Effectiveness of digital interventions to improve household and community infection prevention and control behaviours and to reduce incidence of respiratory and/or gastro-intestinal infections: a rapid systematic review

Kukaa Salama (Staying Safe): a pre-post trial of an interactive informational mobile health intervention for increasing COVID-19 prevention practices with urban refugee youth in Uganda

BACKGROUND

Tailored coronavirus disease 2019 (COVID-19) prevention strategies are needed for urban refugee youth in resource-constrained contexts. We developed an 8-wk interactive informational mobile health intervention focused on COVID-19 prevention practices informed by the Risk, Attitude, Norms, Ability, Self-regulation-or RANAS-approach.

METHODS

We conducted a pre-post trial with a community-recruited sample of refugee youth aged 16-24 y in Kampala, Uganda. Data were collected before (T1) and immediately following (T2) the intervention, and at the 16-wk follow up (T3), to examine changes in primary (COVID-19 prevention self-efficacy) and secondary outcomes (COVID-19 risk awareness, attitudes, norms and self-regulation practices; depression; sexual and reproductive health [SRH] access; food/water security; COVID-19 vaccine acceptability).

RESULTS

Participants (n=346; mean age: 21.2 [SD 2.6] y; cisgender women: 50.3%; cisgender men: 48.0%; transgender persons: 1.7%) were largely retained (T2: n=316, 91.3%; T3: n=302, 87.3%). In adjusted analyses, COVID-19 prevention self-efficacy, risk awareness, attitudes and vaccine acceptance increased significantly from T1 to T2, but were not sustained at T3. Between T1 and T3, COVID-19 norms and self-regulation significantly increased, while community violence, water insecurity and community SRH access decreased.

CONCLUSIONS

Digital approaches for behaviour change hold promise with urban refugee youth but may need booster messaging and complementary programming for sustained effects.

Implementing Germ Defence digital behaviour change intervention via all primary care practices in England to reduce respiratory infections during the COVID-19 pandemic: an efficient cluster randomised controlled trial using the OpenSAFELY platform

BACKGROUND

Germ Defence ( www.germdefence.org ) is an evidence-based interactive website that promotes behaviour change for infection control within households. To maximise the potential of Germ Defence to effectively reduce the spread of COVID-19, the intervention needed to be implemented at scale rapidly.

METHODS

With NHS England approval, we conducted an efficient two-arm (1:1 ratio) cluster randomised controlled trial (RCT) to examine the effectiveness of randomising implementation of Germ Defence via general practitioner (GP) practices across England, UK, compared with usual care to disseminate Germ Defence to patients. GP practices randomised to the intervention arm (n = 3292) were emailed and asked to disseminate Germ Defence to all adult patients via mobile phone text, email or social media. Usual care arm GP practices (n = 3287) maintained standard management for the 4-month trial period and then asked to share Germ Defence with their adult patients. The primary outcome was the rate of GP presentations for respiratory tract infections (RTI) per patient. Secondary outcomes comprised rates of acute RTIs, confirmed COVID-19 diagnoses and suspected COVID-19 diagnoses, COVID-19 symptoms, gastrointestinal infection diagnoses, antibiotic usage and hospital admissions. The impact of the intervention on outcome rates was assessed using negative binomial regression modelling within the OpenSAFELY platform. The uptake of the intervention by GP practice and by patients was measured via website analytics.

RESULTS

Germ Defence was used 310,731 times. The average website satisfaction score was 7.52 (0-10 not at all to very satisfied, N = 9933). There was no evidence of a difference in the rate of RTIs between intervention and control practices (rate ratio (RR) 1.01, 95% CI 0.96, 1.06, p = 0.70). This was similar to all other eight health outcomes. Patient engagement within intervention arm practices ranged from 0 to 48% of a practice list.

CONCLUSIONS

While the RCT did not demonstrate a difference in health outcomes, we demonstrated that rapid large-scale implementation of a digital behavioural intervention is possible and can be evaluated with a novel efficient prospective RCT methodology analysing routinely collected patient data entirely within a trusted research environment.

TRIAL REGISTRATION

This trial was registered in the ISRCTN registry (14602359) on 12 August 2020.

Investigation of the prevalence of non-COVID-19 infectious diseases during the COVID-19 pandemic

Objectives

This study aimed to investigate non-COVID-19-related upper respiratory tract infections (URTIs), gastrointestinal infections (GIIs) and urinary tract infections (UTIs) during the COVID-19 pandemic in Germany.

Study design

Cross-sectional study.

Methods

Patients with diagnoses of URTIs, GIIs and UTIs from 994 general practitioners (GP) and 192 paediatric practices that routinely send anonymous data to the Disease Analyzer database (IQVIA) were investigated. We studied the differences in recorded URTIs, GIIs and UTIs between April 2019–March 2020 (non-pandemic period) and April 2020–March 2021 (pandemic period) in terms of rates and baseline characteristics by comparing absolute frequencies.

Results

Compared with the non-pandemic period, the total number of patients with defined diagnoses was lower in the pandemic period (URTIs: 810,324 vs 520,800; GIIs: 253,029 vs 142,037; UTIs: 132,425 vs 117,932). The number of patients per practice with URTIs (683 vs 439, –36%, P < 0.001) and GIIs (213 vs 120, –44%, P < 0.001) decreased significantly during the pandemic period; the decrease in the number of recorded UTIs was smaller (112 vs 99, –11%, P < 0.05). The decrease in diagnoses was more pronounced among paediatricians than GPs (URTIs: −39% vs −35%; GIIs: −57% vs −39%; UTIs: −15% vs −9%). The decrease in URTIs varied between −35% and −40% depending on the age group.

