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BackgroundThe COVID-19 pandemic is characterized by rapid increases in infection burden owing to the emergence of new variants with higher transmissibility and immune escape. To date, monitoring the COVID-19 pandemic has mainly relied on passive surveillance, yielding biased epidemiological measures owing to the disproportionate number of undetected asymptomatic cases. Active surveillance could provide accurate estimates of the true prevalence to forecast the evolution of the pandemic, enabling evidence-based decision-making. ObjectiveThis study compared 4 different approaches of active SARS-CoV-2 surveillance focusing on feasibility and epidemiological outcomes. MethodsA 2-factor factorial randomized controlled trial was conducted in 2020 in a German district with 700,000 inhabitants. The epidemiological outcome comprised SARS-CoV-2 prevalence and its precision. The 4 study arms combined 2 factors: individuals versus households and direct testing versus testing conditioned on symptom prescreening. Individuals aged ≥7 years were eligible. Altogether, 27,908 addresses from 51 municipalities were randomly allocated to the arms and 15 consecutive recruitment weekdays. Data collection and logistics were highly digitized, and a website in 5 languages enabled low-barrier registration and tracking of results. Gargle sample collection kits were sent by post. Participants collected a gargle sample at home and mailed it to the laboratory. Samples were analyzed with reverse transcription loop-mediated isothermal amplification (RT-LAMP); positive and weak results were confirmed with real-time reverse transcription–polymerase chain reaction (RT-PCR). ResultsRecruitment was conducted between November 18 and December 11, 2020. The response rates in the 4 arms varied between 34.31% (2340/6821) and 41.17% (2043/4962). The prescreening classified 16.61% (1207/7266) of the patients as COVID-19 symptomatic. Altogether, 4232 persons without prescreening and 7623 participating in the prescreening provided 5351 gargle samples, of which 5319 (99.4%) could be analyzed. This yielded 17 confirmed SARS-CoV-2 infections and a combined prevalence of 0.36% (95% CI 0.14%-0.59%) in the arms without prescreening and 0.05% (95% CI 0.00%-0.108%) in the arms with prescreening (initial contacts only). Specifically, we found a prevalence of 0.31% (95% CI 0.06%-0.58%) for individuals and 0.35% (95% CI 0.09%-0.61%) for households, and lower estimates with prescreening (0.07%, 95% CI 0.0%-0.15% for individuals and 0.02%, 95% CI 0.0%-0.06% for households). Asymptomatic infections occurred in 27% (3/11) of the positive cases with symptom data. The 2 arms without prescreening performed the best regarding effectiveness and accuracy. ConclusionsThis study showed that postal mailing of gargle sample kits and returning home-based self-collected liquid gargle samples followed by high-sensitivity RT-LAMP analysis is a feasible way to conduct active SARS-CoV-2 population surveillance without burdening routine diagnostic testing. Efforts to improve participation rates and integration into the public health system may increase the potential to monitor the course of the pandemic. Trial RegistrationDeutsches Register Klinischer Studien (DRKS) DRKS00023271; https://tinyurl.com/3xenz68a International Registered Report Identifier (IRRID)RR2-10.1186/s13063-021-05619-5

Abstract Background The current COVID-19 pandemic affects the entire world population and has serious health, economic and social consequences. Assessing the prevalence of COVID-19 through population-based serological surveys is essential to monitor the progression of the epidemic, especially in African countries where the extent of SARS-CoV-2 spread remains unclear. Methods A two-stage cluster population-based SARS-CoV-2 seroprevalence survey was conducted in Bobo-Dioulasso and in Ouagadougou, Burkina Faso, Fianarantsoa, Madagascar and Kumasi, Ghana between February and June 2021. IgG seropositivity was determined in 2,163 households with a specificity improved SARS-CoV-2 Enzyme-linked Immunosorbent Assay. Population seroprevalence was evaluated using a Bayesian logistic regression model that accounted for test performance and age, sex and neighbourhood of the participants. Results Seroprevalence adjusted for test performance and population characteristics were 55.7% [95% Credible Interval (CrI) 49·0; 62·8] in Bobo-Dioulasso, 37·4% [95% CrI 31·3; 43·5] in Ouagadougou, 41·5% [95% CrI 36·5; 47·2] in Fianarantsoa, and 41·2% [95% CrI 34·5; 49·0] in Kumasi. Within the study population, less than 6% of participants performed a test for acute SARS-CoV-2 infection since the onset of the pandemic. Conclusions High exposure to SARS-CoV-2 was found in the surveyed regions albeit below the herd immunity threshold and with a low rate of previous testing for acute infections. Despite the high seroprevalence in our study population, the duration of protection from naturally acquired immunity remains unclear and new virus variants continue to emerge. This highlights the importance of vaccine deployment and continued preventive measures to protect the population at risk.

