Come rain or shine: Is weather a risk factor for musculoskeletal pain? A systematic review with meta-analysis of case-crossover studies

OBJECTIVES

The weather is frequently blamed for changes in musculoskeletal health behaviour and adverse events. However, despite the frequency with which this phenomenon is endorsed, past research is largely conflicting. This meta-analysis has reviewed, appraised and summarised case-crossover studies assessing the transient risk of musculoskeletal health events associated with weather parameters (e.g. temperature, relative humidity, air pressure, and precipitation).

METHODS

A meta-analysis of case-crossover studies was conducted. Two reviewers independently searched MEDLINE, EMBASE, CINAHL, Web of Science, Scopus, and PsycINFO from inception to 10/09/2023. Published studies that employed a case-crossover design to evaluate the risk of musculoskeletal health events (e.g. symptoms, hospitalisation) associated with weather parameters were included. Primary outcome was pain (new episodes of pain or flares). Quality of included studies was assessed based on selection bias, exposure assessment, confounding, and outcome assessment. Pooling of results was conducted using random effects models and separately performed for each condition and weather factor. Heterogeneity among included studies was assessed using I2 measures.

FINDINGS

Of the 1,107 studies identified in the search, 11 were included (15,315 participants), providing data on 28,010 events (102,536 control periods), for seven musculoskeletal conditions. Pooled analyses showed no association between relative humidity, air pressure, temperature, or precipitation and the risk of rheumatoid arthritis, knee pain or low back pain. High temperatures combined with low humidity were associated with increased pain, redness, and joint swelling in people with gout (Odds Ratio: 2.04; 95 % Confidence Interval: 1.26 to 3.30).

INTERPRETATION

Despite anecdotal reports from patients, changes in weather factors do not seem to be risk factors for rheumatoid arthritis, knee, hip, or low back pain, but may have a significant influence in gout disease.

Socio-economic and agricultural factors associated with stunting of under 5-year children: findings from surveys in mountains, dry zone and delta regions of rural Myanmar (2016-2017)

OBJECTIVE

The study's objective was to investigate multiple underlying social, economic and agricultural determinants of stunting among under-five children in three distinct ecological areas in rural Myanmar.

DESIGN

Repeated cross-sectional surveys in three states of Myanmar.

SETTING

Rural households in Chin (mountainous), Magway (plains) and Ayeyarwady (delta).

PARTICIPANTS

From two purposively selected adjacent townships in each state, we randomly selected twenty villages and, in each village, thirty households with under-five children. Households in the first survey in 2016 were revisited in late 2017 to capture seasonal variations.

RESULTS

Stunting increased from 40·4 % to 42·0 %, with the highest stunting prevalence in Chin state (62·4%). Univariate Poisson regression showed factors contributing to child stunting varied across the regions. Adjusted Poisson regression models showed that child's age and short maternal stature (aRR = 1·14 for Chin, aRR = 1·89 for Magway and aRR = 1·86 for Ayeyarwady) were consistently associated with child stunting across three areas. For Chin, village-level indicators such as crop consumption (aRR = 1·18), crop diversity (aRR = 0·82) and land ownership (aRR = 0·89) were significantly associated with stunting. In Magway, the number of household members (aRR = 1·92), wealth status (aRR = 0·46), food security status (aRR = 1·14), land ownership (aRR = 0·85) and in Ayeyarwady, women's decision-making (aRR = 0·67) and indicators related to hygiene (aRR = 1·13) and sanitation (aRR = 1·45) were associated with stunting.

CONCLUSIONS

Area-specific factors were associated with stunting. Maternal short stature and child age were consistent determinants of stunting. A multi-sectoral local approach, including improvements in transport, is needed to address the intergenerational malnutrition problem.

Evaluation of the SUCCESS health literacy app for Australian adults with chronic kidney disease: Study protocol for a pragmatic randomised controlled trial (Preprint)

Background

We developed a smartphone app—the SUCCESS (Supporting Culturally and Linguistically Diverse CKD Patients to Engage in Shared Decision-Making Successfully) app—to support Australian adults with kidney failure undertaking dialysis to actively participate in self-management and decision-making. The content of the SUCCESS app was informed by a theoretical model of health literacy that recognizes the importance of reducing the complexity of health information as well as providing skills necessary to access, understand, and act on this information.

Objective

The purpose of this study is to investigate the efficacy of the SUCCESS app intervention.

