In South Korea, the number of coronavirus disease (COVID-19) cases has declined rapidly and much sooner than in other countries. South Korea is one of the most digitalized countries in the world, and YouTube may have served as a rapid delivery mechanism for increasing public awareness of COVID-19. Thus, the platform may have helped the South Korean public fight the spread of the disease.The aim of this study is to compare the reliability, overall quality, title–content consistency, and content coverage of Korean-language YouTube videos on COVID-19, which have been uploaded by different sources.A total of 200 of the most viewed YouTube videos from January 1, 2020, to April 30, 2020, were screened, searching in Korean for the terms “Coronavirus,” “COVID,” “Corona,” “Wuhan virus,” and “Wuhan pneumonia.” Non-Korean videos and videos that were duplicated, irrelevant, or livestreamed were excluded. Source and video metrics were collected. The videos were scored based on the following criteria: modified DISCERN index, Journal of the American Medical Association Score (JAMAS) benchmark criteria, global quality score (GQS), title–content consistency index (TCCI), and medical information and content index (MICI).Of the 105 total videos, 37.14% (39/105) contained misleading information; independent user–generated videos showed the highest proportion of misleading information at 68.09% (32/47), while all of the government-generated videos were useful. Government agency–generated videos achieved the highest median score of DISCERN , JAMAS , GQS , and TCCI , while independent user–generated videos achieved the lowest median score of DISCERN , JAMAS , GQS , and TCCI . However, the total MICI was not significantly different among sources. “Transmission and precautionary measures” were the most commonly covered content by government agencies, news agencies, and independent users. In contrast, the most mentioned content by news agencies was “prevalence,” followed by “transmission and precautionary measures.”Misleading videos had more likes, fewer comments, and longer running times than useful videos. Korean-language YouTube videos on COVID-19 uploaded by different sources varied significantly in terms of reliability, overall quality, and title–content consistency, but the content coverage was not significantly different. Government-generated videos had higher reliability, overall quality, and title–content consistency than independent user–generated videos. The coronavirus disease COVID-19) is rapidly spreading all over the world. South Korea has noticeably flattened the curve of infection and recorded low fatality rates despite an explosion of cases after the 31st patient was confirmed ) as of May 1, 2020, were collected.As shown in This study was reviewed and approved as exempt research by the corresponding author’s Institutional Review Board (CR-20-102-L). The VPI was used to assess video popularity . The forVideos were categorized based on their source, which comprised of government agencies, news agencies, health care professionals, and independent users. Government agencies include the Korea Centers for Disease Control and Prevention (KCDC), central disaster management headquarters, Cheongwadae , the regional health departments, medical associations, academic institutions, and hospitals. News agencies include news clips from newspapers or a broadcast television network. Health care professionals include physicians, nurses, pharmacists, or other health care providers, who do not represent the opinion of their affiliation. Independent users are individuals who are not health care professionals and have no established affiliation, and we included YouTubers from both Korea and other countries who made Korean-language videos.Videos were classified as useful or misleading, and useful videos were defined as those with scientifically correct information. This study’s authors are physicians who have provided patient care in Korea during the COVID-19 pandemic and are aware of the uncertainty regarding the disease; therefore, KCDC guidelines as of May 1, 2020, were used as a standard to determine whether a video’s content was scientifically correct. Misleading videos were defined as those with scientifically unproven information, and we considered a video misleading if it contained any misleading information at all because it still had the potential to disseminate misinformation. The complete list of misleading information is available in • The coronavirus disease (COVID-19) outbreak is not a concern for the public.• COVID-19 does not exist, and it is a hoax perpetrated to make money.• COVID-19 has been weaponized.• Conspiracy theories are concerned with where it originated, how it spread, and who was responsible for it.• Authorities are hiding the truth.• COVID-19 was manufactured with the goal of human depopulation.• One type of food or supplement is recommended over another as a cure or for the prevention of COVID-19.• COVID-19 has occurred as part of nature’s revenge on humankind for cruelty to wild animals.• People are recommended to not follow the guidelines of the Korea Centers for Disease Control and Prevention.• People are recommended to follow scientifically unproven measures.• The COVID-19 pandemic was prophesied by clairvoyants.• COVID-19 was started to insert microchips into people under the guise of a vaccine.• COVID-19 was created to build a global surveillance system.Videos classified as useful were further analyzed for reliability, overall quality, title–content consistency, and content. There is still no consensus on how to evaluate medical information contained in videos; therefore, we adopted the evaluation tools commonly used in previous studies on online consumer health information, such as tools for websites  and written patient information on treatment choices (DISCERN) ,39,41-43The overall quality of the videos was determined by the GQS, which is a 5-point Likert scale ranging from 1  to 5  ,41,43. IWe created a novel scoring system for assessing title–content consistency because there was no validated evaluation tool for this. The title–content consistency index (TCCI) is a 5-point Likert scale ranging from 1 (poor consistency) to 5 (high consistency), which rates the sensationalist style of a video, that is, the gap between title and content. This index was developed based on previous research on junk news and clickbait ,54. The We used the MICI for content analysis ,36. MICIt test for continuous variables and chi-square test for categorical variables were used to compare misleading and useful videos. Kruskal-Wallis test and Mann-Whitney test with Bonferroni correction were used to compare the four sources. All analyses were conducted with the R statistical package version 3.6.3 . A P value<.05 was considered statistically significant.All videos were reviewed and evaluated by two independent authors. Discrepancies between the authors were resolved by discussion. Interreviewer agreement for categorical variables was analyzed using the Cohen kappa coefficient. Interreviewer agreement for continuous variables was analyzed using intraclass correlation coefficient (ICC) estimates and their 95% confidence intervals based on average measures, absolute agreement, and two-way random model. The kappa coefficients of agreement regarding the classification of source and the usefulness of the videos were k=1 in both cases, indicating full agreement between the authors. ICCs regarding DISCERN, JAMAS, GQS, TCCI, and MICI were 0.47 (95% CI –0.29 to 0.81), 0.93 (95% CI 0.80 to 0.98), 0.71 (95% CI 0.17 to 0.90), 0.89 (95% CI 0.70 to 0.96), and 0.91 (95% CI 0.73 to 0.97), respectively. The Shapiro-Wilk test was used to assess the normality of data. Normally distributed continuous variables were presented as mean (SD). Nonnormally distributed continuous variables were presented as median (IQR). Categorical variables were compared by chi-square test or Fisher exact tests and presented as a number (percentage). Student P=.03). The mean number of comments was 1.42 times higher in useful videos . Misleading videos had almost twice the running time than useful videos . There was no significant difference in the mean views, dislikes, and VPI between the two groups .The characteristics of misleading and useful videos are contained in P=.04, news agencies: P=.005, health care professionals: P=.03, and government agencies: P=.002). Videos by government agencies had the shortest median running time of 41 seconds, with the highest views. VPI, as a measurement of popularity, was not significantly different among sources. Government agency–generated videos achieved the highest median score of DISCERN , JAMAS , and GQS , while independent user–generated videos achieved the lowest median score of DISCERN , JAMAS , and GQS . These differences were statistically significant . The median scores of TCCI were 3.0 (IQR 3.0-4.0) in independent users, 5.0 (IQR 4.0-5.0) in news agencies, 3.0 (IQR 2.0-4.0) in health care professionals, and 5.0 (IQR 5.0-5.0) in governmental agencies (P<.001).Video metrics, reliability, overall quality, title–content consistency, and content of the useful videos by source are presented in P=.77). The highest median score among individual MICI components was shown in “transmission and precautionary measures” of government agency–generated videos .Of the useful videos, 74.24% (49/105) provided information on “transmission and precautionary measures,” 66.67% (44/105) contained information on “prevalence,” 46.97% (31/105) contained “signs and symptoms,” 45.45% (30/105) contained “testing,” and 36.36% (24/105) contained “treatment and outcome.” “Transmission and precautionary measures” were the most discussed topic by government agencies, news agencies, and independent users. Every video by government agencies covered “transmission and precautionary measures,” and 7 out of 8 (87.50%) videos mentioned “signs and symptoms.” On the other hand, the most mentioned topic by news agencies was “prevalence,” followed by “transmission and precautionary measures.” The total score of MICI was not significantly different among sources . Furthermore, useful videos earned more comments but fewer likes than misleading videos . Previously, there was an attempt to compare Mandarin videos regarding COVID-19 to English ones. They reported that misleading Mandarin videos gained more views than useful ones, but the result was the opposite for English videos  [P=.50, P=.79, P=.10, respectively) [Out of 105 videos, 39 37.14%) were found to be misleading. This percentage is higher than that from a previous study that evaluated English-language videos addressing COVID-19  . Useful .14% were P<.001) . Anotherctively) .In this study, most of the misleading information was delivered by independent users . Moreover, some of these videos generated a lot of interaction from viewers. For example, one video suggested that because of COVID-19, a microchip will be inserted into people under the guise of a vaccine to build a global surveillance system; this video gained 330,672 views with 2454 comments. Another video mentioned a conspiracy theory that COVID-19 is a biological weapon, and it was manufactured for human depopulation. Another video with 1,478,262 views claimed that COVID-19 was predicted in works of fiction or in movies. One video posted by a shaman was entirely misleading. It consisted of question-answer pairs, and a shaman answered questions about COVID-19 such as, “When will the COVID-19 pandemic end?” and “When will a COVID-19 vaccine be available?”The mere fact that a video uploader is a doctor or health expert does not imply that their videos provide accurate medical information. There were 3 out of 11 videos posted by health care professionals that were misleading; 2 videos addressed misleading information throughout the entire running time. There was 1 video that alleged the existence of a conspiracy theory as to when COVID-19 originated and who is responsible for the virus. Another video recommended one vitamin supplement as a cure for COVID-19. In contrast, one video posted by a pharmacist provided partially useful information, but it was still classified as misleading since videos containing any misleading