Social constructs, behaviour change, and the uptake of community-based WASH interventions: Metrics and analytical approaches for measuring collective efficacy

It has become commonplace in international development to intervene upon communities with interventions that require collective action without first gauging the communities’ perceptions regarding their ability and autonomy to engender and maintain change. Programmes and research studies employing community-based interventions often overlook important interpersonal behavioural factors that may well affect uptake and effectiveness. Social constructs such as collective efficacy, social capital, social cohesion, and social norms are important interpersonal behavioural factors and predictors of collective action, which may be needed to realise downstream health and development impacts. This doctoral thesis examined the conceptualisations of various social constructs and their theoretical underpinnings. Theoretical examinations were used to establish hypotheses regarding the underlying structure of collective efficacy (CE). A factor analytic approach was used to develop four CE measurement scales from data collected in Odisha, India and Amhara, Ethiopia to empirically test these hypotheses. The India CE scale was subsequently used to ascertain whether there were independent associations between CE-factors and the uptake and influence of a community-based water supply and sanitation intervention. Compared to controls, intervention households had higher CE factor scores for village leadership (β=0.16, 95% CI: 0.08, 0.25) and agency (β=0.08, 95% CI: 0.01, 0.15), and lower scores for social disorder, conditional on education. Prevalence of improved WASH behaviours was associated with CE factors: improved water piped on-premise was associated with village leadership (aPR=2.25, 95% CI: 1.12, 4.53); improved on-site toilets with social disorder (aPR=0.90, 95% CI: 0.84, 0.97); enclosed bathing rooms with social response (aPR=1.12, 95% CI: 1.02, 1.23); and utilisation of improved sanitation facilities by all family members with agency (aPR=1.17, 95% CI: 1.00, 1.37) and village leadership (aPR=3.86, 95% CI: 1.67, 8.97). Agency, social response, and social disorder factors were associated with nutritional outcomes. Implications for enhanced intervention design, targeting, and evaluation are discussed throughout

The adrenal cortex and the kidney

The adrenal cortex regulates renal function in a number of important ways; indeed, normal renal function cannot be understood without recognition of such regulation. Well-recognized examples of such regulation are the control of body fluid tonicity through regulation of urinary solute concentration-a function controlled “primarily” by vasopressin, but secondarily and importantly by the adrenal cortex-and control of body sodium-a function controlled primarily by renal tubular sodium reabsorption but regulated by sodium-retaining steroids.The kidney can regulate adrenal function by changing reabsorption of sodium and secretion of potassium, and also by release of renin. The primary target of such regulation is the secretion of aldosterone, which may be influenced by body fluid volume, potassium ion and angiotensin II.Because of these interrelationships, the pathophysiology of certain disease states may be described as aberrations in feedback loops between adrenal cortex and kidney. In this paper we will consider this “system” in some detail, and attempt to explain four disorders as examples of errors in control.In the form of “primary” aldosteronism resulting from hyperplasia of all adrenal cortical tissue, overproduction of aldosterone persists in the absence of all known stimulatory factors. In renovascular hypertension, angiotensin and aldosterone production may persist despite systemic hypertension. In the non-salt-losing form of the adrenogenital syndrome of congenital adrenal hyperplasia without treatment, failure of feedback inhibition by Cortisol may result in overproduction of adrenocorticotropic hormone (ACTH) which, in turn, may lead to overproduction of progesterone. Progesterone may cause sodium loss and overproduction of renin and aldosterone while blocking their effects. In the syndrome of juxtaglomerular hyperplasia with normal blood pressure, overproduction of renin may result from unresponsiveness of blood vessels leading to a lack of feedback inhibition by pressure rise. Under certain circumstances sodium loss can potentiate both the overproduction and the unresponsiveness. Excessive renin leads to aldosteronism and potassium loss

Overall Survival Endpoint in Oncology Clinical Trials: Addressing the Effect of Crossover - The Case of Pazopanib in Advanced Renal Cell Carcinoma

Objective: To identify the issues of using overall survival (OS) as a primary endpoint in the presence of crossover and the statistical analyses available to adjust for confounded OS due to crossover in oncology clinical trials. Methods: An indirect comparison was conducted between pazopanib and sunitinib in advanced renal cell carcinoma. Statistical adjustment methods were used to estimate the true comparative effectiveness of these treatments. Recently, a head-to-head trial comparing pazopanib and sunitinib was completed. This provided the opportunity to compare the OS treatment effect estimated for pazopanib versus sunitinib using indirect comparison and statistical adjustment techniques with that observed in the head-to-head trial. Results: Using a rank-preserving structural failure time model to adjust for crossover in the pazopanib registration trial, the indirect comparison of pazopanib versus sunitinib resulted in an OS hazard ratio (HR) of 0.97, while an unadjusted analysis resulted in an OS HR of 1.96. The head-to-head trial reported a final OS HR of 0.92 for pazopanib versus sunitinib. Conclusion: This case study supports the need to adjust for confounded OS due to crossover, which enables trials to meet ethical standards and provides decision makers with a more accurate estimate of treatment benefit

Comparison of respondent-reported and sensor-recorded latrine utilization measures in rural Bangladesh: a cross-sectional study.

Background: Health improvements realized through sanitation are likely achieved through high levels of facilities utilization by all household members. However, measurements of sanitation often rely on either the presence of latrines, which does not guarantee use, or respondent-reported utilization of sanitation facilities, which is prone to response bias. Overstatement of sanitation metrics limits the accuracy of program outcome measures, and has implications for the interpretation of related health impact data. Methods: We conducted a cross-sectional study of 213 households in 14 village water, sanitation and hygiene committee clusters throughout rural Bangladesh and used a combined data- and relationship-scale approach to assess agreement between respondent-reported latrine utilization and sensor-recorded measurement. Results: Four-day household-level respondent-reported defecation averaged 28 events (inter-quartile range [IQR] 20-40), while sensor-recorded defecation averaged 17 events (IQR 11-29). Comparative analyses suggest moderately high accuracy (bias correction factor=0.84), but imprecision in the data (broad scatter of data, Pearson's r=0.35) and thus only weak concordance between measures (ρc=0.29 [95% BCa CI 0.15 to 0.43]). Conclusions: Respondent-reported latrine utilization data should be interpreted with caution, as evidence suggests use is exaggerated. Coupling reported utilization data with objective measures of use may aid in the estimation of latrine use