Effects of a community-driven water, sanitation, and hygiene programme on COVID-19 symptoms, vaccine acceptance and non-COVID illnesses: A cluster-randomised controlled trial in rural Democratic Republic of Congo.

OBJECTIVE: The government of the Democratic Republic of Congo (DRC) responded to COVID-19 with policy measures, such as business and school closures and distribution of vaccines, which rely on citizen compliance. In other settings, prior experience with effective government programmes has increased compliance with public health measures. We study the effect of a national water, sanitation, and hygiene programme on compliance with COVID-19 policies. METHODS: Prior to the COVID-19 pandemic, 332 communities were randomly assigned to the Villages et Écoles Assainis (VEA) programme or control. After COVID-19 reached DRC, individuals who owned phones (590/1312; 45%) were interviewed by phone three times between May 2020 and August 2021. Primary outcomes were COVID symptoms, non-COVID illness symptoms, child health, psychological well-being, and vaccine acceptance. Secondary outcomes included COVID-19 preventive behaviour and knowledge, and perceptions of governmental performance, including COVID response. All outcomes were self-reported. Outcomes were compared between treatment and control villages using linear models. RESULTS: The VEA programme did not affect respondents' COVID symptoms (-0.11, 95% CI -0.55 to 0.33), non-COVID illnesses (-0.01, 95% CI -0.05 to 0.03), child health (0.07, 95% CI -0.19 to 0.33), psychological well-being (-0.05, 95% CI -0.35 to 0.24), or vaccine acceptance (-0.04, 95% CI -0.19 to 0.10). There was no effect on village-level COVID-19 preventive behaviour (0.03, 95% CI -0.23 to 0.29), COVID-19 knowledge (0.16, 95% CI -0.08 to 0.39), or trust in institutions. CONCLUSIONS: Although the VEA programme increased access to improved water and sanitation, we found no evidence that it increased trust in government or compliance with COVID policies, or reduced illness.

Cash-like vouchers improve psychological well-being of vulnerable and displaced persons fleeing armed conflict.

The psychological burden of conflict-induced displacement is severe. Currently, there are 80 million displaced persons around the world, and their number is expected to increase in upcoming decades. Yet, few studies have systematically assessed the effectiveness of programs that assist displaced persons, especially in settings of extreme vulnerability. We focus on eastern Democratic Republic of Congo, where myriad local armed conflicts have driven cycles of displacement for over 20 years. We conducted a within-village randomized field experiment with 976 households, across 25 villages, as part of the United Nations' Rapid Response to Population Movements program. The program provided humanitarian relief to over a million people each year, including vouchers for essential nonfood items, such as pots, pans, cloth, and mattresses. The vouchers led to large improvements in psychological well-being: a 0.32 standard deviation unit (SDU) improvement at 6 weeks, and a 0.18 SDU improvement at 1 year. There is no evidence that the program undermined social cohesion within the village, which alleviates worries related to programs that target some community members but not others. Finally, there was no improvement in child health.

Effects of a community-driven water, sanitation and hygiene intervention on water and sanitation infrastructure, access, behaviour, and governance: a cluster-randomised controlled trial in rural Democratic Republic of Congo.

INTRODUCTION: Inadequate water and sanitation is a central challenge in global health. Since 2008, the Democratic Republic of Congo government has implemented a national programme, Healthy Villages and Schools (Villages et Ecoles Assainis (VEA), with support from UNICEF, financed by UK's Foreign, Commonwealth and Development Office. METHODS: A cluster-level randomised controlled trial of VEA was implemented throughout 2019 across 332 rural villages, grouped into 50 treatment and 71 control clusters. Primary outcomes included time spent collecting water; quantity of water collected; prevalence of improved primary source of drinking water; and prevalence of improved primary defecation site. Secondary outcomes included child health, water governance, water satisfaction, handwashing practices, sanitation practices, financial cost of water, school attendance and water storage practices. All outcomes were self-reported. The primary analysis was on an intention-to-treat basis, using linear models. Outcomes were measured October-December 2019, median 5 months post-intervention. RESULTS: The programme increased access to improved water sources by 33 percentage points (pp) (95% CI 22 to 45), to improved sanitation facilities by 26 pp (95% CI 14 to 37), and improved water governance by 1.3 SDs (95% CI 1.1 to 1.5), water satisfaction by 0.6 SD (95% CI 0.4 to 0.9), handwashing practices by 0.5 SD (95% CI 0.3 to 0.7) and sanitation practices by 0.3 SD (95% CI 0.1 to 0.4). There was no significant difference in financial cost of water, school attendance, child health or water storage practices. CONCLUSION: VEA produced large increases in access to and satisfaction with water and sanitation services, in self-reported hygiene and sanitation behaviour, and in measures of water governance. TRIAL REGISTRATION NUMBER: AEARCTR-0004648; American Economic Association RCT registry.