information could potentially disseminate misinformation. This video included helpful information during the first half of the running time, such as characteristics of the viral disease, transmission, hand hygiene, and face masks. However, during the second half, the video recommended several foods such as ginger, onions, green tea, and black beans as immune boosters against COVID-19. Although good nutrition is key to staying healthy, this video was classified as misleading because no food or dietary supplement alone can prevent COVID-19.Most videos by news agencies in this study provided scientifically accurate information . Video clips of television-based news were often posted on YouTube, amplifying the impact of traditional media. Given the inclusion criterion for this study, it can be reasoned that consumers may have the social media literacy skills to choose appropriate videos among the hundreds of thousands of videos that can be viewed on YouTube.P=.04). They also had the shortest median running time at 41 seconds (P=.002) and showed higher reliability and overall quality . These findings are consistent with previous studies. A systematic review of health care information on YouTube found that government agency–generated videos had credible information [P=.008; JAMAS: 2.71 vs 1.50, P=.03) [Government-generated videos were effective delivery tools. Although they comprised only 7.62% (8/105) of the total videos, they were all useful and gained the highest median views  .P=.005, P=.03, respectively), they failed to encourage viewer interaction and engagement. They also showed the lowest VPI as a measurement of popularity, but the VPI was not significantly different (P=.54). Government or news agencies were also more likely to post videos with a proper title . In contrast, independent users were more likely to post clickbait videos with sensationalist headlines or eye-catching, attention-grabbing thumbnails with large gaps between the title and their content . Viewers are more likely to select emotionally appealing titles, regardless of the correctness of the content [However, credible videos with high quality were not popular. Considering that videos generated by government agencies received the least number of likes and comments ( content .Several studies have reported content differences among analyzed COVID-19–related YouTube videos. Basch et al  reportedThrough content analysis, we can understand the characteristics of popular COVID-19–related videos in Korea. As shown in I am young and healthy. It looks like I will probably be okay, but what if I spread the virus to my parents without knowing it? They are old and weak. I’ve got to stay at home.The second most common content area in Korean videos regarding COVID-19 covered “signs and symptoms.” These videos may encourage people who develop suspicious symptoms to be screened as soon as possible. Early detection of the symptoms of COVID-19 may enable people to visit the hospital early on, improving treatment responses and leading to decreased mortality.Furthermore, videos frequently mentioned call centers run by KCDC or the regional health department. In addition, they recommended having a consultation from the call center first before visiting a hospital if an individual had suspicious symptoms or had come in contact with a patient with COVID-19. This could prevent the spread of the virus from patients who are infected to health care providers.Of the videos uploaded by independent users, two were “patient experience” videos. One video is filmed by a patient lying in a hospital bed who has COVID-19. The patient, who was having difficulty breathing, was trying to talk to the viewers about not taking any risks regarding COVID-19. The other video includes a survivor of COVID-19 who shares his personal story and experience with viewers. Viewers shared their opinions through the comments under these videos.Thank you for sharing your story. I hope you will get better soon.It looks like so much pain. It is so sad and scary.When you go outside, please wear a mask. It is for our family and friends.Science is not supposed to be a popularity contest, but governments should exert more effort to disseminate accurate and complete information via social media to ameliorate the negative health consequences of misinformation. Peer-reviewed or expert-approved videos are expected to provide credible medical information . HoweverThis study includes several limitations. First, this is a cross-sectional study, so it is limited to capturing YouTube scenes at a certain point in time. Common search terms or the most viewed videos may change over time, and longitudinal changes in video metrics such as views, likes, dislikes, or comments were not captured. Second, there is no validated tool for evaluating video-based medical information. Therefore, we adopted the evaluation tools commonly used in previous studies on online consumer health information. A comprehensive evaluation tool for the medical content of videos needs to be developed. Third, we could not tell whether watching a video clip led to a change in health behavior. For example, some people enjoy watching conspiracy videos to pass time and may be able to distinguish which stories are valid. Thus, they may end up following the guidelines of authorities regardless of their viewing such videos. More research is needed to evaluate the relationship between exposure to misinformation and health behaviors. Fourth, we did not collect any data on the viewers. All the YouTube video metrics were collected anonymously, so we could not grasp the viewers’ demographic characteristics.Misleading videos had more likes, fewer comments, and longer running times than useful videos. Korean-language YouTube videos on COVID-19 uploaded by different sources varied significantly in terms of reliability, overall quality, and title–content consistency, but the content coverage was not significantly different. Government-generated videos had higher reliability, overall quality, and title–content consistency than independent user–generated videos.Although there is concern about the spread of misinformation via YouTube, the educational value of this website cannot be ignored. YouTube can be a powerful tool to keep the public informed during a crisis in a controlled and reassuring manner. However, to do so, accurate information must be made available on such platforms. Therefore, governments should have a stronger presence on social media and produce more online videos to reach a wider audience. First, to accomplish this, policy makers should support health institutions financially so they can use social networking platforms to their full potential. For example, an educational program could be developed to teach health care providers how to make YouTube videos and engage with the audience on social media. Second, health care professionals should cooperate with social media influencers, not compete with them, to reach more people. For example, the top-10 most subscribed YouTubers could create and upload a video in collaboration with a physician guest that provides a combination of entertainment and information on COVID-19. Thus, YouTube users would be able to obtain more high-quality information than false data. Third, compelling content should be used, as it can grab viewers’ attention. For example, visually attractive recordings can receive more views, and emotionally persuasive videos with exemplar stories are more likely to catch viewers’ attention than those with statistical evidence . In this


To analyse and improve the Namibian maternity care system by implementing maternal near-miss surveillance during 1 October 2018 and 31 March 2019, and identifying the challenges and benefits of such data collection.From the results of an initial feasibility study, we adapted the World Health Organization’s criteria defining a maternal near miss to the Namibian health-care system. We visited most (27 out of 35) participating facilities before implementation and provided training on maternal near-miss identification and data collection. We visited all facilities at the end of the surveillance period to verify recorded data and to give staff the opportunity to provide feedback.During the 6-month period, we recorded 37 106 live births, 298 maternal near misses (8.0 per 1000 live births) and 23 maternal deaths (62.0 per 100 000 live births). We observed that obstetric haemorrhage and hypertensive disorders were the most common causes of maternal near misses . Of the 49 maternal near misses due to pregnancies with abortive outcomes, ectopic pregnancy was the most common cause . Fetal or neonatal outcomes were poor; only 50.3% (157/312) of the infants born to maternal near-miss mothers went home with their mother.Maternal near-miss surveillance is a useful intervention to identify within-country challenges, such as lack of access to caesarean section or hysterectomy. Knowledge of these challenges can be used by policy-makers and programme managers in the development of locally tailored targeted interventions to improve maternal outcome in their setting. After an initial feasibility study, the National Maternal Death Review Committee of the Ministry of Health and Social Services agreed to include surveillance of maternal near misses within the national obstetric surveillance system for a 6-month period. The aim of this surveillance was to obtain more robust data on pregnancy outcomes and assess the benefits of such surveillance in comparison with maternal death surveillance only.We describe the implementation of maternal near-miss surveillance from 1 October 2018 to 31 March 2019 in Namibia, and discuss the challenges and benefits of such data collection. Using a cross-sectional study design, we provide nationwide incidence data and discuss the underlying causes of maternal near misses, while also examining neonatal outcomes.All Namibian public hospitals, 1 tertiary, 4 regional and 30 district, participated in the surveillance of maternal near misses. The largest hospital complex, located in the capital of Windhoek and comprising the tertiary and a regional hospital, has around 12 000 births per annum. This hospital employs three consultant obstetrician-gynaecologists. The intensive care unit has advanced equipment including ventilators and dialysis. The other three regional hospitals (6500 births per year each) have high-dependency units with mechanical ventilation, and renal dialysis can be performed at two of these hospitals. District hospitals have two to eight general medical doctors who provide care across all specialities. District hospitals have basic haematology and chemistry laboratory tests available, such as blood count, renal function and basic liver function tests. Most district hospital blood banks only have access to 2 units of packed red cells. All hospitals are expected to have functioning operating theatres for basic surgical procedures, such as caesarean section or laparotomy for ruptured ectopic pregnancy.,As a result of the limited availability of laboratory tests and management options resulting in the underreporting of maternal near-miss cases, other sub-Saharan African countries have indicated that the WHO maternal near-miss criteria may not be suitable for use in district hospitals in low-income settings.Box 1a oliguria non-responsive to fluids or diuretics;b failure to form clots; loss of consciousness lasting > 12 hours ; cardiac arrest; stroke; uncontrollable fit/total paralysis; and jaundice in the presence of pre-eclampsia. WHO: Acute cyanosis; gasping; respiratory rate > 40 or < 6/min; shock;Namibia: the same as WHO.Pao2/FiO2 < 200 mmHg; creatinine 300 μmol/L or 3.5 mg/dL; bilirubin > 100 mmol/L or > 6.0 mg/dL; pH < 7.1; lactate > 5 mq/mL; acute thrombocytopenia (< 50 000 platelets/mL); and loss of consciousness and ketoacids in urine.WHO: Oxygen saturation < 90% for 60 minutes; Namibia: the same as WHO.WHO: Use of continuous vasoactive drugs; hysterectomy following infection or haemorrhage; transfusion of 5 units of red blood cells; intubation and ventilation for 60 minutes not related to anaesthesia; dialysis for acute renal failure; cardio–pulmonary resuscitation.Namibia: As for WHO with the exception