Association between footwear use and neglected tropical diseases: a systematic review and meta-analysis

BACKGROUND The control of neglected tropical diseases (NTDs) has primarily focused on preventive chemotherapy and case management. Less attention has been placed on the role of ensuring access to adequate water, sanitation, and hygiene and personal preventive measures in reducing exposure to infection. Our aim was to assess whether footwear use was associated with a lower risk of selected NTDs. METHODOLOGY We conducted a systematic review and meta-analysis to assess the association between footwear use and infection or disease for those NTDs for which the route of transmission or occurrence may be through the feet. We included Buruli ulcer, cutaneous larva migrans (CLM), leptospirosis, mycetoma, myiasis, podoconiosis, snakebite, tungiasis, and soil-transmitted helminth (STH) infections, particularly hookworm infection and strongyloidiasis. We searched Medline, Embase, Cochrane, Web of Science, CINAHL Plus, and Popline databases, contacted experts, and hand-searched reference lists for eligible studies. The search was conducted in English without language, publication status, or date restrictions up to January 2014. Studies were eligible for inclusion if they reported a measure of the association between footwear use and the risk of each NTD. Publication bias was assessed using funnel plots. Descriptive study characteristics and methodological quality of the included studies were summarized. For each study outcome, both outcome and exposure data were abstracted and crude and adjusted effect estimates presented. Individual and summary odds ratio (OR) estimates and corresponding 95% confidence intervals (CIs) were calculated as a measure of intervention effect, using random effects meta-analyses. PRINCIPAL FINDINGS Among the 427 studies screened, 53 met our inclusion criteria. Footwear use was significantly associated with a lower odds of infection of Buruli ulcer (OR=0.15; 95% CI: 0.08-0.29), CLM (OR=0.24; 95% CI: 0.06-0.96), tungiasis (OR=0.42; 95% CI: 0.26-0.70), hookworm infection (OR=0.48; 95% CI: 0.37-0.61), any STH infection (OR=0.57; 95% CI: 0.39-0.84), strongyloidiasis (OR=0.56; 95% CI: 0.38-0.83), and leptospirosis (OR=0.59; 95% CI: 0.37-0.94). No significant association between footwear use and podoconiosis (OR=0.63; 95% CI: 0.38-1.05) was found and no data were available for mycetoma, myiasis, and snakebite. The main limitations were evidence of heterogeneity and poor study quality inherent to the observational studies included. CONCLUSIONS/SIGNIFICANCE Our results show that footwear use was associated with a lower odds of several different NTDs. Access to footwear should be prioritized alongside existing NTD interventions to ensure a lasting reduction of multiple NTDs and to accelerate their control and elimination. PROTOCOL REGISTRATION PROSPERO International prospective register of systematic reviews CRD42012003338

Barriers to antenatal care in an urban community in the Gambia: an in-depth qualitative interview study

This qualitative study investigated the barriers to obtaining access to antenatal care in a small, urban government-supported health centre in the Gambia. It thus addresses an important issue related to maternal health and the prevention of maternal deaths. In-depth interviews were conducted with 25 pregnant women, 13 healthcare workers and 9 male partners. Three areas were identified for study: recognition and acknowledgment of pregnancy, recognition of the need for care and practical barriers to attendance. Intentional concealment of early pregnancy was common to avoid adverse social consequences or for fear that malign interventions would cause a miscarriage. In the absence of symptoms many women considered it unnecessary to attend the antenatal clinic until well into the second trimester. Practical barriers to attendance included conflicting domestic demands and the attitude of some healthcare workers. Access to antenatal care in the Gambia throughout pregnancy should be considered in a stepwise fashion and barriers to care were identified at each stage. Interviews with male partners and health workers highlighted their key role

Overview of included neglected tropical diseases (NTDs) in the current systematic review and meta-analysis.

<p>+Additional search terms for intervention (exp shoes OR shoe* OR footwear* OR boots OR sandals OR footgear OR exp primary prevention) and all NTDs (exp neglected diseases OR neglected tropical disease* OR NTD* OR exp tropical disease).</p><p>Overview of included neglected tropical diseases (NTDs) in the current systematic review and meta-analysis.</p

Forest plot of studies showing the association between footwear use and any soil-transmitted helminth infection.+*

<p>+Note different x-axis. *Stratified exposure totals were not given for the following studies: Phiri et al. (N = 273) <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Phiri1" target="_blank">[56]</a>, Mihrshahi et al. (N = 366) <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Mihrshahi1" target="_blank">[57]</a>, Kurup et al. (N = 554) <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Kurup1" target="_blank">[58]</a>, and Gamboa et al. (N = 194) <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Gamboa1" target="_blank">[24]</a>, Aimpun et al. (N = 553) <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Aimpun1" target="_blank">[59]</a>, and Lello et al. (N = 330) <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Lello1" target="_blank">[60]</a>. *A 95% confidence interval/standard error (SE) was not available so it was not included in the forest plot: Lello et al. (odds ratio: 0.81) <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Lello1" target="_blank">[60]</a>. *Adjusted effect estimate: Phiri et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Phiri1" target="_blank">[56]</a>and Mihrshahi et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Mihrshahi1" target="_blank">[57]</a>. *Inverted Log [odds ratio] and SE from effect estimate of barefoot exposure: Phiri et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Phiri1" target="_blank">[56]</a>, Modjarrad et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Modjarrad1" target="_blank">[25]</a>, Mihrshahi et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Mihrshahi1" target="_blank">[57]</a>, Kurup et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Kurup1" target="_blank">[58]</a>, Gunawardena et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Gunawardena1" target="_blank">[23]</a>, Gamboa et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Gamboa1" target="_blank">[24]</a>. *Log [odds ratio] and SE calculated from raw data: Martinez et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-MartinezCardenas1" target="_blank">[61]</a>, Liabsuetrakul et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Liabsuetrakul1" target="_blank">[62]</a>, and Khan et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-YunusKhan1" target="_blank">[63]</a>.</p

Included studies: Time, place, design of study, and descriptive results in the current systematic review and meta-analysis.

