Analysis of group randomized trials with multiple binary endpoints and small number of groups

Evaluating Coaching Intervention for Financial Risk Perception and Credit Risk Management in a Nigerian Sample

There is no doubt that a negative perception of financial risk and a lack of credit risk management adversely impact business growth and business owners’ wellbeing. Past studies suggest that most Nigerian traders have poor risk perceptions and manage risk poorly. A business coaching program within rational-emotive behavior therapy framework (REBT-based business coaching) was evaluated in order to determine its effects on financial risk perception and credit risk management among Nigerian traders. This study used an open-label parallel randomized control design. This 8-weeks coaching program had 60 traders in the REBT-based business coaching group and 59 traders in the control group. The mixed-model repeated measures ANOVA was utilized for analysis of the study data. Results show that relative to a control group, traders’ financial risk perception [F(1.09,127.15) = 637.29, p < 0.001, ω2 = 0.69] and credit risk management [F(1.55,181.22) = 795.51, p < 0.001, ω2 = 0.80] significantly improved after participating in REBT-based business coaching program. This study shows that REBT-based business coaching program is integral to increasing financial risk perception and credit risk management among Nigerian traders. This study contributes to the advancement of business coaching program within the rational-emotive behavior therapy framework for market traders, and its application in similar situations. The study considered the benefits of business coaching program for market traders from a developing country, which is a rarely studied group. It is highly recommended that professionals study the relationship between REBT-based business coaching and economic decision-making within various organizational contexts.

Efficacy of guided internet-assisted intervention on depression reduction among educational technology students of Nigerian universities

BACKGROUND/OBJECTIVE

The study's objective was to determine the efficacy of guided internet-assisted intervention (GIAI) on depression reduction among educational technology students of Nigerian universities.

METHODS

The design of the study was a 10-weeks group-randomized trial (GRT) which involved a pre-test, post-test, and follow-up assessment. A total of 192 educational technology students who were identified as having depression formed the sample of the study. Beck's Depression Inventory-II (BDI-II) was the measure used for data collection in the study. Data collected were analyzed using ANOVA with repeated measures.

RESULTS

The initial assessment results showed that the participants in both treatment and usual-care control groups had depression. After 10-weeks participation in GIAI, the assessment results showed a significant reduction in depression among students in the treatment group when compared to those in the usual-care control group. The follow-up assessment indicated a further significant reduction in the depression among participants in the treatment group when compared to those in the usual-care control group.

CONCLUSION

The authors concluded that GIAI was significantly effective in reducing depression among university students in the treatment group compared to those in the usual-care control group. Therefore, educational technologists, counselors, psychologists, health workers, and other social workers should adopt educational intervention using GIAI in helping university students undergo depression reduction.

Power analysis for cluster randomized trials with multiple binary co-primary endpoints

Cluster randomized trials (CRTs) are widely used in different areas of medicine and public health. Recently, with increasing complexity of medical therapies and technological advances in monitoring multiple outcomes, many clinical trials attempt to evaluate multiple co-primary endpoints. In this study, we present a power analysis method for CRTs with K ≥ 2 binary co-primary endpoints. It is developed based on the GEE (generalized estimating equation) approach, and three types of correlations are considered: inter-subject correlation within each endpoint, intra-subject correlation across endpoints, and inter-subject correlation across endpoints. A closed-form joint distribution of the K test statistics is derived, which facilitates the evaluation of power and type I error for arbitrarily constructed hypotheses. We further present a theorem that characterizes the relationship between various correlations and testing power. We assess the performance of the proposed power analysis method based on extensive simulation studies. An application example to a real clinical trial is presented.

Efficacy of cognitive behavior language therapy for aphasia following stroke: Implications for language education research

BACKGROUND/OBJECTIVE

Evidence from previous research has shown that the incidence of aphasia following a stroke is high in Nigeria and other countries, and there is a call for intervention programs. The objective of the current study was to investigate the efficacy of cognitive behavior language therapy (CBLT) on aphasia following a stroke.