Methods

We designed a multicenter pragmatic randomized controlled trial to compare the SUCCESS app plus usual care (intervention) to usual care alone (control). A total of 384 participants receiving in-center or home-based hemodialysis or peritoneal dialysis will be recruited from six local health districts in the Greater Sydney region, New South Wales, Australia. To avoid intervention contamination, a pragmatic randomization approach will be used for participants undergoing in-center dialysis, in which randomization will be based on the days they receive hemodialysis and by center (ie, Monday, Wednesday, and Friday or Tuesday, Thursday, and Saturday). Participants undergoing home-based dialysis will be individually randomized centrally using simple randomization and two stratification factors: language spoken at home and research site. Consenting participants will be invited to use the SUCCESS app for 12 months. The primary endpoints, which will be assessed after 3, 6, and 12 months of app usage, are health literacy skills, evaluated using the Health Literacy Questionnaire; decision self-efficacy, evaluated using the Decision Self-Efficacy Scale; and rates of unscheduled health encounters. Secondary outcomes include patient-reported outcomes (ie, quality of life, evaluated with the 5-level EQ-5D; knowledge; confidence; health behavior; and self-management) and clinical outcomes (ie, symptom burden, evaluated with the Palliative care Outcome Scale–Renal; nutritional status, evaluated with the Patient-Generated Subjective Global Assessment; and intradialytic weight gain). App engagement will be determined via app analytics. All analyses will be undertaken using an intention-to-treat approach comparing the intervention and usual care arms.

Results

The study has been approved by Nepean Blue Mountains Human Research Ethics Committee (2020/ETH00910) and recruitment has begun at nine sites. We expect to finalize data collection by 2023 and publish the manuscript by 2024.

Conclusions

Enhancing health literacy skills for patients undergoing hemodialysis is an important endeavor, given the association between poor health literacy and poor health outcomes, especially among culturally diverse groups. The findings from this trial will be published in peer-reviewed journals and disseminated at conferences, and updates will be shared with partners, including participating local health districts, Kidney Health Australia, and consumers. The SUCCESS app will continue to be available to all participants following trial completion.

Trial Registration

Australia New Zealand Clinical Trials Registry (ANZCTR) ACTRN12621000235808; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380754&isReview=true

International Registered Report Identifier (IRRID)

DERR1-10.2196/39909

Delayed Initiation of Breastfeeding and Role of Mode and Place of Childbirth: Evidence from Health Surveys in 58 Low- and Middle- Income Countries (2012-2017)

Background: Timely initiation of breastfeeding is the first step towards achieving recommended breastfeeding behaviours. Delayed breastfeeding initiation harms neonatal health and survival, including infection associated neonatal mortality. Eighty percent of neonatal deaths occur in the low-and middle-income countries (LMICs), where delayed breastfeeding initiation is the highest. Place and mode of childbirth are important factors determining the time of initiation of breastfeeding. In this study, we report the prevalence of delayed breastfeeding initiation from 58 LMICs and investigate the relationship between place and mode of childbirth and delayed breastfeeding initiation in each country. Methods: We analysed data from the most recent Demographic and Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS) collected between 2012 and 2017 and reported by 2019. The study sample comprised all women who had a live birth in the 24 months preceding the survey. ‘Delayed’ initiation of breastfeeding was defined using WHO recommendations as starting breastfeeding after one hour of birth. We coded the stratifying variable for the place and mode of childbirth as “vaginal birth at a facility (VBF)”, “caesarean section birth (CSB) “, and “vaginal birth at home (VBH)”. We used respondent-level sampling weights to account for individual surveys and de-normalised the standard survey weights to ensure the appropriate contribution of data from each country. We report the prevalence and population attributable fractions with robust standard errors. The population attributable risk identifies the proportion of delayed initiation that we could avert among VBH and CSB if everyone had the same risk of delaying breastfeeding as in VBF. Results: The overall prevalence of delayed initiation of breastfeeding was 53.8% (95% CI 53.3, 54.3), ranging from 15.0% (95% CI 13.8, 16.2) in Burundi to 83.4% (95% CI 80.6, 86.0) in Guinea. The prevalence of delayed initiation of breastfeeding was consistently high among women who experienced caesarean section births; however, there was no direct association with each country’s national caesarean section rates. The prevalence of delayed initiation among women who experienced VBF was high in Sub-Saharan Africa and South Asia, even though the CSB rates were low. In some countries, women who give birth vaginally in health facilities were more likely to delay breastfeeding initiation than women who did not. In many places, women who give birth by caesarean section were less likely to delay breastfeeding initiation. Population attributable risk percent for VBH ranged from −28.5% in Ukraine to 22.9% in Moldova, and for CSB, from 10.3% in Guinea to 54.8% in Burundi. On average, across all 58 countries, 24.4% of delayed initiation could be prevented if all women had the same risk of delaying breastfeeding initiation as in VBF. Discussion: In general, women who give birth in a health facility were less likely to experience delayed initiation of breastfeeding. Programs could avert much of the delayed breastfeeding initiation in LMICs if the prevalence of delayed initiation amongst women who experience CSB were the same as amongst women who experience VBF. Crucial reforms of health facilities are required to ensure early breastfeeding practices and to create pro-breastfeeding supportive environments as recommended in intervention packages like the Baby-friendly hospital initiative and Early essential newborn care. The findings from this study will guide program managers to identify countries at varying levels of preparedness to establish and maintain a breastfeeding-friendly environment at health facilities. Thus, governments should prioritise intervention strategies to improve coverage and settings surrounding early initiation of breastfeeding while considering the complex role of place and mode of childbirth.