<p>*Age mean reported.</p><p>+Missing raw data.</p><p>Abrevation: CLM: Cutaneous larva migrans, Cross-sec.: cross-sectional study; RCT: randomized controlled trial.</p><p>Included studies: Time, place, design of study, and descriptive results in the current systematic review and meta-analysis.</p

Forest plot of studies showing the association between footwear use and tungiasis.*

<p>*Adjusted effect estimate: Ugbomoiko et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Ugbomoiko1" target="_blank">[79]</a>. *Stratified exposure totals were not given for the following studies: Njau et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Njau1" target="_blank">[80]</a> (N = 385) and Thielecke et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Thielecke1" target="_blank">[34]</a> (N = 147). *The magnitude of the odds ratio and the 95% confidence interval/standard error (SE) were not available so it was not included in the forest plot: Thielecke et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Thielecke1" target="_blank">[34]</a> (marginal decrease in intensity of infection with footwear use).</p

A summary of descriptive information ofand study quality by outcome.

<p>+Missing data.</p><p>A summary of descriptive information ofand study quality by outcome.</p

Forest plot of studies showing the association between footwear use and hookworm infection.+*

<p>+Note different x-axis. *Stratified exposure totals were not given for the following studies: Woodburn et al. (N = 2498) <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Woodburn1" target="_blank">[64]</a>, Traub et al. (N = 328) <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Traub1" target="_blank">[65]</a>, Pullan et al. (N = 1803) <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Pullan1" target="_blank">[66]</a>, Nmor et al. (N = 978) <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Nmor1" target="_blank">[67]</a>, Lee et al. (N = 118) <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Lee1" target="_blank">[68]</a>, Gutman et al. (N = 537) <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Gutman1" target="_blank">[69]</a>, Alemu et al. (N = 319) <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Alemu1" target="_blank">[70]</a> and Behnke et al. (N = 285) <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Behnke1" target="_blank">[71]</a>. *The magnitude of the odds ratio and the 95% confidence interval/standard error (SE) were not available so it was not included in the forest plot: Behnke et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Behnke1" target="_blank">[71]</a> (odds ratio for footwear use not significant) and Bethony et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Bethony1" target="_blank">[14]</a> (footwear use was not significantly associated with hookworm infection). *Adjusted effect estimate: Woodburn et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Woodburn1" target="_blank">[64]</a>, Traub et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Traub1" target="_blank">[65]</a>, Pullan et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Pullan1" target="_blank">[66]</a>, Nmor et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Nmor1" target="_blank">[67]</a>, Lee et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Lee1" target="_blank">[68]</a>, Jiraanankul et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Jiraanankul1" target="_blank">[72]</a>, Humphries et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Humphries1" target="_blank">[73]</a>, and Gutman et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Gutman1" target="_blank">[69]</a>. *Inverted Log [odds ratio] and SE from effect estimate of barefoot exposure: Woodburn et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Woodburn1" target="_blank">[64]</a>, Traub et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Traub1" target="_blank">[65]</a>, Pullan et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Pullan1" target="_blank">[66]</a>, Nmor et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Nmor1" target="_blank">[67]</a>, Lee et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Lee1" target="_blank">[68]</a>, Jiraanankul et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Jiraanankul1" target="_blank">[72]</a>, Humphries et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Humphries1" target="_blank">[73]</a>, Gutman et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Gutman1" target="_blank">[69]</a>, Erosie et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Erosie1" target="_blank">[74]</a>, Alemu et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Alemu1" target="_blank">[70]</a>. *Log [odds ratio] and SE calculated from raw data: Tadesse et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Tadesse1" target="_blank">[75]</a>, Ilechukwu et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Ilechukwu1" target="_blank">[76]</a>, Mukerji et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Mukerji1" target="_blank">[77]</a>, Ali et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Ali1" target="_blank">[78]</a>.</p

A forest plot of studies showing the association between footwear use and strongyloidiasis.*

<p>*Stratified exposure totals were not given for the following studies: Yori et al. (N = 492) <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Yori1" target="_blank">[53]</a> and Steinmann et al. (N = 180) <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Steinmann1" target="_blank">[54]</a>. * A 95% confidence interval/standard error (SE) was not available so it was not included in the forest plot: Steinmann et al. (odds ratio: 0.64) <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Steinmann1" target="_blank">[54]</a>. *Adjusted effect estimate: Yori et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Yori1" target="_blank">[53]</a>. *Inverted Log [odds ratio] and SE from effect estimate of barefoot exposure: Yori et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Yori1" target="_blank">[53]</a>. *Log [odds ratio] and SE calculated from raw data (comparing severe form of illness to chronic infection): Sanchez et al. <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003285#pntd.0003285-Sanchez1" target="_blank">[55]</a>.</p