BackgroundDespite the important role of testing as a measure against the COVID-19 pandemic, user perspectives on SARS-CoV-2 tests remain scarce, inhibiting an improvement of testing approaches. As the world enters the third year of the pandemic, more nuanced perspectives of testing, and opportunities to expand testing in a feasible and affordable manner merit consideration.MethodsConducted amid the second pandemic wave (late 2020–early 2021) during and after a multi-arm trial evaluating SARS-CoV-2 surveillance strategies in the federal state Baden-Württemberg, Germany, this qualitative sub-study aimed to gain a deeper understanding of how test users and test rejectors perceived mail-in SARS-CoV-2 gargle tests. We conducted 67 semi-structured in-depth interviews (mean duration: 60 min) via telephone or video call. Interviews were audio-recorded, transcribed verbatim and analyzed inductively using thematic analysis. The Consolidated Framework for Implementation Research guided the findings' presentation.ResultsRespondents generally described gargle sampling as simple and comfortable. However, individual perceptions of the testing method and its feasibility varied widely from disgusting and complicated to simple and brilliant. Self-sampling was appreciated for lowering infection risks during testing, but also considered more complex. Gargle-sampling increased participants' self-efficacy to sample correctly. Communication (first contact, quantity and content of information, reminders, support system) and trust (in the study, its institutional affiliation and test method) decisively influenced the intervention's acceptability.ConclusionUser-driven insights on how to streamline testing include: consider communication, first impressions of tests and information as key for successful mail-in testing; pay attention to the role of mutual trust between those taking and administering tests; implement gargle self-sampling as a pleasant alternative to swab testing; offer multiple test methods to increase test up-take.

Background: Mobile Health i.e. m-Health Education (MHE) and Traditional Health Education (THE) interventions are both used for education of diabetic patients. However, it is not yet reported which one is the most effective. This study was designed to compare the effectiveness of these two types of intervention on adherence to the seven dimensions of diabetes' self-management in a peripheral district of Bangladesh. Methods: A randomized controlled trial was conducted in Thakurgaon district, in Bangladesh, with two intervention arms (-MHE and THE- and one control group. All groups received an initial educational session including the control group. During the educational session pictorial materials was used and patients received a logbook to register their different activities related to diabetes. The intervention was conducted over a period of 12 months. MHE group received additionally a monthly reminder and monitoring through mobile phone calls. THE group received a monthly home visit reminder and monitoring through personal visits. 330 adult diabetics patients were included in each group. Data were collected by face-to-face interview using a semi-structured questionnaire at baseline and endline. Adherence to the seven self-management dimensions was measured and compared in the different groups before and after the intervention using analysis of co-variance (ANCOVA) and logistic regression technique. Findings: Study participants took place from January 2016 to June 2017. Among the 990 included patients, 86 were lost to follow-up. Both MHE and THE groups showed significant (p

Although a majority of SARS-COV-2 diagnosis are asymptomatic, presymptimatic or minimally symptomatic, little has been described and understood about the illness careers of these individuals. This study explored the lived experience of a SARS-COV-2 diagnosis and subsequent quarantine among individuals in Germany who were diagnosed with SARS-COV-2 during the second wave of the pandemic (late 2020-early 2021), but whose diagnosis was unexpected due to a lack of a known contact, or the asymptomatic nature of their case at the time of diagnosis. In-depth interviews (n ​= ​22) were conducted by phone or video call, audio-recorded, and transcribed verbatim. Routine debriefings guided data collection and facilitated analysis, which followed a framework approach. Regardless of age, gender or socioeconomic status, data consistently demonstrated a diagnosis and quarantine career marked by five emotional phases: overconfidence, shock and denial, coming to grips and asking questions, enduring, and cautious optimism as quarantine ended. These experiences suggest that providing trustworthy, easily accessible information regarding certain key aspects of the post diagnosis and quarantine period could benefit patients in terms of reducing stress, understanding the consequences of a diagnosis and mitigating foreseeable challenges in terms of personal, logistical and emotional issues. Follow-up research with providers and public health bureaus could inform how to best tailor such messaging for clients who experience an unexpected diagnosis.

Abstract Background To achieve higher effectiveness in population-based SARS-CoV-2 surveillance and to reliably predict the course of an outbreak, screening, and monitoring of infected individuals without major symptoms (about 40% of the population) will be necessary. While current testing capacities are also used to identify such asymptomatic cases, this rather passive approach is not suitable in generating reliable population-based estimates of the prevalence of asymptomatic carriers to allow any dependable predictions on the course of the pandemic. Methods This trial implements a two-factorial, randomized, controlled, multi-arm, prospective, interventional, single-blinded design with cluster sampling and four study arms, each representing a different SARS-CoV-2 testing and surveillance strategy based on individuals’ self-collection of saliva samples which are then sent to and analyzed by a laboratory. The targeted sample size for the trial is 10,000 saliva samples equally allocated to the four study arms (2500 participants per arm). Strategies differ with respect to tested population groups (individuals vs. all household members) and testing approach (without vs. with pre-screening survey). The trial is complemented by an economic evaluation and qualitative assessment of user experiences. Primary outcomes include costs per completely screened person, costs per positive case, positive detection rate, and precision of positive detection rate. Discussion Systems for active surveillance of the general population will gain more importance in the context of pandemics and related disease prevention efforts. The pandemic parameters derived from such active surveillance with routine population monitoring therefore not only enable a prospective assessment of the short-term course of a pandemic, but also a more targeted and thus more effective use of local and short-term countermeasures. Trial registration ClinicalTrials.gov DRKS00023271 . Registered November 30, 2020, with the German Clinical Trials Register (Deutsches Register Klinischer Studien)