of transfusion of 4 units of blood products, and inclusion of laparotomy other than caesarean section or ectopic pregnancy of < 12 weeks gestationWHO: No criteria.cNamibia: Eclampsia and uterine rupture.2: fraction of inspired oxygen; min: minute(s); Pao2: arterial oxygen partial pressure; WHO: World Health Organization. FiOa Persistent systolic blood pressure of < 80 mmHg, or a persistent systolic blood pressure < 90 mmHg with a pulse rate of ≥ 120 bpm. b Urinary output < 30 mL/hour over 4 hours or < 400 mL per 24 hours. c Complete rupture of uterus during labour confirmed by laparotomy.Before national implementation of maternal near-miss surveillance, most participating facilities were visited; due to a lack of funding, eight smaller district hospitals could not be visited. Medical staff involved in the care of pregnant and/or postpartum women were trained in the identification of maternal near misses and relevant data collection. Staff at the eight hospitals that could not be visited received training when presenting at one of the referral hospitals  for other training courses. At all 35 hospitals, a maternal near-miss doctor and nurse were nominated to supervise data collection and provide the research team with verbal monthly updates during pre-arranged telephone calls.A case of a maternal near miss was defined as a woman either pregnant , or within 42 days of termination of pregnancy or birth, fulfilling at least one of the criteria listed in We identified possible missed cases in the Windhoek hospital complex during weekly ward visits or through personal communication with nominated medical staff. Although we had planned to visit all facilities 2 months after the onset of the surveillance, we had to cancel these visits because of a lack of resources. At the request of staff at two of the hospitals, we made an extra visit to provide additional training on data collection. After 6 months, we visited all hospitals to verify the recorded surveillance data against medical records. We screened the ward registers of maternity, female, high-dependency and intensive care units, theatre registers and referral registers for missed cases. During this visit, at least one member of the National Maternal Death Review Committee met with the local hospital staff, including the nominated doctor and nurse, the doctor and nurse in-charge, and all available doctors and nurses involved in the care of pregnant women. During these meetings, staff were given the opportunity to describe their experience with data collection and the challenges encountered related to clinical duties.We obtained the total number of live births in Namibia from the National Health Information Systems. We collected data on maternal deaths from the national reporting and audit system.Direct and indirect causes of maternal near misses were defined according to the International Statistical Classification of Diseases-Maternal Mortality definitions.As a result of poor documentation of blood loss, we diagnosed major obstetric haemorrhage as a woman with obstetric haemorrhage who either needed 4 units of blood; fulfilled the criteria of shock;Finally, because an outbreak of hepatitis E had been causing significant maternal mortality since December 2017, we also calculated the incidence and mortality index of severe maternal outcomes for women with acute hepatitis E with a bilirubin concentration of more than 100 mmol/L.We shared all findings with the executive management committee of the Ministry of Health and Social Services during a meeting in July 2019, attended by representatives of the departments of human resources, clinical support services and quality assurance division, responsible for training clinical staff. We addressed several issues and set priorities for the following year, namely: (i) the human resources department to focus on recruiting and retaining doctors and nurses with obstetric experience and/or essential surgical skills; and (ii) the clinical support services department to ensure functionality of operating theatres in district hospitals. We also discussed the possibility of launching a debate within parliament to legalize abortion, using data describing abortion-related complications. In the same month we also shared all findings with all participating facilities through video conferencing and during a 2-day national conference organized by the Ministry of Health and Social Services and the University of Namibia, funded by several Namibian companies, the WHO, United Nations Population Funds and the European Union. A doctor and nurse from each facility were invited to attend the conference, where we provided staff training and issued relevant guidelines according to the most common issues identified in the maternal near miss and death reviews. The guidelines were written by doctors working in maternity departments of the regional hospitals, and reviewed by members of the National Maternal Death Review Committee. Costs were kept as low as possible. When feasible, facility visits for maternal near-miss surveillance were combined with visits for other training courses. Most of the available budget was spent on travel and accommodation; the costs for two committee members to travel 9600 km to visit participating hospitals before and after completion of data collection were approximately 8000 United States dollars (US$). A further US$ 700 was spent on stationary, such as the printing of case reporting forms and guidelines. External advisors from outside Namibia were not remunerated.This study was reviewed and approved by the research unit of the Ministry of Health and Social Services. After stabilizing and treating the women, data were collected from medical records without identification of the patient; inclusion in the study had no effect on clinical management. The need for individual informed consent was therefore waived.Over the 6-month surveillance period, we recorded 37 106 live births, 298 maternal near misses and 23 maternal deaths. We calculated the incidence of maternal near misses in Namibia as 8.0 per 1000 live births, the maternal mortality ratio as 62.0 per 100 000 live births and the ratio of maternal near misses to maternal deaths as 13:1.We list the characteristics of the women identified as having experienced a maternal near miss or death in The main underlying causes of maternal near misses are summarized in Direct causes of maternal deaths were haemorrhage (three), hypertension (two), puerperal sepsis after caesarean section (two) and anaesthesia-related complications (two). Indirect causes were hepatitis E (five), cardiac disorder (four), tuberculosis (two) and gastric perforation (one). The cause of death remained unclear for two women.We present incidence calculations and mortality indices in The proportion of births by caesarean section varied across the regions from 2.7% (114/4203) in Ohangwena to 30.5% (1033/3392) in Oshana . For fivFetal and neonatal outcomes were poor . Only 50The most common challenge reported by medical personnel was understaffing and lack of experience in the staff present. Basic equipment, including blood pressure machines, was often lacking or not functioning. In 13 of the 30 district hospitals, no or only a few uncomplicated caesarean sections or laparotomies for ectopic pregnancies were performed as a result of a lack of skills, staff or equipment.,Our collection of maternal near-miss data, in addition to routine maternal death analysis, has proven to be useful for several reasons. First, these data provide insights into the functioning of the health-care system, and several issues were addressed immediately. With less than 1500 live births per annum, maternal deaths seldom occur in district hospitals. The challenges met by these smaller facilities, such as a lack of access to basic surgery, have been highlighted. For several women, this lack of access to surgery led to a maternal near-miss complication, such as uterine rupture or shock during transport to a referral hospital. We observed a low prevalence (0.6 per 1000 live births) of the life-saving intervention of hysterectomy, one of the few management options for haemorrhage when medical treatment fails; the relevant surgical skills are only available in eight of Namibia’s 35 hospitals. This prevalence is lower than the global estimate of 0.9 per 1000 live births or 1.4 per 1000 live births in a South African district.Second, an unanticipated, but important benefit of maternal near-miss data collection was the positive effect on the morale of staff. Medical personnel are working under difficult circumstances with a high workload and constrained resources. However, by participating in the maternal near-miss surveillance, staff could take pride in their jobs by acknowledging the number of women they had saved.Third, as maternal near misses are more frequent than maternal deaths, near-miss data may be more useful in advocacy, for instance in abortion-related complications. Using data on the extent and complications of unsafe abortions was key in the battle to legalize abortion in Rwanda.Our study had several limitations. First, we only aimed to describe the implementation of maternal near-miss surveillance, although it is the resulting improvement in maternal outcome that is important. As surveillance continues, we anticipate that an apparent increase in the incidence of near misses will be observed as a result of improved data collection, rather than any change in maternal outcome. Similarly, an apparent increase in maternal deaths was reported in South Africa as a result of the implementation of national maternal death reviews.,Second, our calculated incidence of maternal near misses must be interpreted with caution, as we amended criteria to the local situation. Although this approach may hamper international comparison, the use of WHO criteria led to severe underreporting of maternal near misses in the feasibility study conducted previously because of the limited diagnostics and management options in smaller facilities.,–Third, our calculated maternal mortality ratio (62.0 per 100 000 live births) is much lower than that estimated by the Demographic Health Survey or WHO.Fourth, our biggest challenge to successful implementation of the surveillance was a limited budget. We were not able to fund any administrative staff to support data collection or visit every participating facility before the onset of the surveillance. Cases may have been missed, affecting the quality of our data. However, as data collection depended on local staff, the approach gave them the opportunity to show leadership and take ownership of data collection. In general, it appeared staff were more likely to collect accurate data when trained personally and when aware of the aim of the project. Barriers to accurate data collection by local staff were lack of time due to a high workload and the fear of making mistakes in data collection.,–,–The maternal near-miss surveillance identified several issues that need to be explored further before they can be addressed. First, over 80% of maternal near misses were the result of direct causes compared with less than half of the maternal deaths, which corresponds with findings in Brazil and Nigeria.,Second, nearly half of the women who experienced a maternal near miss during our 6-month survey gave birth by caesarean section; caesarean sections are used for varying proportions of births across the regions, by up to as many of 30% of births at a population level . The hig,Third, overall fetal and neonatal outcomes were poor, which is commonly seen among women with severe morbidity.We identified two potentially important facilitators that will support the continuation of maternal near-miss surveillance in Namibia: its independence of the availability of donor funding and the motivation of staff to continue collecting data. Causes of maternal death are similar for most countries, but individual countries experience local challenges. Maternal near-miss surveillance is a useful intervention to identify these challenges, the knowledge of which can be used by policy-makers and programme managers in the development of locally tailored targeted interventions to improve maternal outcome in their setting.


