the strength of each link with a number (between 5 for the strongest and 1 for the weakest). We combined maps for women, men and government officers. We grouped similar causes together into broader categories. We calculated the overall influence of each category on kunika or no-kunika and produced summary maps to communicate findings. The maps identified the strongest causes of kunika as frequent sex, not using modern or traditional contraception, and family dynamics. Women indicated forced sex as an important cause, but men focused on lack of awareness about contraception and fear of side effects. The maps of protective factors mirrored those of the causes. The groups who created the maps approved the summary maps. The maps showed the complex causes of kunika in Bauchi. Promoting contraception is unlikely to be enough on its own to reduce kunika. The summary maps will help local stakeholders to co-design culturally safe ways of reducing kunika.

Background: Cultural safety, whereby health professionals respect and promote the cultural identity of patients, could reduce intercultural tensions that hinder patient access to effective health services in Colombia. Game jams are participatory events to create educational games, a potentially engaging learning environment for Millennial medical students. We set out to determine whether medical student participation in a game jam on cultural safety is more effective than more conventional education in changing self-reported intended patient-oriented behavior and confidence in transcultural skills., Methods: We conducted a parallel-group, two-arm randomized controlled trial with 1:1 allocation. Colombian medical students and medical interns at University of La Sabana participated in the trial. The intervention was a game jam to create an educational game on cultural safety, and the reference was a standard lesson plus an interactive workshop on cultural safety. Both sessions lasted eight hours. Stratified randomization allocated the participants to the intervention and control groups, with masked allocation until commencement., Results: 531 students completed the baseline survey, 347 completed the survey immediately after the intervention, and 336 completed the survey after 6 months. After the intervention, game jam participants did not have better intentions of culturally safe behaviour than did participants in the reference group (difference in means: 0.08 95% CI - 0.05 to 0.23); both groups had an improvement in this outcome. Multivariate analysis adjusted by clusters confirmed that game jam learning was associated with higher transcultural self-efficacy immediately after the intervention (wt OR 2.03 cl adj 95% CI 1.25-3.30)., Conclusions: Game jam learning improved cultural safety intentions of Colombian medical students to a similar degree as did a carefully designed lecture and interactive workshop. The game jam was also associated with positive change in participant transcultural self-efficacy. We encourage further research to explore the impact of cultural safety training on patient-related outcomes. Our experience could inform initiatives to introduce cultural safety training in other multicultural settings., Trial Registration: Registered on ISRCTN registry on July 18th 2019. Registration number: ISRCTN14261595 .

Background: The Most Significant Change is a story-based evaluation approach used in many international development programs. This practice review summarises practical experience with the approach in complex health interventions in ten countries, with the objective of making it more accessible in evaluation of other complex health interventions., Results: Participatory research practitioners and trainees discussed five themes following brief presentations by each of the seven attendees who led the exercise: (i) sampling and recruitment; (ii) phrasing the questions to elicit stories; (iii) story collection strategies; (iv) quality assurance; and (v) analysis. Notes taken during the meeting provided the framework for this article. Recruitment strategies in small studies included universal engagement and, in larger studies, a purposive, systematic or random sampling. Meeting attendees recommended careful phrasing and piloting of the question(s) as this affects the quality and focus of the stories generated. They stressed the importance of careful training and monitoring of fieldworkers collecting stories to ensure full stories are elicited and recorded. For recording, in most settings they preferred note taking with back-checking or self-writing of stories by story tellers, rather than audio-recording. Analysis can combine participatory selection of a small number of stories, deductive or inductive thematic analysis and discourse analysis. Meeting attendees noted that involvement in collection of the stories and their analysis and discussion had a positive impact for research team members., Conclusions: Our review confirms the plasticity, feasibility and acceptability of the Most Significant Change technique across different sociopolitical, cultural and environmental contexts of complex interventions. Although the approach can surface unexpected impacts, it is not a 360-degree evaluation. Its strength lies in characterising the changes, where these happen, in the words of the beneficiaries. We hope this distillation of our practice makes the technique more readily available to health sector researchers.

Background: Screening across a multitude of normal and malignant tissues revealed an enhanced expression of lymphocyte antigen 6 superfamily member D (LY6D) in squamous epithelium and urothelium, as well as in malignancies derived therefrom. The aim of this study was to further delineate the protein expression of LY6D in urothelial bladder cancer, with particular attention to its relationship with clinicopathological characteristics and patient outcome., Methods: Immunohistochemical expression of LY6D was assessed in tissue microarrays with urothelial bladder cancer tumours from three independent patient cohorts; one with transurethral resection of the bladder (TURB) specimens of mixed tumour stages from 110 consecutive cases, one with tumours of mixed stages from 260 incident cases in a population-based cohort, and one with paired TURB specimens, resected tumours and a subset of lymph node metastases from 145 patients with muscle-invasive bladder cancer (MIBC). Chi-square and non-parametric tests were applied to examine associations of LY6D expression with clinicopathological characteristics. Kaplan-Meier and Cox regression analyses were applied to examine 5-year overall survival (OS) and recurrence free survival (RFS) in relation to LY6D expression., Results: In the two cohorts with mixed stages, positive LY6D expression was denoted in 63 and 64% of the cases, respectively, and found to be significantly higher in low-grade and less invasive tumours. Negative LY6D expression was significantly associated with a reduced 5-year OS, although not independently of established prognostic factors. In the population-based cohort, LY6D expression was higher in tumours with squamous differentiation and lower in other variant histologies compared to pure urothelial tumours, and the association of LY6D expression with survival was somewhat enhanced after exclusion of the former. LY6D expression was generally lower in the MIBC cohort, and even more reduced in resected tumours compared to TURB specimens in patients who had not received neoadjuvant chemotherapy. There were no significant associations between LY6D expression and RFS, neither allover nor in relation to neoadjuvant chemotherapy., Conclusion: LY6D is a marker of urothelial and squamous differentiation that may add useful diagnostic and prognostic information to better guide the clinical management of bladder cancer, given that the presence of variant histology is taken into account., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s) 2020.)

Background: Among Canadian Inuit, cervical cancer incidence and mortality rates are up to three times higher than the Canadian average. Cervical cancer is preventable through regular screening which, in Quebec, is opportunistic and requires physical examination and Papanicolaou ("Pap") smears. Since Human Papillomavirus (HPV) is the necessary cause of cervical cancer, HPV testing is a plausible screening alternative. HPV testing by self-sampling also addresses several barriers associated with physical examination and access to healthcare. In a participatory research paradigm, we worked with two communities of Nunavik to explore the possible implementation of HPV self-sampling., Method: Key community stakeholders formed an Advisory Committee to guide direct discussions with Inuit women. We presented available facts around cervical cancer, HPV and the female anatomy, and used Fuzzy Cognitive Mapping to collate women's views. A thematic analysis summarized data, adding links and weights to represent the relationship of each factor on the outcome: screening for cervical cancer., Results: According to the 27 Inuit women who participated, the most influential factor in using health services was the cultural awareness of the healthcare provider. A significant barrier to screening was patient lack of information. The principal vector of change - the factor most likely to influence other factors - was the means of communication between the healthcare provider and the patient: visual communication was told to be the most effective., Conclusion: Fuzzy Cognitive Mapping is a practical tool for discussing possible health actions with stakeholders and to inform future research. The tool offers a visual aid for discussion across cultural and educational differences. It can help to build the partnerships that incorporate community voices into co-design of interventions that are relevant to and aligned with the needs of those who use them.

