Revisiting the Harm of Hate: A Quasi-Experimental Approach Using the National Crime Victimization Survey

Early legal challenges to the 1990 Hate Crime Statistics Act were originally excused on the argument that hate crimes "hurt more," but there remain some empirical gaps on this topic. Although many works have concluded that biased offenders cause greater harms to their victims relative to unbiased perpetrators, this effect tends to be sensitive to individual and situational factors like victim and offender characteristics, bias motivation, weapon use, or crime location. This type of confounding has the potential to introduce selection bias in the estimation of victimization harms among biased criminal incidents. With data from the National Crime Victimization Survey (2010-2020), I use propensity scores and inverse-probability weighting to show that, on average, victims of bias motivated offenses are more likely to report later physical and emotional harms despite not suffering greater initial injury in incidence. Findings also demonstrate that the harm of hate varies across different bias motivations, with such crimes directed toward those on the basis of disability, gender, and sexual orientation causing greater short- and long-term individual trauma and damage.

Effects of a Remote Multimodal Intervention Involving Diet, Walking Program, and Breathing Exercise on Quality of Life Among Newly Diagnosed People with Multiple Sclerosis: A Quasi-Experimental Non-Inferiority Pilot Study

Background

Interventions involving diet, physical activity, and breathing exercises are shown to be beneficial in managing both fatigue and quality of life (QoL) related to MS; however, the impact of such interventions among people newly diagnosed with clinically isolated syndrome (CIS) or relapsing-remitting multiple sclerosis (RRMS) who decline disease-modifying therapies (DMTs) is unknown.

Methods

A 12-month prospective quasi-experimental non-inferiority trial recruited people newly diagnosed with CIS or RRMS who voluntarily declined DMTs (health behavior group; HB, n = 29) or followed standard of care (SOC, n = 15). Participants in the HB group were remotely coached on the study diet, moderate-intensity walking, and breathing exercises. All participants completed questionnaires validated to assess MS symptoms, including perceived mental and physical QoL (MSQOL54); fatigue (Fatigue Severity Scale, FSS; and Modified Fatigue Impact Scale, MFIS); mood (Hospital Anxiety and Depression Scale, HADS); and cognitive function (Perceived Deficits Questionnaire, PDQ).

Results

During the 12 months, the HB group experienced improvement in scores for mental QoL (MSQOL54 - Mental, 0.24, 95% CI 0.01, 0.47; p = 0.04), fatigue (Total MFIS, -7.26, 95% CI -13.3,-1.18; p = 0.02), and perceived cognitive function (Total PDQ, PDQ-Attention, PDQ-Promemory, and PDQ-Planning, p ≤ 0.03 for all). A between-group difference was observed only for PDQ-Planning (p = 0.048). Non-inferiority analysis revealed that the 12-month changes in means for the HB group were not worse than those for the SOC group with respect to fatigue (FSS, p = 0.02), mood (HDS-Anxiety, p = 0.02; HADS-Depression, p < 0.0001), physical QoL (MSQOL54 - Physical, p = 0.02), or cognitive dysfunction (Total PDQ, p = 0.01).

Conclusion

The multimodal lifestyle intervention for individuals newly diagnosed with CIS or RRMS, who voluntarily decline DMTs, did not yield patient-reported outcomes worse than those observed in the SOC group regarding perceived mental quality of life, mood, fatigue, and cognitive function.

Trial Registration

clinicaltrials.gov identifier: NCT04009005.

Effect of Positive Deviance Approach on Promotion of Safe Disposal of Child's Feces in Rural Tamil Nadu: A Community-Based Quasi-Experimental Study

Introduction

Safe disposal of feces is ensured when it is deposited into a toilet, whereas unsafe disposal of child's feces plays a crucial role in disease transmission and environmental pollution. These areas are overlooked by many sanitation promotion interventions.

Objective

To determine the effect of positive deviance (PD) approach on safe disposal of child's feces among households who owned a toilet.

Materials and Methods

A community-based quasi-experimental study was conducted in the four field practice villages of the Urban Health Training Center, Villupuram, for 18 months. Households who owned a toilet and had a child less than 5 years old were included. After IEC clearance, information was collected from a representative sample of 100 households before intervention and another 100 households after intervention. PD approach was applied for 6 months to promote safe disposal practices in the study villages. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) software (version 24). The Chi-square test was used to determine the significance of difference between baseline and endline data. The effect size was calculated to estimate the magnitude of difference between baseline and endline data.

Results

Before intervention, only 3% of households disposed the feces into a toilet, while after intervention, almost 38% of households disposed in the toilet (χ2 = 37.39; df = 1; P = 0.001). The effect size (Cramer's V) was found to be 0.43.

Conclusion

PD approach demonstrated considerable improvements in safe disposal of child's feces in rural settings. Further, to sustain the behavior change, frequent reinforcement of key messages at frequent intervals needs to be emphasized.

Nursing capacity building in health coaching with hospitalised chronic heart failure patients: a quasi-experimental study

BACKGROUND

Difficulty in adherence to treatment and self-care behaviours is a leading cause of preventable readmission in people with chronic heart failure (CHF). Although there is evidence of benefits of health coaching for the management of this situation, few interventions have been tested in the hospital setting.

AIM

To evaluate a coaching programme (H-Coaching) designed to develop nursing capacity in health coaching for chronic heart failure inpatients.

METHODS

A quasi-experimental pre-post study including all nurses in a single centre cardiology ward (N = 19). The intervention consisted of two training packages: (1) five theoretical-practical sessions on health-coaching competencies, emotional intelligence, communication and support of chronic heart failure patients in their illness in the hospital setting; and (2) training sessions seven months after the first training package to reinforce the theoretical and practical knowledge. On four occasions, the Competence Instrument of Health Education for the Nursing professional was used to measure nurses' knowledge, skills and attitudes in health coaching for chronic heart failure patients.

RESULTS

The difference between the preintervention and postintervention scores were statistically significant for knowledge [mean difference = 1.00 (95% CI -1.45 to -0.51; p = 0.000)], skills in general [mean difference = 0.50 (95% CI -1.41 to -0.21; p = 0.015)] and personal/social skills [mean difference = 1.00 (95% CI -1.10 to -0.01; p = 0.048)]. While attitudinal and affective domains did not differ, there were differences in knowledge and skills.

CONCLUSION

The H-Coaching programme proved to be effective for building nursing capacity in health coaching CHF inpatients. Similar programmes designed to improve knowledge in verbal and nonverbal communication techniques, and skills for coaching interventions adapted to meet the needs of individual patients, should be tested in future interventional experimental studies.

CLINICAL TRIAL REGISTRATION NUMBER

NCT05300880.

IMPACT STATEMENT

To our knowledge, this is the first nursing training intervention in health coaching for chronic heart failure the inpatient setting. This study has demonstrate improvements in both the knowledge and personal and social skills of cardiology nurses with regard to the development of health coaching in a hospital setting. Given the study design, further research is warranted.

PLAIN LANGUAGE SUMMARY

Many patients with chronic heart failure have problems in adhering to the treatment and self-care behaviours and this is one of the main causes of preventable readmission. To promote self-care, patients need to be empowered to integrate these habits into their daily lives and we should implement innovative strategies to achieve this. Health coaching is an ideal alternative to this but very few nurses in the hospital cardiology setting are experienced in health coaching. Our study has shown preliminary results demonstrating that a structured theoretical and practical training programme for nurses can improve nurses' knowledge and skills in health coaching for inpatient patients with chronic heart failure. This study provides an opportunity for future research to demonstrate whether nurses with this training have a positive impact on the health outcomes of chronic heart failure patients and, more specifically, on their levels of self-care and empowerment.

Differential exposure to gun or knife violence over two decades is associated with sibling differences in depression

We tested whether exposure to gun or knife violence over two decades is a cause of depression in young adulthood using data from a nationally representative sample in the United States. The National Longitudinal Study of Adolescent to Adult Health is a sample of 20,745 adolescents, assessed in 1994-95 with follow-ups in 1995-1996 (n = 14,738), 2001-2002 (n = 15,197) and 2007-2008 (n = 15,701; 24 to 32 years old). At each wave, respondents reported exposure to gun or knife violence and symptoms of depression. Regression and sibling fixed effects analyses were conducted to test whether cumulative exposure to gun or knife violence was associated with depression. In fully adjusted models, greater cumulative exposure to gun or knife violence was associated with more symptoms of depression (b = 0.12, 95% C. I. = 0.05; 0.19, p < 0.01) and higher risk for clinically significant depression in young adulthood (OR = 1.07, 95% C. I. = 1.02; 1.13, p < 0.01). Results replicated in sibling fixed effects models (b = 0.21, 95% C. I. = 0.01; 0.42, p < 0.05). These quasi-experimental data suggest that exposure to gun or knife violence is a cause of depression in young adulthood.

An Integrated Patient-Centred Medical Home (PCMH) Care Model Reduces Prospective Healthcare Utilisation for Community-Dwelling Older Adults with Complex Needs: A Matched Observational Study in Singapore

The global ageing population is associated with increased health service use. The PCMH care model integrates primary care and home-based care management to deliver comprehensive and personalised healthcare to community-dwelling older adults with bio-psycho-social needs. We examined if an integrated PCMH reduced healthcare utilisation burden of older persons in Singapore. We compared the healthcare utilisation between the intervention group and coarsened exact matched controls for a follow-up of 15 months. Baseline matching covariates included socio-demographics, health status, and past healthcare use. We accounted for COVID-19 social distancing effects on health-seeking behaviour. The intervention group consisted of 165 older adults with complex needs. We analysed national administrative healthcare utilisation data from 2017 to 2020. We applied multivariable zero-inflated regression modelling and presented findings stratified by high (CCI ≥ 5) and low disease burden (CCI < 5). Compared to controls, there were significant reductions in emergency department (β = -0.85; 95%CI = -1.55 to -0.14) and primary care visits (β = -1.70; 95%CI = -2.17 to -1.22) and a decrease in specialist outpatient visits (β = -0.29; 95%CI = -0.64 to 0.07) in the 3-month period immediately after one-year enrolment. The number of acute hospitalisations remained stable. Compared to controls, the intervention group with high and low comorbidity burden had significant decreases in primary care use, while only those with lower comorbidity burden had significant reductions in utilisation of other service types. An integrated PCMH appears beneficial in reducing healthcare utilisation for older persons with complex needs after 1 year in the programme. Future research can explore longer-term utilisation and scalability of the care model.