Abstract Background Sub-Saharan Africa (SSA) is facing a rapid growth of non-communicable diseases (NCDs), while communicable diseases still prevail. For rural SSA, evidence for this development is scarce. We aimed at quantifying self-reported major disease groups according to season, and determining the associations with socio-economic factors in rural Burkina Faso. Methods This study used data of 4192 adults (age range: 18–101 years; male: 49.0%) from the Nouna Health and Demographic Surveillance System (HDSS) in north-west Burkina Faso, rainy season of 2010 and dry season of 2011. We assessed the proportions and their 95% confidence intervals (CIs) of self-reported major disease groups as defined by the World Health Organization. For their associations with socio-economic factors, odds ratios (OR), 95% CIs and p-values were calculated by logistic regression. Results The surveys were completed by 3949 adults in 2010 (mean age: 37.5 ± 14.9 years, male: 48.8%) and by 4039 adults in 2011 (mean age: 37.3 ± 16.2 years, male: 49.1%). The proportions of self-reported communicable diseases were 20.7% (95% CI: 19.4–21.9%) in the rainy season and 11.0% (10.0–11.9%; McNemar’s p

Abstract Objectives In this cluster-randomised controlled study (CoV-Surv Study), four different “active” SARS-CoV-2 testing strategies for general population surveillance are evaluated for their effectiveness in determining and predicting the prevalence of SARS-CoV-2 infections in a given population. In addition, the costs and cost-effectiveness of the four surveillance strategies will be assessed. Further, this trial is supplemented by a qualitative component to determine the acceptability of each strategy. Findings will inform the choice of the most effective, acceptable and affordable strategy for SARS-CoV-2 surveillance, with the most effective and cost-effective strategy becoming part of the local public health department’s current routine health surveillance activities. Investigating its everyday performance will allow us to examine the strategy’s applicability to real time prevalence prediction and the usefulness of the resulting information for local policy makers to implement countermeasures that effectively prevent future nationwide lockdowns. The authors would like to emphasize the importance and relevance of this study and its expected findings in the context of population-based disease surveillance, especially in respect to the current SARS-CoV-2 pandemic. In Germany, but also in many other countries, COVID-19 surveillance has so far largely relied on passive surveillance strategies that identify individuals with clinical symptoms, monitor those cases who then tested positive for the virus, followed by tracing of individuals in close contact to those positive cases. To achieve higher effectiveness in population surveillance and to reliably predict the course of an outbreak, screening and monitoring of infected individuals without major symptoms (about 40% of the population) will be necessary. While current testing capacities are also used to identify such asymptomatic cases, this rather passive approach is not suitable in generating reliable population-based estimates of the prevalence of asymptomatic carriers to allow any dependable predictions on the course of the pandemic. To better control and manage the SARS-CoV-2 pandemic, current strategies therefore need to be complemented by an active surveillance of the wider population, i.e. routinely conducted testing and monitoring activities to identify and isolate infected individuals regardless of their clinical symptoms. Such active surveillance strategies will enable more effective prevention of the spread of the virus as they can generate more precise population-based parameters during a pandemic. This essential information will be required in order to determine the best strategic and targeted short-term countermeasures to limit infection spread locally. Trial design This trial implements a cluster-randomised, two-factorial controlled, prospective, interventional, single-blinded design with four study arms, each representing a different SARS-CoV-2 testing and surveillance strategy. Participants Eligible are individuals age 7 years or older living in Germany’s Rhein-Neckar Region who consent to provide a saliva sample (all four arms) after completion of a brief questionnaire (two arms only). For the qualitative component, different samples of study participants and non-participants (i.e. eligible for study, but refuse to participate) will be identified for additional interviews. For these interviews, only individuals age 18 years or older are eligible. Intervention and comparator Of the four surveillance strategies to be assessed and compared, Strategy A1 is considered the gold standard for prevalence estimation and used to determine bias in other arms. To determine the cost-effectiveness, each strategy is compared to status quo, defined as the currently practiced passive surveillance approach. Strategy A1: Individuals (one per household) receive information and study material by mail with instructions on how to produce a saliva sample and how to return the sample by mail. Once received by the laboratory, the sample is tested for SARS-CoV-2 using Reverse Transcription Loop-mediated Isothermal