Background: In Northern Nigeria, short birth interval is common. The word kunika in the Hausa language describes a woman becoming pregnant before weaning her last child. A sizeable literature confirms an association between short birth interval and adverse perinatal and maternal health outcomes. Yet there are few reported studies about how people view short birth interval and its consequences. In support of culturally safe child spacing in Bauchi State, in North East Nigeria, we explored local perspectives about kunika and its consequences., Methods: A qualitative descriptive study included 12 gender-segregated focus groups facilitated by local men and women in six communities from the Toro Local Government Area in Bauchi State. Facilitators conducted the groups in the Hausa language and translated the reports of the discussions into English. After an inductive thematic analysis, the local research team reviewed and agreed the themes in a member-checking exercise., Results: Some 49 women and 48 men participated in the 12 focus groups, with an average of eight people in each group. All participants were married with ages ranging from 15 to 45 years. They explained their understanding of kunika, often in terms of pregnancy while breastfeeding. They described many disadvantages of kunika, including health complications for the mother and children, economic consequences, and adverse impact on men's health and family dynamics. The groups concluded that some people still practise kunika, either intentionally (for example, in order to increase family size or because of competition between co-wives) or unintentionally (for example, because of frequent unprotected sex), and explained the roles of men and women in this., Conclusion: Men and women in our study had a clear understanding of the concept of kunika. They recognized many adverse consequences of kunika beyond the narrow health concerns reported in quantitative studies. Their highlighted impacts of kunika on men's wellbeing can inform initiatives promoting the role of men in addressing kunika.

Background: Effective health care requires services that are responsive to local needs and contexts. Achieving this in indigenous settings implies communication between traditional and conventional medicine perspectives. Adequate interaction is especially relevant for maternal health because cultural practices have a notable role during pregnancy, childbirth and the postpartum period. Our work with indigenous communities in the Mexican state of Guerrero used fuzzy cognitive mapping to identify actionable factors for maternal health from the perspective of traditional midwives., Methods: We worked with twenty-nine indigenous women and men whose communities recognized them as traditional midwives. A group session for each ethnicity explored risks and protective factors for maternal health among the Me'phaa and Nancue ñomndaa midwives. Participants mapped factors associated with maternal health and weighted the influence of each factor on others. Transitive closure summarized the overall influence of each node with all other factors in the map. Using categories set in discussions with the midwives, the authors condensed the relationships with thematic analysis. The composite map combined categories in the Me'phaa and the Nancue ñomndaa maps., Results: Traditional midwives in this setting attend to pregnant women's physical, mental, and spiritual conditions and the corresponding conditions of their offspring and family. The maps described a complex web of cultural interpretations of disease - "frío" (cold or coldness of the womb), "espanto" (fright), and "coraje" (anger) - abandonment of traditional practices of self-care, women's mental health, and gender violence as influential risk factors. Protective factors included increased male involvement in maternal health (having a caring, working, and loving husband), receiving support from traditional healers, following protective rituals, and better nutrition., Conclusions: The maps offer a visual language to present and to discuss indigenous knowledge and to incorporate participant voices into research and decision making. Factors with higher perceived influence in the eyes of the indigenous groups could be a starting point for additional research. Contrasting these maps with other stakeholder views can inform theories of change and support co-design of culturally appropriate interventions.

Background: There is ample evidence of associations between short birth interval and adverse maternal and child health outcomes, including infant and maternal mortality. Short birth interval is more common among women in low- and middle-income countries. Identifying actionable aspects of short birth interval is necessary to address the problem. To our knowledge, this is the first systematic review to systematize evidence on risk factors for short birth interval in low- and middle-income countries., Methods: A systematic mixed studies review searched PubMed, Embase, LILACS, and Popline databases for empirical studies on the topic. We included documents in English, Spanish, French, Italian, and Portuguese, without date restriction. Two independent reviewers screened the articles and extracted the data. We used the Mixed Methods Appraisal Tool to conduct a quality appraisal of the included studies. To accommodate variable definition of factors and outcomes, we present only a narrative synthesis of the findings., Results: Forty-three of an initial 2802 documents met inclusion criteria, 30 of them observational studies and 14 published after 2010. Twenty-one studies came from Africa, 18 from Asia, and four from Latin America. Thirty-two reported quantitative studies (16 studies reported odds ratio or relative risk, 16 studies reported hazard ratio), 10 qualitative studies, and one a mixed-methods study. Studies most commonly explored education and age of the mother, previous pregnancy outcome, breastfeeding, contraception, socioeconomic level, parity, and sex of the preceding child. For most factors, studies reported both positive and negative associations with short birth interval. Shorter breastfeeding and female sex of the previous child were the only factors consistently associated with short birth interval. The quantitative and qualitative studies reported largely non-overlapping results., Conclusions: Promotion of breastfeeding could help to reduce short birth interval and has many other benefits. Addressing the preference for a male child is complex and a longer-term challenge. Future quantitative research could examine associations between birth interval and factors reported in qualitative studies, use longitudinal and experimental designs, ensure consistency in outcome and exposure definitions, and include Latin American countries., Trial Registration: Prospectively registered on PROSPERO (International Prospective Register for Systematic Reviews) under registration number CRD42018117654.

Background: Dengue is increasing in its global presence with an estimated 4 billion people at-risk of infection in at least 128 countries. Despite the promising results of EcoHealth and community mobilization approaches to Aedes reduction, more evidence of their efficacy on reducing dengue risk is needed. The principal research question is to determine if interventions based upon community mobilization reduce the risk of dengue virus infection among children 3 to 9 years old compared to usual dengue control practice in Fortaleza, Brazil., Methods: The present study will follow a pragmatic cluster randomized controlled trial (cRCT) design with randomization at the census tract level with equal allocation to the two arms. In each arm, there will be 34 clusters of 86 children between 3 to 9 years old for an expected total of 5848 children enrolled in the study, assuming a risk reduction of 29.5% based upon findings from a previous multi-site cRCT. The primary outcomes are rates of anti-dengue Immunoglobulin G (IgG) seroconversion and adult female Aedes density. The intervention is based upon a participatory health research approach, Socializing Evidence for Participatory Action (SEPA), where the research evidence is used to foster community engagement and ownership of the health issue and solution. Following allocation, intervention communities will develop and implement their own solutions that will likely include a wide variety of collective events and media approaches. Data collection activities over a period of 3 years include household visits for blood collection, household surveys, and entomological surveys; and qualitative activities including focus groups, in-depth interviews, and document analysis to evaluate the process, acceptability, fidelity, and sustainability of the intervention. Study participants will be aware of their assignment and all research staff will be blinded although the intervention assignment will likely be revealed to field staff through interaction with participants., Discussion: The results of our study will provide evidence on community mobilization as an intervention for dengue control. We anticipate that if community mobilization is effective in Fortaleza, the results of this study will help develop evidence-based vector control programs in Brazil, and also in other countries struggling with Aedes-transmitted diseases., Trial Registration: ISRCTN66131315, registration date: 1 October 2018.