Effects of WAKE.TAIWAN Healthy Lifestyle Web-Based Promotion Programs on Adults' Awareness of Self-perceived Weight Status and Their Healthy Lifestyle Stages: Retrospective Analysis

BACKGROUND

Obesity is a major risk factor of many chronic diseases. However, current obesity control policies and actions are not sufficient to halt the pandemic. It has been documented that more than half of all adults are not able to interpret their own weight status, not to mention to practice healthy lifestyles. Social media and interactive websites can reach people on a long-term basis, which may be used as intervention vehicles to build up cognition for weight control and to promote healthy behavior practices.

OBJECTIVE

WAKE.TAIWAN is an ongoing web-based multifaceted healthy lifestyle promotion program with social media and interactive websites as the intervention vehicle. This study aimed to examine whether adults reached by our program would have increased awareness to their own anthropometric measures, correctly judge their body weight status, and practice healthy behaviors over time.

METHODS

This study adopted a quasi-experimental design with web-based questionnaire surveys. The experimental group consisted of WAKE.TAIWAN Facebook group members aged 20-65 years who have used the interactive website health education resources (n=177). The group was further stratified into 2 subgroups based on their duration of participation (E1 group: duration <1 year; E2 group: duration ≥1 year). The control group consisted of other Facebook users (n=545) in the same age range who had not been exposed to the health education materials of this project. A total of 722 people (male: n=267, 37%; and female: n=455, 63%) participated in our survey in 2019. Data were analyzed to evaluate program effectiveness using a generalized linear model.

RESULTS

The proportion of people correctly interpreting their own weight status in the experimental group was greater than that of the control group (control group: 320/545, 58.7%; group E1: 53/88, 60%; and group E2: 64/89, 72%). The E2 experimental group was significantly better than the control group in paying attention to weight-related measures and in correctly interpreting their own weight status (odds ratio 1.73, 95% CI 1.04-2.89; P=.04). With respect to the behavioral stages of practicing healthy eating and active living, both experimental groups, E1 and E2, performed significantly better than the control group (group E1: P=.003 and P=.02; and group E2: P=.004 and P<.001, respectively).

CONCLUSIONS

This study demonstrates that the longer the participants were exposed to our social media-based programs, the higher the proportion of them that would have the correct judgement on their weight status and fall in the higher stages of healthy lifestyle behaviors. A longitudinal follow-up survey is in place to verify these findings.

Knowledge, Skills, and Self-Disclosure Following a Sexual Abuse Prevention Program Among Iranian Preschoolers: A Cluster Quasi-Experimental Controlled Study

Standard empirical studies are needed despite three decades of research on child sexual abuse prevention programs (CSAPPs). This study aimed to investigate the effects of CSAPP on the child's sexual safety. A multicenter, random cluster, quasi-experimental controlled survey was conducted in a 1:1 ratio in Tehran, Iran, from May to December 2019 in seventy 5- to 6-years-old children from 10 kindergartens. In groups of 7 to 8, the intervention group participated in four sessions of 45 minutes of face-to-face sexual self-care training, 3 to 4 days apart. The control groups received one session on accident safety. Knowledge, self-protective skills, fear, and self-disclosure were assessed respectively by the "Personal Safety Questionnaire (PSQ)," "What If Situation Test (WIST)," "Fear Assessment Thermometer Scale (FATS)," and researcher-made questions before and 8 weeks after the intervention. At the baseline, children obtained 70% of knowledge and 45% of protective skills scores. After the intervention, knowledge, protective skills, and detection of "appropriate requests" were significantly promoted (p < .001). Detecting "inappropriate requests" did not differ; however, all quadruple skills (Say, Do, Tell, and Report) improved significantly. "Girl sex" and "parents' education" were related factors promoting children's protective skills. Sexual abuse self-disclosure was 4.2% (n = 3), and one child reported child sexual abuse (CSA) only after the intervention. Despite the lack of formal education, children's basic knowledge reflects the importance of parents in preventing CSA. However, the CSAPP significantly improved children's skills and revealed one CSA case. CSAPP should not focus solely on risky scenarios because if children cannot distinguish between safe and unsafe situations, they will experience unnecessary anxiety. Even after recognizing the dangerous conditions, CSA prevention will practically fail without appropriate reactions such as escaping and reporting. CSAPP should emphasize individual rights such as body ownership and assertiveness skills and explain the "danger of known people" with detailed scenarios, especially in collectivistic and traditional societies.

Effects of a 24-Week Low-Cost Multicomponent Exercise Program on Health-Related Functional Fitness in the Community-Dwelling Aged and Older Adults

Background and Objectives: This study aimed to examine the effects of a low-cost multicomponent exercise program on health-related functional fitness in the community-dwelling aged and older adults. As a second objective, this study compared the exercise program between aged adults (<65 years) and those considered elderly (≥65 years). Materials and Methods: Forty-eight participants were included in the exercise program, and their mean age was 64.73 years (±5.93 years). The Senior Fitness Tests were performed by each participant. A dynamometer was used to assess hand grip strength, and body composition was assessed considering the body mass index. Paired-sample t test was used to compare data at baseline and after the exercise program, considering the total sample. Afterwards, a 2 × 2 analysis of variance was used to examine differences within and between groups. Results: Statistically significant improvements in the chair stand (t = -14.06; p < 0.001; d = 0.42), arm curl (t = -12.10; p < 0.001; d = 0.58), 2 min step test (t = -9.41; p < 0.001; d = 0.24), timed up and go test (t = 5.60; p < 0.001; d = 0.19), and hand grip strength (t = -3.33; p < 0.001; d = 0.15) were observed. There were also significant differences in the back scratch (t = -6.68; p < 0.001; d = 0.18) and chair sit and reach test (t = 5.04; p < 0.001; d = 0.05), as well as body mass index (p < 0.05). No significant differences were found between groups (p > 0.05). Conclusion: This study provides evidence that a 24-week low-cost community-based exercise program can improve functional fitness in aged and in older adults. The exercise program supplied the necessary data to construct further randomized controlled trials that can be performed in the community in an environmentally sustainable fashion and applied, not only to the elderly, but also to those transitioning to this age group.

Did Dental Insurance Expansion Improve Dental Care Needs Among Korean Adults? Difference in Difference Analysis

BACKGROUND

In 2012, the Korean government expanded dental insurance for the elderly to promote improved access to dental care. We examined the causal effect of this policy on dental care needs, focusing on low-income older adults.

METHODS

We compared data before and after policy implementation using double difference (DD) and triple difference (DDD) analyses. We used the nationally representative data from the Korea National Health and Nutrition Examination Survey from 2010 and 2016-2018. Individuals aged ≥65 years were included in the treatment group, and individuals aged <65 years were included in the control group.

RESULTS

Dental insurance expansion was associated with a paradoxical increase in perceived unmet dental needs among elderly individuals (8.8 percentage points increase, 95% CI: 4.7 to 13.0). However, there were improvements in dental prosthetics outcomes (denture wearing [4.0 percentage points, 95% CI: 0.2 to 7.9] and dental implants [5.0 percentage points, 95% CI: 2.1 to 7.9]; P < 0.01). Upon analyzing low-income elderly individuals using DDD analysis, we found that the insurance expansion led to a 21.6% smaller increase in unmet dental needs among low-income adults, compared to high-income adults (95% CI, -35.0 to -8.5; P < 0.01).

CONCLUSION

Dental insurance expansion in South Korea resulted in improvements in access to dental prosthetic services overall. It also led to a smaller increase in unmet dental needs among low-income older adults, compared to high-income adults.

An Intervention Program to Reduce Medication-Related Problems Among Polymedicated Home-Dwelling Older Adults (OptiMed): Protocol for a Pre-Post, Multisite, Pilot, and Feasibility Study

BACKGROUND

Effective medication management is one of the essential preconditions for enabling polymedicated home-dwelling older adults with multiple chronic conditions to remain at home and preserve their quality of life and autonomy. Lack of effective medication management predisposes older adults to medication-related problems (MRPs) and adverse health outcomes, which can lead to the degradation of a patient's acute clinical condition, physical and cognitive decline, exacerbation of chronic medical conditions, and avoidable health care costs. Nonetheless, it has been shown that MRPs can be prevented or reduced by using well-coordinated, patient-centered, interprofessional primary care interventions.

OBJECTIVE

This study aimed to explore the feasibility and acceptability of an evidence-based, multicomponent, interprofessional intervention program supported by informal caregivers to decrease MRPs among polymedicated home-dwelling older adults with multiple chronic conditions.

METHODS

This quasi-experimental, pre-post, multisite pilot, and feasibility study will use an open-label design, with participants knowing the study's objectives and relevant information, and it will take place in primary health care settings in Portugal and Switzerland. The research population will comprise 30 polymedicated, home-dwelling adults, aged ≥65 years at risk of MRPs and receiving community-based health care, along with their informal caregivers and health care professionals.

