Adolescent Girls Empowerment Program (AGEP): Evaluation—Round 4 update

To assess the impact of the Adolescent Girls Empowerment Program (AGEP) on mediating and longer-term demographic, reproductive, and health outcomes, Population Council researchers designed and implemented a longitudinal, cluster randomized controlled trial across all program areas. A baseline survey was conducted in 2013 prior to program implementation and data have been collected annually. A third round of data collection in 2015 produced the midline findings, measuring the program effect immediately at the end of AGEP. Details of the midterm results were published in a full technical report, executive summary, and brief. The focus of this brief is to provide an update using the fourth round of data collection, representing the experiences and outcomes of adolescent girls one year after the program ended

Adolescent Girls Empowerment Programme: Research and evaluation mid-term technical report

The Adolescent Girls Empowerment Programme (AGEP) was a social, health, and economic asset-building program targeting vulnerable adolescent girls aged 10–19. The Population Council, in partnership with the Young Women’s Christian Association of Zambia, successfully implemented the AGEP program from late 2013 to early 2016. The results presented in this midterm report have implications for recommendations on future programming for adolescent girls in Zambia and elsewhere and should be coupled with burgeoning evidence from AGEP and the literature to adapt programming for vulnerable adolescent girls in order to improve impact. While the underlying root causes of girls’ vulnerabilities are interrelated, it is possible that a more direct focus on a particular outcome, driven by a more targeted intervention, would have led to greater impact in the shorter term. For older adolescents, it may imply a direct focus on livelihoods and entrepreneurship, whereas younger adolescents may need more focus on educational support. Also, providing direct resources through incentivized activities may be a constructive approach to increasing engagement with the program

Adolescent Girls Empowerment Programme: Research and evaluation mid-term technical report—Executive Summary

The Adolescent Girls Empowerment Programme (AGEP) was an ambitious project directed toward changing girls’ lives in a significant and meaningful way across areas of education, sexual and reproductive health, marriage and fertility, and experience of violence. This Executive Summary of the project’s findings shows that, overall, the AGEP cohort data, and lessons they have generated from the AGEP are rich, nuanced, and important for informing the next generation of programs for adolescents in Zambia and elsewhere. Even though the study is still under way, and the full longer-term effects of AGEP remain to be seen, the information presented in this report can be used to guide programs and policymakers on program areas of promise, gaps that need to be filled, and a range of questions about how to best serve this population that still need to be answered

Adolescent Girls Empowerment Program (AGEP): Nutrition

Adolescence is a critical period in the lives of young people and potentially a time to reap lasting benefits from interventions that improve general, sexual, nutritional, and maternal and child health. The government of Zambia is committed to improving the nutritional status of adolescents and pregnant women and their children. Nonetheless, adolescent girls in Zambia remain at risk for macro- and micro-nutrient deficiencies that have deleterious effects on growth, development, and maternal and child health. The Adolescent Girls Empowerment Program (AGEP) nutritional curriculum, developed in partnership with PATH, was tailored to provide age-appropriate information and covered six sessions on nutrition. This brief summarizes the impact of the nutrition curriculum on nutrition outcomes of adolescents and their children one year after the AGEP program ended. The results of this rigorous randomized evaluation indicate that the AGEP nutrition training component with context-relevant participatory and interactive educational sessions did not improve adolescent or child nutritional outcomes

Utilization of mechanical power and associations with clinical outcomes in brain injured patients: a secondary analysis of the extubation strategies in neuro-intensive care unit patients and associations with outcome (ENIO) trial

Background: There is insufficient evidence to guide ventilatory targets in acute brain injury (ABI). Recent studies have shown associations between mechanical power (MP) and mortality in critical care populations. We aimed to describe MP in ventilated patients with ABI, and evaluate associations between MP and clinical outcomes. Methods: In this preplanned, secondary analysis of a prospective, multi-center, observational cohort study (ENIO, NCT03400904), we included adult patients with ABI (Glasgow Coma Scale ≤ 12 before intubation) who required mechanical ventilation (MV) ≥ 24 h. Using multivariable log binomial regressions, we separately assessed associations between MP on hospital day (HD)1, HD3, HD7 and clinical outcomes: hospital mortality, need for reintubation, tracheostomy placement, and development of acute respiratory distress syndrome (ARDS). Results: We included 1217 patients (mean age 51.2 years [SD 18.1], 66% male, mean body mass index [BMI] 26.3 [SD 5.18]) hospitalized at 62 intensive care units in 18 countries. Hospital mortality was 11% (n = 139), 44% (n = 536) were extubated by HD7 of which 20% (107/536) required reintubation, 28% (n = 340) underwent tracheostomy placement, and 9% (n = 114) developed ARDS. The median MP on HD1, HD3, and HD7 was 11.9 J/min [IQR 9.2-15.1], 13 J/min [IQR 10-17], and 14 J/min [IQR 11-20], respectively. MP was overall higher in patients with ARDS, especially those with higher ARDS severity. After controlling for same-day pressure of arterial oxygen/fraction of inspired oxygen (P/F ratio), BMI, and neurological severity, MP at HD1, HD3, and HD7 was independently associated with hospital mortality, reintubation and tracheostomy placement. The adjusted relative risk (aRR) was greater at higher MP, and strongest for: mortality on HD1 (compared to the HD1 median MP 11.9 J/min, aRR at 17 J/min was 1.22, 95% CI 1.14-1.30) and HD3 (1.38, 95% CI 1.23-1.53), reintubation on HD1 (1.64; 95% CI 1.57-1.72), and tracheostomy on HD7 (1.53; 95%CI 1.18-1.99). MP was associated with the development of moderate-severe ARDS on HD1 (2.07; 95% CI 1.56-2.78) and HD3 (1.76; 95% CI 1.41-2.22). Conclusions: Exposure to high MP during the first week of MV is associated with poor clinical outcomes in ABI, independent of P/F ratio and neurological severity. Potential benefits of optimizing ventilator settings to limit MP warrant further investigation