METHODS

The study was designed as a group randomized trial, which involved treatment and no-treatment control procedures. The participants of the study were 86 patients who had experienced aphasia following a stroke. The Porch Index of Communicative Ability (PICA) and Speech-Language Unhelpful Thoughts and Beliefs Scale (SLUTBS) were the measures used in the study. The repeated measures analysis of variance procedure, with Partial eta squared (Equation is included in full-text article.), adjusted R, mean, standard deviation, and upper/lower limit was followed in analyzing the data collected in the study.

RESULTS

The CBLT intervention significantly reduced aphasia following a stroke and significantly reduced speech-language and unhelpful thought and beliefs among aphasic stroke patients exposed to the treatment intervention when compared with the no-treatment control group.

CONCLUSION

Based on the findings of the study, language educators, speech and language pathologists and therapists in education institutions, hospitals, and rehabilitation centers should adopt the principles of CBLT used in the current study to help them improve communication ability among aphasia stroke patients.

Cluster randomized trial of comprehensive gender-based violence programming delivered through the HIV/AIDS program platform in Mbeya Region, Tanzania: Tathmini GBV study

The Tathmini GBV study was a cluster randomized trial to assess the impact of a comprehensive health facility- and community-based program delivered through the HIV/AIDS program platform on reduction in gender-based violence and improved care for survivors. Twelve health facilities and surrounding communities in the Mbeya Region of Tanzania were randomly assigned to intervention or control arms. Population-level effects were measured through two cross-sectional household surveys of women ages 15–49, at baseline (n = 1,299) and at 28 months following program scale-out (n = 1,250). Delivery of gender-based violence services was assessed through routine recording in health facility registers. Generalized linear mixed effects models and analysis of variance were used to test intervention effects on population and facility outcomes, respectively. At baseline, 52 percent of women reported experience of recent intimate partner violence. The odds of reporting experience of this violence decreased by 29 percent from baseline to follow-up in the absence of the intervention (time effect OR = 0.71, 95% CI: 0.57–0.89). While the intervention contributed an additional 15 percent reduction, the effect was not statistically significant. The program, however, was found to contribute to positive, community-wide changes including less tolerance for certain forms of violence, more gender equitable norms, better knowledge about gender-based violence, and increased community actions to address violence. The program also led to increased utilization of gender-based violence services at health facilities. Nearly three times as many client visits for gender-based violence were recorded at intervention (N = 1,427) compared to control (N = 489) facilities over a 16-month period. These visits were more likely to include provision of an HIV test (55.3% vs. 19.6%, p = .002). The study demonstrated the feasibility and impact of integrating gender-based violence and HIV programming to combat both of these major public health problems. Further opportunities to scale out GBV prevention and response strategies within HIV/AIDS service delivery platforms should be pursued.

Trial Registration: Pan African Clinical Trials Registry No. PACTR201802003124149.

A stress management intervention for adults living with HIV in Nigerian community settings: An effects study

BACKGROUND

This study evaluated the effectiveness of a group-based cognitive-behavioral stress management intervention among community-dwelling adults living with HIV in Southeastern Nigeria.

METHOD

A total of 28 HIV-positive adults meeting the criteria for high perceived stress, anxiety, and depression were randomized into 1 of 2 groups: treatment group (n = 14); and no-treatment control group (n = 14). Stress level was measured using the 10-item Perceived Stress Scale (PSS-10). Depression and anxiety symptoms were assessed using Hospital Anxiety and Depression Scale (HADS). Secondary outcome measure was Satisfaction with Life Scale (SWLS). The intervention was delivered over the course of 10 weeks, using an evidence-based cognitive-behavioral stress management manual. We employed repeated-measures between and within-subjects analysis of variance (ANOVA) and Eta squared in the analyses and interpretation of data collected from the study participants at 3 time points.

RESULTS

Our results showed that, after benefitting from the cognitive behavioral stress management intervention, the PSS-10 and HADS scores were lowered significantly in the treatment group participants than those in the no-treatment control group during evaluations of post-treatment and 3 months follow-up outcomes. Significant improvements were also recorded in the treatment group participants' SWLS scores at post-treatment and follow-up compared with participants in the no-treatment group.