Amplification (RT-LAMP). Strategy A2: Individuals (one per household) receive information and study material by mail with instructions on how to produce their own as well as saliva samples from each household member and how to return these samples by mail. Once received by the laboratory, the samples are tested for SARS-CoV-2 using RT-LAMP. Strategy B1: Individuals (one per household) receive information by mail on how to complete a brief pre-screening questionnaire which asks about COVID-19 related clinical symptoms and risk exposures. Only individuals whose pre-screening score crosses a defined threshold, will then receive additional study material by mail with instructions on how to produce a saliva sample and how to return the sample by mail. Once received by the laboratory, the saliva sample is tested for SARS-CoV-2 using RT-LAMP. Strategy B2: Individuals (one per household) receive information by mail on how to complete a brief pre-screening questionnaire which asks about COVID-19 related clinical symptoms. Only individuals whose pre-screening score crosses a defined threshold, will then receive additional study material by mail with instructions how to produce their own as well as saliva samples from each household member and how to return these samples by mail. Once received by the laboratory, the samples are tested for SARS-CoV-2 using RT-LAMP. In each strategy, RT-LAMP positive samples are additionally analyzed with qPCR in order to minimize the number of false positives. Main outcomes The identification of the one best strategy will be determined by a set of parameters. Primary outcomes include costs per correctly screened person, costs per positive case, positive detection rate, and precision of positive detection rate. Secondary outcomes include participation rate, costs per asymptomatic case, prevalence estimates, number of asymptomatic cases per study arm, ratio of symptomatic to asymptomatic cases per study arm, participant satisfaction. Additional study components (not part of the trial) include cost effectiveness of each of the four surveillance strategies compared to passive monitoring (i.e. status quo), development of a prognostic model to predict hospital utilization caused by SARS-CoV-2, time from test shipment to test application and time from test shipment to test result, and perception and preferences of the persons to be tested with regard to test strategies. Randomisation Samples are drawn in three batches of three continuous weeks. Randomisation follows a two-stage process. First, a total of 220 sampling points have been allocated to the three different batches. To obtain an integer solution, the Cox-algorithm for controlled rounding has been used. Afterwards, sample points have been drawn separately per batch, following a probability proportional to size (PPS) random sample. Second, for each cluster the same number of residential addresses is randomly sampled from the municipal registries (self-weighted sample of individuals). The 28,125 addresses drawn per municipality are then randomly allocated to the four study arms A1, A2, B1, and B2 in the ratio 5 to 2.5 to 14 to 7 based on the expected response rates in each arm and the sensitivity and specificity of the pre-screening tool as applied in strategy B1 and B2. Based on the assumptions, this allocation should yield 2500 saliva samples in each strategy. Although a municipality can be sampled by multiple batches and the overall number of addresses per municipality might vary, the number of addresses contacted in each arm is kept constant. Blinding (masking) The design is single-blinded, meaning the staff conducting the SARS-CoV-2 tests are unaware of the study arm assignment of each single participant and test sample. Sample sizes Total sample size for the trial is 10,000 saliva samples equally allocated to the four study arms (i.e. 2,500 participants per arm). For the qualitative component, up to 60 in-depth interviews will be conducted with about 30 study participants (up to 15 in each arm A and B) and 30 participation refusers (up to 15 in each arm A and B) purposefully selected from the quantitative study sample to represent a variety of gender and ages to explore experiences with admission or rejection of study participation. Up to 25 asymptomatic SARS-CoV-2 positive study participants will be purposefully selected to explore the way in which asymptomatic men and women diagnosed with SARS-CoV-2 give meaning to their diagnosis and to the dialectic between feeling concurrently healthy and yet also being at risk for transmitting COVID-19. In addition, 100 randomly selected study participants will be included to explore participants’ perspective on testing processes and implementation. Trial Status Final protocol version is “Surveillance_Studienprotokoll_03Nov2020_v1_2” from November 3, 2020. Recruitment started November 18, 2020 and is expected to end by or before December 31, 2020. Trial registration The trial is currently being registered with the German Clinical Trials Register (Deutsches Register Klinischer Studien), DRKS00023271 ( https://www.drks.de/drks_web/navigate.do?navigationId=trial . HTML&TRIAL_ID=DRKS00023271). Retrospectively registered 30 November 2020. Full protocol The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.