Factors associated with delayed initiation of breastfeeding in health facilities: secondary analysis of Bangladesh demographic and health survey 2014

Background

Irrespective of the place and mode of delivery, ‘delayed’ initiation of breastfeeding beyond the first hour of birth can negatively influence maternal and newborn health outcomes. In Bangladesh, 49% of newborns initiate breastfeeding after the first hour. The rate is higher among deliveries at a health facility (62%). This study investigates the maternal, health service, infant, and household characteristics associated with delayed initiation of breastfeeding among health facility deliveries in Bangladesh.

Methods

We used data from the 2014 Bangladesh Demographic and Health Survey. We included 1277 last-born children born at a health facility in the 2 years preceding the survey. ‘Delayed’ breastfeeding was defined using WHO recommendations as initiating after 1 h of birth. We performed univariate and multivariable logistic regression to determine factors associated with delayed initiation.

Results

About three-fifth (n = 785, 62%) of the children born at a health facility delayed initiation of breastfeeding beyond 1 h. After adjusting for potential confounders, we found delayed initiation to be common among women, who delivered by caesarean section (adjusted Odds Ratio (aOR): 2.93; 95% CI 2.17, 3.98), and who were exposed to media less than once a week (aOR: 1.53; 95% CI 1.07, 2.19). Women with a higher body mass index had an increased likelihood of delaying initiation (aOR: 1.05; 95% CI 1.01, 1.11). Multiparous women were less likely to delay (aOR: 0.71; 95% CI 0.53, 0.96).

Conclusions

Delayed initiation of breastfeeding following caesarean deliveries continues to be a challenge, but several other health facility and maternal factors also contributed to delayed initiation. Interventions to promote early breastfeeding should include strengthening the capacity of healthcare providers to encourage early initiation, especially for caesarean deliveries.

Overweight and obesity among urban women with iron deficiency anaemia in Bangladesh

In this study, we aimed to determine the prevalence and factors associated with overweight and obesity among nonpregnant and nonlactating (NPNL) women of reproductive age with iron deficiency anaemia (IDA) in urban Bangladesh. We obtained data from the baseline assessment of a randomized control trial conducted among 525 women of reproductive age (18–49 years) with IDA (Hb < 12 gdl⁻¹ and serum ferritin <30 μg L⁻¹). The study was carried out in Mirpur, Dhaka, Bangladesh, between December 2017 and January 2019. We collected information on women's socio‐demographic characteristics and anthropometry. Body mass index (BMI) was calculated using the following formula: weight in kilograms per height in square metres. BMI ≥ 25–29.9 kg m⁻² was considered as overweight, whereas BMI ≥ 30 kg m⁻² as obese. A multivariable logistic regression model was used to ascertain the risk factors of overweight and obesity. The prevalence of overweight and obesity was 29.9% (95% CI: 26.0–34.0) and 13.1% (95% CI: 10.4–16.3), respectively. The combined prevalence of overweight and obesity was 43.0% (95% CI: 38.7–47.4). The multivariable analysis showed married women (aOR: 4.4; CI: 1.8–11.1), women aged 30–49 years (aOR: 7.6; CI: 2.4–24.1), unemployed women (aOR 1.5; CI: 1.0–2.4) and women from the wealthier households (aOR 3.9; CI: 2.3–6.8) had the highest risk of being overweight and obese compared with their counterparts. Both age and household wealth statuses showed dose–response relationships. Combination of overweight and obesity with IDA poses a particular challenge for public health interventions. The policymakers should consider what new interventions and policy initiatives are needed to address this combination of overweight and obesity with IDA.