RESULTS

Before a projected full-scale study, this pilot and feasibility study will focus on recruiting and ensuring the active collaboration of its participants and on the feasibility of expanding this evidence-based, multicomponent, interprofessional intervention program throughout both study regions. This study will also be essential to projected follow-up research programs on informal caregivers' multiple roles, enhancing their coordination tasks and their own needs. Results are expected at the end of 2024.

CONCLUSIONS

Designing, establishing, and exploring the feasibility and acceptability of an intervention program to reduce the risks of MRPs among home-dwelling older adults is an underinvestigated issue. Doing so in collaboration with all the different actors involved in that population's medication management and recording the first effects of the intervention will make this pilot and feasibility study's findings very valuable as home care becomes an ever more common solution.

TRIAL REGISTRATION

Swiss National Clinical Trials Portal 000004654; https://tinyurl.com/mr3yz8t4.

Real-Time Mental Health Crisis Response in the United States to COVID-19

Background: Data are scarce on assessing the impact of the COVID-19 pandemic on young people. Aim: To examine changes in crisis text patterns in the United States during the pandemic compared to the prepandemic period. Method: Nonintrusive data from a national digital crisis texting platform were analyzed using an interrupted time series design. Poisson regression with repeated-measures examined help-seeking patterns for stress, anxiety, depression, suicidal thoughts, and other mental health concerns in the pandemic (March 13 to July 20, 2020) compared to the prepandemic period (March 13 to July 20, 2019). Results: An abrupt increase in national crisis response texts occurred during the pandemic for stress and anxiety, substance abuse, bereavement, isolation, and abuse compared to the prepandemic period. Similar trends of excess texts for isolation and abuse were reported among children (relative risk [RR]_abuse: 1.16, CI: 1.03, 1.31; RR_isolation: 1.15, CI: 1.09, 1.21) and adolescents (RR_abuse: 1.17, CI: 1.11, 1.24; RR_isolation: 1.08, CI: 1.05, 1.11), bereavement among Black (RR: 1.31, CI: 1.12, 1.54) and Hispanic (RR: 1.28, CI: 1.10, 1.49) texters, and isolation and bereavement in female (RR_isolation: 1.09, CI: 1.06, 1.11; RR_bereavement: 1.21, CI: 1.13, 1.28) or nonconforming youth (RR_isolation: 1.19, CI: 1.08, 1.32; RR_bereavement: 1.50, CI: 1.08, 2.09) texters. Conversely, the risks of reporting bullying, depression, relationship issues, and suicidal thoughts as reasons for texting were significantly lower during COVID-19. Limitations: Results may underestimate crisis support-seeking in some groups because demographic data were not captured on all texters. Conclusion: Findings illuminated the real-time crisis response of young people across the United States and can inform more responsive interventions to alleviate the mental health consequences brought on by the COVID-19 pandemic.

Effect of integrated nutrition-sensitive and nutrition-specific intervention package on maternal malnutrition among pregnant women in Rwanda

Maternal undernutrition remains a major public health concern in Rwanda despite significant gains and progress. An integration of nutrition‐specific and nutrition‐sensitive interventions was implemented in five districts of Rwanda to improve maternal and child nutrition. The package included nutrition education and counselling, promotion of agricultural productivity, promotion of financial literacy/economic resilience and provision of Water, Hygiene and Sanitation services. However, there is limited evidence about the effect of such interventions in reducing maternal undernutrition. A postintervention quasi‐experimental study was conducted among pregnant women to determine the effect of the integrated intervention on their nutritional status. It was carried out in two intervention districts, namely Kicukiro and Kayonza, and two control districts, namely Gasabo and Gisagara between November 2020 and June 2021. Five hundred and fifty‐two women were recruited for the intervention arm, while 545 were recruited for the control arm. Maternal undernutrition was defined as either having low mid‐upper arm circumference (<23 cm) during delivery or low body mass index (<18.5 kg/m²) in the first trimester or both. A multivariable logistic regression model was used to assess the effect of the integrated interventions. The prevalence of maternal undernutrition was significantly lower in the intervention group compared with the control group (4.7% vs. 18.2%; p < 0.001). After controlling the potential confounders, the risk of maternal undernutrition was 77.0% lower in the intervention group than in the control group [adjusted odds ratio= 0.23; 95% confidence interval = 0.15–0.36; p < 0.001]. Further studies are therefore recommended to establish causation and inform the potential scale‐up of these interventions nationally in Rwanda.

Empirical evidence on the effect of integrated nutrition‐specific and nutrition‐sensitive interventions on maternal undernutrition is limited as existing studies are mainly directed at the effectiveness of nutritional interventions on improving child nutritional status.

The results indicated that the integrated nutrition‐specific and nutrition‐sensitive intervention package was significantly associated with low maternal undernutrition.

This study adds more evidence to the 2008, 2013 and 2021 Lancet Series regarding the proposed effectiveness of integrated nutrition‐sensitive and nutrition‐specific interventions.

Further research should focus on follow‐up randomized controlled trials and the cost‐effectiveness of these integrated nutrition‐specific and nutrition‐sensitive interventions.

Health impacts of a scale-up of supervised injection services in a Canadian setting: an interrupted time series analysis

BACKGROUND AND AIMS

In response to a dramatic rise in overdose deaths due to injection drug use, there was a rapid scale-up of low-threshold supervised injection services (SIS), termed 'overdose prevention sites' (OPS), in Vancouver, Canada in December 2016. We measured the potential impact of this intervention on SIS use and related health outcomes among people who inject drugs (PWID).

DESIGN

Segmented regression analyses of interrupted time series data from two community-recruited prospective cohorts of PWID from January 2015 to November 2018 were used to measure the impact of the OPS scale-up on changes in SIS use, public injection, syringe sharing and addiction treatment participation, controlling for pre-existing secular trends.

SETTING

Vancouver, Canada.

PARTICIPANTS

Of 745 PWID, 292 (39.7%) were women, 441 (59.6%) self-reported white ancestry and the median age was 47 years (interquartile range = 38, 53) at baseline.

MEASUREMENTS

Immediate (i.e. step level) and gradual (i.e. slope) changes in the monthly proportion of participants who self-reported past 6-month SIS use, public injection, syringe sharing and participation in any form of addiction treatment.

FINDINGS

Post OPS expansion, the monthly prevalence of SIS use immediately increased by an estimated 6.4% [95% confidence interval (CI) = 1.7, 11.2] and subsequently further increased by an estimated 0.7% (95% CI = 0.3, 1.1) per month. The monthly prevalence of addiction treatment participation immediately increased by an estimated 4.5% (95% CI = 0.5, 8.5) following the OPS expansion, while public injection and syringe sharing were estimated to immediately decrease by 5.5% (95% CI = 0.9, 10.0) and 2.5% (95% CI = 0.5, 4.6), respectively. Findings were inconclusive as to whether or not an association was present between the intervention and subsequent gradual changes in public injection, syringe sharing and addiction treatment participation.

CONCLUSIONS

Scaling-up overdose prevention sites in Vancouver, Canada in December 2016 was associated with immediate and continued gradual increases in supervised injection service engagement and immediate increases in related health benefits.

Cost-Benefit Analysis of an Intervention in Divorced Parents: Implications for Society, Public Administrations and Family Visitation Centers

Families going through conflictive divorce processes are at increased risk of developing mental health problems. The Egokitzen program is a group intervention for parents who have undergone a divorce process, funded by the public administration. Budgetary constraints cause funding institutions to be interested in the effectiveness and economic efficiency of these programs. Therefore, the objective of this research is to carry out an efficiency analysis of the Egokitzen program, implemented by family visitation centers in Spain, through a cost-benefit analysis, to determine whether the positive impact on symptomatology (measured using CBCL and SCL-90 instruments) is translated into a positive economic impact for society. A sample of 382 parents participated. Costs will be first identified and valued; secondly, benefits achieved with the program will be identified through a prevalence analysis and, finally, the cost-benefit comparative analysis will be carried out. Additionally, a sensitivity analysis will be performed. The results obtained in the analysis indicate that for every euro spent on this program, the public administration and society save 3.10 euros in future interventions through medical costs and productivity losses. The study has practical implications for public administration, organizations, and the family visitation centers that implement the program.

The effect of college education on health and mortality: Evidence from Canada

We investigate the returns to college attendance in Canada in terms of health and mortality reduction. To do so, we first use a dynamic health microsimulation model to document how interventions that incentivize college attendance among high school graduates may impact their health trajectory, health care consumption, and life expectancy. We find large returns both in terms of evity (4.1 years additional years at age 51), reduction in the prevalence of various health conditions (10-15 percentage points reduction in diabetes and 5 percentage points for stroke), and health care consumption (27.3% reduction in lifetime hospital stays, 19.7 for specialists). We find that education impacts mortality mostly by delaying the incidence of health conditions as well as providing a survival advantage conditional on having diseases. Second, we provide quasi-experimental evidence on the impact of college attendance on long-term health outcomes by exploiting the Canadian Veteran's Rehabilitation Act, a program targeted towards returning WW-II veterans and which incentivized college attendance. The impact on mortality is found to be larger than those estimated from the health microsimulation model (hazard ratio of 0.216 compared with 0.6 in the simulation model), which suggests substantial returns to college education in terms of healthy life extension which we estimate to be approximately one million canadian dollars.

Systematic Review and Meta-analysis of Genetically Informed Research: Associations Between Parent Anxiety and Offspring Internalizing Problems

OBJECTIVE

Parent anxiety is associated with offspring internalizing problems (emotional problems related to anxiety and depression). This may reflect causal processes, whereby exposure to parent anxiety directly influences offspring internalizing (and/or vice versa). However, parent-offspring associations could also be attributable to their genetic relatedness. A systematic review and meta-analysis were conducted to investigate whether exposure to parent anxiety is associated with offspring internalizing after controlling for genetic relatedness.