Ethnic diversity has been a topic of contention across the globe, contrasted with economic development, social security, and political stability. The link between health and ethnic diversity is not yet well established especially in low-middle- income countries. Our study aims to explore the association between ethnic diversity and all-cause mortality in rural areas of Burkina Faso. We used data from the Nouna Health & Demographic Surveillance System (HDSS) collected between 2000 and 2012. To derive Standardized Mortality Ratios (SMR), the observed number of deaths was compared to the expected deaths based on the entire HDSS taking into account sex, age, rainy season, calendar year, and village. SMR were calculated for ethnic and religious diversity on a village level (using the Simpson Index), sub-region, wealth, and distance to Healthcare Facilities (HCF). Furthermore, we modeled SMR with a multilevel random intercept Poisson regression considering individual ethnic and religious groups in addition to the above-mentioned village-level information. Village wealth (poorest fifth: SMR 1.07; 95% CI: 1.02-1.13, richest fifth: SMR 0.85; 95% CI: 0.82-0.88), distance to HCF (within the village: SMR 0.88; 95% CI: 0.85-0.91, further than 5km: SMR 1.13; 95% CI: 1.10-1.16), and sub-region showed significant associations with overall mortality. Villages belonging to the third with the highest ethnic diversity had lowered SMR (0.86; 95% CI: 0.84-0.89) compared to the entire HDSS, while those belonging to the lowest diversity third yielded elevated SMR (1.13; 95% CI: 1.09-1.17). The multilevel model confirmed the association. Our study showed that historically established ethnic diversity in rural areas of Burkina Faso was associated with lower all-cause mortality. Generally, the literature suffers from a lack of standardization in defining ethnic diversity, along with measuring it. More research is needed to understand this relation and to establish it in different settings.

Abstract Background In 2017, 80% of 425 million adults with diabetes worldwide were living in low and middle-income countries. Diabetes affected 6.9 million adults in Bangladesh and accounted for 3% of the country’s total mortality. Proper management of diabetes is the key to positive health outcomes. This study investigated how mobile phone-based health intervention could increase patient adherence and thereby improve the disease outcomes for diabetes type 2 in Bangladesh. Methods A mobile phone-based health project (including mobile phone reminders and 24/7 call center) was implemented in Dhaka District, Bangladesh from January to December 2014. A randomized control trial was carried out, recruiting randomly in intervention and control groups among the patients receiving treatment for type 2 diabetes at the Bangladesh Institute of Health Sciences Hospital, Dhaka, Bangladesh. A total of 320 patients from both groups at baseline and 273 at endline were interviewed. Results A significant improvement in patient adherence to diet, physical exercise, the cessation of use of tobacco and betel nut, and blood glycaemic control was found in the intervention group, whereas no such significant improvement was found in the control group. Cost and other co-morbidities were found to be the main reasons for non-adherence. Conclusion A mobile-health intervention should be considered as an additional option for non-communicable disease programs.

Abstract Background In 2017, 425 million adults worldwide had diabetes; 80% were living in low and middle-income countries. Bangladesh had 6.9 million adults with diabetes; death from diabetes comprised 3% of the country’s total mortality. This study looked at different factors (personal, familial, social, and financial) affecting both the life of patients with diabetes type 2 and the management of the disease. It also explored patient’s perception of the mobile health intervention in the context of disease management and helped to explain the findings obtained from the quantitative part of this study. Method The study was a mixed-method, sequential explanatory design. A mobile health project (interactive voice call and call center) was implemented in Dhaka district, Bangladesh from January to December, 2014. Patients received treatment at the outpatient department of Bangladesh Institute of Health Science Hospital, Dhaka, Bangladesh, were included in intervention and control groups of the main study following a Randomized Control Trial. Among them, a total of 18 patients (9 + 9) were selected purposefully for the qualitative study, which was conducted in July, 2015. The sample was selected purposefully considering the age, sex, socio-economic status and proximity of living due to the political instability of the country during the data collection period. The interviews were transcribed and analyzed applying investigator triangulation. Results Most patients stated that diabetes has affected their lives. In general, both groups´ evaluation of mobile health services were good and both regarded the recommendations for medication, diet, physical exercise, and other lifestyle behaviors (use of tobacco and betel nuts) as helpful. The cost of overall treatment (medications, physician consultations, laboratory investigations), the lack of availability of safe public places for physical exercise and unfavorable weather conditions (heat, rainfall) were mentioned as barriers to the overall management of the disease. Conclusion A patient-centered mobile health intervention supported by a collaborative patient-provider relationship, a strong family support system, available public spaces for exercise and the introduction of a functional public health insurance system could be beneficial for the better management of diabetes.

Abstract Background The last two decades have seen a growing recognition of the need to expand the impact evaluation toolbox from an exclusive focus on randomized controlled trials to including quasi-experimental approaches. This appears to be particularly relevant when evaluation complex health interventions embedded in real-life settings often characterized by multiple research interests, limited researcher control, concurrently implemented policies and interventions, and other internal validity-threatening circumstances. To date, however, most studies described in the literature have employed either an exclusive experimental or an exclusive quasi-experimental approach. Methods This paper presents the case of a study design exploiting the respective advantages of both approaches by combining experimental and quasi-experimental elements to evaluate the impact of a Performance-Based Financing (PBF) intervention in Burkina Faso. Specifically, the study employed a quasi-experimental design (pretest-posttest with comparison) with a nested experimental component (randomized controlled trial). A difference-in-differences approach was used as the main analytical strategy. Discussion We aim to illustrate a way to reconcile scientific and pragmatic concerns to generate policy-relevant evidence on the intervention’s impact, which is methodologically rigorous in its identification strategy but also considerate of the context within which the intervention took place. In particular, we highlight how we formulated our research questions, ultimately leading our design choices, on the basis of the knowledge needs expressed by the policy and implementing stakeholders. We discuss methodological weaknesses of the design arising from contextual constraints and the accommodation of various interests, and how we worked ex-post to address them to the best extent possible to ensure maximal accuracy and credibility of our findings. We hope that our case may be inspirational for other researchers wishing to undertake research in settings where field circumstances do not appear to be ideal for an impact evaluation. Trial registration Registered with RIDIE (RIDIE-STUDY-ID-54412a964bce8) on 10/17/2014.