Background: Control of the Aedes aegypti mosquito is central to reducing the risk of dengue, zika, chikungunya, and yellow fever. Randomised controlled trials, including the Camino Verde trial in Mexico and Nicaragua, demonstrate the convincing impact of community mobilisation interventions on vector indices. These interventions might work through building social capital but little is known about the relationship between social capital and vector indices., Methods: A secondary analysis used data collected from 45 intervention clusters and 45 control clusters in the impact survey of the Mexican arm of the Camino Verde cluster randomised controlled trial. Factor analysis combined responses to questions about aspects of social capital to create a social capital index with four constructs, their weighted averages then combined into a single scale. We categorised households as having high or low social capital based on their score on this scale. We examined associations between social capital and larval and pupal vector indices, taking account of the effects of other variables in a multivariate analysis. We report associations as odds ratios and 95% confidence intervals., Results: The four social capital constructs were involvement, participation, investment, and communication. Among the 10,112 households, those in rural communities were much more likely to have a high social capital score (OR 4.51, 95% CIca 3.26-6.26). Households in intervention sites had higher social capital, although the association was not significant at the 5% level. Households with high social capital were more likely to be negative for larvae or pupae (OR 1.38, 95% CIca 1.12-1.69) and for pupae specifically (OR 1.37, 95% CIca 1.08-1.74). There was interaction between intervention status and social capital; in multivariate analysis, a combined variable of intervention/high social capital remained associated with larvae or pupae (ORa l.56, 95% CIca 1.19-2.04) and with pupae specifically (ORa 1.65, 95% CIca 1.20-2.28)., Conclusion: This is the first report of an association of high social capital with low vector indices. Our findings support the idea that the Camino Verde community mobilisation intervention worked partly through an interaction with social capital. Understanding such interactions may help to maximise the impact of future community mobilisation interventions.

Background: Many Canadian adolescents and young adults with mental health problems face delayed detection, long waiting lists, poorly accessible services, care of inconsistent quality and abrupt or absent inter-service transitions. To address these issues, ACCESS Open Minds, a multi-stakeholder network, is implementing and systematically evaluating a transformation of mental health services for youth aged 11 to 25 at 14 sites across Canada. The transformation plan has five key foci: early identification, rapid access, appropriate care, the elimination of age-based transitions between services, and the engagement of youth and families., Methods: The ACCESS Open Minds Research Protocol has multiple components including a minimum evaluation protocol and a stepped-wedge cluster randomized trial, that are detailed in this paper. Additional components include qualitative methods and cost-effectiveness analyses. The services transformation is being evaluated at all sites via a minimum evaluation protocol. Six sites are participating in the stepped-wedge trial whereby the intervention (a service transformation along the key foci) was rolled out in three waves, each commencing six months apart. Two sites, one high-population and one low-population, were randomly assigned to each of the three waves, i.e., randomization was stratified by population size. Our primary hypotheses pertain to increased referral numbers, and reduced wait times to initial assessment and to the commencement of appropriate care. Secondary hypotheses pertain to simplified pathways to care; improved clinical, functional and subjective outcomes; and increased satisfaction among youth and families. Quantitative measures addressing these hypotheses are being used to determine the effectiveness of the intervention., Discussion: Data from our overall research strategy will help test the effectiveness of the ACCESS Open Minds transformation, refine it further, and inform its scale-up. The process by which our research strategy was developed has implications for the practice of research itself in that it highlights the need to actively engage all stakeholder groups and address unique considerations in designing evaluations of complex healthcare interventions in multiple, diverse contexts. Our approach will generate both concrete evidence and nuanced insights, including about the challenges of conducting research in real-world settings. More such innovative approaches are needed to advance youth mental health services research., Trial Registration Number: Clinicaltrials.gov, ISRCTN23349893 (Retrospectively registered: 16/02/2017).

Background: Indigenous Maya women in Guatemala show some of the worst maternal health indicators worldwide. Our objective was to test acceptability, feasibility and impact of a co-designed group psychosocial intervention (Women's Circles) in a population with significant need but no access to mental health services., Methods: A parallel group pilot randomised study was undertaken in five rural Mam and three periurban K'iche' communities. Participants included 84 women (12 per community, in seven of the communities) randomly allocated to intervention and 71 to control groups; all were pregnant and/or within 2 years postpartum. The intervention consisted of 10 sessions co-designed with and facilitated by 16 circle leaders. Main outcome measures were: maternal psychosocial distress (HSCL-25), wellbeing (MHC-SF), self-efficacy and engagement in early infant stimulation activities. In-depth interviews also assessed acceptability and feasibility., Results: The intervention proved feasible and well accepted by circle leaders and participating women. 1-month post-intervention, wellbeing scores (p-value 0.008) and self-care self-efficacy (0.049) scores were higher among intervention compared to control women. Those women who attended more sessions had higher wellbeing (0.007), self-care and infant-care self-efficacy (0.014 and 0.043, respectively), and early infant stimulation (0.019) scores., Conclusions: The pilot demonstrated acceptability, feasibility and potential efficacy to justify a future definitive randomised controlled trial. Co-designed women's groups provide a safe space where indigenous women can collectively improve their functioning and wellbeing., Trial Registration: ISRCTN13964819 . Registered 26 June 2018, retrospectively registered.

Background: In Botswana, one fifth of the adult population is infected with HIV, with young women most at risk. Structural factors such as poverty, poor education, strong gender inequalities and gender violence render many young women unable to act on choices to protect themselves from HIV. A national trial is testing an intervention to assist young women to access government programs for returning to education, and improving livelihoods. Accessing marginalised young women (aged 16-29 and not in education, employment or training) through door-to-door recruitment has proved inefficient. We investigated social networks of young women to see if an approach based on an understanding of these networks could help with recruitment., Methods: This mixed methods study used social network analysis to identify key young women in four communities (using in-degree centrality), and to describe the types of people that marginalised young women (n = 307) turn to for support (using descriptive statistics and then generalized linear mixed models to examine the support networks of sub-groups of participants). In discussion groups (n = 46 participants), the same young women helped explain results from the network analysis. We also tracked the recruitment method for each participant (door to door, peers, or key community informants)., Results: Although we were not able to identify characteristics of the most central young women in networks, we found that marginalised young women went most often to other women, usually in the same community, and with children, especially if they had children themselves. Rural women were better connected with each other than women in urban areas, though there were isolated young women in all communities. Peer recruitment contributed most in rural areas; door-to-door recruitment contributed most in urban areas., Conclusions: Since marginalised young women seek support from others like themselves, outreach programs could use networks of women to identify and engage those who most need help from government structural support programs. Methods that rely on social networks alone may be insufficient, and so a combination of approaches, including, for instance, peers, door-to-door recruitment, and key community informants, should be explored as a strategy for reaching marginalised young women for supportive interventions.

