The pathogenesis of interstitial cystitis/bladder pain syndrome (IC/BPS) has not been elucidated, but urinary microorganisms and metabolites have been shown to be closely associated with the inflammatory response of IC/BPS. Nevertheless, the exact mechanisms related to this response have not been clarified.16S rRNA sequencing and untargeted metabolomics techniques were used to analyse the urinary microbial and metabolite profiles of 30 IC/BPS patients and 30 healthy controls, and correlation analyses were performed to explore the mechanisms by which they might be involved in the inflammatory response of IC/BPS.Lactobacillus and Sphingomonas, were identified. A total of 44 differential metabolites such as 1,3,7-trimethyluric acid and theophylline were screened. The abundance of Lactobacillus and Escherichia-Shigella was significantly higher in the urine of female IC/BPS patients and healthy controls compared to males, while Bacteroides and Acinetobacter were lower than in males. The results of the Pearson correlation analysis suggested that differential microorganisms may influence the composition of metabolites. The Lactobacillus genus may be a protective bacterium against IC/BPS, whereas Sphingomonas may be a pathogenic factor. The differential metabolite theophylline, as an anti-inflammatory substance, may downregulate the inflammatory response of IC/BPS.Twenty-eight differential genera, such as This study revealed microbial and metabolite profiles in the urine of IC/BPS patients versus healthy controls in both males and females. We also found some microorganisms and metabolites closely related to the inflammatory response of IC/BPS, which provided directions for future aetiological and therapeutic research.The online version contains supplementary material available at 10.1186/s12967-023-04115-5. Interstitial cystitis/bladder pain syndrome (IC/BPS) is a clinical syndrome characterized by symptoms such as urinary frequency, urgency, and bladder and/or pelvic pain . IC/BPS Lactobacillus, is low and that women with a lower abundance of Lactobacillus in their urine have an increased risk of IC/BPS-related symptoms , and p values were calculated based on the Fisher-Z transformation. Statistical analysis was performed using R 4.1.3 and the statistical package for the social sciences . Normally distributed numerical variables were described by the mean ± standard deviation (X ± s), and a two-tailed Student's t test was used to compare the differences between groups. Nonnormally distributed data were described by quartiles, and the Wilcoxon test was used to analyse the intergroup differences. Categorical variables were described as percentages, and the chi-square test or Fisher’s test was used for the comparison. The correlation analysis between differential metabolites and differential microorganisms was performed by Pearson correlation analysis, and a P < 0.05 was considered to be statistically significant.P > 0.05). The BMI of the IC/BPS group was lower than that of the healthy control group . IC/BPS-related clinical symptom scores were determined for all participants. In the IC/BPS group, the VAS (2.40 vs. 0.30), PUF (16.70 vs. 4.33), ICSI (13.80 vs. 1.87), ICPI (11.37 vs. 1.57), SDS (53.23 vs. 40.27), and SAS (54.20 vs. 41.78) scores were significantly higher than those in the control group (P < 0.01), as shown in Table A total of 30 IC/BPS patients and 30 age- and sex-matched healthy controls were included in this study. There were no significant differences in basic clinical information such as age, sex, marital status, fertility status, and smoking or not between the two groups of participants . Detailed 16S sequencing information for IC/BPS and control patients are provided in Additional file Ralstonia, Lactobacillus, Acinetobacter, Prevotella and Escherichia-Shigella, Brevibacillus, Bradyrhizobium, Rikenellaceae, and Pseudomonas. There were significant differences in species composition and abundance between the two groups at the genus level. The abundance of Ralstonia in the IC/BPS group was significantly higher than that in the control group, while the abundance of Lactobacillus and Acinetobacter in the IC/BPS group was significantly lower than that in the control group.We counted and analysed the microbial community composition of the IC/BPS group and control group at each bacterial taxonomic level . Limited by the sequencing depth of 16S rRNA, many microorganisms at the species level could not be identified, so we focused on the analysis of microorganisms at the genus level. The species stacking diagram Fig. A visuallLactobacillus and Escherichia-Shigella were significantly higher in females than in males in the IC/BPS group and control group, while the abundances of Bacteroides and Acinetobacter were higher in males than in females. We also found that there were significant differences in microbial composition and abundance between the IC/BPS group and the control group of the same sex. For example, the abundance of Lactobacillus in the control group was significantly higher than that in the IC/BPS group, while Ralstonia in the IC/BPS group was higher than that in the control group, which further indicates that the urinary flora of IC/BPS patients has been significantly changed.The results of differential genus analysis between males and females Fig. B showed t test, P < 0.01) was performed between the IC/BPS group and the control group, and the results are shown in Fig. Lactobacillus, Acinetobacter, Brevibacillus, Pseudomonas, Stenotrophomonas, and Azospirillum in the IC/BPS group were significantly lower than in the control group, while the abundances of Ralstonia, Bradyrhizobium, Sphingomonas, and Bosea were significantly higher than those of the control group (P < 0.01). LEfSe analysis results : carbohydrate metabolism, amino acid metabolism, lipid metabolism, energy metabolism, cofactor, and vitamin metabolism, nucleic acid synthesis and decomposition, production of metabolites, cell growth and death, environmental adaptation, signal transduction, etc.According to the species annotation and abundance information of OTUs, we predicted the gene functions and pathways that might be affected by the differential microorganisms. The results Fig. A showed Ralstonia, Bradyrhizobium, Sphingomonas, and Bosea were positively correlated with SDS, ICSI, ICPI, PUF, and VAS scores, while demographic characteristics such as age, sex, and fertility status had relatively small impact.To study the correlation between age, sex, fertility status, BMI, and other demographic characteristics and clinical symptoms of IC/BPS patients and healthy controls with their urinary flora, we carried out a correlation analysis between differential bacteria and environmental factors . The correlation heatmap Fig. B shows tFirst, we performed a quality control analysis, and the red QC samples in the PCA plot were densely distributed, indicating that our research results were reliable Fig. A, B. TheTo explore the functions of differential metabolites and the metabolic pathways that they may participate in, Kyoto Encyclopedia of Genes and Genomes (KEGG) functional annotation and metabolic pathway enrichment analysis were conducted for differential metabolites. The results Fig.  showed tRalstonia, Bradyrhizobium, Sphingomonas, Bosea, and Undibacterium. The genera that were significantly lower in the IC group than in the control group were as follows: Lactobacillus, Gardnerella, Achromobacter, Atopobium, Megasphaera, and Peptostreptococcus. A total of 10 differential metabolites were identified, and the metabolites in the IC/BPS group were significantly lower than those in the control group: dihydro-2-methoxy-2-methyl-3(2H)-thiophene, 2-phosphinomethylmalate, disodium malate, 2-bromo-1H-indole-3-carboxaldehyde, erythroprono-1,4-lactone, 1,3,7-trimethyluric acid, and theophylline. The metabolites in the IC/BPS group were significantly higher than those in the control group: potassium dichromate, MC-7181, and 1-methylguanine. We found that Sphingomonas was negatively correlated with the contents of the differential metabolites dihydro-2-methoxy-2-methyl-3(2H)-thiophene and theophylline, while the abundance of other differential genera and differential metabolites were positively correlated. We plotted correlation networks .Since it is difficult to accurately identify microorganisms at the species level with 16S sequencing, we focused on the correlation between differential microorganisms and differential metabolites at the genus level. At the genus level, a total of 11 differential microorganisms associated with differential metabolites were identified, of which the genera in the IC/BPS group were significantly higher than those in the control group: The commensal microorganisms and pathogenic microorganisms in the human urinary system together constitute the microecosystem of the human urinary system. Both an increase in pathogenic microorganisms and a decrease in probiotics may lead to bladder disease through a variety of mechanisms. Urinary microbiota may produce small molecules that interact with the nervous system and play a role in the regulation and maintenance of bladder function. Commensal bacteria may form a protective barrier in urothelial cells, produce antibacterial compounds, and degrade harmful products, thereby defending against the invasion of foreign urinary pathogens, and pathogenic microorganisms may directly lead to the occurrence of bladder inflammation or may attack commensal bacteria, resulting in an imbalance of the flora in the urinary system and indirectly leading to the occurrence of bladder diseases. Urinary metabolites not only reflect the metabolic state of the human body but also may convey the pathophysiological information of urinary system-related diseases. Because urinary metabolites are easily affected by food, drugs, and nutrients, the metabolites of urinary microorganisms are also involved in the composition of urinary metabolites. Therefore, only analysing the correlation between urinary metabolites and diseases will result in large individual differences. Combined microbiome and metabolomics analysis of the characteristics of urinary microorganisms and metabolites in IC/BPS patients and the correlation analysis of differential urine microorganisms and differential