Objectives: This study was designed to determine the extent of non‐adherence to the different dimensions of diabetes self‐management and to identify the factors influencing non‐adherence among peripheral patients in Bangladesh. Methods: A cross‐sectional study was conducted among 990 adult diabetic patients residing in Thakurgaon district, Bangladesh. Data were collected through face‐to‐face interviews including socio‐demographic information, disease and therapeutic, health services, knowledge and adherence to self‐management components. Results: The proportion of non‐adherence to drug prescription was 66.7%, dietary regimen (68.9%), physical exercise (58.0%), follow‐up visit/blood glucose test (88.2%), stopping tobacco (50.6%), and regular foot care (93.9%). Significant predictors for non‐adherence to drug were poorest socio‐economic status (OR = 2.47), absence of diabetic complications (OR = 1.43), using non‐clinical therapy (OR = 5.61), and moderate level of knowledge (OR = 1.87). Non‐adherence to dietary recommendations was higher for women (OR = 1.72), poorest socio‐economic status (OR = 3.17), and poor technical knowledge (OR = 4.68). Non‐adherence to physical exercise was lower for women (OR = 0.62), combined family (OR = 0.63), middle socio‐economic status (OR = 0.54), and moderate knowledge on physical exercise (OR = 0.55). Non‐adherence to follow‐up visits/blood glucose test was higher among patients who did not have diabetic complications (OR = 1.81) and with own transport (OR = 2.57), and respondents from high‐income group (OR = 0.23) were less likely to be non‐adherent. Non‐adherence to stopping tobacco was higher for older individuals (OR = 1.86); but lower for women (OR = 0.48), individuals with higher education level (OR = 0.17) and patients sick for a longer time (OR = 0.52). Non‐adherence to foot care was higher for patients who needed longer time to go to hospital (OR = 4.07) and had poor basic knowledge on diabetes (OR = 17.80). Conclusion: An alarmingly high proportion of diabetic patients did not adhere to diabetes self‐management. Major predictors for non‐adherence were related to patient's demographic characteristics and their experience with disease, treatment and health care services. [ABSTRACT FROM AUTHOR]

Abstract Background This qualitative study aimed to investigate the health seeking behaviour of rural women in northern Tajikistan, with specific focus on antenatal and obstetric complications as a result of delayed access to health services. Due to the unprecedented level of labour migration among men in the border region of Tajikistan, Isfara, the study specifically focused on migrants’ wives residing with their in-laws. Methods Using an adapted “Three delays” model which suggests three major causes of delayed access to maternity services - decision to seek care , reaching a healthcare facility and receiving necessary care – we conducted 29 in-depth interviews with labour migrants’ wives, 16 semi-structured interviews with healthcare service providers and 2 focus-group discussions with 16 mothers-in-law in Isfara district. Results Our study demonstrated that the most crucial and conditioned factor of access to maternity services for labour migrants’ wives is a decision to seek care. While reaching a healthcare facility (geographical accessibility, time and transportation costs) and receiving necessary care (availability of services, financial affordability and perceived quality of care) were rarely reported as obstacles towards timely access to maternity services, decision to seek care was found to be an intricate interplay of several factors: traditional gender and family roles (particularly in the absence of the husband), the age of the mother-in-law, cultural beliefs and perceptions about pregnancy and maternity, and widely spread myths about certain health conditions and services. Conclusions Our study concludes that the traditional pattern of seeking health care among women in northern Tajikistan may often cause delays in accessing necessary maternity services and result in adverse health outcomes for women. We suggest that effective strategies to reduce maternal morbidity and mortality in rural Tajikistan should, along with strengthening healthcare structures, embark on community education and awareness raising with special focus on mothers-in-law and other traditional decision-makers in households.