METHOD

A literature search across 5 databases identified 429 unique records. Publications were retained if they used a quasi-experimental design in a general population sample to control for participant relatedness in associations between parent anxiety and offspring internalizing outcomes. Publications were excluded if they involved an experimental exposure or intervention. Studies of prenatal and postnatal anxiety exposure were meta-analyzed separately. Pearson's correlation coefficient estimates (r) were pooled using multilevel random-effects models.

RESULTS

Eight publications were retained. Data were drawn from 4 population cohorts, each unique to a quasi-experimental design: adoption, sibling-comparison, children-of-twins or in vitro fertilization. Cohorts were located in northern Europe or America. Families were predominantly of European ancestry. Three publications (Nfamilies >11,700; offspring age range, 0.5-10 years) showed no association between prenatal anxiety exposure and offspring internalizing outcomes after accounting for participant relatedness (r = .04; 95% CI: -.07, .14). Six publications (Nfamilies >12,700; offspring age range, 0.75-22 years) showed a small but significant association between concurrent symptoms in parents and offspring after accounting for participant relatedness (r = .13; 95% CI: .04, .21).

CONCLUSION

Initial literature, derived from homogeneous populations, suggests that prenatal anxiety exposure does not cause offspring internalizing outcomes. However, postnatal anxiety exposure may be causally associated with concurrent offspring internalizing via nongenetic pathways. Longitudinal stability, child-to-parent effects, and the role of moderators and methodological biases require attention.

The short- and long-term effects of a course on rational drug use: A comparative study between prefinal- and final-year undergraduate medical students who attended the course in different clinical years

BACKGROUND

Rational pharmacology use and appropriate prescribing are among the key learning outcomes in medical education. Some medical faculties include rational pharmacotherapy course in their education programs at different years of education in Turkey. The aims of this study were to investigate the differences in effect of rational pharmacotherapy course on short- and long-terms by comparing two cohorts who attended the course in different clinical years of medical education by identifying which parameters of prescription items are different among groups.

MATERIALS AND METHODS

This quasi-experimental study was conducted in School of Medicine. Participants consisted of 157 students who attended the course in Grade 4 (n = 110, Group A) and Grade 5 (n = 47, Group B). Students were asked to complete a prescribing task both upon completion of the course and 1 year after. The performance in prescribing was determined by prescription scoring form. Repeated measures ANOVA was employed to test the intervention effect between two periods. McNemar test was employed to measure the change in each item on the prescription. Point-biserial correlations between each item on the prescription and their scores on the test as a whole were calculated.

RESULTS

The mean score of Group A dropped to 59.41 (standard deviation [SD] = 14.06) from 90.43 (SD = 8.90), and the mean score of Group B dropped to 73.37 (SD = 12.56) from 83.91 (SD = 10.03). All the prescription components in the scripts of the Group A students worsened significantly, except the "name of drug," whereas Group B students maintained most of them after 1 year.

CONCLUSIONS

This study shows that the long-term retention effect of rational pharmacotherapy course conducted in later years of education is better than the course conducted in earlier years of education, which may be related to the fact that students in later years are more likely to take on responsibility for patient therapy process in clinical education.

Can synthetic controls improve causal inference in interrupted time series evaluations of public health interventions?

Interrupted time series designs are a valuable quasi-experimental approach for evaluating public health interventions. Interrupted time series extends a single group pre-post comparison by using multiple time points to control for underlying trends. But history bias-confounding by unexpected events occurring at the same time of the intervention-threatens the validity of this design and limits causal inference. Synthetic control methodology, a popular data-driven technique for deriving a control series from a pool of unexposed populations, is increasingly recommended. In this paper, we evaluate if and when synthetic controls can strengthen an interrupted time series design. First, we summarize the main observational study designs used in evaluative research, highlighting their respective uses, strengths, biases and design extensions for addressing these biases. Second, we outline when the use of synthetic controls can strengthen interrupted time series studies and when their combined use may be problematic. Third, we provide recommendations for using synthetic controls in interrupted time series and, using a real-world example, we illustrate the potential pitfalls of using a data-driven approach to identify a suitable control series. Finally, we emphasize the importance of theoretical approaches for informing study design and argue that synthetic control methods are not always well suited for generating a counterfactual that minimizes critical threats to interrupted time series studies. Advances in synthetic control methods bring new opportunities to conduct rigorous research in evaluating public health interventions. However, incorporating synthetic controls in interrupted time series studies may not always nullify important threats to validity nor improve causal inference.

The Effect of E-Learning on the Attitude Toward Dengue Prevention and the Acceptance of Dengue Vaccination

BACKGROUND

A community's attitude toward dengue prevention and its acceptance of dengue vaccine and vaccination play an essential role in the success of the dengue infection prevention program. To develop their attitude and acceptance, the implementation of learning media is required.

OBJECTIVE

The objective of the study was to examine the effectiveness of e-learning for developing the community's attitude toward dengue prevention and its acceptance of dengue vaccine and vaccination.

METHODS

This study employed a quasi-experimental method with pre- and post-test design by involving 85 subjects that were purposively selected from the low-prevalence area of dengue infection in the City of Bandung, West Java Province, Indonesia. A valid and reliable questionnaire was delivered during pre- (day 1) and post-test (day 7). For the e-learning, it was given on day 1 after completing the pre-test. A descriptive statistical method was applied to describe the research variables, to analyze the correlation between the subjects' attitude and acceptance, and to examine the significant differences (pre- and post-test) between the subjects' attitude toward dengue prevention and their acceptance of dengue vaccine and vaccination.

RESULTS

Approximately 88.24% and 11.76% of subjects have good and fair knowledge about dengue disease, respectively. Concerning knowledge about dengue vaccine, 44.71% and 55.29% of them them have good and fair knowledge, respectively. In particular, there is an increase in their attitude toward dengue prevention (p-value <0.05), their acceptance of dengue vaccine (p-value <0.05) and their acceptance of dengue vaccination program (p-value <0.05) after they got information from e-learning.

CONCLUSION

E-learning could have significant effects to increase the community's attitude toward dengue prevention and their acceptance of dengue vaccine and vaccination.

The impact of health-related supports in senior housing on ambulance transfers and visits to emergency departments: The Right Care, Right Place, Right Time Project

OBJECTIVE

To test the impact of placing a wellness team (nurse and social worker) in senior housing on ambulance transfers and visits to emergency departments over 18 months.

DATA SOURCES/STUDY SETTING

Intervention sites included seven Boston-area buildings, with five buildings at comparable settings acting as controls. Data derive from building-level ambulance data from emergency responders; building-level Medicare claims data on emergency department utilization; and individual-level baseline assessment data from participants in the intervention (n = 353) and control (n = 208) sites.

STUDY DESIGN

We used a pre/postdifference in difference quasi-experimental design applying several analytic methods. The preintervention period was January 2016-March 2017, while the intervention period was July 2017-December 2018.

DATA COLLECTION/EXTRACTION METHODS

Emergency responders provided aggregate transfer data on a daily basis for intervention and control buildings; the Quality Improvement Organization provided quarterly aggregate data on emergency department visit rates; and assessment data came from a modified Vitalize 360 assessment and coaching tool.

PRINCIPAL FINDINGS

The study found an 18.2% statistically significant decline in ambulance transfers in intervention buildings, with greater declines in buildings that had fewer services available at baseline, compared to other intervention sites. Analysis of Medicare claims data, adjusted for the proportion of residents over 75 per building, found fewer visits to emergency departments in intervention buildings.

CONCLUSIONS

Health-related supports in senior housing sites can be effective in reducing emergency transfers and visits to emergency departments.

Estimating counterfactuals for evaluation of ecological and conservation impact: an introduction to matching methods

Matching methods encompass non-parametric approaches to estimating counterfactual states through a rigorous selection of control units with similar characteristics to units submitted to an intervention. These methods enable comparisons between treated and control units in a way that facilitates understanding of causal relationships between interventions and outcomes. Matching methods have been used only recently in ecology and conservation biology, where such applications changed the way the field investigates causal questions, for example, in impact-evaluation studies. However, the strengths and limitations of matching methods are not well understood by most ecologists and environmental scientists. Herein, we review state-of-the-art matching methods aiming to help fill this gap in understanding. First, we present relevant theoretical concepts related to matching methods and related subjects such as counterfactual states and causation. Next, we propose guidelines and strategies for the application of matching methods in ecology and conservation biology. Finally, we discuss the possibilities for future applications of matching methods in the environmental sciences.

Outcomes of a walking exercise intervention in postpartum women with disordered sleep

AIM

Good sleep quality is essential to physical and mental-health-related quality of life. The purpose of this study was to evaluate the effects of a walking exercise in relieving sleep quality, fatigue, and depression in new mothers during the postpartum period.

METHODS

This quasi-experimental study was conducted at a teaching hospital in southern Taiwan. One hundred and four eligible postpartum women with poor sleep quality (Postpartum Sleep Quality Scale; PSQS score ≧16) were assigned to either the experimental group (n = 50) or the control group (n = 54) according to their individual preferences. The participants in the experimental group participated in a 12-week stride walking exercise intervention. The control group did not receive any exercise intervention. The PSQS, Postpartum Fatigue Scale, and Edinburgh Postnatal Depression Scale were used to assess outcomes.

RESULTS

Repeated measures ANOVA demonstrated that the experimental group participants perceived milder physical symptoms associated with sleep inefficiency at 4-week posttest (F = 7.25, p < 0.01) than their control group peers. However, no significant differences were found between two groups in terms of either fatigue or depression at 4-week and 12-week posttest.

CONCLUSION

Significant improvement in the physical symptoms associated with sleep inefficiency was observed. The findings may be used to encourage postpartum women with disordered sleep to incorporate 20-30 min of stride walking into their regular routine to improve sleep quality.