Tutorial on directed acyclic graphs

Directed acyclic graphs (DAGs) are an intuitive yet rigorous tool to communicate about causal questions in clinical and epidemiologic research and inform study design and statistical analysis. DAGs are constructed to depict prior knowledge about biological and behavioral systems related to specific causal research questions. DAG components portray who receives treatment or experiences exposures; mechanisms by which treatments and exposures operate; and other factors that influence the outcome of interest or which persons are included in an analysis. Once assembled, DAGs - via a few simple rules - guide the researcher in identifying whether the causal effect of interest can be identified without bias and, if so, what must be done either in study design or data analysis to achieve this. Specifically, DAGs can identify variables that, if controlled for in the design or analysis phase, are sufficient to eliminate confounding and some forms of selection bias. DAGs also help recognize variables that, if controlled for, bias the analysis (e.g., mediators or factors influenced by both exposure and outcome). Finally, DAGs help researchers recognize insidious sources of bias introduced by selection of individuals into studies or failure to completely observe all individuals until study outcomes are reached. DAGs, however, are not infallible, largely owing to limitations in prior knowledge about the system in question. In such instances, several alternative DAGs are plausible, and researchers should assess whether results differ meaningfully across analyses guided by different DAGs and be forthright about uncertainty. DAGs are powerful tools to guide the conduct of clinical research

Correlates of contraceptive use and health facility choice among young women in Malawi

We explore whether differential access to family-planning services and the quality of those services explain variability in uptake of contraception among young women in Malawi. We accomplish this by linking the Malawi Schooling and Adolescent Study, a longitudinal survey of young people, with the Malawi Service Provision Assessment collected in 2013–14. We also identify factors that determine choice of facility among those who use contraception. We find that the presence and characteristics of nearby facilities with contraception available did not appear to affect use. Rather, characteristics such as facility type and whether contraception was provided free of charge determined where women deciding to use contraception obtained their contraception. We argue that in a context where almost all respondents resided within 10 kilometers of a health facility, improving access to and quality of family-planning services may not markedly increase contraceptive use among young women without broader shifts in norms regarding childbearing in the early years of marriage

Breakthrough SARS-CoV-2 Infection Outcomes in Vaccinated Patients with Chronic Liver Disease and Cirrhosis: A National COVID Cohort Collaborative Study

Background and Aims The incidence and outcomes of breakthrough SARS-CoV-2 infections in vaccinated chronic liver disease (CLD) patients have not been well-characterized in non-veteran populations. We used the National COVID Cohort Collaborative (N3C), a dataset of 10.7 million patients, of whom 0.9 million have vaccination data, to describe outcomes in vaccinated CLD patients. Methods We identified all CLD patients with or without cirrhosis regardless of vaccination status who had SARS-CoV-2 testing in the N3C Data Enclave as of 1/15/2022. We used Poisson regression to estimate incidence rates of breakthrough infections and Cox survival analyses to associate vaccination status with all-cause mortality at 30 days among infected CLD patients. Results We isolated 278,457 total CLD patients: 43,079 (15%) vaccinated and 235,378 (85%) unvaccinated. Of the 43,079 vaccinated CLD patients, 32,838 (76%) were without cirrhosis and 10,441 (24%) were with cirrhosis. Estimated incidence rates for breakthrough infections were 5.6 and 5.1 per 1,000 person-months for 27,235 fully vaccinated CLD patients without cirrhosis and for 8,218 fully vaccinated CLD patients with cirrhosis, respectively. Of the 68,048 unvaccinated and 10,441 vaccinated CLD patients with cirrhosis in our cohort, 15% and 3.7%, respectively, developed SARS-CoV-2 infection. The combined 30-day all-cause rate of mechanical ventilation (without death) or death after SARS-CoV-2 infection for unvaccinated and vaccinated CLD patients with cirrhosis were 15.2% and 7.7%, respectively. Compared to unvaccinated patients with cirrhosis, full vaccination was associated with a 0.34-times adjusted hazard of death at 30 days. Conclusions In this N3C Data Enclave study, breakthrough infection rates were similar amongst CLD patients with and without cirrhosis. Full vaccination was associated with a 66% reduction in risk of all-cause mortality among CLD patients with cirrhosis after infection. These results provide an additional impetus for increasing vaccination uptake among patients with severe liver disease