metabolites will have more clinical significance.P > 0.01), but there was a significant difference in β diversity (P < 0.01). There were differences in the urinary microbiota between males and females in the IC/BPS group and the healthy control group, and the differences in bacterial genera of different sexes between the groups were significantly greater than the differences between males and females in the same group, suggesting that the urinary microflora structure of IC/BPS patients changed greatly. This study found that the abundances of Lactobacillus, Acinetobacter, Brevibacterium, Pseudomonas, Stenotrophomonas, and Azospirillum in the urine of IC/BPS patients were significantly lower than those of the control group, while the abundances of Ralstonia, Bradyrhizobium, Sphingomonas, and Bosea were significantly higher than those of the control group (P < 0.01). This study not only confirmed the findings of previous studies but also found many new differential microorganisms. The reason for the difference may be related to the fact that the patients included in this study all had severe lower urinary tract symptoms. This may also be because some male IC/BPS patients were included in this study, while most previous studies focused on female IC/BPS patients. In addition, different databases may be referenced in the analysis of different studies, which can also lead to differences in results. In this study, the SILVA (Version 132) database was used for taxonomic assignment to 16S rRNA reads and PICRUSt analysis.Previous studies on the urinary microbiota of IC/BPS patients mostly focused on women. In our long-term outpatient work, we found that there were also many male IC/BPS patients, and there was a trend of gradual increase. Therefore, 11 male and 19 female IC/BPS patients were included in this study. The healthy control group consisted of 10 males and 20 females with matched demographic characteristics. Our results showed that compared with the healthy control group, there was no significant difference in α diversity in the urine of IC/BPS group patients  could exert an immunomodulatory effect by reducing the level of mast cell degranulation [Ralstonia and Sphingomonas in the IC/BPS group than in the control group. Ralstonia is a low pathogenic microorganism, and its enrichment is associated with infectious diseases such as cystic fibrosis of the lung, osteomyelitis, and meningitis [Sphingomonas is an opportunistic pathogen, an emerging pathogen of hospital-acquired infections, and has previously been found to be the dominant genus in thymomas [Combining the findings of previous studies and the inflammatory mechanism of IC/BPS, we speculated that the differential genera bacteria –20. A labacteria –23. Furunulation . The resningitis , 26. Sphthymomas , 28. HowThe results of nontargeted metabolomics analysis showed that metabolites such as purine, allantoin, and o-hydroxyphenylacetic acid were significantly higher in the IC/BPS group than in the control group, and the increase in these metabolites may potentially increase the burden on the kidney and cause damage to renal function. Allantoin, a metabolite of purine, is an excellent biomarker of oxidative stress in humans . AnotherSphingomonas and levels of theophylline, and a positive correlation between the abundance of Lactobacillus and Gardnerella and levels of theophylline. These differential microbial-metabolite associations point to potential targets for further exploration of the specific mechanisms by which urinary microbes and metabolites are involved in the inflammatory response to IC/BPS.Most of the current studies on urinary microbial and metabolite alterations in IC/BPS are still preliminary explorations of the differences from the control group, and few involve in-depth studies of the mechanism. Although some studies have explored the combination of certain differential microorganisms and/or metabolites as diagnostic markers for IC/BPS, their sensitivity, and specificity still require further clinical validation , 13. ConIt should be noted that this study also has some limitations. First, the 16S rRNA sequencing method we employed can be used to identify microbes to only the genus level, and metagenomic sequencing was needed to identify the species level; the untargeted metabolomics analysis we used cannot obtain accurate differential metabolite concentrations, and targeted metabolomics analysis is necessary to accurately detect the concentration of target metabolites in future research. Second, the number of cases we included was small, and metabolites in urine were easily affected by local dietary habits, water quality, and urinary microbiota. Therefore, the results of this study need to be further confirmed by multicentre studies involving more patients from different regions.This study reveals the urinary microbial and metabolite profiles of IC/BPS patients, identifying some microorganisms and metabolites that differ in the urine of the IC/BPS group versus healthy controls, as well as between male and female patients. Combined with the results of the correlation analysis, we propose several urinary microorganisms and metabolites that may influence the inflammatory response to IC/BPS. Our preliminary findings provide a reference and preliminary basis for further studies on the mechanism of specific microorganisms and metabolites involved in the inflammatory response of IC/BPS.Additional file 1: Table S1. 16S rRNA sequencing information of IC/BPS patients and healthy controls.Additional file 2: Table S2. Urinary differential metabolites in IC/BPS group and control group.Additional file 3: Table S3. Qualitative and Quantitative results of urinary metabolites in IC/BPS group and control group by positive ion mode.Additional file 4: Table S4. Qualitative and Quantitative results of urinary metabolites in IC/BPS group and control group by negative ion mode.


To promote early childhood development (ECD), we require information not only on what needs to be addressed and on what effects can be achieved but also on effective delivery methods that can be adapted to local context. We describe design, implementation, and evaluation of a complex intervention to strengthen nurturing environment for young children.Study participants were pregnant women and their children from birth to 2 years. We used design and redesign, implementation, and evaluation approaches for the study. We co-created curriculum and delivery plan with stakeholders, based on the theoretical framework, findings from formative research, and our preliminary work. We recruited 656 pregnant women and newborns, 326 (49.69%) from intervention and 330 (50.30%) from the control group. We conducted a cluster randomized controlled trial to evaluate the program’s effectiveness. The outcomes of children were assessed at 12 and 24 months.At recruitment, study participants from both the study arms were similar in sociodemographic characteristics. We conducted 6,665 home visits, 25 toy-making workshops, and 65 caregiver-meetings. The initial examination of program data revealed gaps in quality and coverage of interventions. The intervention was redesigned based on feedback from stakeholders in community meetings. At recruitment, participants in both study groups had similar socio-demographics. We conducted 6,665 home visits, 25 toy workshops, and 65 caregiver meetings. Initial program data showed intervention quality and coverage gaps, leading to a redesign program based on community and stakeholder feedback. Post-re-designing, session quality improved, with program coverage rising from 32 to 98%. Male participation in home visits increased from 4.3 to 32.65%, and data errors reduced from 270 to 140 per month on average. At 24 months, program showed moderate–mild impact on ECD – cognitive , language , and socioemotional-development , moderate effect on home-environment and mother–child interaction. 96% of women initiated breastfeed within one-hour of delivery, and exclusive-breastfeeding rate of 89.80%.The study provides an evidence-based community centered ECD curriculum and implementation strategies to enhance service providers, and caregivers’ knowledge and skills for promoting ECD in low-resource settings with the potential to scale within existing Government Program.The trial was funded by the Saving Brains Round 5 Initiative of Grand Challenges Canada (Grant no. SB-1707-05084), and we are grateful for their ongoing support through online sessions and orientation workshops. The trial was also supported by the Indian Council of Medical Research (File No: 5/7/1693/CH/Adhoc/RBMCH-2020). The early years are crucial to ensure that each child reaches their productive and creative potential in adulthood , 2. To pA Holistic Early Childhood Development (ECD) fosters the overall growth of a child, with the various domains of child development collectively shaping a child’s development and growth. This includes their physical development , brain or cognitive development, language development, socio-emotional development and behavioral development.India’s national Integrated Child Development Service (ICDS) program was initiated in 1975 to tackle child malnutrition and illnesses. ICDS is one of the government’s most extensive and prominent initiatives that offer nutritional supplementation, immunization, height and weight monitoring, and non-formal education to children under six through Anganwadi Centers (AWCs). An Anganwadi Worker (AWW), operating at the grassroots level, is responsible for catering to a thousand population through an Anganwadi Center (AWC), with assistance from the Anganwadi Helper (AWH). However, the recent assessment of the ICDS programs recommended reinforcing the infrastructure, training, and support systems for AWC and staff. The report suggested an adapted curriculum and a framework to oversee the program implementation. Despite the primary emphasis of ICDS being on the early years of life, its efforts primarily revolve around nutritional supplementation and children’s healthcare needs. Unfortunately, the responsive parenting program, vital for fostering early childhood development, is considerably underrepresented within ICDS .In India, 55% of children under 6 months are exclusively breastfed. Although breastfeeding is nearly universal in Maharashtra, only 