BackgroundMost data on COVID-19 was collected in hospitalized cases. Much less is known about the spectrum of disease in entire populations. In this study, we examine a representative cohort of primarily symptomatic cases in an administrative district in Southern Germany.MethodsWe contacted all confirmed SARS-CoV-2 cases in the administrative district. Consenting participants answered a retrospective survey either via a telephone, electronically or via mail. Clinical and sociodemographic features were compared between hospitalized and non-hospitalized patients. Additionally, we assessed potential risk factors for hospitalization and time to hospitalization in a series of regression models.ResultsWe included 897 participants in our study, 69% out of 1,305 total cases in the district with a mean age of 47 years (range 2-97), 51% of which were female and 47% had a pre-existing illness. The percentage of asymptomatic, mild, moderate (leading to hospital admission) and critical illness (requiring mechanical ventilation) was 54 patients (6%), 713 (79%), 97 (11%) and 16 (2%), respectively. Seventeen patients (2%) died. The most prevalent symptoms were fatigue (65%), cough (62%) and dysgeusia (60%). The risk factors for hospitalization included older age (OR 1.05 per year increase; 95% CI 1.04-1.07) preexisting lung conditions (OR 3.09; 95% CI 1.62-5.88). Female sex was a protective factor (OR 0.51; 95% CI 0.33-0.77).ConclusionThis representative analysis of primarily symptomatic COVID-19 cases confirms age, male sex and preexisting lung conditions but not cardiovascular disease as risk factors for severe illness. Almost 80% of infection take a mild course, whereas 13% of patients suffer moderate to severe illness.Trial registrationGerman Clinical Trials Register, DRKS00022926. URL: https://www.drks.de/drks_web/setLocale_EN.do.

BackgroundAntimicrobial resistance (AMR) thwarts the curative power of drugs and is a present-time global problem. We present data on antimicrobial susceptibility and resistance determinants of bacteria the WHO has highlighted as being key antimicrobial resistance concerns in Africa, to strengthen knowledge of AMR patterns in the region.MethodsBlood, stool, and urine specimens of febrile patients, aged between ≥ 30 days and ≤ 15 years and hospitalized in Burkina Faso, Gabon, Ghana, and Tanzania were cultured from November 2013 to March 2017 (Patients > 15 years were included in Tanzania). Antimicrobial susceptibility testing was performed for all Enterobacterales and Staphylococcus aureus isolates using disk diffusion method. Extended-spectrum beta-lactamase (ESBL) production was confirmed by double-disk diffusion test and the detection of blaCTX–M, blaTEM and blaSHV. Multilocus sequence typing was conducted for ESBL-producing Escherichia coli and Klebsiella pneumoniae, ciprofloxacin-resistant Salmonella enterica and S. aureus. Ciprofloxacin-resistant Salmonella enterica were screened for plasmid-mediated resistance genes and mutations in gyrA, gyrB, parC, and parE. S. aureus isolates were tested for the presence of mecA and Panton-Valentine Leukocidin (PVL) and further genotyped by spa typing.ResultsAmong 4,052 specimens from 3,012 patients, 219 cultures were positive of which 88.1% (n = 193) were Enterobacterales and 7.3% (n = 16) S. aureus. The prevalence of ESBL-producing Enterobacterales (all CTX-M15 genotype) was 45.2% (14/31; 95% CI: 27.3, 64.0) in Burkina Faso, 25.8% (8/31; 95% CI: 11.9, 44.6) in Gabon, 15.1% (18/119; 95% CI: 9.2, 22.8) in Ghana and 0.0% (0/12; 95% CI: 0.0, 26.5) in Tanzania. ESBL positive non-typhoid Salmonella (n = 3) were detected in Burkina Faso only and methicillin-resistant S. aureus (n = 2) were detected in Ghana only. While sequence type (ST)131 predominated among ESBL E. coli (39.1%;9/23), STs among ESBL K. pneumoniae were highly heterogenous. Ciprofloxacin resistant nt Salmonella were commonest in Burkina Faso (50.0%; 6/12) and all harbored qnrB genes. PVL were found in 81.3% S. aureus.ConclusionOur findings reveal a distinct susceptibility pattern across the various study regions in Africa, with notably high rates of ESBL-producing Enterobacterales and ciprofloxacin-resistant nt Salmonella in Burkina Faso. This highlights the need for local AMR surveillance and reporting of resistances to support appropriate action.

Problem: The Pacific region has widely dispersed populations, limited financial and human resources and a high burden of disease. There is an urgent need to improve the availability, reliability and timeliness of useable health data. Context: The purpose of this paper is to share lessons learnt from a three-year pilot field epidemiology training programme that was designed to respond to these Pacific health challenges. The pilot programme built on and further developed an existing field epidemiology training programme for Pacific health staff. Action: The programme was delivered in country by epidemiologists working for Pacific Public Health Surveillance Network partners. The programme consisted of five courses: four one-week classroom-based courses and one field epidemiology project. Sessions were structured so that theoretical understanding was achieved through interaction and reinforced through practical hands-on group activities, case studies and other interactive practical learning methods. Outcome: As of September 2016, 258 students had commenced the programme. Twenty-six course workshops were delivered and one cohort of students had completed the full five-course programme. The programme proved popular and gained a high level of student engagement. Discussion: Face-to-face delivery, a low student-to-facilitator ratio, substantial group work and practical exercises were identified as key factors that contributed to the students developing skills and confidence. Close engagement of leaders and the need to quickly evaluate and adapt the curriculum were important lessons, and the collaboration between external partners was considered important for promoting a harmonized approach to health needs in the Pacific.