The effects of changes in distance to nearest health facility on under-5 mortality and health care utilization in rural Malawi, 1980-1998.

BACKGROUND: Despite important progress, the burden of under-5 mortality remains unacceptably high, with an estimated 5.3 million deaths in 2018. Lack of access to health care is a major risk factor for under-5 mortality, and distance to health care facilities has been shown to be associated with less access to care in multiple contexts, but few such studies have used a counterfactual approach to produce causal estimates. METHODS: We combined retrospective reports on 18,714 births between 1980 and 1998 from the 2000 Malawi Demographic and Health Survey with a 1998 health facility census that includes the date of construction for each facility, including 335 maternity or maternity/dispensary facilities built in rural areas between 1980 and 1998. We estimated associations between distance to nearest health facility and (i) under-5 mortality, using Cox proportional hazards models, and (ii) maternal health care utilization (antenatal visits prior to delivery, place of delivery, receiving skilled assistance during delivery, and receiving a check-up following delivery), using linear probability models. We also estimated the causal effect of reducing the distance to nearest facility on those outcomes, using a two-way fixed effects approach. FINDINGS: We found that greater distance was associated with higher mortality (hazard ratio 1.007 for one additional kilometer [95%CI 1.001 to 1.014]) and lower health care utilization (for one additional kilometer: 1.2 percentage point (pp) increase in homebirth [95%CI 0.8 to 1.5]; 0.8 pp. decrease in at least three antenatal visits [95% CI - 1.4 to - 0.2]; 1.2 pp. decrease in skilled assistance during delivery [95%CI - 1.6 to - 0.8]). However, we found no effects of a decrease in distance to the nearest health facility on the hazard of death before age 5 years, nor on antenatal visits prior to delivery, place of delivery, or receiving skilled assistance during delivery. We also found that reductions in distance decrease the probability that a woman receives a check-up following delivery (2.4 pp. decrease for a 1 km decrease [95%CI 0.004 to 0.044]). CONCLUSION: Reducing under-5 mortality and increasing utilization of care in rural Malawi and similar settings may require more than the construction of new health infrastructure. Importantly, the effects estimated here likely depend on the quality of health care, the availability of transportation, the demand for health services, and the underlying causes of mortality, among other factors.

Measuring and correcting bias in indirect estimates of under-5 mortality in populations affected by HIV/AIDS: a simulation study.

BACKGROUND: In populations that lack vital registration systems, under-5 mortality (U5M) is commonly estimated using survey-based approaches, including indirect methods. One assumption of indirect methods is that a mother's survival and her children's survival are not correlated, but in populations affected by HIV/AIDS this assumption is violated, and thus indirect estimates are biased. Our goal was to estimate the magnitude of the bias, and to create a predictive model to correct it. METHODS: We used an individual-level, discrete time-step simulation model to measure how the bias in indirect estimates of U5M changes under various fertility rates, mortality rates, HIV/AIDS rates, and levels of antiretroviral therapy. We simulated 4480 populations in total and measured the amount of bias in U5M due to HIV/AIDS. We also developed a generalized linear model via penalized maximum likelihood to correct this bias. RESULTS: We found that indirect methods can underestimate U5M by 0-41% in populations with HIV prevalence of 0-40%. Applying our model to 2010 survey data from Malawi and Tanzania, we show that indirect methods would underestimate U5M by up to 7.7% in those countries at that time. Our best fitting model to correct bias in U5M had a root median square error of 0.0012. CONCLUSIONS: Indirect estimates of U5M can be significantly biased in populations affected by HIV/AIDS. Our predictive model allows scholars and practitioners to correct that bias using commonly measured population characteristics. Policies and programs based on indirect estimates of U5M in populations with generalized HIV epidemics may need to be reevaluated after accounting for estimation bias.