57% of children under 6 months are exclusively breastfed, as the World Health Organization (WHO) recommends. Encouragingly, 87% of infants are introduced to breastfeeding within the first day of their lives, but it drops to 57% for those who begin breastfeeding within the recommended first hour of life. In the context of child health, the infant mortality rate in Maharashtra in NFHS-4 is estimated at 24 deaths before the age of 1 year per 1,000 live births .Integrating parenting with nutrition interventions blended with traditional community-focused child-rearing approaches for Early Child Development (ECD) are evidence-based practices proven effective for ECD , 10–12. In this paper, we describe the design, implementation, and evaluation of a complex intervention to strengthen the nurturing environment for young children. The evidence for ECD intervention programs is well established; however, a critical design issue for such complex interventions is adequately addressing the sociocultural context and current childcare practices . Our proThis study aims to determine the effectiveness of the integrated responsive parenting and nutrition program on child development outcomes in children under 2 years from rural India. The study also reflects upon the cycle of design, implementation, and evaluation using the lens of the Measurement for Change , 20 to dThe study area was a hard-to-reach rural setting, remotely located in two Blocks of the Wardha and the Nagpur districts in central India. The study villages were in the Forest Buffer Zone, a Tiger Sanctuary. People in the study area had an average annual per-capita income below the state average and worked as unskilled daily wage laborers in forests, farms, or cattle rearing. The traditional socio-cultural customs greatly influence childcare practices in these regions. Availability and accessibility of education, health, and social services for people from these villages are challenging, and access worsens during the rains and summer. Women in these villages are overburdened; as they are traditionally responsible for childcare, they work for income and face gender-specific risks and vulnerabilities. Wages for women are lower than for men. This social and economic distress contributes to challenges to adequate nutrition and caregiving.We evaluated an integrated community-based intervention using a Cluster-Randomized Control Trial (C-RCT) design. We ensured all cluster members received similar interventions. Administratively, districts are subdivided into talukas or blocks in India. One taluka has around five Primary Health Centers (PHCs), and PHCs comprise five to six sub-centers (SCs). Sub-center caters to nearly five to six villages with a population of around 5,000. Each village has an Anganwadi center (AWC) catering to a population of 1,000 in a rural area.We selected two adjacent blocks in central India, the Seloo and the Hingna blocks. The study team has strong community linkages in these areas, so delivering intervention and data collection in selected blocks was convenient. Since the community volunteers administered the intervention at the village level (Anganwadi center area) and the villages are situated very close to each other, we defined the sub-center as a unit of randomization to minimize the risk of contamination across the intervention and control groups. We used a stratified randomization approach.The unit of randomization were sub centers. We randomly selected four PHCs comprising 21 sub-centers (clusters) and 106 villages from the study area. The 21 subcenters were randomly allocated using a random number sequence in the intervention and the control group. The random allocation of clusters were masked for the study team. The intervention group had 11 sub-centers (clusters) comprising 58 villages, and the control had ten sub-centers (clusters), including 48 villages. The intervention clusters received study intervention in addition to the routine ICDS services, while the participants from the control clusters received the routine ICDS services as part of the study .The participants were pregnant women and their children from birth to 2 years residing in selected villages. We recruited pregnant women in the first or second trimester of pregnancy, permanently residing in study areas after informed written consent. High-risk pregnancies have the potential to introduce confounding factors into the study, making it challenging to determine the true impact of the intervention. By excluding high-risk cases, we aimed to enhance the quality and reliability of the data, thereby reducing the likelihood of bias that could affect the child outcome assessment. Additionally, this exclusion not only prioritized the safety of high-risk pregnant women by referring them to specialized healthcare facilities but also enhanced the generalizability of our findings, increasing their relevance to a wider range of expectant mothers. We recruited the participants over a period of 6 months, during which we provided counseling to pregnant women and their families, explaining the nature and purpose of the study.We conducted formative research and collected data on the household, community, and environmental factors related to caregiving practices that influence the growth and development of children under 3 years through three group discussions at village levels and six interviews of Anganwadi workers, caregivers and other stakeholders. The formative research also explored the underlying beliefs and attitudes around childcare practices, nutrition practices, breastfeeding and complementary feeding practices, household decision-making, income levels, cultural traditions, and social norms around childcare. Additionally, the study team conducted three community meetings to understand the sociocultural and childcare practices and specific challenges to access health and childcare services. In these meetings, the study team informed the community about the proposed Project and sought their consent for intervention. We engaged the community at all levels including intervention design, implementation, and program monitoring. During these community meetings, through a collaborative approach, community members collectively selected Balsakhi- a community volunteer from the village to implement the intervention. The team also collected data on nutrition practices, including breastfeeding and complementary feeding practices, household decision-making, income levels, and cultural traditions and social norms around childcare.The development of a responsive parenting package drew its theoretical framework from Vygotsky’s Zone of Proximal Development (ZPD). The ZPD is a theoretical framework that focuses on the difference between a learner’s actual developmental level and their potential developmental level when provided with appropriate guidance and support. This concept involves nurturing independent actions, skills, and knowledge by offering the necessary scaffolding . Based oThe study team co-created a curriculum comprising locally/culturally appropriate play-based activities covering these six groups’ identified parental competencies. Community members, Anganwadi workers and supervisors, schoolteachers/early childhood educators, and other stakeholders participated in the curriculum development process. The enhanced nutrition program included a nutrition demonstration center and locally and culturally relevant recipes for pregnant women and infant and young child complementary feeding. The program linked the study participants with local Anganwadi centers to provide them with supplementary nutrition support. The program also integrated monitoring, evaluation, and learning (MEL) processes to track progress, direct adaptation for improved efficiency, and evaluate impact. Thus, the intervention package comprised age-appropriate content, curriculum, and necessary tools and materials. We designed tools to enable parents to use them with their children to promote their children’s cognitive, language, socioemotional, and physical development at 2 years of age.The intervention delivery approach was community-driven, as community-based programs are an essential service delivery approach for early childhood intervention in under-resourced and developing contexts. Community-based implementation provides scope for identifying and analyzing specific community issues and prioritizing, designing, and managing activities at the local level . Our delA ‘Balsakhi’ community volunteer delivered the intervention. Balsakhi is a local Marathi word, and it means ‘child’s friend.’ Balsakhi were women from the village, preferably married, with some education , and willing to volunteer for 2–3 h daily. We selected one Balsakhi for each study village by conducting interviews and administering written examinations to evaluate basic skills and trained them.The initial training spanned 3 days, certifying participants for conducting home visits, group sessions, and community workshops. During the Project’s initial phase, the Project Research Associates accompanied each Balsakhi to provide initial support. The Balsakhi received refresher training on a one-to-one basis whenever required. The Balsakhi were mentored and supported by Anganwadi workers from the same village to deliver the responsive parenting intervention in the respective villages. Competencies of Balsakhis are assessed through regular supervision, observations of their interactions with children and parents, and periodic evaluations to gauge their knowledge and performance in providing childcare and early education services. Each Balsakhi received a monthly honorarium for their services.The focus was on the early initiation of breastfeeding, exclusive breastfeeding, and the appropriate introduction of complementary feeding. The Balsakhi through 44 home visits delivered the intervention over 24 months. We trained the Balsakhi to deliver the session interactively, using activities and reflective practice. We equipped the Balsakhis with guidebooks, manuals, posters, flyers, flip charts, books, and toys to support session delivery. In addition to the material provided to Balsakhi, she was encouraged to use everyday household items in sessions. The trained and motivated Balsakhi to avoid being directive, adapt to the family’s