Entertainment-education (E-E) media can improve behavioral intent toward health-related practices. In the era of COVID-19, millions of people can be reached by E-E media without requiring any physical contact. We have designed a short, wordless, animated video about COVID-19 hygiene practices—such as social distancing and frequent hand washing—that can be rapidly distributed through social media channels to a global audience. The E-E video’s effectiveness, however, remains unclear.Quantify people’s interest in watching a short, animated video about COVID-19 hygiene (abbreviated to CoVideo).Establish the CoVideo’s effectiveness in increasing behavioural intent toward COVID-19 hygiene.Establish the CoVideo’s effectiveness in improving COVID-19 hygiene knowledge.The study aims to achieve the following objectives. To:Arm 1: the CoVideo, list experiment, and questionnaire survey. Arm 2: the APC video, list experiment, questionnaire survey, and CoVideo. Arm 3: the list experiment, questionnaire survey, and CoVideo. For each list experiment, participants will be randomized to a control or treatment group. The control group will receive a list of five items and the treatment group will receive the same five items plus one item about COVID-19 hygiene. We will use the list experiment to reduce response bias associated with socially desirable answers to COVID-19 questions. The questionnaire survey will include items about the participant’s age, sex, country of residence, highest education, and knowledge of COVID-19 spread. After completing the list experiment and questionnaire survey, participants in Arms 2 and 3 will receive the CoVideo to ensure post-trial access to treatment.The present study is a multi-site, parallel group, randomized controlled trial (RCT) comparing the effectiveness of the CoVideo against an attention placebo control (APC) video or no video. The trial has an intervention arm (CoVideo), placebo arm (APC), and control arm (no video). Nested in each trial arm is a list experiment and questionnaire survey, with the following ordering. https://www.prolific.co) to recruit participants and host our study on the Gorilla™ platform (www.gorilla.sc). To be eligible, participants must be between the age of 18 and 59 years  and have current residence in the United States, the United Kingdom, Germany, Spain, Mexico, or France. Participants will be excluded from the study if they cannot speak English, German, French, or Spanish (since the instructions and survey questions will be available in these 4 languages only).This will be an online study setting. We will use Prolific Academic (ProA: https://www.youtube.com/watch?v=rAj38E7vrS8.The intervention is an E-E video about COVID-19 hygiene (CoVideo). Developed by our co-author (MA) for Stanford Medicine, the CoVideo is animated with sound effects, and has no words, speech, or text. The CoVideo shows how the novel coronavirus is spread  and summarizes the public’s response to the COVID-19 outbreak. Key components of the CoVideo are the promotion of five hygiene practices: i) social distancing and avoiding group gatherings, ii) frequently washing hands with soap and water or sanitizer, iii) cleaning surfaces at home , iv) not sharing eating utensils, and v) avoidance of stockpiling essential goods (such as toilet paper and face masks). The CoVideo, which was designed for universal reach and optimized for release on social media channels, can be viewed at https://www.youtube.com/watch?v=_HEnohs6yYw. Each list experiment will have a control list as the comparator. The control list is needed to measure the prevalence of behavioral intent toward COVID-19 hygiene.The comparators are an APC video (Arm 2) or no video (Arm 3). The APC video is similar in style to the CoVideo; it is also animated with a duration of 2.30 minutes, has sound effects but no words, speech, or text. The video message is about how small choices become actions, which become habits, which become a way of life. It is available at This study will measure primary and secondary outcomes related to COVID-19 hygiene. By hygiene, we mean the adoption of behaviors or practices that reduce the chances of being infected or spreading COVID-19. As our primary outcome, we will measure changes in behavioral intent toward five hygiene practices: social distancing, washing hands, cleaning household surfaces, not sharing eating utensils, and not stockpiling essential goods. As a secondary outcome, we will measure knowledge about behaviors that can prevent the spread of COVID-19.Using a web-based randomization algorithm, Gorilla will randomly allocate participants to the intervention (CoVideo), placebo (APC), or control (no video) arm (sequence generation) at a 1:1:1 ratio. Within each trial arm, Gorilla will randomly allocate participants at a 1:1 ratio to the control or treatment group. Items in the lists will be randomly ordered to avoid order effects. The presentation order of the list experiments will also be randomized.Because ProA handles the interaction between the study investigators and participants, the participants will be completely anonymous to the study investigators. The outcome measures will be self-reported and submitted anonymously. All persons in the study team will be blinded to the group allocation.The Gorilla algorithm will randomize 6,700 participants to each trial arm, giving a total sample size of 20,100.The protocol version number is 1.0 and the date is 18 May 2020. Recruitment is expected to end by 22 June 2020. Thus far, the study investigators have recruited 2,500 participants on ProA. Of these participants, 800 have completed the study on the Gorilla platform.(www.drks.de) on May 12th, 2020, protocol number: #DRKS00021582. The study was registered before any data was collected.The study and its outcomes were registered at the German Clinical Trials Register The full protocol is attached as an additional file, accessible from the Trials website (Additional file  Additional file 1. Full Protocol.