CONCLUSION

The present results suggest the need for further implementation of group-based cognitive-behavioral stress management interventions for people living with HIV. Cognitive-behavioral stress management clinicians should make efforts toward identifying HIV-positive adults experiencing psychological distress and design cognitive-behavioral stress management interventions in order to better assist them.

Efficacy of rational emotive digital storytelling intervention on knowledge and risk perception of HIV/AIDS among schoolchildren in Nigeria

BACKGROUND

This investigation was aimed at determining the efficacy of a rational emotive digital storytelling (REDStory) therapy on knowledge and perception of risk of HIV/AIDS among schoolchildren in Enugu State, Nigeria.

METHODS

The researchers adopted a group randomized controlled trial design involving a pretest, posttest, and follow-up design involving a treatment group and a waiting-list control group. Participants were 80 junior secondary schoolchildren attending public and private schools who met the criteria for inclusion in the sample of this study. The REDStory intervention program lasted for 8-week duration of REDStory therapy. The HIV Knowledge Questionnaire and the Perceived Risk of HIV Scale (PRHS) were used for data collection for this study. Repeated measures analysis of variance and t test were used for data analysis.

RESULTS

The results revealed that REDStory therapy had a significant effect in increasing knowledge level and perceived risk of HIV among schoolchildren compared to those in waitlisted control group. Lastly, the positive benefits of this study were significantly sustained by the treatment group at the follow-up.

CONCLUSION

The current study therefore suggests the use of REDStory therapy in increasing knowledge and perception of risk of HIV/AIDS among schoolchildren in Enugu, Nigeria.

A readily available improvement over method of moments for intra-cluster correlation estimation in the context of cluster randomized trials and fitting a GEE-type marginal model for binary outcomes

BACKGROUND/AIMS

Cluster randomized trials are popular in health-related research due to the need or desire to randomize clusters of subjects to different trial arms as opposed to randomizing each subject individually. As outcomes from subjects within the same cluster tend to be more alike than outcomes from subjects within other clusters, an exchangeable correlation arises that is measured via the intra-cluster correlation coefficient. Intra-cluster correlation coefficient estimation is especially important due to the increasing awareness of the need to publish such values from studies in order to help guide the design of future cluster randomized trials. Therefore, numerous methods have been proposed to accurately estimate the intra-cluster correlation coefficient, with much attention given to binary outcomes. As marginal models are often of interest, we focus on intra-cluster correlation coefficient estimation in the context of fitting such a model with binary outcomes using generalized estimating equations. Traditionally, intra-cluster correlation coefficient estimation with generalized estimating equations has been based on the method of moments, although such estimators can be negatively biased. Furthermore, alternative estimators that work well, such as the analysis of variance estimator, are not as readily applicable in the context of practical data analyses with generalized estimating equations. Therefore, in this article we assess, in terms of bias, the readily available residual pseudo-likelihood approach to intra-cluster correlation coefficient estimation with the GLIMMIX procedure of SAS (SAS Institute, Cary, NC). Furthermore, we study a possible corresponding approach to confidence interval construction for the intra-cluster correlation coefficient.

METHODS

We utilize a simulation study and application example to assess bias in intra-cluster correlation coefficient estimates obtained from GLIMMIX using residual pseudo-likelihood. This estimator is contrasted with method of moments and analysis of variance estimators which are standards of comparison. The approach to confidence interval construction is assessed by examining coverage probabilities.

RESULTS

Overall, the residual pseudo-likelihood estimator performs very well. It has considerably less bias than moment estimators, which are its competitor for general generalized estimating equation-based analyses, and therefore, it is a major improvement in practice. Furthermore, it works almost as well as analysis of variance estimators when they are applicable. Confidence intervals have near-nominal coverage when the intra-cluster correlation coefficient estimate has negligible bias.

CONCLUSION

Our results show that the residual pseudo-likelihood estimator is a good option for intra-cluster correlation coefficient estimation when conducting a generalized estimating equation-based analysis of binary outcome data arising from cluster randomized trials. The estimator is practical in that it is simply a result from fitting a marginal model with GLIMMIX, and a confidence interval can be easily obtained. An additional advantage is that, unlike most other options for performing generalized estimating equation-based analyses, GLIMMIX provides analysts the option to utilize small-sample adjustments that ensure valid inference.