Background: Wide recognition that structural factors are important in the HIV epidemic has not generated much evidence of impact of structural interventions. Few randomised controlled trials of structural interventions for HIV prevention have an HIV endpoint, and most of those did not show a significant impact. It has proved difficult to prevent new HIV infections in Botswana, especially among young women, many of whom are unable to act on HIV preventive choices. Proposed by a government think tank in Botswana, the Inter-ministerial National Structural Intervention trial (INSTRUCT) tests whether addressing social and economic factors, including gender inequality, gender violence, poverty, and poor access to education, can lower HIV infection rates among young women. Focussed on increasing access by marginalised young women to government support programs, the intervention seeks to change their structural position, reducing their vulnerability to transactional sex, and thus to HIV infection., Methods: This parallel group cluster randomised controlled trial compares HIV rates among young women in districts with and without the structural interventions. The 30 administrative districts in the country, stratified by HIV prevalence and development status, will be randomly assigned to 5-district implementation waves. The intervention in the first-wave districts will include: (i) recruiting and preparing vulnerable young women to apply to government support programs, (ii) making the support programs more accessible to young women by engaging local program officers and young women in co-evaluation of programs and co-design of solutions; and (iii) generating an enabling environment for change in communities through an audio-drama edutainment program. In year five, an impact survey will measure HIV rates among vulnerable young women (15-29 years) in a random sample of communities in the five intervention districts and in the five second-wave (control) districts. Fieldworkers will undertake rapid HIV screening and interview young women and young men, collecting information on secondary outcomes of attitudes and behaviours., Discussion: This is the first step in a planned stepped-wedge design that will roll out the intervention, modified as necessary, to all districts. Strong government commitment provides an important opportunity to reduce new HIV cases in Botswana, and guide prevention efforts in other countries., Trial Registration: Registration number: ISRCTN 54878784 . Registry: ISRCTN. Date of registration: 11 June 2013.

Background: Indigenous women in the southern Mexican state of Guerrero face poor maternal health outcomes. Living as they do at the very periphery of the Western health system, they often receive low-quality care from health services that lack human and financial resources. Traditional health systems remain active in indigenous communities where traditional midwives accompany women through motherhood. Several interventions have explored training birth attendants in Western birthing skills, but little research has focussed on supporting traditional midwives by recognising their knowledge. This trial supports traditional midwifery in four indigenous groups and measures its impact on maternal health outcomes., Methods: The study includes four indigenous populations in the State of Guerrero (Nahua, Na savi/Mixteco, Me'phaa/Tlapaneco and Nancue ñomndaa/Amuzgo), covering approximately 8000 households. A parallel-group cluster-randomised controlled trial will compare communities receiving usual care with communities where traditional midwives received support in addition to the usual care. The intervention was defined in collaboration with participants in a 2012 pilot study. Supported midwives will receive a small stipend, a scholarship to train one apprentice, and support from an intercultural broker to deal with Western health personnel; additionally, the health staff in the intervention municipalities will participate in workshops to improve understanding and attitudes towards authentic traditional midwives. A baseline and a final survey will measure changes in birth and pregnancy complications (primary outcomes), and changes in gender violence, access to healthcare, and engagement with traditional cultural activities (secondary outcomes). The project has ethical approval from the participating communities and the Universidad Autónoma de Guerrero., Discussion: Indigenous women at the periphery of Western health services do not benefit fully from the attenuated services which erode their own healthcare traditions. Western health service providers in indigenous communities often ignore traditional knowledge and resources, inadvertently or in ignorance, disrespecting indigenous cultures. Improved understanding between midwives and the official healthcare system can contribute to more appropriate referral of high-risk cases, improving the use of scarce resources while lowering costs of healthcare for indigenous families., Trial Registration: ISRCTN12397283 . Retrospectively registered on 6 December 2016.

Background: Maternal mortality in Nigeria is one of the highest in the world. Access to antenatal care is limited and the quality of services is poor in much of the country. Previous research in Bauchi State found associations between maternal morbidity and domestic violence, heavy work in pregnancy, lack of knowledge about danger signs, and lack of spousal communication about pregnancy and childbirth. This cluster randomized controlled stepped-wedge trial will test the impact of universal home visits to pregnant women and their partners, and the added value of video edutainment., Methods: The trial will take place in six wards of Toro Local Government Area in Bauchi State, Nigeria, randomly allocated into three waves of two wards each. Home visits will begin in wave 1 wards immediately; in wave 2 wards after one year; and in wave 3 wards after a further year. In each wave, one ward, randomly allocated, will receive video edutainment during the home visits. Female home visitors will contact all households in their catchment areas of about 300 households, register all pregnant women, and visit them every two months during pregnancy, after delivery and one year later. They will use android handsets to collect information on pregnancy progress, send this to a central server, and discuss with the women the evidence about household factors associated with higher maternal risks, using video clips in the edutainment wards. Male home visitors will contact the partners of the pregnant women and discuss with them the same evidence. We will compare outcomes between wave 1 and wave 2 wards at about one year, between wave 2 and wave 3 wards at about two years, and finally between wards with and without added edutainment. Primary outcomes will be complications in pregnancy and delivery, and child health at one year. Secondary outcomes include knowledge and attitudes, use of health services, knowledge of danger signs, and household care of pregnant women., Discussion: Demonstrating an impact of home visits and understanding potential mechanisms could have important implications for reducing maternal morbidity and mortality in other settings with poor access to quality antenatal care services., Trial Registration: Registration number: ISRCTN82954580 . Registry: ISRCTN. Date of registration: 11 August 2017. Retrospectively registered.

Background: Episiotomy and perineal tears remain common in vaginal deliveries. This study estimated the frequency of and factors associated with perineal tears, episiotomies, and postnatal infections among women in two predominantly indigenous municipalities in southern Mexico, where traditional midwives play an important role in women's health., Methods: A cross-sectional study contacted women who gave birth in the previous three years. An administered questionnaire asked about place of delivery, birthing position, birth attendant, episiotomy, perineal tears, and wound infection after delivery. Cluster adjusted bivariate and then multivariate analysis examined factors potentially associated with self-reported perineal trauma (episiotomy and/or perineal tear). Key informant interviews sought insights into some of the findings., Results: Among women with a vaginal delivery, 71% (876/1238) of indigenous women and 18% (36/197) of non-indigenous women delivered at home. Some 17% (247/1416) of women overall, and 33% (171/525) of those delivering in a health facility, reported an episiotomy during delivery. Among 171 women reporting an episiotomy in a health facility, 30% (52) also reported a perineal tear. Overall, 13% (190/1412) of women reported they had a perineal tear during delivery, 17% (86/515) of those delivering in a health facility and 12% (104/897) of those delivering at home. A quarter of the women had self-reported perineal trauma during their last delivery, 38% (196/511) of those delivering in a health facility and 18% (160/893) of those delivering at home. In bivariate analysis, indigenous ethnicity, home delivery, upright posture in labour, and delivery by a traditional midwife were associated with a lower risk of perineal trauma, while primiparas had a higher risk. In the final multivariate model, delivery by a traditional midwife was protective (ORa 0.41, 95%CIca 0.32-0.54) and primiparity was a risk factor (ORa 2.01, 95%CIca 1.5-2.68) for perineal trauma. Women suggested that fear of bad treatment and being cut made them unwilling to deliver in health facilities., Conclusions: The rate of perineal trauma among women giving birth in indigenous communities could be reduced by efforts to decrease the use of episiotomies in health facilities, and by opening a dialogue with traditional midwives to increase their interaction with formal health services.