This study compared the connectivity of video sessions to telephone sessions delivered to smokers in rural areas and whether remoteness and video app (video only) were associated with the connectivity of video or telephone sessions. Participants were recruited into a randomised trial where two arms offered smoking cessation counselling via: (a) real-time video communication software (201 participants) or (b) telephone (229 participants). Participants were offered up to six video or telephone sessions and the connectivity of each session was recorded. A total of 456 video sessions and 606 telephone sessions were completed. There was adequate connectivity of the video intervention in terms of no echoing noise (97.8%), no loss of internet connection during the session (88.6%), no difficulty hearing the participant (88.4%) and no difficulty seeing the participant (87.5%). In more than 94% of telephone sessions, there was no echoing noise, no difficulty hearing the participant and no loss of telephone line connection. Video sessions had significantly greater odds of experiencing connectivity difficulties than telephone sessions in relation to connecting to the participant at the start , loss of connection during the session  and hearing the participant . There were no significant associations between remoteness and video app and connectivity difficulties in the video or telephone sessions. Real-time video sessions are a feasible option for smoking cessation providers to provide support in rural areas. The services routinely offered by quitlines for smoking cessation include telephone counselling (reactive and/or proactive) and written materials . TelephoSimilar to telephone-based support, real-time video communication technology  has the potential to eliminate barriers to accessing face-to-face smoking cessation care ,9,10. InQuitlines have not implemented video counselling for smoking cessation as part of routine practice and a potential barrier may be the perceived connectivity of video communication technology such as the quality of the internet connection , video e(i)The connectivity of real-time video counselling sessions compared to telephone sessions delivered to smokers in rural and remote areas;(ii)The factors ) associated with connectivity of video sessions and telephone sessions.No prior research has investigated the connectivity of real-time video counselling for smoking cessation in rural and remote locations. This study, therefore, aims to investigate:This study reports on the process measures of participants in a randomised smoking cessation trial, specifically, participants receiving smoking cessation counselling via either (1) real-time video counselling or (2) telephone counselling. A detailed description of the study design has been published elsewhere . BrieflyBetween 25th May 2017 and 2nd October 2018, 655 participants were recruited from rural and remote locations of New South Wales (NSW), classified using the Accessibility and Remoteness Index of Australia (ARIA+) . The ARIParticipants were recruited via traditional methods such as local newspapers, magazines, flyers and posters and via online strategies such as the study website, Facebook and Twitter . PotentiParticipants allocated to the video counselling condition received up to six video smoking cessation support sessions using the participant’s preferred form of video communication . The advisors used cognitive behaviour therapy  and motiThose participants that indicated readiness to quit within a month during the initial video session were offered five more counselling sessions on the quit date, and 3, 7, 14 and 30 days after the quit date. This evidence-based call schedule involves calls being scheduled close to the first two weeks following a quit attempt, which is the period where relapse often occurs .Participants who indicated during the initial video session that they did not wish to quit within the next month were offered an additional three counselling calls at 2, 4 and 6 weeks after the initial call. The content of the video sessions included: assessment of smoking status and smoking history; identifying barriers to smoking cessation  and potential solutions; discussing effective smoking cessation strategies including both behavioural interventions and pharmacotherapies , bupropion, varenicline); and promoting self-efficacy and relapse prevention strategies to quit smoking. The mean duration of the video sessions was 19.18 min .Telephone counselling participants received up to six smoking cessation telephone calls. The callback schedules, content and counselling techniques used in the telephone support calls were identical to those described for the video support sessions. The mean duration of the telephone calls was 16.08 min (SD 7.27).Did you have difficulty hearing the participant? (Yes/No). (b) Did you have difficulty seeing the participant? (Yes/No). (c) Was there an echoing noise during the video session? (Yes/No) (d) Did you lose internet connection during the video session? (Yes/No). (e) Did you find it difficult to connect to the participant at the start of the session? (Yes/No) and (f) Did you have difficulty operating the video application and equipment? (Yes/No).After the completion of each video session, the smoking cessation advisor recorded in a database information related to the connectivity of the video session by answering the following questions: (a) Did you have difficulty hearing the participant? (Yes/No). (b) Was there an echoing noise during the telephone session? (Yes/No). (c) Did you lose telephone line connection during the telephone call? (Yes/No). (d) Did you find it difficult to connect to the participant at the start of the call? (Yes/No) and (e) Did you have difficulty operating the telephone equipment? (Yes/No).After the delivery of each telephone counselling session, the smoking cessation advisor recorded in a database information related to the connectivity of the telephone call by answering the following questions: (a) During the baseline survey, participants in the real-time video counselling condition were asked which video software application they preferred to use. The video software application was recorded by the counsellor for each video counselling session.Participants were asked to provide their residential postcode during the baseline survey, which was categorised using the Accessibility and Remoteness Index of Australia (ARIA+) into inner regional (> 0.2–≤ 2.4), outer regional (> 2.4–≤ 5.92), remote (> 5.92–≤ 10.53) or very remote (> 10.53) areas of New South Wales .During the baseline survey, participant sociodemographic characteristics collected included age, gender, country of birth, Aboriginal or Torres Strait Islander origin, education, marital status, and occupational status.Statistical analysis was completed using the SAS software version 9.3 . Categorical data were described using frequencies and percentages.For each connectivity issue assessed across both arms , video sessions were compared to telephone sessions by conducting Mixed Logistic Regression Models, to account for participant level clustering while adjusting for remoteness.To examine the factors associated with each connectivity difficulty in the video sessions , the proportion of calls where the connectivity issue occurred was first assessed, and a threshold of 5% was set to determine whether there was enough variation in the data to warrant conducting further analysis. Multiple Logistic Mixed Regression models were used to determine whether the type of video app used, or the remoteness were associated with each eligible connectivity issue.Similarly, to explore the factors associated with connectivity difficulties in the telephone sessions , the proportion of calls where each connectivity issue occurred was first assessed, and a threshold of 5% was set to reflect when there was some degree of variation in the data before further analysis was conducted. Multiple Logistic Mixed Regression models were used to determine whether remoteness was associated with each eligible connectivity issue.n = 201) or telephone counselling (n = 229) arms of the randomised trial. Among the video counselling participants, the mean number of calls was 2.27 calls (SD = 2.44). Among the telephone counselling condition, the mean number of calls was 2.62 (SD = 2.35). There was no significant difference in the mean number of calls between the video and telephone counselling conditions. Between 25 May 2017 and 2 October 2018, there was a total of 430 participants recruited into either the video counselling  were delivered via Facebook Messenger, 157 (34.4%) via FaceTime, 58 (12.7%) via Skype and 5 (1.1%) via Google Hangouts. For 99.6% (454/456) of video sessions, the advisors had no difficulty operating the video equipment, 97.8% (446/456) of video sessions had no echoing noise, and in 94.5% (431/456) there was no difficulty connecting with the participant at the start of the session. In 88.6% (404/456) of the video sessions, there was no loss of internet connection during the session, and in 88.4% (403/456) there was no difficulty hearing the participant, while in 87.5% (399/456) of the video sessions there was no difficulty seeing the participant .Overall, 606 telephone counselling calls were completed. After adjusting for remoteness and participant level clustering, the video sessions had significantly greater odds, compared to the telephone sessions, of difficulty hearing the participant , loss of connection during the session , and difficulty connecting at the start of the session  .Where a particular connectivity difficulty was reported for >5% of the video sessions, we explored the characteristics associated with that connectivity measure. For the video sessions, there were no characteristics significantly associated with (a) difficulty seeing the participant, (b) difficulty connecting to the participant at the start of the video session, (c) loss of internet connection during video session  and diffWhere connectivity difficulties were reported for >5% of the telephone calls, we explored the characteristics associated with each of those connectivity measures. As shown in This is the first study to examine the connectivity of real-time video smoking cessation sessions and telephone calls in rural and remote locations. The findings demonstrated that real-time video counselling sessions were feasible for most rural smokers with only minimal connectivity problems.Poor internet connection has been cited as a challenge in using video communication technology in Australia and internationally  and is cVideo sessions had significantly greater odds of connectivity difficulties than telephone sessions in relation to connecting to the participant at the start of the session, losing connection during the session and difficulty hearing the participant. This suggests that the delivery of smoking cessation counselling via telephone or video should operate on a flexible model, where connectivity is a key criterium. For people in rural areas who cannot easily access existing face to face services due to associated travel costs ,35, bothUnderstanding whether any factors are associated with the connectivity of video sessions or telephone calls, could help to identify for which subgroups improved technological infrastructure is needed for the delivery of such interventions. However, in this study there were no factors associated with connectivity difficulties for the video sessions and for the telephone calls. This suggests that the delivery of real-time video counselling and telephone counselling for smoking cessation is feasible in terms of connectivity, irrespective of rural location and video app (video sessions only). Given that there were very limited data collected in remote locations and none in very remote locations, this study is unable to draw conclusions about connectivity difficulties in remote and very remote locations for either video communication or telephone.The study had a number of limitations. First, there was a very small number of video or telephone sessions delivered to remote areas and none to very remote locations, and therefore the findings reported predominately reflect the connectivity difficulties experienced in rural areas. Second, data were not collected about the type of the device the participant used (smartphone/tablet or computer), internet provider  their internet connection  or subscription option (prepaid or post-paid), and therefore we were unable to determine whether these factors were associated with connectivity difficulties during the video sessions. Future research should collect such information to assess whether these factors are associated with connectivity difficulties. Third, participants were recruited via online and traditional recruitment methods and therefore there may be self-selection bias. It is, however, important to note that the recruitment methods used in this study are the same as those used by real-world quitlines to enroll clients into their services. Therefore, our study recruited people seeking treatment, which is the sub-group that quitlines and other smoking cessation services target to use their services. Fourth, this study examined connectivity difficulties in video or telephone sessions in rural and remote areas of New South Wales, Australia, and there may be limited generalisability of the findings to other geographical locations. Fifth, the connectivity of the video and telephone sessions were only recorded from the service provider’s perspective and no information about the connectivity of each session was collected from the participant’s perspective.The connectivity of real-time video counselling and telephone counselling for smoking cessation was sufficiently achievable in rural locations. There were no factors identified in this study that were associated with connectivity difficulties in rural locations for either video counselling or telephone counselling. Quitlines and other smoking cessation providers could consider integrating a real-time video counselling option as part of their services. Further research is needed to examine the connectivity and feasibility of video sessions in remote and very remote areas.