needs, and keep the family actively engaged in developing their knowledge and skills as responsive parents.We organize a community workshop to support caregivers in preparing ECD play materials using accessible materials in alternate months. The workshops also demonstrated how to use the toys/play material, what development domain they stimulate, and what to observe while using the play material. The emphasis focused on health and safety issues when using the play materials. We provided the caregivers with a booklet and activity cards to guide them in toy making and play activities.We conducted monthly group meetings to create an enabling environment for ECD at the village level by intentionally building partnerships to support this process. The research assistants and Balsakhi coordinated these community meetings, inviting all stakeholders: Anganwadi workers, caregivers/parents, panchayat leaders, schoolteachers, volunteers, and the research team. We used a collaborative learning and sharing approach by inviting caregivers and parents to share their experiences around ECD and asking the larger group to reflect on those experiences. Based on the data, the stakeholders discussed the implementation progress and formulated a plan to improve intervention delivery and coverage. A total of 58 sessions were conducted in all the intervention villages.We created one demonstration center in each PHC area. The caregivers/mothers were invited to this demonstration center monthly for interaction and discussions on creating recipes for pregnant mothers and young children. In addition to these activities, we created a nutrition garden in households, wherever at least 200 square feet of space was available. Eighteen kitchen gardens were set up in the intervention villages. The Project team provided the seeds and saplings, whereas the household members sowed the seeds and maintained the nutrition garden. More preference was given to foods that were locally consumed.Each child received the program for 24 months. To ensure the coverage and fidelity of the intervention, we analyzed intervention data weekly and tracked information on utilization and engagement, as well as the quality of interactions. Data on attendance, meeting schedules, and using the intelligent register application to give personalized feedback to parents were collected on a PC tablet application. Program supervisors used this application to monitor activity, give feedback and initiate discussions with the delivery team to improve the quality and coverage of the intervention .Every participant in the study was enrolled in the standard services offered by Anganwadi centers, where children under six receive non-formal education, nutrition supplementation, and growth monitoring. Furthermore, the intervention group benefited from responsive parenting and enhanced nutrition initiatives delivered through home visits, group sessions, and community workshops. This intervention strategy synergizes with the existing components of the ICDS program, introducing an adaptable community-focused, responsive parenting curriculum for children under 2 years of age. The ICDS program’s Anganwadi Workers played a supportive role, guiding the Balsakhi and aiding in addressing challenges related to intervention delivery.At recruitment, the study team collected household sociodemographic data and antenatal characteristics of pregnant women using the Government of India Demographic Health Survey (DHS) tool . Field sDevelopmental Milestones Checklist (DMC) is a reliable and sensitive tool for evaluating motor, language, and personal-social development , 24. We The field staff who administered assessment tools received training and certification . The outAt recruitment, we captured the household information and mothers’ maternal characteristics using the Demographic Health Survey tool of the Government of India. At 12 months and 24 months, we assessed all child development outcomes (primary outcomes) – Physical, cognitive, language, and socioemotional development. We also evaluated mother–child interaction and home environment at 12 and 18 months of interventions.We aimed to detect differences of 0.3SD between the intervention and the control groups. The preliminary data from the study area calculated the child development score of 67 in the cognitive domain. We assume the Intra-cluster Correlation Coefficient (ICC) of child development as 0.02, with the average number of pregnancies per cluster per year as 30, resulting in the design effect 1.58. Hence, to detect the desired improvement of 0.3SD in development score in the intervention group, with 95% confidence and 80% power, a total sample size of 452 mother–child dyads. Based on the previous experience, we accounted for a 20% loss to follow-up. Thus, the final sample size is 542 from 21 clusters, 271 in each group. However, from an ethical perspective, we enrolled all eligible participants fulfilling the inclusion criteria from the intervention and the control clusters in the study.p < 0.05 for the statistical significance. We also estimated the intervention’s effect size at 12 and 24 months as ‘Cohens d’, as the difference in the adjusted mean between the intervention and the control group divided by the pool SD.We used STATA version 14 for analysis. We compared household and sociodemographic data from the intervention and the control group to ensure the robustness of the randomization process and to examine the characteristics of participants lost to follow-up. We used the intention-to-treat analysis to compare the child outcomes between the intervention and control groups at 12 months and 24 months by a mixed effect regression model adjusted for cluster and assessors and controlled for potential confounders . The mean child development scores for all domains are presented with a 95% confidence interval, considering We registered the trial with clinical trial registry of India under the CTRI Number: CTRI/2017/05/008553 on 15/05/2017. The Institutional Ethics Committee of Datta Meghe Institute of Medical Sciences (Deemed to be University) approved the trial vide letter with Ref no: DMIMS (DU)/IEC/2017–18/6306 dated 27.03.2017.We assessed 824 participants for eligibility and recruited 656 (79.61%) eligible women in their second trimester of pregnancy and their newborns. The intervention group had 326 (49.69%), and the control group had 330 (50.30%) participants at the enrolment. At 24 months, the study endpoint, 68 (10.36%) participants lost to follow-up.p = 0.965). At the endpoint, the mean wealth score was comparable to that at recruitment. Thus, the socio-economic status of the families was almost identical throughout the study period. Out of 656 newborns, 49.84% were boys, and 50.16% were girls.We conducted 6,665 home visits throughout the intervention period. The preliminary review of first-quarter intervention data revealed that home visits were directive, 139 (23%) were family-centered. In 360 (69.62%) home visits, the average duration was less than expected, and 68 (11%) took more than 60 min. Despite rigorous training and certification, monitoring data and interactions in monthly meetings with the Balsakhi revealed low motivation and confidence to deliver interventions. Based on the findings and feedback, we re-designed the intervention delivery approach and introduced the community supervisors to retrain, handhold, and mentor the Balsakhi. We randomly supervised 1,670 (25%) home visits to ensure quality.In the subsequent quarter, the indicator improved. Out of the total of 1,670 home visits supervised, 1,169 (70%) had interactive discussions, 1,458 (87.30%) used tools and other materials effectively during the session delivery, and in 295 17.66%) home visits, male members from the household participated in the discussion and participation of male members increased from 4.3 to 32.65%. The coverage of the home visits also increased from 31.93% in the first quarter of intervention to 98.6% in the 6th quarter. Out of 294 households from the intervention group, 190 (64.63%) families received more than 75% of home visits, and 104 (35.37%) households received less than 75% of planned home visits  and outreach staff coordinated these meetings. Anganwadi workers, community members, mothers, and other care providers attended these meetings. These meetings allowed participants to reflect on their learnings, gaps, or challenges in service delivery and potential solutions.We held monthly meetings of Balsakhi (service providers) at each PHC. We conducted 65 Balsakhi meetings to share experiences and reflect on their learnings and challenges. The field supervisors presented the monthly coverage data to the stakeholders and discussed coverage gaps and opportunities to reach out to those who missed out in the previous months. The refresher training sessions were conducted during these meetings, whenever needed, to enhance the skills and competencies of the Balsakhi for conducting home visits. During these meetings, the collaborative re-design process associated with improved delivery indicators was agreed upon. The community and Project staff meetings helped improve the quality and coverage of the intervention. Another paper presents the data on improving the service delivery indicators .p < 0.001). The intervention arm had a lower proportion of low birth weight newborns 68 (20.86%) than the control arm 88 (26.67%), but this difference was not statistically significant. However, the birth weight was significantly higher in the intervention arm 2.71 (SD 0.44) than in the control arm 2.61 (SD 0.45). Ninety-six percent of women started breastfeeding within 1 h of delivery and the exclusive breastfeeding rate was 89.80%.The average weight gain for women from the intervention group was 9.01 (SD 3.74) kilogram weight, which was significantly more than the weight gain in women from the control group  during pregnancy (p > 0.05). The effect sizes increased for cognitive , language , motor ; socioemotional development  at 24 months compared to 12 months of intervention. The intervention had a statistically significant effect on child development outcomes between the intervention and the control arm at 24 months  and motor domain . However, the difference was not statistically significant for language and socioemotional