Can an Enhanced Iron-Folic Acid Supplementation Program Reduce Neonatal Mortality? Analysis of Pooled Nepal Demographic and Health Surveys

Objectives

Nepal has improved the national antenatal iron-folic acid (IFA) supplementation program through the ‘Iron Intensification Project’ (IIP) between 2003 and 2011. This study assesses the effect of this enhanced IFA supplementation on the risk of neonatal mortality over a 20-year period in Nepal.

Methods

For the impact evaluation, we used a non-randomized stepped wedge study design, using survival information from 16,159 most recent live births from the pooled data from four Nepal Demographic and Health Surveys (2001, 2006, 2011 and 2016). The primary outcomes were neonatal mortality indicators. The use of any antenatal care (ANC) services and antenatal IFA supplements were the secondary outcomes. The main exposure variable was the status of the IIP in the district of the mother's residence at the time of birth. Analyses used multivariate Cox proportional hazards regression, adjusted for up to 22 potential confounders, and the cluster sampling design.

Results

After the IIP, the risk of death on the first day of life was significantly reduced by 35% [adjusted hazard ratio (aHR) 0.65, 95% confidence interval (95% CI) 0.43 to 0.97], in the early neonatal period by 32% (aHR 0.68, 95% CI 0.48 to 0.96), and in the neonatal period by 29% (aHR 0.71, 95% CI 0.51 to 0.99). After the IIP, there was a significant reduction of the odds of non-use of ANC services and IFA supplements.

Conclusions

An enhanced IFA supplementation program was associated with a significant reduction in neonatal mortality in Nepal.

Funding Sources

Ph.D. scholarship from the University of Sydney.

Bangladesh: a success case in combating childhood diarrhoea

BACKGROUND

Bangladesh had a large reduction in childhood deaths due to diarrhoeal disease in recent decades. This paper explores the preventive, promotive, curative and contextual drivers that helped Bangladesh achieve this exemplary success.

METHODS

Primary and secondary data collection approaches were used to document trends in reduction of Diarrhoea Specific Mortality Rate (DSMR) between 1980 and 2015, understand what policies and programmes played key roles, and estimate the contribution of specific interventions that were implemented during the period. Data acquisition involved relevant document reviews and in-depth interviews with key stake-holders. A systematic search of literature was undertaken to explore socio-economic, aetiological, behavioural, and nutritional drivers of diarrhoeal disease reduction in Bangladesh. Finally, we used LiST (Lives Saved Tool) to model the contributions of the relevant interventions during three time periods (1980-2015, 1980-2000 and 2000-2015), and to project the number of lives saved in 2030 (compared to 2015) if these interventions were implemented at near universal coverage (90%).

RESULTS

The factors which likely had the most impact on DSMR were the coordinated efforts of the Government of Bangladesh (GoB) with non-government organizations (NGOs) and the private sector that enabled swift implementation, at scale, of interventions like oral rehydration solution (ORS) and zinc, promotion of breastfeeding, handwashing and sanitary latrines (WASH), as well as improvements in female education and nutrition. Compared to 1980, we found ORS and reduction in stunting prevalence had the greatest impact on DSMR, saving roughly 70 000 lives combined in 2015. Until 2000, ORS had a higher contribution to DSMR reduction than reduction in stunting prevalence. This proportionate contribution was reversed during 2000-2015. At near universal coverage (90%) of combined direct diarrhoeal disease, nutrition and WASH interventions, we project that an additional 5356 deaths due to diarrhoea could be averted in 2030.

CONCLUSION

Bangladesh's achievement in reduction of DSMR highlights the important role of an enabling policy environment that fostered coordinated efforts of the public and private sectors and NGOs for maximal impact. To maintain this momentum, evidence-based interventions should be scaled up at universal coverage.

Early initiation of breastfeeding and severe illness in the early newborn period: An observational study in rural Bangladesh

BACKGROUND

In Bangladesh, neonatal sepsis is the cause of 24% of neonatal deaths, over 65% of which occur in the early-newborn stage (0-6 days). Only 50% of newborns in Bangladesh initiated breastfeeding within 1 hour of birth. The mechanism by which early initiation of breastfeeding reduces neonatal deaths is unclear, although the most likely pathway is by decreasing severe illnesses leading to sepsis. This study explores the effect of breastfeeding initiation time on early newborn danger signs and severe illness.