Background: Although continuity of care in paediatric palliative care (PPC) is considered to be an essential element of quality of care, it's implementation is challenging. In Belgium, five paediatric liaison teams (PLTs) deliver palliative care. A Royal Decree issued in 2010 provides the legal framework that defines the PLTs' missions, as ensuring continuity of curative and palliative care between the hospital and home for children diagnosed with life-limiting conditions. This national study describes how PLTs ensure continuity of care by describing their activities and the characteristics of the children they cared for from 2010 to 2014., Methods: Thematic analysis of open-ended questions was performed and descriptive statistics of aggregated data issued from annual reports, collected by the Belgian Ministry of Public Health through the Cancer Plan was used. A review panel of PLT members discussed the results and contributed to their interpretation., Results: Between 2010 and 2014, 3607 children and young adults (0-21 years) were cared for by the 5 Belgian PLTs (mean of 721/per year). Of these children, 50% were diagnosed with an oncological disease, 27% with a neurological or metabolic disease. Four hundred and twenty eight (428) children had died. For 51% of them, death took place at home. PLT activities include coordination; communication; curative and palliative care; education; research and fundraising. Different perceptions of what constitutes a palliative stage, heterogeneity in reporting diagnosis and the current lack of specific valid indicators to report PPC activities were found., Conclusion: PLTs are offering highly individualised, flexible and integrated care from diagnosis to bereavement in all care settings. Improvements in data registration and implementation of outcome measures are foreseen.

Background: A modified theory of planned behaviour (acronym CASCADA) proposes that Conscious knowledge precedes a change in Attitude, which in turn precedes positive deviations from negative Subjective norms, intention to Change, perception of Agency to change, Discussion of possible action, and Action itself. We used this as a results chain to investigate gender-specific behaviour dynamics in chemical-free dengue prevention., Methods: Secondary analysis of the Mexican arm of a cluster randomised controlled trial used household survey data on intermediate outcomes of dengue prevention behaviour. We used a matrix of odds ratios between outcomes, transformed to a symmetrical range (-1, 1), to compute fuzzy transitive closure of the results chain for control and intervention clusters, then for male and female respondents separately in each group. Transitive closure of a map computes the influence of each factor on each other factor, taking account of all influences in the system. Cumulative net influence was the sum of influences across the results chain., Results: Responses of 5042 women and 1143 men in 45 intervention clusters contrasted with those of 5025 women and 1179 men in 45 control clusters. Control clusters showed a distal block (negative influence) in the results chain with a cumulative net influence of 0.88; intervention clusters showed no such block and a cumulative net influence of 1.92. Female control respondents, like the overall control picture, showed a distal block, whereas female intervention responses showed no such blocks (cumulative net influence 0.78 and 1.73 respectively). Male control respondents showed weak distal blocks. Male intervention responses showed several new negative influences and a reduction of cumulative net influence (1.38 in control and 1.11 in intervention clusters)., Conclusions: The overall influence of the intervention across the results chain fits with the trial findings, but is different for women and men. Among women, the intervention overcame blocks and increased the cumulative net influence of knowledge on action. Among men, the intervention did not reinforce prevention behaviour. This might be related to emphasis, during the intervention, on women's participation and empowerment. The fuzzy transitive closure of the CASCADA map usefully highlights the differences between gender-specific results chains., Trial Registration: ISRCTN27581154 .

Camino Verde (the Green Way) is an evidence-based community mobilisation tool for prevention of dengue and other mosquito-borne viral diseases. Its effectiveness was demonstrated in a cluster-randomised controlled trial conducted in 2010-2013 in Nicaragua and Mexico. The common approach that brought functional consistency to the Camino Verde intervention in both Mexico and Nicaragua is Socialisation of Evidence for Participatory Action (SEPA). In this article, we explain the SEPA concept and its theoretical origins, giving examples of its previous application in different countries and contexts. We describe how the approach was used in the Camino Verde intervention, with details that show commonalities and differences in the application of the approach in Mexico and Nicaragua. We discuss issues of cost, replicability and sustainability, and comment on which components of the intervention were most important to its success. In complex interventions, multiple components act in synergy to produce change. Among key factors in the success of Camino Verde were the use of community volunteers called brigadistas, the house-to-house visits they conducted, the use of evidence derived from the communities themselves, and community ownership of the undertaking. Communities received the intervention by random assignment; dengue was not necessarily their greatest concern. The very nature of the dengue threat dictated many of the actions that needed to be taken at household and neighbourhood levels to control it. But within these parameters, communities exercised a large degree of control over the intervention and displayed considerable ingenuity in the process., Trial Registration: ISRCTN27581154 .

We discuss two ethical issues raised by Camino Verde, a 2011-2012 cluster-randomised controlled trial in Mexico and Nicaragua, that reduced dengue risk though community mobilisation. The issues arise from the approach adopted by the intervention, one called Socialisation of Evidence for Participatory Action. Community volunteer teams informed householders of evidence about dengue, its costs and the life-cycle of Aedes aegypti mosquitoes, while showing them the mosquito larvae in their own water receptacles, without prescribing solutions. Each community responded in an informed manner but on its own terms. The approach involves partnerships with communities, presenting evidence in a way that brings conflicting views and interests to the surface and encourages communities themselves to deal with the resulting tensions.One such tension is that between individual and community rights. This tension can be resolved creatively in concrete day-to-day circumstances provided those seeking to persuade their neighbours to join in efforts to benefit community health do so in an atmosphere of dialogue and with respect for personal autonomy.A second tension arises between researchers' responsibilities for ethical conduct of research and community autonomy in the conduct of an intervention. An ethic of respect for individual and community autonomy must infuse community intervention research from its inception, because as researchers succeed in fostering community self-determination their direct influence in ethical matters diminishes., Trial Registration: ISRCTN 27581154.

Background: The follow-up survey of a cluster-randomised controlled trial of evidence-based community mobilisation for dengue control in Nicaragua and Mexico included entomological information from the 2012 rainy and dry seasons. We used data from the Mexican arm of the trial to assess the impact of the community action on pupal production of the dengue vector Aedes aegypti in both rainy and dry seasons., Methods: Trained field workers inspected household water containers in 90 clusters and collected any pupae or larvae present for entomological examination. We calculated indices of pupae per person and pupae per household, and traditional entomological indices of container index, household index and Breteau index, and compared these between rainy and dry seasons and between intervention and control clusters, using a cluster t-test to test significance of differences., Results: In 11,933 houses in the rainy season, we inspected 40,323 containers and found 7070 Aedes aegypti pupae. In the dry season, we inspected 43,461 containers and counted 6552 pupae. All pupae and entomological indices were lower in the intervention clusters (IC) than in control clusters (CC) in both the rainy season (RS) and the dry season (DS): pupae per container 0.12 IC and 0.24 CC in RS, and 0.10 IC and 0.20 CC in DS; pupae per household 0.46 IC and 0.82 CC in RS, and 0.41 IC and 0.83 CC in DS; pupae per person 0.11 IC and 0.19 CC in RS, and 0.10 IC and 0.20 CC in DS; household index 16% IC and 21% CC in RS, and 12.1% IC and 17.9% CC in DS; container index 7.5% IC and 11.5% CC in RS, and 4.6% IC and 7.1% CC in DS; Breteau index 27% IC and 36% CC in RS, and 19% IC and 29% CC in DS. All differences between the intervention and control clusters were statistically significant, taking into account clustering., Conclusions: The trial intervention led to significant decreases in pupal and conventional entomological indices in both rainy and dry seasons., Trial Registration: ISRCTN27581154 .