domains.The number of children with improved scores in the intervention group at 24 months was more compared to 12 months for the cognitive domain , motor development ; language development . The intervention had a lower effect on other wealth quantiles. Study participants below the poverty line as per the Indian Government’s categorization had a statistically significant minimal to moderate effect size on cognitive , motor , language  and socio-emotional development   .Our study also demonstrated that the effectiveness of a responsive parenting program integrated with nutrition intervention significantly affected the development of children under 2 years of age and promoted a conducive home environment and mother-to-child interactions. The optimum growth and development of children under three may break the cycle of inequality and vulnerability and lay the foundation for achieving sustainable development goals , 31.We co-created and implemented a responsive parenting and nutrition program delivered through community networks that included Government Anganwadi Centers for 24 months. The findings emphasized that community engagement, a theory-driven conceptual framework, and formative research are needed to design and implement complex interventions effectively. A paper by Bentley and colleagues also stressed a need to contextualize a program through an inclusive process and sustained stakeholder engagement to improve the quality of delivery .Our program’s key highlight was sustained community engagement. A ‘Balsakhi,’ meaning the friend of a child in the local language, delivered the entire intervention. Despite the well-conceptualized intervention, which draws upon the community’s strengths and is contextually appropriate, we faced challenges in intervention delivery by the community volunteers in the initial stages. Quality of service delivery was a primary concern, and data revealed coverage gaps, including community volunteers’ low motivation and engagement. Thus, we redesigned the implementation approach to motivate and engage service providers to deliver the intervention with fidelity. We appointed a community supervisor for handholding and mentoring community volunteers. Supervisors accompanied the community volunteers in at least 25% of the home visits. The implementation data revealed that the coverage improved over time and significantly improved the quality of intervention delivery. We presented the data in a separate paper, . We adopOur program included fortnightly home visits along with monthly group sessions. Our trial’s frequency of contact with caregivers was similar to earlier studies from India  and BangOur data showed a positive and statistically significant impact on the home environment and mother–child interaction. Mothers from the intervention group showed improved knowledge and skills for responsive parenting. Our study substantiates the findings of a systematic review that parenting interventions improve parenting knowledge, skills, parent–child interactions, and home environment are the critical pathways to bringing positive change in child development .The intervention had a maximum effect on Cognitive development, followed by language, motor, and socio-emotional development. Our results were comparable to the systematic review by Jeong and colleagues, which included 102 studies from 33 countries, concluding that parenting interventions in the first 3 years of life improve a child’s cognitive, language, motor, and socioemotional development and reduce behavioral problems .We observed that these effects on child developmental outcomes increased over time. Assessing the impact of the duration of the intervention on child development outcomes was not the primary objective of this trial; however, our data highlighted that the intervention given for a longer duration, that is 24 months, shows more benefits than an intervention delivered over 12 months. A systematic review published in 2021 reported a lack of evidence on the effect of variable program duration on child development outcomes . FurtherOne of the limitations of our study is that we should have included nutrition supplementation. However, to avoid duplication of services offered at the Anganwadi Centers under the current ICDS program of India, we linked the beneficiaries to the Anganwadi Centers for nutritional supplementation. In previous studies, direct nutrition supplementation within a parenting intervention has shown significant benefits for 24 months of child age , 43. TheOur program has several strengths. Despite the strong evidence from neurosciences and economics regarding the benefit of the intervention in the early years, most parenting interventions for cognitive and behavioral development are targeted at older children, at preschoolers . Our stuIn addition to the evidence of the combined effect of nutrition and responsive parenting programs on child development, our study has provided program and delivery level guidance to positively influence interventions’ quality, engagement, and sustainability. The needs-based approach we employed guides the rapid re-design of delivery mechanisms, which was associated with acceptance by the community and led to a shift in responsibility and accountability at a local level . To furtThe strength of our innovation is that it aligns with the recommendation of 2013 National Early Childhood Education and Care Policy of the Government of India, enhancing the potential for sustainable scaling. Our innovation was designed to address scalability and replicability, to establish self-sustaining village-level units that serve as models for neighboring communities, and to foster expansion. To ensure the sustainability and expansion of our program, we prioritized community engagement and ownership, engaging local stakeholders, parents, and community leaders in the design and implementation of our intervention. We optimized resource utilization by leveraging locally local assets and investing in capacity building, thereby reducing reliance on external funding. A robust monitoring and evaluation system built around shared accountability, ensures continuous assessment. Regular review of effectiveness and impact of the program enables data-driven adjustments to meet evolving needs. This comprehensive approach ensures our program’s lasting impact and continued expansion of the innovation, benefiting a wider population of children, their families and communities.To conclude, our study emphasized the importance of developing a conceptual framework integrating a theoretical model with formative research for designing and redesigning a complex intervention. The study provides an evidence-based, responsive curriculum, with implementation strategies grounded in social learning theory that enhance caregivers’ knowledge and skills for promoting early child development. Due to the pragmatic nature of the study, our intervention also has the potential to integrate within the existing Integrated Child Development Program in India.The original contributions presented in the study are included in the article/The studies involving humans were approved by Institutional Ethics Committee of Datta Meghe Institute of Medical Sciences (Deemed to be University) approved the trial vide letter with Ref no: DMIMS (DU)/IEC/2017-18/6306 dated 27.03.2017. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.ZQS and AG conceptualized the study and led the design as the primary author, analyzed data, and led the write-up. ST developed the data collection materials with inputs from ZQS, AG, and PH. PH and MNK oversaw the study, data analysis, and interpretation, and drafted the manuscript. PK and MP trained and supervised the data collection team. ST and AG oversaw the quality assurance. MP administrated the project work. SG, PK, PH, DS, and SC assisted with the write-up and participated in the study design, data analysis, and interpretation. All authors contributed to the article and approved the submitted version. All authors critically reviewed drafts of the manuscript.


The obstructive sleep apnea syndrome (OSA) is a highly prevalent condition. In Spain and other countries, only 5%–9% of patients with OSA have been diagnosed and treated. The lack of accessibility to diagnosis is considered the main cause of this situation through easy-to-use screening instruments, it is necessary to check their validity and reliability in the context where they are to be used.To validate the Spanish translation of the Berlin questionnaire for screening for moderate or severe OSA in patients aged 40 years or more detected in primary care.A descriptive observational study, with a first qualitative phase of transcultural adaptation to Spanish using the translation-back-translation method. Setting: primary care level of the Spanish National Health System. A total of 255 patients recruited from 7 healthcare centers completed the study. The Berlin questionnaire was administered to the recruited patients, and subsequently, a respiratory polygraphy was performed to confirm the diagnosis of OSA. The concurrent criterion validity of the questionnaire and its reliability in terms of internal consistency and reproducibility (intra-observer agreement) were analyzed.The patients’ mean age was 54.76 years , and 54.12% were men (95% CI: 47.96–60.27). We found that 61.57% (95% CI: 55.57–67.57) presented OSA (apnea-hypopnea index-AHI >5), and 45.5% (95% CI: 17.05–57.92) presented moderate or severe (AHI >15) OSA. The Berlin questionnaire, with a cut-off point of 4.5, showed a sensitivity of 76.77% (95% CI: 67.94–85.59), a specificity of 74.49% (95% CI: 65.35–83.63), a positive predictive value of 75.25% (95% CI: 66.34–84.16), a negative predictive value of 76.04% (95% CI: 66.98–85.10), and an area under the curve of 0.786 (95% CI: 0.721–0.851). Cronbach’s alpha coefficient was 0.730 (95% CI: 0.668–0.784), and the Kappa index was 0.739 .The Spanish adaptation of the Berlin questionnaire has good validity and reliability as a test for the diagnostic screening of moderate or severe OSA in patients aged 40 years or older. The findings of our study confirm that primary care physicians should use such screening tools to predict OSA. Obstructive sleep apnea syndrome (OSA) is a multifactorial clinical condition whose pathophysiology