Effects of an empowerment program for survivors of sexual violence on attitudes and beliefs: evidence from the Democratic Republic of Congo.

BACKGROUND: Women's empowerment may require women to change their beliefs and views about their rights and capabilities. Empowerment programs often target women who have survived sexual and gender-based violence (SGBV), with the justification that these women may develop disempowered beliefs as a coping mechanism, or face greater barriers to, or derive greater benefits from, the adoption of empowered beliefs and preferences. We investigated an intensive, six-month residential empowerment program ("City of Joy") for SGBV survivors in eastern Democratic Republic of the Congo (DRC), where more than one in five women have experienced SGBV. METHODS: We asked 175 participants about their beliefs and preferences pertaining to political, financial, and domestic empowerment. Interviews took place immediately before and after participation in the program, and we tested for differences in views of empowerment between entry and exit using paired t-tests and McNemar's test. We also conducted 50 semi-structured interviews about empowerment with an additional 30 women who had completed the program up to 5 years earlier and then returned to their home community. RESULTS: Prior to enrolling in the program, participants had fairly empowered views regarding politics, less empowered views regarding finances, and still less empowered views regarding the domestic sphere. After completing the program, participants had significantly more empowered views in all three domains, particularly regarding domestic violence, how families should treat men and women, and women's economic rights. Participants in their home communities reported taking a more active role in community affairs and speaking out against the mistreatment of women. CONCLUSION: This study adds to the evidence that women's empowerment programs can change participants' beliefs and thus increase the confidence with which they participate in their communities and support one another.

The impact of support programmes for survivors of sexual violence: micro-level evidence from eastern Democratic Republic of the Congo.

In the eastern Democratic Republic of the Congo there are several support programmes for sexual violence survivors, but their impacts are rarely systematically assessed. We investigated the effects for women from two support programmes that include both survivors of sexual and gender-based violence (SGBV) and others. Specifically, we estimated (1) the effect of SGBV on social exclusion and economic well-being, and (2) the effects of support programmes on social exclusion and economic well-being, as well as differential effects for SGBV survivors and others. Based on an original survey of 1,203 women, we found that survivors felt less included across various social settings, but their economic well-being was no different than that of other women. We also found that support programmes significantly improve both perceived social inclusion and economic well-being for survivors and non-survivors. The effects on economic well-being were larger for survivors. In conclusion, these support programmes brought important benefits to survivors and non-survivors alike, although there is potential for improvement, particularly on social inclusion for SGBV survivors.

Spatial analysis of under-5 mortality and potential risk factors in the Basse Health and Demographic Surveillance System, the Gambia.

OBJECTIVES: To describe the spatial pattern in under-5 mortality rates in the Basse Health and Demographic Surveillance System (BHDSS) and to test for associations between under-5 deaths and biodemographic and socio-economic risk factors. METHODS: Using data on child survival from 2007 to 2011 in the BHDSS, we mapped under-5 mortality by km(2) . We tested for spatial clustering of high or low death rates using Kulldorff's spatial scan statistic. Associations between child death and a variety of biodemographic and socio-economic factors were assessed with Cox proportional hazards models, and deviance residuals from the best-fitting model were tested for spatial clustering. RESULTS: The overall death rate among children under 5 was 0.0195 deaths per child-year. We found two spatial clusters of high death rates and one spatial cluster of low death rates; children in the two high clusters died at a rate of 0.0264 and 0.0292 deaths per child-year, while in the low cluster, the rate was 0.0144 deaths per child-year. We also found that children born to Fula mothers experienced, on average, a higher hazard of death, whereas children born in the households in the upper two quintiles of asset ownership experienced, on average, a lower hazard of death. After accounting for the spatial distribution of biodemographic and socio-economic characteristics, we found no residual spatial pattern in child mortality risk. CONCLUSION: This study demonstrates that significant inequality in under-5 death rates can occur within a relatively small area (1100 km(2) ). Risks of under-5 mortality were associated with mother's ethnicity and household wealth. If high mortality clusters persist, then equity concerns may require additional public health efforts in those areas.