Warning Labels Reduce Sugar-Sweetened Beverage Intake among College Students

BACKGROUND

Health-related warning labels may reduce the intake of sugar-sweetened beverages (SSBs), but the effectiveness of such labels in real-world settings is not well established.

OBJECTIVES

We investigated the influence of warning labels on SSB intake among college students at a large public Midwestern university.

METHODS

We conducted a quasi-experimental intervention study among 840 undergraduate students recruited from 3 dining halls on 1 university campus. One dining hall was selected as the intervention (I) site, whereas the other dining halls served as control (C) sites. In January 2019, warning labels were posted on SSB dispensers at the I site. All students reported their beverage intake using a modified beverage frequency questionnaire 2 mo before and 2 mo after the warning label implementation. Generalized linear models examined the influence of the warning labels on SSB consumption at the I site compared with the C sites, adjusting for students' sociodemographic characteristics.

RESULTS

In the sample, 68% were aged 17-18 y old at baseline, and 51% identified as female. From baseline to follow-up, there was a 19% decrease in SSB intake at the I site, compared with a 5% decrease at the C sites (P = 0.049 comparing I with C). This difference was driven by significant decreases in the intakes of fruit-flavored drinks, sweetened teas, and flavored milk at the I site compared with the C sites. Although not an SSB, 100% fruit juce consumption decreased 21% at the I site, compared with a 1% increase at the C sites (P = 0.01 comparing I with C). No significant differences were observed in the intakes of soda, energy drinks, sweetened coffees, and nonsugary drinks at the I site compared with the C sites.

CONCLUSIONS

Warning labels were effective in reducing SSB intake among college students, particularly for fruit-flavored drinks, sweetened teas, and flavored milk.This trial was registered at clinicaltrials.gov as NCT04435145.

Effectiveness of "Hand Hygiene Fun Month" for Kindergarten Children: A Pilot Quasi-Experimental Study

Early childhood is a formative period during which healthy habits are developed, including proper hand hygiene practices. The aim of this quasi-experimental study was to determine the effectiveness of a 4-week series of educational sessions that consider the cognitive developmental stage of children on increasing their knowledge and promoting hand hygiene practices. The intervention group (n = 33) observed the hand hygiene program, whereas another group served as the waitlist control (n = 20). Creative activities were planned for the illustration of hand hygiene concepts in terms of "right moments", "right steps", and "right duration". Hand sanitizer coverage was evaluated using a hand scanner. After the intervention, the experimental group had higher knowledge level toward hand hygiene than the control group (p < 0.001). Significant improvements in hand hygiene performance at the left palm and dorsum (p < 0.05), right palm (p < 0.05), and overall hand coverage (p < 0.05) were observed in the experimental group. The study demonstrated that the knowledge and proper hand hygiene (HH) practice of children can be positively influenced by the use of an age-appropriate education program. The results of this study have implications for school health educators and parents for promoting HH practices among children at home and at the school level.

Focused Family Planning Counseling Increases Immediate Postpartum Intrauterine Contraceptive Device Uptake: A Quasi-Experimental Study

PURPOSE

The aim of the study was to assess the effectiveness of focused family planning counseling (FFPC) in increasing postpartum intrauterine contraceptive device (PPIUCD) uptake among mothers who gave birth in the public health facilities of the towns of Adama and Olenchiti from April 1 to May 30, 2017.

METHODS

A quasi-experimental study design was employed, taking a sample of 726 postpartum mothers: 484 in the non-intervention group (NIG) and 242 in the intervention group (IG). Focused family planning counseling was given to the IG using a newly designed cue card adapted from World Health Organization (WHO) guidelines and developed based on the constructs of the health belief model. Counseling based on a routine counseling approach was given to the NIG. The interviewer administered a semi-structured questionnaire for data collection. Data were analyzed using SPSS software, version 20. Descriptive statistics were used to characterize the study participants. The difference in the proportion of PPIUCD uptake in the two groups was tested using an independent Z-test at an alpha level of 0.05. Binary logistics regression was used to identify factors associated with the odds of taking IUCD. The significance of association was declared for P-values less than 0.05.

RESULTS

The proportion of PPIUCD uptake in the IG [12.4%; 95% CI: 8.6, 17.4] was significantly higher than in the NIG [4.8%; 95% CI: 2.9, 6.7] with a P-value = 0.000. The odds of IUCD uptake among the IG was about 6 times higher (AOR: 5.92; 95% CI: 2.79, 12.60) than in the NIG. In addition, being unmarried women (AOR: 12.96; 95% CI: 4.30, 34.56), having higher education (AOR: 3.07; 95% CI: 1.13, 8.36), grand multiparity (AOR: 3.76; 95% CI: 1.58, 8.95), making a mutual decision (AOR: 0.16, 95% CI: 0.07, 0.38) and having a better knowledge of family planning (AOR: 5.92, 95% CI: 2.79, 12.60) were factors associated with uptake.

CONCLUSION

Providing FFPC immediately increases PPIUCD uptake. The uptake was also associated with marital status, education, parity, decision and knowledge on family planning.

Evaluation of a psychoeducational intervention compared with education in people with Parkinson's disease and their informal caregivers: a quasi-experimental study

AIM

To evaluate the effects of a psychoeducational intervention compared with an education programme to strengthen quality of life, psychosocial adjustment, and coping in people with Parkinson's disease and their informal caregivers.

DESIGN

A quasi-experimental study was performed with repeated measures at baseline, after the intervention and 6 months post-intervention.

METHODS

The study was carried out at seven primary care centres from 2015-2017. A total of 140 people with Parkinson's and 127 informal caregivers were allocated to the experimental and the control groups. The experimental group received a 9-week psychoeducational intervention, whereas the control group received a 5-week education programme. Repeated measures ANOVA were used to test differences in quality of life, psychosocial adjustment, and coping between the experimental and control groups and over time.

RESULTS

Patients and informal caregivers in both the experimental and control groups showed significantly better psychosocial adjustment at the post-intervention measurement compared with baseline data. We also found significantly greater quality of life in patients and coping skills in caregivers after the end of the interventions in the experimental and control groups. Nevertheless, no significant differences were identified on the outcomes at the 6-month post-intervention measurement.

CONCLUSION

The effect of the psychoeducational intervention was not different from the effect of the education programme. The strategies applied in both interventions followed a group approach led by a multidisciplinary team covering information about PD, healthy lifestyles, and social resources. They might be easily sustained in Primary Care to improve care for people with Parkinson's and informal caregivers.

Effects of a Lifestyle Intervention Based on Type D Personality in Overweight and Obese Middle-Aged Women: A Feasibility Study

BACKGROUND

Obesity is an important public health problem, particularly among middle-aged women. Type D personality, characterized by negative affectivity and social inhibition, is prevalent among obese and overweight middle-aged women and has been linked to maladaptive health-related behaviors and unhealthy lifestyle. Lifestyle interventions based on type D personality could be a first step in combatting obesity in middle-aged women.

AIM

To identify the effects of a lifestyle intervention based on type D personality on health-promoting lifestyle behaviors, psychological distress, type D personality, and body composition in overweight and obese middle-aged women.

METHODS

A total of 36 overweight and obese middle-aged women participated in a quasi-experimental design using a non-equivalent control group pretest-posttest. The experimental group received a total of eight sessions of a lifestyle intervention program based on type D personality over the course of four weeks. Outcomes were measured health-promoting lifestyle behaviors, psychological distress, type D personality, and body composition (body weight, body mass index, body fat, and abdominal fat).

RESULTS

Following the intervention, the experimental group scored significantly higher than the control group for health-promoting lifestyle behaviors, and significantly lower than the control group for psychological distress and type D personality. Body weight and body mass index decreased significantly in the experimental group compared to the control group.

LINKING EVIDENCE TO ACTION

Further research on various intervention programs for overweight and obese middle-aged women is warranted, including lifestyle interventions based on type D personality.

Mini-Basketball Training Program Improves Physical Fitness and Social Communication in Preschool Children with Autism Spectrum Disorders

This investigation examined the effects of a 12-week mini-basketball training program (MBTP) on physical fitness and social communication in preschool children with autism spectrum disorders (ASD). The study applied a quasi-experimental design. Fifty-nine preschool children aged 3-6 years with ASD were assigned to either a MBTP group (n = 30) or a control group (n = 29). Participants in the MBTP group received a scheduled mini-basketball training program (5 sessions per week, forty minutes per session) for twelve consecutive weeks, while the control group was instructed to maintain their daily activities. The physical fitness test and the parent-reported Social Responsiveness Scale Second Edition (SRS-2) test were performed before and after the intervention. Results indicated that the 12-week MBTP facilitated performance in the physical fitness test, particularly in speed-agility and muscular strength abilities. Additionally, children in the MBTP group demonstrated improvement in SRS-2 performance in social awareness, social cognition, social communication, and autistic mannerisms, whereas no such changes were found in the control group. It may be concluded that the 12-week MBTP could improve physical fitness and social communication in preschool children with ASD, and thus the use of physical exercise intervention as a therapeutic tool for preschoolers with ASD is recommended.

Impact of Health Education Intervention on Breast Cancer Awareness among Rural Women of Tamil Nadu

Background:

The most common cancer among Indian females is breast cancer. Limited access to early detection and treatment is responsible for more than half of the deaths, primarily in rural areas, where organized mammography screening is neither affordable nor feasible. Therefore, imparting awareness on breast health and breast self-examination (BSE) is highly recommended. This study aimed to assess the impact of a health education interventional program on breast health awareness and BSE among rural women of Tamil Nadu.