is produced by the conjunction of anatomical, muscular, neurological factors and other factors not yet identified, causing a collapse of the upper airway as a result of an imbalance between forces that tend to close it and those that keep it open, resulting in multiple episodes of complete (apnea) or partial (hypopnea) obstruction of the upper airway. This obstruction leads to poor sleep quality and intermittent hypoxemia with vascular repercussions . OSA is OSA is a highly prevalent condition , 3, 6–8.In Spain and other countries, only 5%–9% of patients with OSA have been diagnosed and treated. The lack of accessibility to diagnosis is considered the main cause of this situation . PolysomCurrently, no curative treatment is available for OSA, but the mechanical problem (upper airway closure) can be solved with the use of continuous positive airway pressure (CPAP) devices , 3, whicGiven the high hidden morbidity of OSA, and the lack of accessibility to the diagnostic procedures usually used, OSA screening tools, such as the Berlin questionnaire (BQ) , could bThe main aim of this study was to validate the Spanish translation of the BQ to detect moderate or severe OSA in a population aged 40 years or older residing in Spain. The specific objectives were: (a) to perform the transcultural adaptation of the BQ from English into Spanish, (b) to determine the criterion validity, and (c) to verify its reproducibility in terms and its internal consistency.Multicenter descriptive observational study to validate a measuring tool.The study has been carried out by the Andalusian Health System (SAS), part of the decentralized Spanish National Health System, which provides free universal health insurance to all Spanish citizens. The project was carried out in 7 primary care centers of the Córdoba-Guadalquivir Health District, located in the province of Córdoba, 5 of them urban and 2 rural.The selection criteria were: (a) inclusion criteria: patients aged 40 years or over, of both sexes, who attended the health center for any reason and gave informed consent. (b) Exclusion criteria: patients with a previous diagnosis of OSA or who, due to illness, cognitive status, or low level of studies, were not able to answer the questions of the BQ or to perform the HRP, or patients receiving hypnotics treatment or with chronic alcoholism problems.Based on results of previous studies , 12, andThe steps followed in the process of validating the BQ to Spanish were as follows:Transcultural adaptation: The reverse translation (forward-translation and-backward-translation) methodology was used for the cross-cultural adaptation of questionnaires for use in clinical research, proposed by the WHO . Forwardin situ simulation of the placement of all the device electrodes was performed. The instructor ensured that the patients had correctly assimilated all the information necessary for the device to be placed that same night, which must be returned the next day.Validation of the questionnaire BQ: In a second step, recruitment was conducted in the health centers opportunistically of the subjects meeting the selection criteria. A face-to-face interview was conducted with the subjects who agreed to participate in the study and signed the informed consent. In this interview, a form collecting sociodemographic data (age and sex), anthropomorphic data , and the BQ was completed. Subsequently, each patient was individually trained in the management of HRP, for which an The polygraph used was Screen & Go (Sibelmed), with 6 channels . The recording time for each study was 6 h. A total of 16 out of the 255 HRPs performed were not recorded correctly, so they were repeated the next day, obtaining valid values on this second occasion.Polygraphic studies were automatically analyzed by Bitmelad polygraph software and reviewed by an expert researcher in sleep-disordered breathing following the criteria of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR). This collaborating researcher remained blind to the result of the questionnaire. Between 6 and 8 weeks, a collaborating researcher, other than the one who previously collected the data, randomly selected a subsample of 31 people from all subjects recruited for the study to evaluate the reproducibility or reliability of BQ in terms of the intra-observer concordance. This interview was conducted by telephone. Fieldwork began in June 2019, had to be discontinued in 2020–21 due to the COVID-19 pandemic, and resumed in January 2022, ending in December 2022.The independent variables of the study were age, sex, body mass index (BMI = weight in kg/height in square meters), and neck circumference (in centimeters). The dependent variables were the apnea-hypopnea index (AHI), defined as the number of apneas plus hypopneas per 1 h of polygraphy or polysomnographic study , and quep-value ≤0.05 was considered significant, using two-tailed tests. Statistical analyzes were performed using SPSS V.19 .A descriptive analysis of the quantitative variables  and the qualitative variables  was performed. The statistical parameters were expressed with their 95% confidence intervals (95% CI). Then, a bivariate analysis was performed for sex and degree of OSA, using the Pearson’s chi-square test, a +), and negative likelihood ratio (LR−), in addition to the prevalence or overall efficacy of the test, with their corresponding 95% CI. The AHI obtained by HRP was compared with the sum of the scores of the BQ, calculating the area under the ROC curve (AUC) and determining the optimal cut-off points, performing the sex-disaggregated analysis.Criterion validity parameters were calculated , namely sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LRK), interpreting the agreement level according to the Landis and Koch scale, which establishes the following categories according to the value found: K < 0, poor agreement; K: 0.01–0.20, slight agreement; K: 0.21–0.40, fair agreement; K: 0.41–0.60, moderate agreement; K: 0.61–0.80, substantial agreement; and K: 0.81–1.00, almost perfect agreement  and obtained the authorization of the Management / Direction of the Córdoba and Guadalquivir Health District. The principles established in the Declaration of Helsinki, in the European Convention (Council of Europe) on Human Rights and Biomedicine, and the requirements established in Spanish law were respected. The study complied with the standards of good clinical practice . The processing of the personal data of the subjects participating in the study was in accordance with the provisions of the European Data Protection Regulation and Organic Law 3/2018 on Personal Data Protection and guarantee of digital rights.The cross-cultural adaptation was successful because 8 out of the 10 items of the BQ were equivalent, and only 2 items showed minor modifications without affecting the meaning of the question. Consequently, this questionnaire was used to analyze its validity and reliability.Initial eligibility of 283 was evaluated, of which 255 were invited to participate, signing the informed consent. No patient was excluded or withdrew from the study (completion rate: 100%).2 , and the mean neck circumference was 38.33 cm , with significant differences by sex in neck circumference (p < 0.001) and BMI (p = 0.002).The patients had a mean age of 54.76 years , without statistical differences between men and women, men being 54.12% (95% CI: 47.96–60.27). Regarding the BMI, the mean was 31.17 kg/mA total of 61.57% (95% CI: 55.57–67.57) of the patients were diagnosed with OSA (AHI >5). Moderate/severe OSA (AHI >15) was found in 38.43% of subjects .+ of 3.01, and LR− of 0.312. The AUC was 0.786 (95% CI: 0.721–0.851) (1–0.851) .Regarding the reliability of the questionnaire, Cronbach’s alpha coefficient was 0.730 (95% CI: 0.668–0.784), and the kappa index was 0.739 (95% CI: 0.384–1.000).The BQ is an easy and quick to complete tool. From its origin, it has already proven to be of clinical utility as a screening tool because it has a high predictive capacity to detect OSA in those patients with high clinical suspicion of presenting this condition. This questionnaire resulted from the Sleep Conference, which brought together 120 American and German family practice physicians and sleep researchers in Berlin, Germany, in 1966 , it is necessary to ensure that it has the same qualities regarding its psychometric properties when applied to a population recruited in PC.In the present study, we have successfully translated the BQ according to established guidelines. This study aligned with previous studies that examined sensitivity, specificity, PPV, and NPV. There are other questionnaires, such as the STOP-Bang  for the Our study demonstrates that BQ has a highly diagnostic capacity to detect clinically relevant OSA (AHI ≥15). BQ is simple and easy to understand and fill in, so it can be applied in a PC setting. The use of BQ could potentially identify many patients with OSA, especially when it is moderate or severe, leading to earlier correct diagnosis and faster treatment, decreasing the risk of complications and unwanted effects. With the translation, back-translation, and consensus of experts, a final version of the BQ applicable to Spain was obtained, which is understandable and usable, and retains the meaning of the questionnaire in its source language. This final version can be used for any Spanish patient over 40 years old, regardless of gender, educational level, and/or socioeconomic status. Extending the study with a PSG would be indicated only in the cases of a possible mild OSA. The results of this validation were similar to those of the source version, obtaining a qualified, affordable, and easy-to-use prediction tool in the PC setting with high diagnostic efficacy and acceptable reliability. This tool allows identifying patients with a higher risk of having OSA to schedule treatment more quickly and thus reduce the associated comorbidities.The coronavirus disease (COVID-19) pandemic interrupted fieldwork, and although it was subsequently resumed, it has impacted the predetermined timelines, noticeably delaying the analysis and dissemination of results.Although there may be a doubt that a selection bias could have occurred because we have not used probabilistic sampling techniques, it should be considered that convenience