Background: Temephos in domestic water containers remains a mainstay of Latin American government programmes for control of Aedes aegypti and associated illnesses, including dengue. There is little published evidence about coverage of routine temephos programmes. A cluster randomised controlled trial of community mobilisation in Mexico and Nicaragua reduced vector indices, dengue infection, and clinical dengue cases. Secondary analysis from the Mexican arm of the trial examined temephos coverage and beliefs, and the impact of the trial on these outcomes., Methods: The trial impact survey in December 2012, in 10,491 households in 45 intervention and 45 control clusters, asked about visits from the temephos programme, retention of applied temephos, and views about temephos and mosquito control. Fieldworkers noted if temephos was present in water containers., Results: Some 42.4% of rural and 20.7% of urban households reported no temephos programme visits within the last 12 months. Overall, 42.0% reported they had temephos placed in their water containers less than 3 months previously. Fieldworkers observed temephos in at least one container in 21.1% of households. Recent temephos application and observed temephos were both significantly more common in urban households, when other household variables were taken into account; in rural areas, smaller households were more likely to have temephos present. Most households (74.4%) did not think bathing with water containing temephos carried any health risk. Half (51%) believed drinking or cooking with such water could be harmful and 17.6% were unsure. Significantly fewer households in intervention sites (16.5%) than in control sites (26.0%) (Risk Difference - 0.095, 95% confidence interval - 0.182 to -0.009) had temephos observed in their water; more households in intervention clusters (41.8%) than in control clusters (31.6%) removed the applied temephos quickly. Although fewer households in intervention sites (82.7%) compared with control sites (86.7%) (RD -0.04, 95% CI -0.067 to -0.013) agreed temephos and fumigation was the best way to avoid mosquitoes, the proportion believing this remained very high., Conclusion: Coverage with the government temephos programme was low, especially in rural areas. Despite an intervention encouraging non-chemical mosquito control, most households continued to believe that chemicals are the best control method., Trial Registration: ISRCTN: 27581154 .

Background: The Mexican arm of the Camino Verde trial of community mobilisation for dengue prevention covered three coastal regions of Guerrero state: Acapulco, Costa Grande and Costa Chica. A baseline cross-sectional survey provided data for community mobilisation and for adapting the intervention design to concrete conditions in the intervention areas., Methods: Trained field teams constructed community profiles in randomly selected clusters, based on observation and key informant interviews. In each household they carried out an entomological inspection of water containers, collected information on socio-demographic variables and cases of dengue illness among household members in the last year, and gathered paired saliva samples from children aged 3-9 years, which were subjected to ELISA testing to detect recent dengue infection. We examined associations with dengue illness and recent dengue infection in bivariate and then multivariate analysis., Results: In 70/90 clusters, key informants were unable to identify any organized community groups. Some 1.9% (1029/55,723) of the household population reported dengue illness in the past year, with a higher rate in Acapulco region. Among children 3-9 years old, 6.1% (392/6382) had serological evidence of recent dengue infection. In all three regions, household use of anti-mosquito products, household heads working, and households having less than 5 members were associated with self-reported dengue illness. In Acapulco region, people aged less than 25 years, those with a more educated household head and those from urban sites were also more likely to report dengue illness, while in Costa Chica and Costa Grande, females were more likely to report dengue illness. Among children aged 3-9 years, those aged 3-4 years and those living in Acapulco were more likely to have evidence of recent dengue infection., Conclusions: The evidence from the baseline survey provided important support for the design and implementation of the trial intervention. The weakness of community leadership and the relatively low rates of self-reported dengue illness were challenges that the Mexican intervention team had to overcome. The higher dengue illness occurrence among women in Costa Grande and Costa Chica may help explain why women participated more than men in activities during the Camino Verde trial.

Camino Verde (the Green Way) is an evidence-based community mobilisation tool for prevention of dengue and other mosquito-borne viral diseases. Its effectiveness was demonstrated in a cluster-randomised controlled trial conducted in 2010-2013 in Nicaragua and Mexico. The Nicaraguan arm of the trial was preceded, from 2004 to 2008, by a feasibility study that provided valuable lessons and trained facilitators for the trial itself. Here, guided by the Template for Intervention Description and Replication (TIDieR), we describe the Camino Verde intervention in Nicaragua, presenting its rationale, its time and location, activities, materials used, the main actors, modes of delivery, how it was tailored to encourage community engagement, modifications made from the feasibility study to the trial itself, and how fidelity to the process originally designed was maintained. We also present information on costs and discuss the place of this study within the literature on implementation science., Trial Registration: ISRCTN27581154 .

Background: Since the Aedes aegypti mosquitoes that transmit dengue virus can breed in clean water, WHO-endorsed vector control strategies place sachets of organophosphate pesticide, temephos (Abate), in household water storage containers. These and other pesticide-dependent approaches have failed to curb the spread of dengue and multiple dengue virus serotypes continue to spread throughout tropical and subtropical regions worldwide. A feasibility study in Managua, Nicaragua, generated instruments, intervention protocols, training schedules and impact assessment tools for a cluster randomised controlled trial of community-based approaches to vector control comprising an alternative strategy for dengue prevention and control in Nicaragua and Mexico., Methods/design: The Camino Verde (Green Way) is a pragmatic parallel group trial of pesticide-free dengue vector control, adding effectiveness to the standard government dengue control. A random sample from the most recent census in three coastal regions of Guerrero state in Mexico will generate 90 study clusters and the equivalent sampling frame in Managua, Nicaragua will generate 60 clusters, making a total of 150 clusters each of 137-140 households. After a baseline study, computer-driven randomisation will allocate to intervention one half of the sites, stratified by country, evidence of recent dengue virus infection in children aged 3-9 years and, in Nicaragua, level of community organisation. Following a common evidence-based education protocol, each cluster will develop and implement its own collective interventions including house-to-house visits, school-based programmes and inter-community visits. After 18 months, a follow-up study will compare dengue history, serological evidence of recent dengue virus infection (via measurement of anti-dengue virus antibodies in saliva samples) and entomological indices between intervention and control sites., Discussion: Our hypothesis is that informed community mobilisation adds effectiveness in controlling dengue., Trial Registration: ISRCTN27581154 .