Sample size calculations for group randomized trials with unequal group sizes through Monte Carlo simulations

Group randomized trial design is common in cancer prevention and health promotion research with intervention development. Several methods have been developed to handle the design and analytical issues for group randomized trial including the intraclass correlation coefficient. The widely used methods for the sample size calculation for the group randomized trial assume equal sizes across groups. In practice this assumption often fails and group randomized trial studies suffer from considerably lower statistical power than as planned. A few studies have developed sample size calculation methods for unequal group sizes, but most of them are limited to continuous outcomes. In this study, we develop a method for sample size calculation for group randomized trial studies with unequal group sizes based on Monte Carlo simulation in the mixed effect model framework. This approach incorporates the variation of group sizes and can be applied to group randomized trials with different types of outcomes. Further, it is easy to implement and can be applied to most commonly used group randomized trial designs such as pre-and-post cross-sectional and cohort study designs. We demonstrate the application of the proposed approach to two-arm group randomized trial studies with continuous and binary outcomes through simulations and analysis of a real group randomized trial dataset.

Patient navigation and time to diagnostic resolution: results for a cluster randomized trial evaluating the efficacy of patient navigation among patients with breast cancer screening abnormalities, Tampa, FL

OBJECTIVES

The objective of this study was to evaluate a patient navigation (PN) program that attempts to reduce the time between a breast cancer screening abnormality and definitive diagnosis among medically underserved populations of Tampa Bay, Florida.

METHODS

The Moffitt Patient Navigation Research Program conducted a cluster randomized design with 10 primary care clinics. Patients were navigated from time of a breast screening abnormality to diagnostic resolution. This paper examined the length of time between breast abnormality and definitive diagnosis, using a shared frailty Cox proportional hazard model to assess PN program effect.

RESULTS

1,039 patients were eligible for the study because of an abnormal breast cancer screening/clinical abnormality (494 navigated; 545 control). Analysis of PN effect by two time periods of resolution (0-3 months and > 3 months) showed a lagged effect of PN. For patients resolving in the first three months, the adjusted Hazard Ratio (aHR) was 0.85 (95% Confidence Interval [CI]: 0.64-1.13) suggesting that PN had no effect on resolution time during this period. Beyond three months, however, navigated patients resolved more quickly to diagnostic resolution compared with the control group (aHR 2.8, 95%CI: 1.30-6.13). The predicted aHR at 3 months was 1.2, which was not statistically significant, while PN had a significant positive effect beyond 4.7 months.

CONCLUSIONS

PN programs may increase the timeliness of diagnostic resolution for patients with a breast cancer-related abnormality. PN did not speed diagnostic resolution during the initial three months of follow up but started to reduce time to diagnostic resolution after three months and showed a significant effect after 4.7 months.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00375024.

Patient navigation and time to diagnostic resolution: results for a cluster randomized trial evaluating the efficacy of patient navigation among patients with breast cancer screening abnormalities, Tampa, FL

Objectives

The objective of this study was to evaluate a patient navigation (PN) program that attempts to reduce the time between a breast cancer screening abnormality and definitive diagnosis among medically underserved populations of Tampa Bay, Florida.

Methods

The Moffitt Patient Navigation Research Program conducted a cluster randomized design with 10 primary care clinics. Patients were navigated from time of a breast screening abnormality to diagnostic resolution. This paper examined the length of time between breast abnormality and definitive diagnosis, using a shared frailty Cox proportional hazard model to assess PN program effect.

Results

1,039 patients were eligible for the study because of an abnormal breast cancer screening/clinical abnormality (494 navigated; 545 control). Analysis of PN effect by two time periods of resolution (0-3 months and > 3 months) showed a lagged effect of PN. For patients resolving in the first three months, the adjusted Hazard Ratio (aHR) was 0.85 (95% Confidence Interval [CI]: 0.64-1.13) suggesting that PN had no effect on resolution time during this period. Beyond three months, however, navigated patients resolved more quickly to diagnostic resolution compared with the control group (aHR 2.8, 95%CI: 1.30-6.13). The predicted aHR at 3 months was 1.2, which was not statistically significant, while PN had a significant positive effect beyond 4.7 months.