and consecutive sampling are usually used in this type of validation study. It has also been possible to produce a selection bias when including in the study patients who demand health care in health centers, since these may differ in terms of their personal or physical characteristics from those from the population who do not attend the centers primary care of the health system. It is possible that health professionals tended to include in the study those patients with symptoms suggestive of OSA, which would partly explain the high prevalence found. Likewise, and in consistency with what the stated by epidemiologist experts in methodology for validation of measuring tools , what isOur study achieved the advantages of RP over polysomnography, especially in patients with a high probability of suffering from OSA. RP is a diagnostic modality of great interest because it represents a way of bringing the sleep study closer to the patient’s home and allows detection in a setting similar to that of the patient when he or she is about to sleep, without this being altered when performed in their natural environment and not in a setting, such as a hospital, which can cause dysfunctions and, as a consequence, increase the rate of false negatives or inconclusive results. This is supported by previous studies such as the one by Borsini et al. , where iThe blinded process used can be considered as a strength of the study, preventing the researcher who performed the polygraphic analysis from having prior knowledge of the results of the BQ, ensuring the decrease in committing a bias of information inherent to the psychological influence of knowledge of the interventions performed on the study participants.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Comite de etica e investigacion clinica del hospital Reina Sofia, Córdoba, Spain. The patients/participants provided their written informed consent to participate in this study.RM-G, JS-M, LAP-dT, MV-A, and EN-M contributed to the conception and design of the study. JS-M, EN-M, and LAP-dT reviewed the database and performed the statistical analysis. EN-M wrote the first draft of the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


A lack of enough knowledge about the mother-to-child transmission (MTCT) of the human immunodeficiency virus (HIV) among reproductive-age women is thought to be a key contributor to new pediatric HIV infections worldwide, and rising HIV-related infant mortality, particularly in resource-limited countries. Knowledge of MTCT of HIV is key to halt the progression of HIV/AIDS. Therefore, this study aimed to assess knowledge of MTCT of HIV and its associated factors among reproductive-age women in high HIV/AIDS prevalent countries.A secondary data analysis was performed using 8 HIV/AIDS prevalent countries’ Demographic and Health Surveys. A total weighted sample of 97,130 respondents was included in this study. Stata 17 was used for data extraction, coding, and analysis. A multilevel binary logistic regression model was fitted. The odds ratios along with the 95% confidence interval were generated to determine the factors of good knowledge of MTCT of HIV among reproductive-age women. A 95% confidence interval and a p-value of less than 0.05 were used to declare statistical significance.The prevalence of good knowledge of MTCT HIV was 57.89% . Mothers aged 25–34 , 35 and above, mothers’ primary education ,), secondary education , higher education , exposed to mass media  rich wealth status , talked about MTCT , visited by field worker , health facility visit , urban dwellers , ever tested for HIV, currently working status  were factors associated with good knowledge of MTCT of HIV/AIDS among reproductive age women.Overall, the prevalence of good knowledge of MTCT was low in high HIV/AIDS prevalent countries. Maternal age, primary education and above, exposed to media, having higher wealth status, talked about MTCT during ANC visits, being visited by a field worker, visited a health facility, currently working, living in the urban area, and ever been tested for HIV were positively associated with knowledge of MTCT. Health policy and programs should focus on educating mothers, encouraging women to contact health facilities and a well-targeted communications program is required to enhance knowledge of MTCT of HIV. Globally, 1.5 million people were newly infected with HIV in 2021, and about 40.1 million people were living with HIV in 2023 . Even thMother-to-child transmission (MTCT), also known as vertical HIV transmission, has been identified as the primary cause of HIV infection in children under the age of 15 years , 7. It iAmong the top prevalent countries in the world, the prevalence of HIV/AIDS ranges from 7.3% to 26.8% in Equatorial Guinea and Eswatini, respectively in 2020 . To reduIn order to eliminate MTCT of HIV, maternal knowledge of MTCT and its prevention is a cornerstone. Besides, it is a path to reach the UNAIDS 95:95:95 targets  , 15, andCorrect knowledge of MTCT and PMTCT among reproductive-age women is critical because it influences behavior modification and supports the adoption of self-protective attitudes such as increased perceived vulnerability, condom usage, and HIV testing , 24. Knowww.measuredhs.com after authorization was given by online request by stating the objective of our study on June 07/2023. We retrieved the outcome and independent variables from the woman record (IR file) data set. DHS is a nationally representative household survey that employs face-to-face interviews to follow and analyze a wide range of population, health, and nutrition parameters. The stratified, multi-stage, random sampling approach was used in the surveys. Detailed survey procedures and data collection sample methods have been reported somewhere [In this study, we have used the top ten HIV/AIDS prevalent countries’ DHS, conducted from 2011 to 2018. Among those countries, there were eight countries DHS conducted in the study period. Eswatini and Botswana were excluded because of the absence of DHS data. Those countries with the Highest HIV Rates by increasing order include  [omewhere . For thiThe dependent variable in this study was knowledge of MTCT of HIV/AIDS. It was a composite score of four questions according to the DHS Guideline: “Know that HIV can be transmitted from mother to child during pregnancy (yes/no)”, “know that HIV can be transmitted from mother to child during delivery (yes/no)”, “know that HIV can be transmitted from mother to child by breastfeeding (yes/no) “, and “know that the risk of mother-to-child transmission can be reduced by the mother taking special drugs(yes/no)” . Then a In this study, we have used individual and community level variables to assess factors associated with knowledge of MTCT of HIV/AIDS among reproductive-age women in high HIV prevalent countries.Individual-level variables. Maternal age, maternal education, current working status, current marital status, household wealth status, mass media exposure, visited the health facility, visited by field worker, during antenatal visit talked about mother to child HIV transmission, and Ever been tested for HIV were incorporated as individual-level factors.Community-level variables. Residence, community level women’s literacy, community level poverty, community level of media exposure, distance from the health facility, and country were the community-level variables. The factors like residence  and country are as collected by the DHS survey. For the rest of the community level variables, the individual level responses were aggregated and categorized based on the score of each variable. community-level media exposure was created by adding together all the "yes" responses in each area from women’s exposure to radio, newspaper/magazine, and television. Since the distribution of the variables were not normal based on subjective tests like histogram, we have used the median as a cut of point to categorize as low and high. When the amount of media exposure exceeded or was equal to the median, it was classified as high; otherwise, it was classified as low. The concept of community-level women’s literacy was developed by classifying women with no formal education as "no" and those with primary, secondary, and higher education as "yes". The proportion was then determined from the "yes" education group and categorized as "0" for low (communities in which less than 50% of women had at least a primary education) and "1" for high (clusters in which > = 50% of women had at least a primary education).Stata version 17 software was used to extract, recode, and for the analysis. The DHS data is hierarchical so we have used multilevel analysis. To keep the representativeness, to take into account the non-response rate, and to get an appropriate statistical estimate (robust standard error) weighting was applied throughout the analysis . In thisTo find relevant variables for the multivariable analysis, a bivariable analysis was done. Variables having p-values less than or equal to 0.25 in the bivariable analysis were used for the multivariable analysis. In the multivariable analysis, the adjusted odds ratio (AOR) with its 95% confidence interval (CI) was presented, and variables with p-value less than or equal to 0.05 were judged significant factors of knowledge of MTCT of HIV/AIDS.http://goo.gl/ny8T6X.Ethics approval was not required for this study since the data is secondary and is available publicly. However, we have been given the authorization letter to download the DHS data. More details concerning DHS data and ethical standards are available at This study examined a total weighted sample of 97,130 reproductive women using the recent DHS dataset. The mean age was , and the majority (40.39%) of respondents were between the ages of 15 and 24. The vast majority of participants (62.01%) lived in rural regions. About 25.29% of the respondents were from Malawi, whereas Lesotho, a landlocked kingdom, had the fewest (6.82%) survey participants. Only a small number (5.51%) of the respondents had higher education. Furthermore, over 44% were identified in the rich wealth quantiles, while over 36% were found in the poor wealth quantiles. Seventy-one percent of the respondents had ever been tested for HIV .The percentage of reproductive-age women’s knowledge