In conventional randomised controlled trials (RCTs), researchers design the interventions. In the Camino Verde trial, each intervention community designed its own programmes to prevent dengue. Instead of fixed actions or menus of activities to choose from, the trial randomised clusters to a participatory research protocol that began with sharing and discussing evidence from a local survey, going on to local authorship of the action plan for vector control.Adding equitable stakeholder engagement to RCT infrastructure anchors the research culturally, making it more meaningful to stakeholders. Replicability in other conditions is straightforward, since all intervention clusters used the same engagement protocol to discuss and to mobilize for dengue prevention. The ethical codes associated with RCTs play out differently in community-led pragmatic trials, where communities essentially choose what they want to do. Several discussion groups in each intervention community produced multiple plans for prevention, recognising different time lines. Some chose fast turnarounds, like elimination of breeding sites, and some chose longer term actions like garbage disposal and improving water supplies.A big part of the skill set for community-led trials is being able to stand back and simply support communities in what they want to do and how they want to do it, something that does not come naturally to many vector control programs or to RCT researchers. Unexpected negative outcomes can come from the turbulence implicit in participatory research. One example was the gender dynamic in the Mexican arm of the Camino Verde trial. Strong involvement of women in dengue control activities seems to have discouraged men in settings where activity in public spaces or outside of the home would ordinarily be considered a "male competence".Community-led trials address the tension between one-size-fits-all programme interventions and local needs. Whatever the conventional wisdom about how prevention works at a system level, programmes have to be perceived as locally relevant and they must engage stakeholders who make them work. Locally, each participating community has to know the intervention is relevant to them; they have to want to do it. That happens much more easily if they design the programme themselves.

Background: Studies in different countries have identified irregular water supply as a risk factor for dengue virus transmission. In 2013, Camino Verde, a cluster-randomised controlled trial in Managua, Nicaragua, and Mexico's Guerrero State, demonstrated impact of evidence-based community mobilisation on recent dengue infection and entomological indexes of infestation by Aedes aegypti mosquitoes. This secondary analysis of data from the trial impact survey asks: (1) what is the importance of regular water supply in neighbourhoods with and without the trial intervention and (2) can community interventions like Camino Verde reasonably exclude households with adequate water supply?, Methods: Entomological data collected in the dry season of 2013 in intervention and control communities allow contrasts between households with regular and irregular water supplies. Indicators of entomological risk included the House Index and pupa positive household index. Generalised linear mixed models with cluster as a random effect compared households with and without regular water, and households in intervention and control communities., Results: For the House Index, regular water supply was associated with a protection in both intervention households (OR 0.7, 95%CI 0.6-0.9) and control households (OR 0.6, 95%CI 0.5-0.8). For the pupa positive household index, we found a similar protection from regular water supply in intervention households (OR 0.6, 95%CI 0.4-0.8) and control households (OR 0.7, 95%CI 0.5-0.9). The Camino Verde intervention had a similar impact on House Index in households with regular water supply (OR 0.7, 95%CI 0.5-1.0) and irregular water supply (OR 0.6, 95%CI 0.4-0.8); for the pupa positive household index, the effect of the intervention was very similar in households with regular (OR0.5, 95%CI 0.3-0.8) and irregular (OR 0.5, 95%CI 0.3-0.9) water supply., Conclusion: While Aedes aegypti control efforts based on informed community mobilisation had a strong impact on households without a regular water supply, this intervention also impacted entomological indices in households with a regular water supply. These households should not be excluded from community mobilisation efforts to reduce the Aedes aegypti vector., Trial Registration: ISRCTN27581154 .

Background: Dengue is a serious public health problem with an important economic impact. This study used data from a cluster randomised controlled trial of community mobilisation for dengue prevention to estimate the household costs of treatment of dengue illness. It examined the economic impact of the trial intervention in the three coastal regions of Mexico's Guerrero State., Methods: The 2010 baseline survey covered households in a random sample of 90 clusters in the coastal regions; the clusters were randomly allocated to intervention or control and re-surveyed in 2012. The surveys asked about dengue cases in the last 12 months, expenditures on their treatment, and work or school days lost by patients and care givers. We did not assign monetary value to days lost, since a lost day to a person of low earning power is of equal or higher value to that person than to one who earns more., Results: The 12,312 households in 2010 reported 1020 dengue cases in the last 12 months (1.9% of the sample population). Most (78%) were ambulatory cases, with a mean cost of USD 51 and 10.8 work/school days, rising to USD 96 and 11.4 work/school days if treated by a private physician. Hospitalised cases cost USD 28-94 in government institutions and USD 392 in private hospitals (excluding additional inpatient charges), as well as 9.6-17.3 work/school days. Dengue cases cost households an estimated 412,825 work/school days throughout the three coastal regions. In the follow up survey, 6.1% (326/5349) of households in intervention clusters and 7.9% (405/5139) in control clusters reported at least one dengue case. The mean of days lost per case was similar in intervention and control clusters, but the number of days lost from dengue and all elements of costs for dengue cases per 1000 population were lower in intervention clusters. If the total population of the three coastal regions had received the intervention, some 149,401 work or school days lost per year could have been prevented., Conclusion: The economic effect of dengue on households, including lost work days, is substantial. The Camino Verde trial intervention reduced household costs for treatment of dengue cases., Trial Registration: The trial was registered as ISRCTN:27,581,154 .

Background: Dengue is a serious public health issue that affects households in endemic areas in terms of health and also economically, imposing costs for prevention and treatment of cases. The Camino Verde cluster-randomised controlled trial in Mexico and Nicaragua assessed the impact of evidence-based community engagement in dengue prevention. The Mexican arm of the trial was conducted in 90 randomly selected communities in three coastal regions of Guerrero State. This study reports an analysis of a secondary outcome of the trial: household use of and expenditure on anti-mosquito products. We examined whether the education and mobilisation activities of the trial motivated people to spend less on anti-mosquito products., Methods: We carried out a household questionnaire survey in the trial communities in 2010 (12,312 households) and 2012 (5349 households in intervention clusters, 5142 households in control clusters), including questions about socio-economic status, self-reported dengue illness, and purchase of and expenditure on insecticide anti-mosquito products in the previous month. We examined expenditures on anti-mosquito products at baseline in relation to social vulnerability and we compared use of and expenditures on these products between intervention and control clusters in 2012., Results: In 2010, 44.2% of 12,312 households reported using anti-mosquito products, with a mean expenditure of USD4.61 per month among those who used them. Socially vulnerable households spent less on the products. In 2012, after the intervention, the proportion of households who purchased anti-mosquito products in the last month was significantly lower in intervention clusters (47.8%; 2503/5293) than in control clusters (53.3%; 2707/5079) (difference - 0.05, 95% CIca -0.100 to -0.010). The mean expenditure on the products, among those households who bought them, was USD6.43; 30.4% in the intervention clusters and 36.7% in the control clusters spent more than this (difference - 0.06, 95% CIca -0.12 to -0.01). These expenditures on anti-mosquito products represent 3.3% and 3.8% respectively of monthly household income for the poorest 10% of the population in 2012., Conclusions: The Camino Verde community mobilisation intervention, as well as being effective in reducing dengue infections, was effective in reducing household use of and expenditure on insecticide anti-mosquito products., Trial Registration: ( ISRCTN27581154 ).