Methodology:

A quasi-experimental study was conducted among 266 women. A preinterventional survey was done using a pretested validated questionnaire. A multipronged breast health education intervention was administered and its effectiveness was measured after 3 months using the same tool.

Results:

There was a statistically significant (P = 0.0001) improvement in the knowledge of breast health, perceived susceptibility, and reasons for practice and proficiency of BSE practice of the interventional group from pre- to post-test. After the interventional program, 71.8% of increase in knowledge about breast health and BSE was observed. In addition, 64.7% of the women practiced BSE compared to 7.14% pretest.

Conclusion:

This study highlights the awareness needs by the women and application of extensive strategies to increase the acceptance of cancer screening programs.

Study Protocol for the Evaluation of the Health Effects of Superblocks in Barcelona: The "Salut Als Carrers" (Health in the Streets) Project

Superblocks are currently being introduced in Barcelona to respond to the city's scarcity of green spaces and high levels of air pollution, traffic injuries, and sedentariness. The aim is to calm the streets by reducing the number of square meters dedicated to private vehicles and to reclaim part of this public space for people. Salut als Carrers (Health in the Streets) is a project to evaluate the potential environmental and health effects of the superblock model with an equity perspective in Barcelona. This study aims to explain the various interventions implemented in different neighborhoods in Barcelona and the methods that will be used to evaluate them in a quasi-experimental and health impact assessment (HIA) approaches. Given the complexity of the intervention evaluated, the project employs mixed methodologies. Quantitative methods include: (a) a pre-post health survey of 1200 people randomly selected from the municipal register asked about self-perceived health and quality of life, social support, mental health, mobility, physical activity, neighborhood characteristics, and housing; (b) pre-post environmental measurements, mainly of nitrogen dioxide (NO₂), particulate matter of less than 10 µm (PM₁₀), and particulate matter of less than 2.5 µm (PM_2.5) and black carbon; (c) pre-post environmental walkability measures using the Microscale Audit of Pedestrian Streetscapes (MAPS) tool; (d) use of public space and physical activity levels using the System for Observing Play and Recreation in Communities (SOPARC), a validated observation tool; (e) pre-post traffic injury measures with a comparison group; and (f) the comparison and integration of pre-post assessment with previous HIAs and the improvement of future HIAs. Qualitative studies will be performed to analyze residents' perception of these effects by using: (a) various focus groups according to different participant characteristics who are more or less likely to use the superblocks; and (b) a guerrilla ethnography, which is a method that combines ethnographic observation and semi-structured interviews. This study, which evaluates the impact of an ambitious urban-renewal program on health, will help to assess the effectiveness of public policy in terms of health and health inequalities.

Effectiveness of pre-operative anaemia screening and increased Tranexamic acid dose policies on outcomes following unilateral primary, elective total hip or knee replacement: a statistical analysis plan for an interrupted time series and regression discontinuity study

Perioperative blood transfusion is associated with poorer postoperative outcomes following hip and knee replacement surgery. Evidence for the effectiveness of some measures aimed at reducing blood transfusions in this setting are limited and often rely on weak pre-post study designs. Quasi-experimental study designs such as interrupted time series (ITS) and regression discontinuity design (RDD) address many of the weaknesses of the pre-post study design. In addition, a priori publication of statistical analysis plans for such studies increases their transparency and likely validity, as readers are able to distinguish between pre-planned and exploratory analyses. As such, this article, written prospective of any analysis, provides the statistical analysis plan for an ITS and RDD study based on a data set of 20,772 primary elective hip and knee replacement patients in a single English NHS Trust. The primary aim is to evaluate the impact of a preoperative anaemia optimisation service on perioperative blood transfusion (within 7 days of surgery) using both ITS and RDD methods. A secondary aim is to evaluate the impact of a policy of increased tranexamic acid dose given at the time of surgery, using ITS methods.

Designs and methods for implementation research: Advancing the mission of the CTSA program

INTRODUCTION

The US National Institutes of Health (NIH) established the Clinical and Translational Science Award (CTSA) program in response to the challenges of translating biomedical and behavioral interventions from discovery to real-world use. To address the challenge of translating evidence-based interventions (EBIs) into practice, the field of implementation science has emerged as a distinct discipline. With the distinction between EBI effectiveness research and implementation research comes differences in study design and methodology, shifting focus from clinical outcomes to the systems that support adoption and delivery of EBIs with fidelity.

METHODS

Implementation research designs share many of the foundational elements and assumptions of efficacy/effectiveness research. Designs and methods that are currently applied in implementation research include experimental, quasi-experimental, observational, hybrid effectiveness-implementation, simulation modeling, and configurational comparative methods.

RESULTS

Examples of specific research designs and methods illustrate their use in implementation science. We propose that the CTSA program takes advantage of the momentum of the field's capacity building in three ways: 1) integrate state-of-the-science implementation methods and designs into its existing body of research; 2) position itself at the forefront of advancing the science of implementation science by collaborating with other NIH institutes that share the goal of advancing implementation science; and 3) provide adequate training in implementation science.

CONCLUSIONS

As implementation methodologies mature, both implementation science and the CTSA program would greatly benefit from cross-fertilizing expertise and shared infrastructures that aim to advance healthcare in the USA and around the world.

Improved breastfeeding duration with Baby Friendly Hospital Initiative implementation in a diverse and underserved population

BACKGROUND

Few studies have evaluated the impact of Baby Friendly Hospital Initiative (BFHI) implementation on underserved populations in the United States. We undertook this study in New Mexico, a large southwestern state with a diverse population and limited health care access.

METHODS

A quasi-experimental, retrospective cohort design was used to compare short-term breastfeeding duration between a pre-BFHI and a post-BFHI cohort. Among the post-BFHI cohort, logistic regression models were fitted to predict short-term breastfeeding duration from both individual and cumulative exposure to inpatient maternity care practices (Steps 4 to 9).

RESULTS

Implementation of the BFHI and cumulative exposure to the Ten Steps increased short-term duration of any breastfeeding and exclusive breastfeeding at 2-6 weeks postpartum. Exposure to all six of the inpatient Ten Steps increased the odds of any breastfeeding by 34 times and exclusive breastfeeding by 24 times. Exposure to Step 9 ("Give no pacifiers or artificial nipples") uniquely increased the likelihood of any breastfeeding at 2-6 weeks postpartum by 5.7 times, whereas Step 6 ("Give infants no food or drink other than breastmilk") increased the rate of exclusive breastfeeding by 4.4 times at 2-6 weeks postpartum.

CONCLUSION

These findings demonstrate that the Baby Friendly Hospital Initiative can have a positive impact on breastfeeding among underserved populations.

Effects of ecotourism on forest loss in the Himalayan biodiversity hotspot based on counterfactual analyses

Ecotourism is developing rapidly in biodiversity hotspots worldwide, but there is limited and mixed empirical evidence that ecotourism achieves positive biodiversity outcomes. We assessed whether ecotourism influenced forest loss rates and trajectories from 2000 to 2017 in Himalayan temperate forests. We compared forest loss in 15 ecotourism hubs with nonecotourism areas in 4 Himalayan countries. We used matching statistics to control for local-level determinants of forest loss, for example, population density, market access, and topography. None of the ecotourism hubs was free of forest loss, and we found limited evidence that forest-loss trajectories in ecotourism hubs were different from those in nonecotourism areas. In Nepal and Bhutan, differences in forest loss rates between ecotourism hubs and matched nonecotourism areas did not differ significantly, and the magnitude of the estimated effect was small. In India, where overall forest loss rates were the lowest of any country in our analysis, forest loss rates were higher in ecotourism hubs than in matched nonecotourism areas. In contrast, in China, where overall forest loss rates were highest, forest loss rates were lower in ecotourism hubs than where there was no ecotourism. Our results suggest that the success of ecotourism as a forest conservation strategy, as it is currently practiced in the Himalaya, is context dependent. In a region with high deforestation pressures, ecotourism may be a relatively environmentally friendly form of economic development relative to other development strategies. However, ecotourism may stimulate forest loss in regions where deforestation rates are low.

Patient safety before and after implementing person-centred inpatient care - A quasi-experimental study

AIMS AND OBJECTIVES

To evaluate aspects of patient safety before and after a person-centred (PC) inpatient care intervention.

BACKGROUND

Transitioning from disease-centred to person-centred care requires great effort but can improve patient safety.

DESIGN

A quasi-experimental study with data collection preceding and 12 months after a PC inpatient care intervention.

METHODS

The study consecutively recruited adult patients (2014, n = 263; 2015/2016, n = 221) admitted to an inpatient care unit. The patients reported experiences of care at discharge and their perceived pain at admission and discharge. Medical records were reviewed to gather data on medications, planned care and clinical observations. The study is reported according to TREND guidelines.

RESULTS

At discharge, patients receiving PC inpatient care reported competent medical-technical care. Patients receiving PC inpatient care reported more effective pain relief. Updated prescribed medications at the ward were maintained, and patients were made aware of planned medical care to higher extent during PC inpatient care. The assessment of pulse and body temperature was maintained, but fewer elective care patients had their blood pressure taken during PC inpatient care. Weight assessment was not prioritised during usual or PC inpatient care.

CONCLUSIONS

Patients receiving PC inpatient care reported that they were given the best possible care and had less pain at discharge. The PC inpatient care included improved documentation and communication of planned medical care to the patients. Vital signs were more frequently recorded for patients admitted for acute care than patients admitted for elective care. PC inpatient care had no effect on frequency of weight measurements.

RELEVANCE TO CLINICAL PRACTICE

PC inpatient care seems beneficial for the patients. Aspects of patient safety such as prescribed medications were maintained, and PC inpatient care seems to enhance the continuity of care. Inpatient clinical observations need further evaluation as healthcare transitions from disease-centred to person-centred care.