METHODS AND FINDINGS

We used data from a community-based trial in Bangladesh in which we enrolled pregnant women from 2013 through 2015 covering 30,646 newborns. Severe illness was defined using newborn danger signs reported by The Young Infants Clinical Science Study Group. We categorized the timing of initiation as within 1 hour, 1 to 24 hours, 24 to 48 hours, ≥48 hours of birth, and never breastfed. The analysis includes descriptive statistics, risk attribution, and multivariable mixed-effects logistic regression while adjusting for the clustering effects of the trial design, and maternal/infant characteristics. In total, 29,873 live births had information on breastfeeding among whom 19,914 (66.7%) initiated within 1 hour of birth, and 4,437 (14.8%) neonates had a severe illness by the seventh day after birth. The mean time to initiation was 3.8 hours (SD 16.6 hours). The proportion of children with severe illness increased as the delay in initiation increased from 1 hour (12.0%), 24 hours (15.7%), 48 hours (27.7%), and more than 48 hours (36.7%) after birth. These observations would correspond to a possible reduction by 15.9% (95% CI 13.2-25.9, p < 0.001) of severe illness in a real world population in which all newborns had breastfeeding initiated within 1 hour of birth. Children who initiated after 48 hours (odds ratio [OR] 4.13, 95% CI 3.48-4.89, p < 0.001) and children who never initiated (OR 4.77, 95% CI 3.52-6.47, p < 0.001) had the highest odds of having severe illness. The main limitation of this study is the potential for misclassification because of using mothers' report of newborn danger signs. There could be a potential for recall bias for mothers of newborns who died after being born alive.

CONCLUSIONS

Breastfeeding initiation within the first hour of birth is significantly associated with severe illness in the early newborn period. Interventions to promote early breastfeeding initiation should be tailored for populations in which newborns are delivered at home by unskilled attendants, the rate of low birth weight (LBW) is high, and postnatal care is limited.

TRIAL REGISTRATION

Trial Registration number: anzctr.org.au ID ACTRN12612000588897.

The Prevalence and Risk Factors of Overweight and Obesity Among Women of Reproductive Age with Iron Deficiency Anaemia in Urban Bangladesh (P10-064-19)

Objectives

This study aims to identify the prevalence and risk factors of overweight and obesity among women of reproductive age (15–49 years) with iron deficiency anaemia in urban Bangladesh.

Methods

We obtained data for this study from the baseline assessment of a randomized control trial conducted among women of reproductive age with iron deficiency anemia (Hb <12 g/dl & serum ferritin <30 μg/L). The trial was carried out in Mirpur, Dhaka, Bangladesh between December 2017 and January 2019. As part of the baseline assessment, we collected data on women's sociodemographic characteristics and reproductive history from 525 participants. We also measured the height, weight, and MUAC at the baseline. We estimated BMI using formula; weight in kilograms divided by the square of height in meters. As per the WHO classification, we considered women with BMI ≥25 kg/m2 to be overweight and ≥30 kg/m2 to be obese. A multivariable logistic regression model was used to ascertain the risk factors of overweight and obesity.

Results

Of the 525 study participants, 157 (30%; 95% CI 26.0 - 34.0) were overweight and 69 (13%; 95% CI 10.3 - 16.3) were obese. Bivariate analysis indicated that the age of women, parity, women's education, women's employment, marital status, husband's education and household wealth were associated with overweight and obesity. The multivariable analysis showed married women (OR 2.9; CI 1.0–8.3), women aged 40 to 49 years (OR 7.4; CI 2.4–22.9) and women from the higher social economic household (OR 5.8; CI 2.7‐12.4) has the highest risk of overweight and obesity. Both age and household socioeconomic status showed dose response relationship.

Conclusions

The prevalence of overweight and obesity among women of reproductive age with iron deficiency anemia in urban Bangladesh is three times higher than the WHO critical threshold of 15%. This highlights that Bangladesh is undergoing an epidemiologic transition characterized by the double burden of malnutrition. It is crucial that the policy makers understand what new interventions and policy initiatives are needed to address the double burden of malnutrition in the country.

Funding Sources

Saving Lives at Birth and Medical Research Council, UK.