Conclusions

PN programs may increase the timeliness of diagnostic resolution for patients with a breast cancer-related abnormality. PN did not speed diagnostic resolution during the initial three months of follow up but started to reduce time to diagnostic resolution after three months and showed a significant effect after 4.7 months.

Trial Registration

ClinicalTrials.gov NCT00375024

An oral health intervention for people with serious mental illness (Three Shires Early Intervention Dental Trial): study protocol for a randomised controlled trial

Background

Oral health is an important part of general physical health and is essential for self-esteem, self-confidence and overall quality of life. There is a well-established link between mental illness and poor oral health. Oral health problems are not generally well recognized by mental health professionals and many patients experience barriers to treatment.

Methods/Design

This is the protocol for a pragmatic cluster randomised trial that has been designed to fit within standard care. Dental awareness training for care co-ordinators plus a dental checklist for service users in addition to standard care will be compared with standard care alone for people with mental illness. The checklist consists of questions about service users’ current oral health routine and condition. Ten Early Intervention in Psychosis (EIP) teams in Nottinghamshire, Derbyshire and Lincolnshire will be cluster randomised (five to intervention and five to standard care) in blocks accounting for location and size of caseload. The oral health of the service users will be monitored for one year after randomisation.

Trial registration

Current Controlled Trials ISRCTN63382258.

Effects of physical activity on teen smoking cessation

OBJECTIVE

To understand the influence of physical activity on teen smoking-cessation outcomes.

METHODS

Teens (N = 233; 14-19 years of age) from West Virginia high schools who smoked >1 cigarette in the previous 30 days were included. High schools with >300 students were selected randomly and assigned to brief intervention (BI), Not on Tobacco (N-O-T) (a proven teen cessation program), or N-O-T plus a physical activity module (N-O-T+FIT). Quit rates were determined 3 and 6 months after baseline by using self-classified and 7-day point prevalence quit rates, and carbon monoxide validation was obtained at the 3-month follow-up evaluation.

RESULTS

Trends for observed and imputed self-classified and 7-day point prevalence rates indicated that teens in the N-O-T+FIT group had significantly higher cessation rates compared with those in the N-O-T and BI groups. Effect sizes were large. Overall, girls quit more successfully with N-O-T compared with BI (relative risk [RR]: >∞) 3 months after baseline, and boys responded better to N-O-T+FIT than to BI (RR: 2-3) or to N-O-T (RR: 1-2). Youths in the N-O-T+FIT group, compared with those in the N-O-T group, had greater likelihood of cessation (RR: 1.48) at 6 months. The control group included an unusually large proportion of participants in the precontemplation stage at enrollment, but there were no significant differences in outcomes between BI and N-O-T (z = 0.94; P = .17) or N-O-T+FIT (z = 1.12; P = .13) participants in the precontemplation stage.

CONCLUSIONS

Adding physical activity to N-O-T may enhance cessation success, particularly among boys.

Lectin microarray analysis of pluripotent and multipotent stem cells

Stem cells have a capability to self-renew and differentiate into multiple types of cells; specific markers are available to identify particular stem cells for developmental biology research. In this study, we aimed to define the status of somatic stem cells and the pluripotency of human embryonic stem (hES) and induced pluripotent stem (iPS) cells using a novel molecular methodology, lectin microarray analysis. Our lectin microarray analysis successfully categorized murine somatic stem cells into the appropriate groups of differentiation potency. We then classified hES and iPS cells by the same approach. Undifferentiated hES cells were clearly distinguished from differentiated hES cells after embryoid formation. The pair-wise comparison means based on 'false discovery rate' revealed that three lectins -Euonymus europaeus lectin (EEL), Maackia amurensis lectin (MAL) and Phaseolus vulgaris leucoagglutinin [PHA(L)]- generated maximal values to define undifferentiated and differentiated hES cells. Furthermore, to define a pluripotent stem cell state, we generated a discriminant for the undifferentiated state with pluripotency. The discriminant function based on lectin reactivities was highly accurate for judgment of stem cell pluripotency. These results suggest that glycomic analysis of stem cells leads to a novel comprehensive approach for quality control in cell-based therapy and regenerative medicine.