Malnutrition is a common problem that often goes unrecognized. In a recent UTMB-OAIC funded pilot, we found 49% of older adults were at risk of malnutrition at hospital admission. Malnutrition is associated with increased length of stay, poorer patient outcomes, and higher risk of mortality. Also, malnutrition severity alters hospital reimbursement rates. In 2018, the UTMB health system recognized the need for institutional guidelines to help identify, diagnose, document, and code mild/moderate/severe malnutrition. At baseline, compared to similar academic medical centers, UTMB ranked in the bottom quartile for malnutrition diagnosis. A multidisciplinary committee formed with physicians, nurses, researchers, dieticians, coding, and information technology. Preliminary data from the pilot study found the Nutritional Risk Screen (NRS) had the best sensitivity, specificity, positive and negative predictive values. The NRS was made more user friendly with scripting/prompts in the electronic medical record (EMR) to improve consistency/compliance among nurses. The Subjective Global Assessment was used in EMR by dieticians to document malnutrition diagnosis. A Best Practice Advisory was created to give physicians the option to easily add malnutrition diagnosis to the problem list. Since “go-live” in February 2019, NRS completion improved from 10.6% to 70.0%. Coding of malnutrition increased from 3.7% to 5.8%. In a 6 month follow-up, 113 patients were found to have direct benefits from the new process, resulting in an estimated financial impact of $945,605. Going forward, we have identified multiple areas of continued education needs to further improve the implementation and uptake of the new screening tool and diagnostic processes.


Predictors of heavy or moderate alcohol drinking behavior have not been investigated using recent nationally representative survey data in Japan. This study investigated the effects of the predictors of heavy and moderate alcohol drinking in Japan using nationally representative survey data.Anonymous data from the 2013 Comprehensive Survey of Living Conditions in Japan were used to compare the predictors of heavy and moderate drinkers with those who abstain. Anonymized data that are resampled from all the survey data from the Ministry of Health, Labour and Welfare were obtained. Age group, marital status, living arrangements, educational level, household income, smoking status, and employment type were used as the explanatory variables. In addition, the drinking status  was used as the outcome variable. A multinomial logistic regression model was used, and an analysis comparing heavy drinkers and abstainers, as well as moderate drinkers and abstainers, was conducted.Moderate drinking was positively associated with high educational level or high household income for men and women, as well as married status for men. In addition, unemployment was found to be negatively associated with heavy drinking for men and women, and an unmarried status was also found to be negatively associated with heavy drinking for men. Moreover, lower educational levels and smoking prevalence were found to be associated with heavy drinking for men and women. Furthermore, living alone for men and working in a large-scale company for women were also found to be predictors of heavy drinking.The preventive measures for heavy drinking were suggested to be particularly needed for those with lower educational levels and smokers. A call for attention among men living alone and among female employees in large-scale workplaces is also needed. Alcohol consumption is a common behavior when interacting with others in Japan as well as in other Asian countries . The ageSocioeconomic factors are associated with heavy alcohol drinking in many countries, including Japan –11. The The data used were from the 2013 Comprehensive Survey of Living Conditions, a survey conducted annually to investigate the household and income status of Japanese citizens. Moreover, a survey for health and savings status is conducted every 3 years . More thsake,” with answer choices of “less than one gou (180 mL of sake),” “one gou or more and less than two gou,” “two gou or more and less than three gou,” “three gou or more and less than four gou,” “four gou or more and less than five gou,” and “five gou or more.” Gou is a familiar unit of alcohol beverage in Japan, and 180 mL of sake contains approximately 22 g of ethanol [sake is equivalent to approximately 500 mL of beer, 135 mL of shochu whose alcohol content is 20%, 110 mL of shochu whose alcohol content is 25%, 80 mL of shochu whose alcohol content is 35%, 350 mL of shochu whose alcohol content is 7%, 60 mL of whiskey, and 240 mL of wine [sake per day has been used as the definition of heavy drinking in previous studies [sake or more per day is considered to be associated with a higher risk of developing lifestyle-related diseases [sake per day. In addition, abstainers were defined as those who responded to the questionnaire that they rarely drink, quit drinking, or do not drink. Other respondents, except those whose drinking status was unknown, were classified as moderate drinkers.The attributes of nonheavy drinkers could be different between those who abstain (abstainers) and moderate drinkers. Therefore, drinking status was divided into three groups: heavy drinkers, moderate drinkers, and abstainers. Two questions were asked about drinking status in the survey questionnaire. The first question was “How many days do you drink alcoholic beverages in a week?” with answer choices of “every day,” “5–6 days per week,” “3–4 days per week,” “1–2 days per week,” “1–3 days per month,” “merely drink,” “stop drinking,” and “not drinking.” The second question was “How much do you drink per day in a drinking day in terms of  of wine . Althougdiseases . Therefolow (elementary or junior high school), middle , and high . Those whose educational level was unknown were classified as unknown. Moreover, household income levels were classified into four levels based on quantile. Employment type was classified into six statuses: working for a large-scale company , working for a medium-scale company (30–1000 employees), working for a small-scale company (< 30 employees), self-employed, others , and unemployed. Smoking status was classified into two statuses: smokers (smoking every day or sometimes) and nonsmokers (former smoker or never smoker). Employment status  was also asked in the survey questionnaire, although it was asked only on a fraction of the workers and was not used in this study.The respondents were classified into six groups based on 10-year age groups  for respondents between 20 and 79 years old. Alcohol drinking is legally permitted at 20 years old in Japan. Thus, subjects who were ≥ 20 years old were utilized. Four types of marital status  were identified. The respondents who were divorced and widowed were grouped into a single status because the number of widowed participants was relatively small. The participants were classified into two statuses for living arrangements based on the number of household members: living alone and living with others. Furthermore, the six educational levels of the survey were classified into three statuses: https://cran.r-project.org/).Participants were removed from the study if their anonymized data on working, alcohol drinking, or smoking statuses were unavailable because these variables were essential for the analysis. Moreover, participants between 20 and 79 years old were used for the analysis. A multinomial logistic regression model was used, and an analysis comparing heavy drinkers and abstainers (reference), as well as moderate drinkers and abstainers (reference), was conducted. A multivariate analysis using all the explanatory variables was conducted, and the adjusted odds ratio of each explanatory variable was calculated. The association between drinking status and socioeconomic factors was difficult to examine in older individuals because older individuals tend to be unemployed compared with younger people. Therefore, a subgroup analysis was also conducted targeting participants between 20 and 59 years old in addition to the analysis of all participants as was also done in a previous study . All staFigure Table Table Table This study analyzed the nationally representative survey data from 2013 and found that household income was not associated with heavy alcohol drinking when adjusting for other factors  although these factors were shown to be associated with heavy drinking. Moreover, the association between each factor and heavy or moderate alcohol drinking was discussed below.The prevalence of heavy and moderate alcohol drinking largely varied depending on age, particularly in men. The prevalence tended to increase with age for men and decrease from the middle ages for women according to a previous study on the prevalence of alcohol drinking in Japan . This isNever-married men were significantly less likely to be heavy alcohol drinkers than married men. In other countries, marriage has been shown to have a protective and harmful effect against alcohol abuse , 20. HowLow educational level for men and middle educational level for women were significantly associated with heavy drinking. The prevalence of moderate drinking was significantly lower for individuals with these educational levels compared with higher educational levels. Consequently, alcohol abuse, but not alcohol consumption, was shown to be related to lower educational levels in this study. A previous regional study also showed the association between low educational background and heavy drinking in men  because Household income was not associated with heavy alcohol drinking. A previous study in 2001 showed the association between the lowest income level and heavy alcohol drinking for women but did not consider educational level . ConsequSmoking prevalence was significantly associated with heavy drinking, regardless of gender and age subgroups. Smoking and alcohol dependence are known to co-occur, and several studies have shown the association between smoking prevalence and alcohol consumption –25. ConfThis study has some limitations. First, self-reported data were analyzed. Therefore, inaccurate responses were possible. In addition, answering patterns  may be related to the predictors. Moreover, the regional data where each individual lived could not be used although a previous study inducted urban areas as a potential risk factor for excess alcohol drinking . FurtherHeavy drinking was positively associated with smoking and lower educational background. Additionally, an association was also observed among men who were living alone. Some previous studies indicated the associations between each of these factors , 28, andThe 2013 nationally representative survey data were used to investigate the effects of the possible predictors of heavy and moderate alcohol drinking. Consequently, lower educational levels and smoking prevalence were found to be positively associated with heavy drinking for men and women. Living alone for men and working in a large-scale company for women were also found to be predictors of heavy drinking. Moreover, unemployment was negatively associated with heavy drinking for men and women. Therefore, preventive measures for heavy drinking are needed for high-risk groups, such as smokers and those with lower educational backgrounds. Also, a call for attention among men living alone and among female employees in large-scale workplaces is needed.