Supporting Tables, Images and/or Graphs

Assessing the Efficacy of Bovine Lactoferrin to Correct Iron Deficiency Anemia in Non-pregnant Non-lactating Women: A Randomized Controlled Trial (FS08-02-19)

Objectives

1. To determine if bovine lactoferrin (bLf) is at least as effective as oral ferrous sulfate in iron deficiency anemia in non-pregnant women of reproductive age (WRA)

2. To determine the optimal dose of oral bLf

3. To compare the side-effects of the treatments

Methods

Design: Non-inferiority, double-blind, individually RCT in non-pregnant WRA with iron deficiency anemia (Hb <12 g/dl & serum ferritin <30 μg/L)

Setting: Mirpur, Dhaka, Bangladesh

Participants: 555 non-pregnant, non-lactating women of 15–49 years.

Interventions: Women were allocated individually (1:1:1) in three arms. Arm A, B and C received daily oral 200 mg bLf, 400 mg bLf and 60 mg ferrous sulfate. All received 400 μg of folic acid daily. Treatment was for 12 weeks.

Outcomes: Serum Hb and serum ferritin at baseline and every 30 days for 3 months. Inflammatory markers: C-reactive protein (CRP); alpha(1)-Acid glycoprotein (AGP); hepcidin, at baseline and end line. Possible adverse effects were assessed.

Results

Women on 200 mg bLf had a decrease in Hb of 0.3 g/dl (95% CI, −0.60 to 0.00 g/dl, P = 0.05), women on 400 mg bLf arm had no change in Hb: 0.0 g/dl (95% CI, −0.32 to 0.32 g/dl, P = 1.00), and women on ferrous sulfate arm had an increase in Hb: 1.1 g/dl (95% CI, 0.83 to 1.37 g/dl, P < 0.0001).

Women on 200 mg bLf had an increase in ferritin: 2.8 μg/l (95% CI, 0.38 to 5.22 μg/l, P = 0.02), women on 400 mg bLf had an increase in ferritin: 3.5 μg/l (95% CI, 0.64 to 6.36 μg/l, P = 0.02) and women on ferrous sulfate arm had an increase in ferritin: 41.1 μg/l (95% CI, 35.74 to 46.47 μg/l, P < 0.0001).

There were no significant differences in AGP and CRP between arms at the base line (P = 0.38 and 0.95) and end line (P = 0.87 and 0.14). Those on ferrous sulfate had a significant increase in hepcidin concentration after 90 days (P = .000).

Abdominal pain, indigestion, diarrhea and black stool were significantly higher on ferrous sulfate group. There were no differences for other side-effects across treatment arms

Conclusions

Ferrous sulfate has better efficacy than bLf for iron deficiency anemia in non-pregnant non-lactating women of reproductive age in urban Bangladesh. This lactoferrin product may be inactive, or there may have been inadequate dietary iron for bLF to promote its absorption.

Funding Sources

Saving Lives at Birth and Medical Research Council, UK.

A community-based cluster randomised controlled trial in rural Bangladesh to evaluate the impact of the use of iron-folic acid supplements early in pregnancy on the risk of neonatal mortality: the Shonjibon trial

BACKGROUND

Iron-deficiency is the most common nutritional deficiency globally. Due to the high iron requirements for pregnancy, it is highly prevalent and severe in pregnant women. There is strong evidence that maternal iron deficiency anaemia increases the risk of adverse perinatal outcomes. However, most of the evidence is from observational epidemiological studies except for a very few randomised controlled trials. IFA supplements have also been found to reduce the preterm delivery rate and neonatal mortality attributable to prematurity and birth asphyxia. These results combined indicate that IFA supplements in populations of iron-deficient pregnant women could lead to a decrease in the number of neonatal deaths mediated by reduced rates of preterm delivery. In this paper, we describe the protocol of a community-based cluster randomised controlled trial that aims to evaluate the impact of maternal antenatal IFA supplements on perinatal outcomes.

METHODS/DESIGN

The effect of the early use of iron-folic acid supplements on neonatal mortality will be examined using a community based, cluster randomised controlled trial in five districts with 30,000 live births. In intervention clusters trained BRAC village volunteers will identify pregnant women & provide iron-folic acid supplements. Groundwater iron levels will be measured in all study households using a validated test kit. The analysis will follow the intention to treat principle. We will compare neonatal mortality rates & their 95% confidence intervals adjusted for clustering between treatment groups in each groundwater iron-level group. Cox proportional hazards mixed models will be used for mortality outcomes & will include groundwater iron level as an interaction term in the mortality model.