Abstract French Contexte La motivation des agents de santé dans les pays à revenu faible et intermédiaire est devenue un sujet de grand intérêt pour les décideurs et les chercheurs au cours des dernières années. Pourtant, de nombreux aspects de la motivation des agents de santé ne sont pas encore bien compris. Ceci est dû en particulier à l’absence d’outils de mesure appropriés. Cet article présente une preuve de la validité conceptuelle d’une échelle psychométrique développée pour mesurer la composition de la motivation, c’est-à-dire le degré auquel des types de motivation d’origine différente à l’intérieur et à l’extérieur d’une personne contribuent à leur motivation globale au travail. L’échelle est fondée sur la théorie de l’auto-détermination (Self-Determination Theory). Méthodes Une enquête transversale a été mise en place auprès de 1 142 infirmières dans 522 formations sanitaires gouvernementales de 24 districts du Burkina Faso. Par analyse factorielle confirmatoire, nous avons examiné si l’échelle mesure ce qu’elle était supposée mesurer (validité structurelle et convergente/discriminante) et si ses propriétés de mesures sont comparables dans différentes sous-groupes d’agents de santé (invariance de la mesure). Résultats Les résultats montrent que l’échelle mesure une version légèrement modifiée du continuum de motivation proposée par la théorie de l’auto-détermination. Les propriétés de mesure étaient globalement comparables entre les sous-groupes, mais une certaine prudence est indiquée si une comparaison des moyennes entre les groupes est l’objectif principal de l’analyse. Conclusion L’échelle est une un apport important au référentiel des outils de mesure de la motivation des agents de santé dans les pays à revenu faible et modérés. Elle sera utile pour une meilleure compréhension de la motivation des prestataires, ainsi que des effets positifs et potentiellement secondaires des interventions visant à renforcer la motivation.

The Ministry of Health in Samoa, in partnership with the Pacific Community, successfully implemented enhanced surveillance for the high-profile Third United Nations Conference on Small Island Developing States held concurrently with the popular local Teuila festival during a widespread chikungunya outbreak in September 2014. Samoa’s weekly syndromic surveillance system was expanded to 12 syndromes and 10 sentinel sites from four syndromes and seven sentinel sites; sites included the national hospital, four private health clinics and three national health service clinics. Daily situation reports were produced and were disseminated through PacNet (the email alert and communication tool of the Pacific Public Health Surveillance Network) together with daily prioritized line lists of syndrome activity to facilitate rapid response and investigation by the Samoan EpiNet team. Standard operating procedures for surveillance and response were introduced, together with a sustainability plan, including a monitoring and evaluation framework, to facilitate the transition of the mass gathering surveillance improvements to routine surveillance. The enhanced surveillance performed well, providing vital disease early warning and health security assurance. A total of 2386 encounters and 708 syndrome cases were reported. Influenza-like illness was the most frequently seen syndrome (17%). No new infectious disease outbreaks were recorded. The experience emphasized: (1) the need for a long lead time to pilot the surveillance enhancements and to maximize their sustainability; (2) the importance of good communication between key stakeholders; and (3) having sufficient staff dedicated to both surveillance and response.

Due to an error introduced during copyediting of this article [1], there are two corrections about the Figs. 1. The caption of Fig. 1 should be changed to “Study design”. 2. The Fig. 2 is missing.

BACKGROUND:The perceived returns on schooling are critical in schooling decision-making but are not well understood. This study examines the perceived returns on secondary schooling in Burkina Faso, where secondary school completion is among the lowest globally (

Mass gatherings pose public health challenges to host countries, as they can cause or exacerbate disease outbreaks within the host location or elsewhere. In July 2012, the 11th Festival of Pacific Arts (FOPA), a mass gathering event involving 22 Pacific island states and territories, was hosted by Solomon Islands. An enhanced syndromic surveillance (ESS) system was implemented for the event. Throughout the capital city, Honiara, 15 sentinel sites were established and successfully took part in the ESS system, which commenced one week before the FOPA (25 June) and concluded eight days after the event (22 July). The ESS involved expanding on the existing syndromic surveillance parameters: from one to 15 sentinel sites, from four to eight syndromes, from aggregated to case-based reporting and from weekly to daily reporting. A web-based system was developed to enable data entry, data storage and data analysis. Towards the end of the ESS period, a focus group discussion and series of key informant interviews were conducted. The ESS was considered a success and played an important role in the early detection of possible outbreaks. For the period of the ESS, 1668 patients with syndrome presentations were received across the 15 sentinel sites. There were no major events of public health significance. Several lessons were learnt that are relevant to ESS in mass gathering scenarios, including the importance of having adequate lead in time for engagement and preparation to ensure appropriate policy and institutional frameworks are put in place.