Conclusions

Measures introduced during the COVID-19 pandemic to reduce transmission of the virus also helped to reduce the spread of non-COVID-19-related URTIs and GIIs. UTIs were impacted to a lesser extent, with rates seeing a slight decrease. An increase in awareness of infectious diseases may have also contributed to the reduction in recorded diagnoses.

A Web-Based Intervention (Germ Defence) to Increase Handwashing During a Pandemic: Process Evaluations of a Randomized Controlled Trial and Public Dissemination

Background

Washing hands helps prevent transmission of seasonal and pandemic respiratory viruses. In a randomized controlled trial (RCT) during the swine flu outbreak, participants with access to a fully automated, digital intervention promoting handwashing reported washing their hands more often and experienced fewer respiratory tract infections than those without access to the intervention. Based on these findings, the intervention was adapted, renamed as “Germ Defence,” and a study was designed to assess the preliminary dissemination of the intervention to the general public to help prevent the spread of seasonal colds and flu.

Objective

This study compares the process evaluations of the RCT and Germ Defence dissemination to examine (1) how web-based research enrollment procedures affected those who used the intervention, (2) intervention usage in the 2 contexts, and (3) whether increased intentions to wash hands are replicated once disseminated.

Methods

The RCT ran between 2010 and 2012 recruiting participants offline from general practices, with restricted access to the intervention (N=9155). Germ Defence was disseminated as an open access website for use by the general public from 2016 to 2019 (N=624). The process evaluation plan was developed using Medical Research Council guidance and the framework for Analyzing and Measuring Usage and Engagement Data. Both interventions contained a goal-setting section where users self-reported current and intended handwashing behavior across 7 situations.

Results

During web-based enrolment, 54.3% (17,511/32,250) of the RCT participants dropped out of the study compared to 36.5% (358/982) of Germ Defence users. Having reached the start of the intervention, 93.8% (8586/9155) of RCT users completed the core section, whereas 65.1% (406/624) of Germ Defence users reached the same point. Users across both studies selected to increase their handwashing in 5 out of 7 situations, including before eating snacks (RCT mean difference 1.040, 95% CI 1.016-1.063; Germ Defence mean difference 0.949, 95% CI 0.766-1.132) and after blowing their nose, sneezing, or coughing (RCT mean difference 0.995, 95% CI 0.972-1.019; Germ Defence mean difference 0.842, 95% CI 0.675-1.008).

Conclusions

By comparing the preliminary dissemination of Germ Defence to the RCT, we were able to examine the potential effects of the research procedures on uptake and attrition such as the sizeable dropout during the RCT enrolment procedure that may have led to a more motivated sample. The Germ Defence study highlighted the points of attrition within the intervention. Despite sample bias in the trial context, the intervention replicated increases in intentions to handwash when used “in the wild.” This preliminary dissemination study informed the adaptation of the intervention for the COVID-19 health emergency, and it has now been disseminated globally.

Trial Registration

ISRCTN Registry ISRCTN75058295; https://www.isrctn.com/ISRCTN75058295

Fewer non-COVID-19 respiratory tract infections and gastrointestinal infections during the COVID-19 pandemic

For preventing the spread of the coronavirus disease 2019 (COVID‐19) pandemic, measures like wearing masks, social distancing, and hand hygiene played crucial roles. These measures may also have affected the expansion of other infectious diseases like respiratory tract infections (RTI) and gastro‐intestinal infections (GII). Therefore, we aimed to investigate non‐COVID‐19 related RTI and GII during the COVID‐19 pandemic. Patients with a diagnosis of an acute RTI (different locations) or acute GII documented anonymously in 994 general practitioner (GP) or 192 pediatrician practices in Germany were included. We compared the prevalence of acute RTI and GII between April 2019–March 2020 and April 2020–March 2021. In GP practices, 715,440 patients were diagnosed with RTI or GII in the nonpandemic period versus 468,753 in the pandemic period; the same trend was observed by pediatricians (275,033 vs. 165,127). By GPs, the strongest decrease was observed for the diagnosis of influenza (−71%, p < 0.001), followed by acute laryngitis (−64%, p < 0.001), acute lower respiratory infections (bronchitis) (−62%, p < 0.001), and intestinal infections (−40%, p < 0.001). In contrast, the relatively rare viral pneumonia strongly increased by 229% (p < 0.001). In pediatrician practices, there was a strong decrease in infection diagnoses, especially influenza (−90%, p < 0.001), pneumonia (−73%, p < 0.001 viral; −76%, p < 0.001 other pneumonias), and acute sinusitis (−66%, p < 0.001). No increase was observed for viral pneumonia in children. The considerable limitations concerning social life implemented during the COVID‐19 pandemic to combat the spread of SARS‐CoV‐2 also resulted in an inadvertent but welcome reduction in other non‐Covid‐19 respiratory tract and gastro‐intestinal infections.

By general practices, in the pandemic time period, the strong decrease was observed for the diagnosis of influenza, acute laryngitis bronchitis, and intestinal infections.

In contrast, the relatively rare viral pneumonia strongly increased in general practices.

In pediatrician practices, there was a strong decrease in influenza, pneumonia, and acute sinusitis.

No increase was observed for viral pneumonia in children.