Niche width collapse in a resilient top predator following ecosystem fragmentation.

Much research has focused on identifying species that are susceptible to extinction following ecosystem fragmentation, yet even those species that persist in fragmented habitats may have fundamentally different ecological roles than conspecifics in unimpacted areas. Shifts in trophic role induced by fragmentation, especially of abundant top predators, could have transcendent impacts on food web architecture and stability, as well as ecosystem function. Here we use a novel measure of trophic niche width, based on stable isotope ratios, to assess effects of aquatic ecosystem fragmentation on trophic ecology of a resilient, dominant, top predator. We demonstrate collapse in trophic niche width of the predator in fragmented systems, a phenomenon related to significant reductions in diversity of potential prey taxa. Collapsed niche width reflects a homogenization of energy flow pathways to top predators, likely serving to destabilize remnant food webs and render apparently resilient top predators more susceptible to extinction through time.

Getting to the fat of the matter: models, methods and assumptions for dealing with lipids in stable isotope analyses.

Within an organism, lipids are depleted in (13)C relative to proteins and carbohydrates (more negative delta(13)C), and variation in lipid content among organisms or among tissue types has the potential to introduce considerable bias into stable isotope analyses that use delta(13)C. Despite the potential for introduced error, there is no consensus on the need to account for lipids in stable isotope analyses. Here we address two questions: (1) If and when is it important to account for the effects of variation in lipid content on delta(13)C? (2) If it is important, which method(s) are reliable and robust for dealing with lipid variation? We evaluated the reliability of direct chemical extraction, which physically removes lipids from samples, and mathematical normalization, which uses the carbon-to-nitrogen (C:N) ratio of a sample to normalize delta(13)C after analysis by measuring the lipid content, the C:N ratio, and the effect of lipid content on delta(13)C (Deltadelta(13)C) of plants and animals with a wide range of lipid contents. For animals, we found strong relationships between C:N and lipid content, between lipid content and Deltadelta(13)C, and between C:N and Deltadelta(13)C. For plants, C:N was not a good predictor of lipid content or Deltadelta(13)C, but we found a strong relationship between carbon content and lipid content, lipid content and Deltadelta(13)C, and between and carbon content and Deltadelta(13)C. Our results indicate that lipid extraction or normalization is most important when lipid content is variable among consumers of interest or between consumers and end members, and when differences in delta(13)C between end members is <10-12 per thousand. The vast majority of studies using natural variation in delta(13)C fall within these criteria. Both direct lipid extraction and mathematical normalization reduce biases in delta(13)C, but mathematical normalization simplifies sample preparation and better preserves the integrity of samples for delta(15)N analysis.

Calorie restriction and late-onset calorie restriction extend lifespan but do not alter protein storage in female grasshoppers.

Calorie restriction (CR) and late-onset CR enhance longevity in many organisms. Resource allocation theory suggests that longevity is enhanced by increasing somatic storage, at the expense of current reproduction. Phytophagous insects accumulate amino acids as hemolymph storage proteins for major developmental events. We hypothesized that protein storage is involved in life extension from CR. In a longitudinal experiment, we tested whether CR altered protein storage in female grasshoppers. Individuals on CR (60 or 70% of ad libitum) or late-onset CR had at least 60% greater longevity than ad libitum individuals. Age at first oviposition, dry mass of the first clutch, or lifetime fecundity were not affected by CR, but CR did increase the number of clutches produced. Most important, females on life-extending CR and late-onset CR did not differ in the concentration of hemolymph storage of proteins in comparison to ad libitum females. Protein storage changed with time in all groups, demonstrating sufficient sensitivity in our methods. Previous experiments have shown that severe CR ( approximately 30% of ad libitum) can reduce hemolymph storage. Therefore, the reduction in intake needed to extend lifespan is not sufficient to reduce protein storage in the hemolymph. These results do not support the hypothesis that protein storage is involved in life extension from CR.