Although several patient education materials on colonoscopy preparation exist, few studies have evaluated or compared them; hence, there is no professional consensus on recommended content or media to use.This study aims to address this need by developing and evaluating a new video on colonoscopy preparation.We developed a new video explaining split-dose bowel preparation for colonoscopy. Of similar content videos on the internet (n=20), the most favorably reviewed video among patient and physician advisers was used as the comparator for the study. A total of 232 individuals attending gastroenterology or urology clinics reviewed the new and comparator videos. The order of administration of the new and comparator videos was randomly counterbalanced to assess the impact of presentation order. Respondents rated each video on the following dimensions: information amount, clarity, trustworthiness, understandability, new or familiar information, reassurance, information learned, understanding from the patient’s point of view, appeal, and the likelihood of recommending the video to others.Overall, 71.6% (166/232) of the participants preferred the new video, 25.0% (58/232) preferred the comparator video, and 3.4% (8/232) were not sure. Furthermore, 64.0% (71/111) of those who viewed the new video first preferred it, whereas 77.7% (94/121) of the participants who viewed the new video second preferred it. Multivariable logistic regression analysis also demonstrated that participants were more likely to prefer the new video if they had viewed it second. Participants who preferred the new video rated it as clearer and more trustworthy than those who preferred the comparator video.This study developed and assessed the strengths of a newly developed colonoscopy educational video. The lifetime risk of developing colorectal cancer is 4.5% among men and 4.2% among women in the United States . The chiColonoscopy is an invasive test, and there can often be a considerable amount of anxiety associated with this procedure . One wayMost importantly, there are no previous studies that have comparatively evaluated different educational videos. Therefore, physicians and clinical practice groups have little information to guide them in the selection of enhanced educational materials, including educational videos. As such, current guidelines do not recommend specific enhanced instruction materials for colonoscopy preparation, in either written or video format .The field of social psychology has paved the way for evaluation studies examining participants’ responses to two or more targets . However, very little research has been conducted by applying this methodology to compare different health-related resources such as videos. Arazy et al  developeMurdock  publisheThis research builds on existing research evaluating patient-oriented educational videos by having the same individuals compare 2 videos directly. As the goal of a new video is to be an improvement over currently available videos, we were interested in how the new video compared with an existing high-quality video in terms of quality and patient preference. The new video assessed in this study was developed by our research team. At the time of video development, we were unable to identify a video that clearly described the split-dose method of bowel preparation. The new video was conceptualized to address this content gap, as split-dose bowel preparation has been shown to lead to superior bowel cleansing and higher colonic polyp detection rates ,26. SpliIn 2017, our research team developed a project titled “Optimizing colonoscopy procedures and reducing unnecessary and over use” and explored the information needs and preferences of patients undergoing colonoscopy . On the To supplement the written materials available on the MyColonoscopy website, our team developed 2 colonoscopy educational videos. The content for the step-by-step patient education video on preparation was informed by a study that included the development of a novel patient educational booklet . A recenThe comparator video was selected by searching YouTube with terms such as “colonoscopy preparation,” “preparing for colonoscopy,” “colonoscopy prep,” and “bowel prep.” The results yielded several (n=20) videos that varied in length (some were too long compared with the length of the new video), varied in the amount of information provided on the process of bowel preparation, and did not involve a demonstration of the preparation. Ultimately, we narrowed it down to 3 videos that were relatively short (under 10 min) and focused on the bowel preparation aspect of colonoscopy. We then surveyed the expert advisory  and patient advisory groups (mentioned above) by asking them to rate each video on the following dimensions: amount of information, clarity, trustworthiness, ease of viewing and understanding, novelty or familiarity of the information (very familiar to very new), reassurance (very worried to very reassured), information learned, understanding from the patient’s point of view, appeal, and whether they would recommend the video to someone undergoing colonoscopy. The highest-ranked video was from the University of Utah Healthcare and made for a strong comparison with our new video (the video is 3 minutes long). Reference to the video developer or originating site was removed from both videos for evaluation purposes.Participants were recruited from the waiting rooms of gastroenterology and urology clinics at the 2 largest hospitals and 2 community-based outpatient gastroenterology clinics in Winnipeg, Manitoba. The patients were seen in this setting for consultation on a wide variety of gastrointestinal and urological problems. Participants were invited by a research assistant to complete a survey evaluating the 2 colonoscopy videos. If the person agreed, the research assistant provided them with an information sheet with a brief description of the study and a web address to complete the survey on the web. They could complete the web-based survey at their convenience. A total of 3 different recruitment approaches were used to recruit participants from the clinics. First, some participants were given a Can $10 (US $7.47) gift card when they agreed to participate but before the completion of the survey; this had a response rate of 46.0% (127 of 276 who were approached to participate completed the survey). Second, some participants received a gift card after completing the survey; this had a response rate of 43.8% (77/176). A final recruitment approach involved emailing invitations to participants who had completed previous survey studies by our group. This group received a gift card after completion . The overall response rate was 45.3% (232/512). All participants reviewed the videos independently after they left the clinics.Participants were asked to review one at a time the new and comparator videos, where the order of video presentation was randomly counterbalanced. They were then asked to rate each video on the following dimensions: amount of information, clarity, trustworthiness, ease of viewing and understanding, novelty or familiarity of the information (very familiar to very new), reassurance (very worried to very reassured), information learned, understanding from the patient’s point of view, appeal, and whether they would recommend the video to someone undergoing a colonoscopy. These dimensions were rated using a 5-point Likert-type scale. Open-ended questions included likes and dislikes about the videos and suggestions for improvement. After the participants viewed both videos and responded to these questions, they were asked, “Which video do you think would be most helpful for people who are considering having a colonoscopy?” They were then asked 4 comparison questions on similar dimensions to those described above . Finally, they were asked an open-ended question about why their preferred video was better than the other video. Participants were also asked background questions, including age, sex, primary language spoken, education, history of gastroenterology visits, and history of a colonoscopy. The survey questions used in this study are given in IBM SPSS statistics version 24.0 was used to conduct the data analysis. Descriptive statistics (including means and proportions) were used to summarize sociodemographic information and the responses to questions about video ratings and preferences. Confidence intervals are reported as they are typically used in survey research and allow for convenient comparisons within and across different survey questions and groups of respondents. Confidence intervals have been recommended rather than pairwise significance tests for this type of comparison as they help the reader understand the magnitude of differences rather than simply concluding whether a difference is statistically significant ,35.Logistic regression was used to examine the predictors of preference for the new video. The following predictors were used: order, previous colonoscopy, gender, age, education, and language most often spoken at home. A median-split approach was used to transform age and education into dichotomous variables.Open-ended questions were analyzed using a descriptive content analysis approach . AuthorsAs can be seen in Overall, 71.6% (166/232) of the participants preferred the new video, 25.0% (58/232) preferred the comparator video, and 3.4% (8/232) were not sure. By comparing with the 2 videos , it was familiarity).r=.1), medium (r=.3), and large (r=.5) Pearson correlations. For the new video, almost all the correlations were significant at the .01 level. For instance, there were moderate and significant positive correlations for clarity and trustworthiness, ease of watching or understandability, reassurance, patient’s point of view, appeal, and likelihood of recommending the video to others. Familiarity was not related to most variables; however, it was positively associated with the information learned. A very similar pattern was observed for the ratings of the comparator video. The small-to-moderate size of most correlations suggest that the concepts are related but not completely overlapping. Appeal and recommendation of the video to others had moderate-to-large positive correlations in most categories, suggesting that these 2  are summarizing variables.red flags  related to the preparation.In the content analysis of open-ended questions, we found that many participants liked the amount of information or details in the new video, whereas others felt that the new video contained too much information and thought that the video was too long. The amount of information in the new video was identified as a strength among those who preferred it. On the other hand, the shorter video length was identified as a strength among those who preferred the comparator video. Many participants commented on the pacing of the video and found the narration in the new video to be easier to listen to and follow; many felt that the pace of the comparator video was too fast. Regardless of the video, clarity of the