DISCUSSION

This paper aims to describe the study protocol of a community based randomised controlled trial evaluating the impact of the use of iron-folic acid supplements early in pregnancy on the risk of neonatal mortality. This study is critical because it will determine if antenatal IFA supplements commenced in the first trimester of pregnancy, rather than later, will significantly reduce neonatal deaths in the first month of life, and if this approach is cost-effective.

TRIAL REGISTRATION

This trial has been registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) on 31 May 2012. The registration ID is ACTRN12612000588897 .

Knowledge and involvement of husbands in maternal and newborn health in rural Bangladesh

BACKGROUND

Access to skilled health services during pregnancy, childbirth and postnatal period for obstetric care is one of the strongest determinants of maternal and newborn health (MNH) outcomes. In many countries, husbands are key decision-makers in households, effectively determining women's access to health services. We examined husbands' knowledge and involvement regarding MNH issues in rural Bangladesh, and how their involvement is related to women receiving MNH services from trained providers.

METHODS

We conducted a cross-sectional survey in two rural sub-districts of Bangladesh in 2014 adopting a stratified cluster sampling technique. Women with a recent birth history and their husbands were interviewed separately with a structured questionnaire. A total of 317 wife-husband dyads were interviewed. The associations between husbands accompanying their wives as explanatory variables and utilization of skilled services as outcome variables were assessed using multiple logistic regression analyses.

RESULTS

In terms of MNH knowledge, two-thirds of husbands were aware that women have special rights related to pregnancy and childbirth and one-quarter could mention three or more pregnancy-, birth- and postpartum-related danger signs. With regard to MNH practice, approximately three-quarters of husbands discussed birth preparedness and complication readiness with their wives. Only 12% and 21% were involved in identifying a potential blood donor and arranging transportation, respectively. Among women who attended antenatal care (ANC), 47% were accompanied by their husbands. Around half of the husbands were present at the birthplace during birth. Of the 22% women who received postpartum care (PNC), 67% were accompanied by their husbands. Husbands accompanying their wives was positively associated with women receiving ANC from a medically trained provider (AOR 4.5, p < .01), birth at a health facility (AOR 1.5, p < .05), receiving PNC from a medically trained provider (AOR 48.8, p < .01) and seeking care from medically trained providers for obstetric complications (AOR 3.0, p < 0.5).

CONCLUSION

Husbands accompanying women when receiving health services is positively correlated with women's use of skilled MNH services. Special initiatives should be taken for encouraging husbands to accompany their wives while availing MNH services. These initiatives should aim to increase men's awareness regarding MNH issues, but should not be limited to this.

A community-based cluster randomised controlled trial to evaluate the effectiveness of different bundles of nutrition-specific interventions in improving mean length-for-age z score among children at 24 months of age in rural Bangladesh: study protocol

BACKGROUND

Prevalence of stunting among under-five children in Bangladesh is 36%, varying with geographic and socio-economic characteristics. Previously, research groups statistically modelled the effect of 10 individual nutrition-specific interventions targeting the critical first 1000 days of life from conception, on lives saved and costs incurred in countries with the highest burden of stunted children. However, primary research on the combined effects of these interventions is limited. Our study directly addresses this gap by examining the effect of combinations of 5 preventive interventions on length-for-age z-scores (LAZ) among 2-years old children.

METHODS

This community-based cluster randomised trial (c-RCT) compares 4 intervention combinations against one comparison arm. Intervention combinations are: 1) Behaviour change communication (BCC) on maternal nutrition during pregnancy, exclusive breastfeeding, and complementary feeding, along with prenatal nutritional supplement (PNS) and complementary food supplement (CFS); 2) BCC with PNS; 3) BCC with CFS; and 4) BCC alone. The comparison arm receives only routine health and nutrition services. From a rural district, 125 clusters were selected and randomly assigned to any one of the five study arms by block randomisation. A bespoke automated tab-based system was developed linking data collection, intervention delivery and project supervision. Total sample size is 1500 pregnant women, with minimum 1050 resultant children expected to be retained, powered to detect a difference of at least 0.4 in the mean LAZ score of children at 24 months, the main outcome variable, between the comparison arm and each intervention arm. Length and other anthropometric measurements, nutritional intake and other relevant data on mother and children are being collected during enrolment, twice during pregnancy, postpartum monthly till 6 months, and every third month thereafter till 24 months.