Optimizing the observer experience in an interprofessional home health simulation: a quasi-experimental study

The purpose of this quasi-experimental study was to explore the influence of an interprofessional simulation experience on student perceptions of interprofessional collaboration, as well as to explore the influence of the participant and observer roles on these beliefs. A two-session simulation experience was developed to engage professional students in the collaborative care of a patient admitted to a home health agency. To provide the simulation experience in a time efficient manner within the curriculum, students participated in two interprofessional teams of nursing and physical therapy students. Each team actively participated in the collaborative care of the patient in one session. In the alternate session, the interprofessional team observed the care of the patient, documented behaviors ideal for interprofessional teamwork, and provided feedback regarding the interprofessional collaboration and communication observed during debriefing. Observers in this study consistently improved their self-perceived comfort in working with others irrespective of the order in which they participated in the simulation scenario. The use of observers in simulation may provide opportunities for programs to integrate large scale simulation experiences in a time efficient manner to further engage students in active learning as a component of interprofessional education.

Enhancing Health Through Access to Nature: How Effective are Interventions in Woodlands in Deprived Urban Communities? A Quasi-experimental Study in Scotland, UK

High prevalence of poor mental health is a major public health problem. Natural environments may contribute to mitigating stress and enhancing health. However, there is little evidence on whether community-level interventions intended to increase exposure to natural environments can improve mental health and related behaviours. In the first study of its kind, we evaluated whether the implementation of a programme designed to improve the quality of, and access to, local woodlands in deprived communities in Scotland, UK, was associated with lower perceived stress or other health-related outcomes, using a controlled, repeat cross-sectional design with a nested prospective cohort. Interventions included physical changes to the woodlands and community engagement activities within the woodlands, with data collected at baseline (2013) and post-intervention (2014 and 2015). The interventions were, unexpectedly, associated with increased perceived stress compared to control sites. However, we observed significantly greater increases in stress for those living >500 m from intervention sites. Visits to nearby nature (woods and other green space) increased overall, and moderate physical activity levels also increased. In the intervention communities, those who visited natural environments showed smaller increases in stress than those who did not; there was also some evidence of increased nature connectedness and social cohesion. The intervention costs were modest but there were no significant changes in quality of life on which to base cost-effectiveness. Findings suggest factors not captured in the study may have contributed to the perceived stress patterns found. Wider community engagement and longer post-intervention follow-up may be needed to achieve significant health benefits from woodland interventions such as those described here. The study points to the challenges in evidencing the effectiveness of green space and forestry interventions to enhance health in urban environments, but also to potential benefits from more integrated approaches across health and landscape planning and management practice.

Person-centred inpatient care - A quasi-experimental study in an internal medicine context

AIM

The aim of this study was to evaluate effects of person-centred inpatient care on care processes in terms of satisfaction with care and person-centred content in medical records, and to evaluate effects on self-reported health and self-efficacy.

BACKGROUND

Internal medicine inpatient care is complex, covering patients varying in age, medical conditions, health status, and other aspects. There has been limited research on the impact of person-centred care (PCC) on satisfaction with care and health outcomes in internal medicine care environments regardless of diagnosis and care pathway.

DESIGN

A quasi-experimental study with pre- and postmeasurements.

METHODS

Adult patients admitted to an internal medicine inpatient unit were consecutively included over 16 weeks in 2014 and 24 weeks in 2015-2016. Data were collected before a person-centred inpatient care intervention (N = 204) and 12 months after the intervention was implemented (N = 177). Data on satisfaction with care and self-reported health were collected at discharge and medical records were reviewed. The intervention included systematically applied person-centred assessment, health plans, and persistent PCC.

RESULTS

After the intervention, patients rated higher satisfaction with care regarding essential components of PCC and more patients had received effective pain relief. There were no differences in information on self-care or medications, self-rated health, or self-efficacy.

CONCLUSION

Care focused on the foundations of person-centredness seems to enhance both patients' perceptions of satisfaction and symptom management. Situational aspects such as care pathways should be considered when implementing person-centred inpatient care.

TRIAL REGISTRATION

CLINICALTRIALS.

GOV, REGISTRATION NUMBER

NCT03725813.

Maternal infection requiring hospitalization during pregnancy and attention-deficit hyperactivity disorder in offspring: a quasi-experimental family-based study

BACKGROUND

Maternal infection during pregnancy (IDP) has been associated with increased risk of attention-deficit/hyperactivity disorder (ADHD) in offspring. However, infection is associated with social adversity, poor living conditions and other background familial factors. As such, there is a need to rule out whether the observed association between maternal IDP and ADHD might be attributed to such confounding.

METHODS

This nationwide population-based cohort study using a family-based, quasi-experimental design included 1,066,956 individuals born in Sweden between 1992 and 2002. Data on maternal IDP (bacterial or viral) requiring hospitalization and ADHD diagnosis in offspring were gathered from Swedish National Registers, with individuals followed up through the end of 2009. Ordinary and stratified Cox regression models were used for estimation of hazard ratios (HRs) and several measured covariates were considered. Cousin- and sibling-comparisons accounted for unmeasured genetic and environmental factors shared by cousins and siblings.

RESULTS

In the entire population, maternal IDP was associated with ADHD in offspring (HR = 2.31, 95% CI = 2.04-2.61). This association was attenuated when accounting for measured covariates (HR = 1.86, 95% CI = 1.65-2.10). The association was further attenuated when adjusting for unmeasured factors shared between cousins (HR = 1.52, 95% CI = 1.12-2.07). Finally, the association was fully attenuated in sibling comparisons (HR = 1.03, 95% CI = 0.76-1.41).

CONCLUSIONS

This study suggests that the association between maternal IDP and offspring ADHD is largely due to unmeasured familial confounding. Our results underscore the importance of adjusting for unobserved familial risk factors when exploring risk factors for ADHD.

Impact of abolishing prescription fees in Scotland on hospital admissions and prescribed medicines: an interrupted time series evaluation

OBJECTIVES

To identify whether the abolition of prescription fees in Scotland resulted in: (1) Increase in the number (cost to NHS) of medicines prescribed for which there had been a fee (inhaled corticosteroids). (2) Reduction in hospital admissions for conditions related to those medications for which there had been a fee (asthma or chronic obstructive pulmonary disease (COPD))-when both are compared with prescribed medicines and admissions for a condition (diabetes mellitus) for which prescriptions were historically free.

DESIGN

Natural experimental retrospective general practice level interrupted time series (ITS) analysis using administrative data.

SETTING

General practices, Scotland, UK.

PARTICIPANTS

732 (73.6%) general practices across Scotland with valid dispensed medicines and hospital admissions data during the study period (July 2005-December 2013).

INTERVENTION

Reduction in fees per dispensed item from April 2008 leading to the abolition of the fee in April 2011, resulting in universal free prescriptions.

PRIMARY AND SECONDARY OUTCOMES

Hospital admissions recorded in the Scottish Morbidity Record - 01 Inpatient (SMR01) and dispensed medicines recorded in the Prescribing Information System (PIS).

RESULTS

The ITS analysis identified marked step reductions in adult (19-59 years) admissions related to asthma or COPD (the intervention group), compared with older or young people with the same conditions or adults with diabetes mellitus (the counterfactual groups). The prescription findings were less coherent and subsequent sensitivity analyses found that both the admissions and prescriptions data were highly variable above the annual or seasonal level, limiting the ability to interpret the findings of the ITS analysis.

CONCLUSIONS

This study did not find sufficient evidence that universal free prescriptions was a demonstrably effective or ineffective policy, in terms of reducing hospital admissions or reducing socioeconomic inequality in hospital admissions, in the context of a universal, publicly administered medical care system, the National Health Service of Scotland.

Needs and Challenges Related to Multilevel Interventions: Physical Activity Examples

The theme of this commentary is to discuss the need for, and challenges of, conceptualizing, implementing, and evaluating multilevel health behavior change interventions. Ecological models, recommendations from national and international authoritative groups, and growing evidence all support the need for interventions designed to change multiple levels of influence, including individuals, social environments, organizations, built environments, and policies, to achieve population improvements in public health. Though multilevel interventions are becoming more common in practice, they are still under-used, and research on multilevel interventions is relatively rare. Drawing on examples from physical activity, several types of evidence are summarized to demonstrate that multilevel interventions are feasible and can be effective. Serious challenges to implementing and evaluating multilevel interventions include the need for teams with diverse expertise, lack of control over intervention implementation, unpredictability of timelines, managing complex teams over extended periods, and need to apply unfamiliar and less-rigorous study designs and methods. Recommendations are offered for changes in training, funding priorities, and academic incentives that could lead to more and better multilevel interventions.

Team Resilience Training in the Workplace: E-Learning Adaptation, Measurement Model, and Two Pilot Studies

BACKGROUND

The majority of resilience interventions focus on the individual. Workplace resilience is a growing field of research. Given the ever-increasing interconnectedness in businesses, teamwork is a guarantee. There is also growing recognition that resilience functions at the team level.

OBJECTIVE

The objective of our work was to address three shortcomings in the study of workplace resilience interventions: lack of interventions focusing on group-level or team resilience, the need for brief interventions, and the need for more theoretical precision in intervention studies.

METHODS

The authors took an established evidence-based program (Team Resilience) and modified it based on these needs. A working model for brief intervention evaluation distinguishes outcomes that are proximal (perceptions that the program improved resilience) and distal (dispositional resilience). A total of 7 hypotheses tested the model and program efficacy.

RESULTS

Two samples (n=118 and n=181) of engineering firms received the Web-based training and provided immediate reactions in a posttest-only design. The second sample also included a control condition (n=201). The findings support the model and program efficacy. For example, workplace resilience was greater in the intervention group than in the control group. Other findings suggest social dissemination effects, equal outcomes for employees at different stress levels, and greater benefit for females.