Background: Community mobilisation for prevention requires engagement with and buy in from those communities. In the Mexico state of Guerrero, unprecedented social violence related to the narcotics trade has eroded most community structures. A recent randomised controlled trial in 90 coastal communities achieved sufficient mobilisation to reduce conventional vector density indicators, self-reported dengue illness and serologically proved dengue virus infection., Methods: The Camino Verde intervention was a participatory research protocol promoting local discussion of baseline evidence and co-design of vector control solutions. Training of facilitators emphasised community authorship rather than trying to convince communities to do specific activities. Several discussion groups in each intervention community generated a loose and evolving prevention plan. Facilitators trained brigadistas, the first wave of whom received a small monthly stipend. Increasing numbers of volunteers joined the effort without pay. All communities opted to work with schoolchildren and for house-to-house visits by brigadístas. Children joined the neighbourhood vector control movements where security conditions permitted. After 6 months, a peer evaluation involved brigadista visits between intervention communities to review and to share progress., Discussion: Although most communities had no active social institutions at the outset, local action planning using survey data provided a starting point for community authorship. Well-known in their own communities, brigadistas faced little security risk compared with the facilitators who visited the communities, or with governmental programmes. We believe the training focus on evidence-based dialogue and a plural community ownership through multiple design groups were key to success under challenging security conditions., Trial Registration: ISRCTN27581154 .

Background: The Aedes aegypti mosquito is the vector for dengue fever, yellow fever, chikungunya, and zika viruses. Inadequate vector control has contributed to persistence and increase of these diseases. This review assesses the evidence of effectiveness of different control measures in reducing Aedes aegypti proliferation, using standard entomological indices., Methods: A systematic search of Medline, Ovid, BVS, LILACS, ARTEMISA, IMBIOMED and MEDIGRAPHIC databases identified cluster randomised controlled trials (CRCTs) of interventions to control Aedes aegypti published between January 2003 and October 2016. Eligible studies were CRCTs of chemical or biological control measures, or community mobilization, with entomological indices as an endpoint. A meta-analysis of eligible studies, using a random effects model, assessed the impact on household index (HI), container index (CI), and Breteau index (BI)., Results: From 848 papers identified by the search, eighteen met the inclusion criteria: eight for chemical control, one for biological control and nine for community mobilisation. Seven of the nine CRCTs of community mobilisation reported significantly lower entomological indices in intervention than control clusters; findings from the eight CRCTs of chemical control were more mixed. The CRCT of biological control reported a significant impact on the pupae per person index only. Ten papers provided enough detail for meta-analysis. Community mobilisation (four studies) was consistently effective, with an overall intervention effectiveness estimate of -0.10 (95%CI -0.20 - 0.00) for HI, -0.03 (95%CI -0.05 - -0.01) for CI, and -0.13 (95%CI -0.22 - -0.05) for BI. The single CRCT of biological control had effectiveness of -0.02 (95%CI -0.07- 0.03) for HI, -0.02 (95%CI -0.04- -0.01) for CI and -0.08 (95%CI -0.15- -0.01) for BI. The five studies of chemical control did not show a significant impact on indices: the overall effectiveness was -0.01 (95%CI -0.05- 0.03) for HI, 0.01 (95% CI -0.01- 0.02) for CI, and 0.01 (95%CI -0.03 - 0.05) for BI., Conclusion: Governments that rely on chemical control of Aedes aegypti should consider adding community mobilization to their prevention efforts. More well-conducted CRCTs of complex interventions, including those with biological control, are needed to provide evidence of real life impact. Trials of all interventions should measure impact on dengue risk.

Background: In the Mexican state of Guerrero, some households place fish in water storage containers to prevent the development of mosquito larvae. Studies have shown that larvivorous fish reduce larva count in household water containers, but there is a lack of evidence about whether the use of fish is associated with a reduction in dengue virus infection. We used data from the follow up survey of the Camino Verde cluster randomised controlled trial of community mobilisation to reduce dengue risk to study this association., Methods: The survey in 2012, among 90 clusters in the three coastal regions of Guerrero State, included a questionnaire to 10,864 households about socio-demographic factors and self-reported cases of dengue illness in the previous year. Paired saliva samples provided serological evidence of recent dengue infection among 4856 children aged 3-9 years. An entomological survey in the same households looked for larvae and pupae of Aedes aegypti and recorded presence of fish and temephos in water containers. We examined associations with the two outcomes of recent dengue infection and reported dengue illness in bivariate analysis and then multivariate analysis using generalized linear mixed modelling., Results: Some 17% (1730/10,111) of households had fish in their water containers. The presence of fish was associated with lower levels of recent dengue virus infection in children aged 3-9 years (OR 0.64; 95% CI 0.45-0.91), as was living in a rural area (OR 0.57; 95% CI 0.45-0.71), and being aged 3-5 years (OR 0.65; 95% CI 0.51-0.83). Factors associated with lower likelihood of self-reported dengue illness were: the presence of fish (OR 0.79; 95% CI 0.64-0.97), and living in a rural area (OR 0.74; 95% CI 0.65-0.84). Factors associated with higher likelihood of self-reported dengue illness were: higher education level of the household head (OR 1.28; 95% CI 1.07-1.52), living in a household with five people or less (OR 1.33; 95% CI 1.16-1.52) and household use of insecticide anti-mosquito products (OR 1.68; 95% CI 1.47-1.92)., Conclusions: Our study suggests that fish in water containers may reduce the risk of dengue virus infection and dengue illness. This could be a useful part of interventions to control the Aedes aegypti vector.

Background: Understanding the breeding patterns of Aedes aegypti in households and the factors associated with infestation are important for implementing vector control. The baseline survey of a cluster randomised controlled trial of community mobilisation for dengue prevention in Mexico and Nicaragua collected information about the containers that are the main breeding sites, identified possible actions to reduce breeding, and examined factors associated with household infestation. This paper describes findings from the Mexican arm of the baseline survey., Methods: In 2010 field teams conducted household surveys and entomological inspections in 11,995 households from 90 representative communities in the three coastal regions of Guerrero State, Mexico. We characterized Ae. aegypti breeding sites and examined the effect of two preventive measures: temephos application in water containers, and keeping the containers covered. We examined associations with household infestation, using bivariate and multivariate analysis adjusted for clustering effects., Results: We conducted entomological inspections in 11,995 households. Among 45,353 water containers examined, 6.5% (2958/45,353) were positive for larvae and/or pupae. Concrete tanks (pilas) and barrels (tambos) together accounted for 74% of pupal productivity. Both covering water containers and inserting temephos were independently associated with a lower risk of presence of larvae or pupae, with the effect of covering (OR 0.22; 95% CIca 0.15-0.27) stronger than that of temephos (OR 0.66; 95% CIca 0.53-0.84). Having more than four water containers was associated with household infestation in both rural areas (OR 1.42; 95% CIca 1.17-1.72) and urban areas (1.81; 1.47-2.25), as was low education of the household head (rural: 1.27; 1.11-1.46, and urban: 1.39; 1.17-1.66). Additional factors in rural areas were: household head without paid work (1.31; 1.08-1.59); being in the Acapulco region (1.91; 1.06-3.44); and using anti-mosquito products (1.27; 1.09-1.47). In urban areas only, presence of temephos was associated with a lower risk of household infestation (0.44; 0.32-0.60)., Conclusion: Concrete tanks and barrels accounted for the majority of pupal productivity. Covering water containers could be an effective means of Ae. aegypti vector control, with a bigger effect than using temephos. These findings were useful in planning and implementing the Camino Verde trial intervention in Mexico.