DISCUSSION

This c-RCT explores the effectiveness of bundles of preventive nutrition intervention approaches addressing the critical window of opportunity to mitigate childhood stunting. The results will provide robust evidence as to which bundle(s) can have significant effect on linear growth of children. Our study also will have policy-level implications for prioritising intervention(s) tackling stunting.

TRIAL REGISTRATION

The study was retrospectively registered on May 2, 2016 and is available online at ClinicalTrials.gov (ID: NCT02768181 ).

Respiratory rate and pulse oximetry derived information as predictors of hospital admission in young children in Bangladesh: a prospective observational study

OBJECTIVE

Hypoxaemia is a strong predictor of mortality in children. Early detection of deteriorating condition is vital to timely intervention. We hypothesise that measures of pulse oximetry dynamics may identify children requiring hospitalisation. Our aim was to develop a predictive tool using only objective data derived from pulse oximetry and observed respiratory rate to identify children at increased risk of hospital admission.

SETTING

Tertiary-level hospital emergency department in Bangladesh.

PARTICIPANTS

Children under 5 years (n=3374) presenting at the facility (October 2012-April 2013) without documented chronic diseases were recruited. 1-minute segments of pulse oximetry (photoplethysmogram (PPG), blood oxygen saturation (SpO2) and heart rate (HR)) and respiratory rate were collected with a mobile app.

PRIMARY OUTCOME

The need for hospitalisation based on expert physician review and follow-up.

METHODS

Pulse rate variability (PRV) using pulse peak intervals of the PPG signal and features extracted from the SpO2 signal, all derived from pulse oximetry recordings, were studied. A univariate age-adjusted logistic regression was applied to evaluate differences between admitted and non-admitted children. A multivariate logistic regression model was developed using a stepwise selection of predictors and was internally validated using bootstrapping.

RESULTS

Children admitted to hospital showed significantly (p<0.01) decreased PRV and higher SpO2 variability compared to non-admitted children. The strongest predictors of hospitalisation were reduced PRV-power in the low frequency band (OR associated with a 0.01 unit increase, 0.93; 95% CI 0.89 to 0.98), greater time spent below an SpO2 of 98% and 94% (OR associated with 10 s increase, 1.4; 95% CI 1.3 to 1.4 and 1.5; 95% CI 1.4 to 1.6, respectively), high respiratory rate, high HR, low SpO2, young age and male sex. These variables provided a bootstrap-corrected AUC of the receiver operating characteristic of 0.76.

CONCLUSIONS

Objective measurements, easily obtained using a mobile device in low-resource settings, can predict the need for hospitalisation. External validation will be required before clinical adoption.

Development and Internal Validation of a Predictive Model Including Pulse Oximetry for Hospitalization of Under-Five Children in Bangladesh

Background

The reduction in the deaths of millions of children who die from infectious diseases requires early initiation of treatment and improved access to care available in health facilities. A major challenge is the lack of objective evidence to guide front line health workers in the community to recognize critical illness in children earlier in their course.

Methods

We undertook a prospective observational study of children less than 5 years of age presenting at the outpatient or emergency department of a rural tertiary care hospital between October 2012 and April 2013. Study physicians collected clinical signs and symptoms from the facility records, and with a mobile application performed recordings of oxygen saturation, heart rate and respiratory rate. Facility physicians decided the need for hospital admission without knowledge of the oxygen saturation. Multiple logistic predictive models were tested.

Findings

Twenty-five percent of the 3374 assessed children, with a median (interquartile range) age of 1.02 (0.42–2.24), were admitted to hospital. We were unable to contact 20% of subjects after their visit. A logistic regression model using continuous oxygen saturation, respiratory rate, temperature and age combined with dichotomous signs of chest indrawing, lethargy, irritability and symptoms of cough, diarrhea and fast or difficult breathing predicted admission to hospital with an area under the receiver operating characteristic curve of 0.89 (95% confidence interval -CI: 0.87 to 0.90). At a risk threshold of 25% for admission, the sensitivity was 77% (95% CI: 74% to 80%), specificity was 87% (95% CI: 86% to 88%), positive predictive value was 70% (95% CI: 67% to 73%) and negative predictive value was 91% (95% CI: 90% to 92%).

Conclusion

A model using oxygen saturation, respiratory rate and temperature in combination with readily obtained clinical signs and symptoms predicted the need for hospitalization of critically ill children. External validation of this model in a community setting will be required before adoption into clinical practice.