CONCLUSIONS

This preliminary research provides evidence for the capabilities of e-learning modules to effectively promote workplace resilience and a working model of team resilience.

If You Build It, Will They Come? A Quasi-experiment of Sidewalk Improvements and Physical Activity

Improving sidewalks could lead to more physical activity through improved access, while providing a safe and defined space to walk. Yet, findings on the association between sidewalks and physical activity are inconclusive.

PURPOSE

The purpose of this study was to examine changes in self-reported and accelerometer-derived physical activity associated with living near recently improved sidewalks in a diverse, community-based sample from the Houston Travel Related Activity in Neighborhoods (TRAIN) Study.

METHODS

Data are from 430 adults and include baseline and first annual follow-up (2014-2017). Fully adjusted, two-step regression models were built to test the hypothesis that living near (within 250-meters) an improved sidewalk was associated with greater levels of physical activity than not living near an improved sidewalk.

RESULTS

The majority of participants were female, non-Hispanic black, low income, low education, and nearly half lived near at least one improved sidewalk. After adjustment, among participants reporting some physical activity, living near two sidewalk improvements was associated with 1.6 times more minutes per week of walking and leisure-time physical activity than those not living near a sidewalk improvement (p<0.05). Based on accelerometry, which does not specifically quantify domain-specific physical activity, there were no significant associations.

CONCLUSION

Although these mixed findings warrant further research, results suggest that improving sidewalks may have an effect on participants' physical activity. Nonspecific definitions of sidewalk improvements could be contributing to type 1 error. Future work should also examine behavioral interventions alongside changes to the built environment to determine the effects on physical activity.

Impact of the community-based newborn care package in Nepal: a quasi-experimental evaluation

OBJECTIVE

To evaluate the impact of the community-based newborn care package (CBNCP) on six essential practices to improve neonatal health.

METHODS

CBNCP pilot districts were matched to comparison districts using propensity scores. Impact on birth preparedness, antenatal care seeking, antenatal care quality, delivery by skilled birth attendant, immediate newborn care and postnatal care within 48 hours were assessed using Demographic and Health Survey (DHS) and Health Management Information System (HMIS) data through difference-in-differences and multivariate logistic regression analyses.

FINDINGS

Changes over time in intervention and comparison areas were similar in difference-in-differences analysis of DHS and HMIS data. Logistic regression of DHS data also did not reveal any significant improvement in combined outcomes: birth preparedness, adjusted OR (aOR)=0.8 (95% CI 0.4 to 1.7); antenatal care seeking, aOR=1.0 (0.6 to 1.5); antenatal care quality, aOR=1.4 (0.9 to 2.1); delivery by skilled birth attendant, aOR=1.5 (1.0 to 2.3); immediate newborn care, aOR=1.1 (0.7 to 1.9); postnatal care, aOR=1.3 (0.9 to 1.9). Health providers' knowledge and skills in intervention districts were fair but showed much variation between different providers and districts.

CONCLUSIONS

This study, while representing an early assessment of impact, did not identify significant improvements in newborn care practices and raises concerns regarding CBNCP implementation. It has contributed to revisions of the package and it being merged with the Integrated Management of Neonatal and Childhood Illness programme. This is now being implemented in 35 districts and carefully monitored for quality and impact. The study also highlights general challenges in evaluating the impacts of a complex health intervention under 'real life' conditions.

Educational Module Intervention for Radiographers to Reduce Repetition Rate of Routine Digital Chest Radiography in Makkah Region of Saudi Arabia Tertiary Hospitals: Protocol of a Quasi-Experimental Study

Background

Repetition of an image is a critical event in any radiology department. When the repetition rate of routine digital chest radiographs is high, radiation exposure of staff and patients is increased. In addition, repetition consumes the equipment’s life span, thus affecting the annual budget of the department.

Objective

The aim of this study is to determine the impact of a printed educational module on reducing the repetition rate of routine digital chest radiography among radiographers in Makkah Region tertiary hospitals.

Methods

A quasi-experimental time series with a control group will be conducted in Makkah Region tertiary hospitals for 8 months starting in the second quarter of 2017. Four hospitals out of 5 in the region will be selected; 2 of them will be selected as the control group and the other 2 as the intervention group. Stratification and a simple random sampling technique will be used to sample 56 radiographers in each group. Pre- and postintervention assessments will be conducted to determine the radiographer knowledge, motivation, and skills and repetition rate of chest radiographs. Radiographs of the chest performed by sampled radiographers in the selected hospitals will be collected for 2 weeks before and after the intervention. A piloted questionnaire will be distributed and collected by a researcher in both groups. One-way multivariate analysis of variance and 2-way repeated multivariate analysis of variance will be used to analyze the data.

Results

It is expected that the repetition rate in the intervention group will decline after implementing the intervention and the change will be statistically significant (P<.05). Furthermore, it is expected that the knowledge, motivation, and skill levels in the intervention group will increase significantly among radiographers after implementation of the intervention (P<.05). Meanwhile, knowledge, motivation, and skills in the control group will not change.

Conclusions

A quasi-experimental time series with a control will be conducted to investigate the effect of printed educational material in reducing the repetition rate of routine digital chest radiographs among radiographers in tertiary hospitals in the Makkah Region of Saudi Arabia.

Patient Navigation Improves Subsequent Breast Cancer Screening After a Noncancerous Result: Evidence from the Patient Navigation in Medically Underserved Areas Study

BACKGROUND

Past efforts to assess patient navigation on cancer screening utilization have focused on one-time uptake, which may not be sufficient in the long term. This is partially due to limited resources for in-person, longitudinal patient navigation. We examine the effectiveness of a low-intensity phone- and mail-based navigation on multiple screening episodes with a focus on screening uptake after receiving noncancerous results during a previous screening episode.

METHODS

The is a secondary analysis of patients who participated in a randomized controlled patient navigation trial in Chicago. Participants include women referred for a screening mammogram, aged 50-74 years, and with a history of benign/normal screening results. Navigation services focused on identification of barriers and intervention via shared decision-making processes. A multivariable logistic regression intent-to-treat model was used to examine differences in odds of obtaining a screening mammogram within 2 years of the initial mammogram (yes/no) between navigated and non-navigated women. Sensitivity analyses were conducted to explore patterns across subsets of participants (e.g., navigated women successfully contacted before the initial appointment; women receiving care at Hospital C).

RESULTS

The final sample included 2,536 women (741 navigated, 1,795 non-navigated). Navigated women exhibited greater odds of obtaining subsequent screenings relative to women in the standard care group in adjusted models and analyses including women who received navigation before the initial appointment.

CONCLUSIONS

Our findings suggest that low-intensity navigation services can improve follow-up screening among women who receive a noncancerous result. Further investigation is needed to confirm navigation's impacts on longitudinal screening.

Effect of health education on awareness about oral cancer and oral self-examination

CONTEXT

Oral cancer is preceded by visible changes in the oral mucosa. These lesions can be detected by oral self-examination, but awareness about oral cancer is still low in developing countries.

AIM

To evaluate the effect of health education on awareness about oral cancer and oral self-examination.

SETTINGS AND DESIGN

Quasi-experimental trial was conducted in an urban resettlement colony of Chandigarh, India.

MATERIALS AND METHODS

A brochure having information and pictorials on oral lesions was used for conducting health education sessions on a one-to-one basis in the household setting among 85 males in age group 15-59 years during 2013, and each participant was encouraged to perform an oral self-examination. Study participants were interviewed about their awareness on oral cancer and oral self-examination before- and after-health education using a pretested interview schedule.

STATISTICAL ANALYSIS

Awareness items were scored, and mean change in awareness score was computed. Paired t-test was used for testing statistical significance.

RESULTS

Thirty-three percent of the study participants were current smokers, 25% consumed alcohol, and 9.4% chewed tobacco. The awareness scores after health education increased significantly from 5.3 to 6.7 (P < 0.05), and 34% of the tobacco or alcohol users expressed their intention to quit these habits, and two persons actually quit tobacco chewing. Out of the 77 study participants who performed oral self-examination, nine were able to detect lesions, and one was found to have submucous fibrosis.

CONCLUSIONS

Health education intervention was able to initiate a favorable behavior change in the community. Hence, oral self-examination programs should be promoted.

Persistent threats to validity in single-group interrupted time series analysis with a cross over design

RATIONALE, AIMS AND OBJECTIVES

The basic single-group interrupted time series analysis (ITSA) design has been shown to be susceptible to the most common threat to validity-history-the possibility that some other event caused the observed effect in the time series. A single-group ITSA with a crossover design (in which the intervention is introduced and withdrawn 1 or more times) should be more robust. In this paper, we describe and empirically assess the susceptibility of this design to bias from history.

METHOD

Time series data from 2 natural experiments (the effect of multiple repeals and reinstatements of Louisiana's motorcycle helmet law on motorcycle fatalities and the association between the implementation and withdrawal of Gorbachev's antialcohol campaign with Russia's mortality crisis) are used to illustrate that history remains a threat to ITSA validity, even in a crossover design.

RESULTS

Both empirical examples reveal that the single-group ITSA with a crossover design may be biased because of history. In the case of motorcycle fatalities, helmet laws appeared effective in reducing mortality (while repealing the law increased mortality), but when a control group was added, it was shown that this trend was similar in both groups. In the case of Gorbachev's antialcohol campaign, only when contrasting the results against those of a control group was the withdrawal of the campaign found to be the more likely culprit in explaining the Russian mortality crisis than the collapse of the Soviet Union.

CONCLUSIONS

Even with a robust crossover design, single-group ITSA models remain susceptible to bias from history. Therefore, a comparable control group design should be included, whenever possible.