information was important to viewers. Visuals and graphics within the video were important for a few respondents. A few participants indicated that they would have liked information about We have developed and assessed patient preferences for a new colonoscopy educational video. This is one of the first studies to evaluate revised educational materials and directly compare them with existing materials among a group of participants (a within-subject design). It builds on a recently published study by our group  that outAn order effect was demonstrated in the previous study and in this study. Participants were twice as likely to prefer the new video if they had viewed the comparator video first—the recency effect; that is, if the new video were viewed second, it was more strongly preferred. These findings emphasize the importance of counterbalancing in a comparative design study to ensure that order effects are assessed and accounted for. There has been little previous research done in this area, particularly regarding the evaluation of health information, including patient colonoscopy preparation educational materials.In this study, we also examined whether there was a difference in response rate using different recruitment methods. A similar response rate among different recruitment methods suggested that the participants were unlikely to complete the survey if they were provided a gift card before the completion of the survey. It will be more efficient  in future studies to provide a gift card after the completion of the survey.We are not aware of any previous study that compared 2 colonoscopy educational videos in a randomized controlled trial (RCT). An RCT compared standard written colonoscopy preparation instructions with written instructions and a video that provided visual instructions about the preparation process . PatientIn our study, almost three-quarters of individuals who had previously undergone a colonoscopy preferred the new video. This is probably because of the fact that people who have previously undergone colonoscopy have a better understanding of the effort and steps required to prepare and undergo the procedure compared with those who have not. However, most participants, regardless of their colonoscopy experience, still preferred the new video. Regardless of previous colonoscopy experience, colonoscopy procedure can still cause significant anxiety in patients. Providing higher quality educational materials can help alleviate some of this anxiety . The newGiven that many patients do not feel adequately informed about the colonoscopy procedure , it is cThis study has a few limitations. First, most participants were enrolled in this study through waiting room recruitment; therefore, whether the results would be generalizable to those coming directly for colonoscopy will need to be evaluated in future studies. Although the overall response rate was reasonable , we cannot comment on the perceptions of nonrespondents, as in any other survey study. The survey included a reasonable number of people  with no previous experience with colonoscopy. The survey included mainly older adults and had a limited number of people who were younger, did not speak English at home, and had very limited education. This may limit the generalizability of the findings to these other groups.good educational video on the web increases the likelihood of primary care practitioners providing information on bowel preparation for colonoscopy to patients and/or encourages patients to ask for the split-dose method of bowel preparation (more efficacious but involving early morning awakening). A final area of future study should be the effects of video length and presentation on its effectiveness .We have developed a new colonoscopy educational video based on the reported needs of patients and health care providers and demonstrated patients’ preference for this new resource as compared with a high-quality video. We have also developed an approach to evaluate and compare different educational materials, which yielded a preference for the new educational video. This study extended our previous findings with counterbalanced presentation of information , demonst


The present study sought to investigate the efficiency and safety of slanted bilateral lateral rectus recession for the treatment of convergence insufficiency-type intermittent exotropia.This retrospective study included 34 patients who underwent slanted bilateral lateral rectus recession for convergence insufficiency-type intermittent exotropia in Shandong Provincial Hospital affiliated to Shandong First Medical University between September 2013 and October 2015 with a minimum follow-up of 6 months. A successful surgical alignment was defined as + 5 (positive for esotropia) to − 10 (negative for exotropia) prism diopters (PD) of orthotropia in the primary position while viewing distant or near targets and a near-distance deviation difference ≤ 8PD.P < 0.001). Each millimeter of difference between the upper and lower poles of the lateral rectus recession was associated with an improvement of 5.65 PD in the near-distance deviation difference. At the final follow up, a near-distance deviation difference of ≤8PD was found in 32 (94.1%) patients. None of the patients developed A-V pattern, torsional diplopia, or restricted abduction of the eyes.The mean age of the patients at surgery was 7.09 ± 3.80 years . The mean distance deviations were − 26.09 ± 6.5 PD  and the mean near deviations, − 37.21 ± 6.3 PD  preoperatively. The mean recession amount of upper pole of the lateral rectus was 5.97 mm  and that of lower pole of the lateral rectus, 7.49 mm . At a mean follow-up of 15.0 months , the surgical success rate was 70.6% (24/34), the under-correction rate was 17.6% (6/34), and the overcorrection rate was 11.8% (4/34). The mean near-distance deviation difference was significantly reduced from 11.12 ± 2.06 PD  preoperatively to 2.47 ± 3.04 PD  postoperatively (Slanted bilateral lateral rectus recession may successfully reduce the distance and near exodeviations and the near-distance deviation difference, thus was proved to be an effective and safe procedure for the treatment of convergence insufficiency-type intermittent exotropia. Convergence insufficiency-type intermittent exotropia (CI-IXT) is defined as exodeviation greater at near than at distance by at least 10 PD . SurgicaIn this retrospective study, the data of 34 patients with CI-IXT who underwent SBLR-rec between September 2013 and October 2015 were analyzed. Informed written consent for the surgical procedure was obtained from adults patients or parents or guardians of the children (<18 years) before surgery according to a protocol approved by the Medical Ethics Committee of Provincial Hospital affiliated to Shandong First Medical University for the protection of human subjects (No.2018–056). Inclusion criteria were as follows: the patients with CI-IXT (greater at near than at distance by at least 10 PD); best-corrected visual acuity in the worse eye 20/40 or better and with interocular difference of visual acuity no more than one line; deviation at distance between − 15 and − 35 PD by the prism and alternate cover test after proper optical correction; myopia or hyperopia <5.00D, astigmatism ≤2.00D (based on cycloplegic refraction) and anisometropia≤2.00D. Exclusion criteria were as follows: histories of strabismus surgery, myopic overcorrection, or convergence or fusion exercises; paralytic or restrictive strabismus; A or V pattern; oblique muscle overaction; vertical deviation greater than 5 PD; ocular disease other than strabismus; congenital anomalies or neurological disorders.Complete ophthalmologic and orthoptic evaluations were performed for each patient, including best-corrected visual acuity, cycloplegic refraction, anterior segment assessment, fundus examination, and motility evaluation. After proper optical correction, the deviations at distance (6 m) and near (33 cm) of each patient were measured by prism and alternate cover tests with fixation on accommodative targets. General or local anesthesia was performed according to the age or cooperation level of the patients. All surgeries were performed by the same surgeon. Following a conjunctival cul-de-sac incision, the muscle was disinserted, recessed and sutured directly to the globe. The upper pole of the muscle was recessed according to the distance exodeviation and the lower pole according to near exodeviation. Surgical doses for the LR recession were calculated primarily based on Park’s method .Postoperatively, the follow-up visits were scheduled at 1 day, 6 weeks, 3 months and 6 months. As in our previous studies , alternaA successful surgical alignment was defined as an exodeviation (exophoria/ tropia) of − 10 PD or less and esodeviation (esophoria/tropia) of + 5 PD or less in primary gaze while viewing distant or near targets, and the N-D deviation difference ≤ 8PD. Under-correction was defined as postoperative exodeviations > − 10 PD or the N-D deviation difference > 8PD. and overcorrection were defined as postoperative esodeviation > + 5 PD.p value of < 0.05 was considered statistically significant.All analyses were performed with SPSS17.0 . Paired t-test was used to analyze the preoperative and postoperative the N-D deviation differences. A Thirty-four patients were enrolled in this study with 23 males and 11 females. The characteristics of the subjects were shown in Table P < 0.001) (Table Table 1) Table . The meaEach millimeter of difference between the upper and lower poles of the LR recession was associated with an improvement of 5.65 PD  in the N-D deviation difference. Till the last follow up, A-V pattern, torsional diplopia, or restricted abduction of the eyes has been observed in none of the patients.In recent years, various surgical procedures for CI-IXT include unilateral or bilateral MR resection(s) with or without adjustable sutures , slantedAlthough the success rates vary, the mean N-D deviation difference in these studies were mostly reduced significantly , 2, 14. The present study indicated a prominent overcorrection rate (67.7%) 1 day postoperatively with a mean deviation angle of 8.38 ± 8.08PD at distance and 4.06 ± 9.39PD at near, which was similar to our previous study  and KwonTo explain the physiologic mechanism of the SBLR-rec for CI-IXT, Snir  considerIn Farid and Abdelbaset’ study , at the The present study is limited by a few factors such as the retrospective nature, and the relatively short follow-up period. As over time, an exotropic drift would happen, which results in a further reduction of the surgical success rate. Even so, the study demonstrated that SBLR-rec procedure is effective in reducing the deviation angles of CI-IXT patients at distance and near, and also in reducing the N-D deviation difference.In summary, our data indicates that SBLR-rec for CI-IXT may successfully reduce the distance and near exodeviations and the N-D deviation difference, thus was proved to be an effective and safe procedure for the treatment of CI-IXT.