on MTCT revealed 57.89% . The lowest and the highest Knowledge of MTCT was observed in Equatorial Guinea and Zimbabwe 27.10% and 68.02%, respectively . FurtherThe odds of knowledge of MTCT of HIV/AIDS among women aged, 25–34, 35 and above, 1.37 , 2.46  times higher compared to those aged 15–24 years, respectively. The odds of knowledge of MTCT of HIV was 1.09 times  higher among women who lived in urban areas relative to those who lived in rural areas. Women who attended primary, secondary and higher education had 1.32 , 1.65 , and 1.72  odds of knowledge of MTCT of HIV, respectively as compared to no education. Women who are exposed to mass media reported 1.12 odds of knowledge of MTCT of HIV compared to those who are not exposed. Category of women from households with middle, and rich wealth index level reported 1.11  odds of knowledge of MTCT HIV compared to those who were from poor households. The likelihood of knowledge of MTCT HIV/AIDS was 1.70  times higher in women who talked about HIV mother-to-child transmission during antenatal visits compared to their counterparts. The odds of knowledge of MTCT of HIV/AIDS among women who are visited by field workers was 1.09 times higher compared to those who are not visited by field workers. Women who visited the health facility in the last 12 months reported 1.15 odds of knowledge of MTCT HIV/AIDS compared to those who did not have a visit. Women who are ever tested for HIV reported 2.18  odds of Knowledge of MTCT HIV/AIDS compared to those who did not have HIV test. Women currently working had 1.15 higher odds of knowledge of MTCT HIV/AIDS compared to those currently not working .Null model-contains no explanatory variables; Model I-includes individual-level factors only; Model II-includes community-level factors only; Model III includes both individual-level and community-level factors, AOR-adjusted odds ratio, CI-confidence internal, ICC-intraclass correlation coefficient, PVC proportional change in varianceThe purpose of this study was to assess reproductive-age women’s knowledge on MTCT of HIV/AIDS and associated factors. In our study, 57.98% of respondents were knowledgeable of HIV/AIDS MTCT and its prevention. This study was lower than a study conducted in Zambia 58.6% , Rwanda Age of the respondents, living in urban area, primary education and above, being exposed to mass media, having higher wealth household, talked about MTCT during ANC visit, visited by field worker, visit health facility in the last 12 months, respondent currently working, ever been tested for HIV were positively associated with women’s good knowledge of MTCT. Accordingly being in the age group of 25–34, 35 and above had higher odds of knowledge on MTCT of HIV/AIDS and its prevention as compared to women aged 15–24 years. This is in agreement with studies done in Tanzania  and SSA The odds of knowledge of MTCT were higher among women who reside in urban areas when compared to rural dwellers. This is in line with different studies in Rwanda , in TanzWomen who had primary education and above had higher odds of knowledge of MTCT compared to those with no formal education. This is in agreement with different studies elsewhere , 30, 32.In our study, women who exposed to mass media had higher odds of Knowledge of MTCT of HIV/AIDS when compared to their counterparts. This is consistent with studies done in SSA , and in Women who are being told about MTCT during ANC visit, visited by field workers, who visited health facilities in the last 12 months, and who had ever been tested for HIV had higher odds of knowledge of MTCT of HIV/AIDS. A similar finding was reported in Zimbabwe  and RwanRegarding the strengths, we used large data set from 8 high HIV prevalent countries DHS, which is representative across the country. In addition, we used a multilevel modeling approach to provide a more accurate conclusion that takes into the consideration of data nature of the survey . However, the study has limitations, One notable limitation is the reliance on secondary data from the DHS, which may not capture all the pertinent variables necessary for a comprehensive analysis of knowledge of MTCT. Furthermore, the cross-sectional design employed in this study precludes establishing causality.Overall, the prevalence of good knowledge of MTCT was low in high HIV/AIDS prevalent countries. Maternal age, primary education and above, exposed to media, having higher wealth status, talked about MTCT during ANC visits, being visited by a field worker, visited a health facility, currently working, living in the urban area, and ever been tested for HIV were positively associated with knowledge of MTCT. Health policies and programs need to prioritize the education of mothers and women of reproductive age regarding MTCT. Efforts should be made to encourage women to seek healthcare services, including ANC visits and HIV testing. Moreover, targeted communication programs should be developed and implemented to effectively enhance knowledge of MTCT of HIV/AIDS.


We formed an international research collaboration that included Japan, South Korea, Brazil, Thailand, Taiwan, the UK, and the US , to better evaluate the role of race, ethnicity, and other risk factors in the pathophysiology of Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). Ophthalmologists often see SJS/TEN patients with severe ocular complications  when the patients are referred to them in the chronic stage after the acute stage has passed. Global data were collected using a Clinical Report Form, capturing pre-onset factors, as well as acute and chronic ocular findings. Key conclusions of this retrospective observational cohort study were as follows: (1) Ingestion of cold medications [acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs)] was significantly and positively correlated with trichiasis, symblepharon, and/or conjunctivalization of the cornea in the chronic stage; (2) common cold symptoms prior to onset of SJS/TEN were significantly and positively correlated with acute conjunctivitis and ocular surface erosions in the acute stage and with trichiasis and symblepharon and/or conjunctivalization of the cornea in the chronic stage; (3) patients with SJS/TEN who presented with SOC tended to be female; (4) patients less than 30 years of age are more likely to develop SOC in the acute and chronic stages of SJS/TEN; (5) patients with acute severe conjunctivitis with ocular surface erosion and pseudomembrane formation in the acute stage are more likely to develop ocular sequelae in the chronic stage; and (6) onychopathy in the acute stage was positively correlated with ocular sequelae in the chronic stage. Our findings show that the ingestion of cold medications, common cold symptoms prior to the onset of SJS/TEN, and a young age might strongly contribute to developing the SOC of SJS/TEN. Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, life-threatening, acute immune-mediated, predominantly adverse drug reactions that affect the skin and mucous membranes including those of the ocular, oral, pulmonary, and urogynecological tissues. Clinical features in the acute stage include fever, skin erythema, and sloughing of both skin and mucosal epithelia. In addition to dermatological findings, it has been reported that in the acute stage of SJS/TEN, about 80% of patients develop ocular involvement, including mild conjunctivitis, and approximately 50% of patients present with severe ocular complications (SOC) with severe conjunctivitis with ocular surface epithelial defects and pseudomembrane .We have previously defined SOC in SJS/TEN in both the acute  and chronic  stages .Typically, dermatologists and burn care physicians diagnose and treat SJS/TEN patients in the acute stage, whereas ophthalmologists often see these patients in both the acute and chronic stages. In some countries, an SJS/TEN patient may only see an ophthalmologist in the chronic phase and may have had a long lapse in multi-system SJS/TEN care between the acute hospitalization and presentation to an ophthalmologist . BecauseDiagnosis of SJS/TEN by an ophthalmologist is based on a confirmed history of acute onset of high fever, a severe mucocutaneous disease with skin eruptions, and at least two mucosal tissues including the ocular surface, when the patients had ocular sequelae of SJS/TEN such as severe dry eye, trichiasis, symblepharon, and/or conjunctivalization of the cornea in the chronic stage .An adverse drug reaction (ADR) in a genetically predisposed individual has been proposed as the most likely pathophysiological mechanism for SJS/TEN. For example, for carbamazepine-induced SJS/TEN, there is a strong association with the HLA-B*15:02 allele in Han Chinese patients in Taiwan  and in TFurthermore, we previously reported that 80% of Japanese patients with SJS/TEN with SOC were taking cold medication before disease onset . This waBecause of strong genetic risk factors for the development of SJS/TEN with SOC that vary by population, an international collaborative research program among Japan, South Korea , 19, 25,This is a retrospective observational cohort study of patients with SJS/TEN.The study population consisted of patients with SJS/TEN from 13 hospitals in seven countries  between 2005 and 2020. SJS/TEN was diagnosed using standardized criteria including a confirmed history of acute onset of high fever, a severe mucocutaneous disease with skin eruptions, and involvement of at least two mucosal tissues including the ocular surface. All participating hospitals had an ophthalmology service delivering specialized care for SJS/TEN treatment. Our study was approved by the institutional review board of all the hospitals. Case Report Forms (CRF) for the retrospective study were made by all hospitals, which documented clinical findings from the pre-onset to the chronic stage, but some CRFs were missing some data, especially of pre-onset and acute stages because ophthalmologists usually saw the patients in their chronic stage.We defined the day of onset of the SJS/TEN-specific skin rash as day 0, the pre-onset period from day −14 to day 0, the acute period from day 0 to 3 months, the sub-acute period from 3 months to 1 year, and the chronic period from 1 year afterward based on our previous study  were examined at three different disease stages: pre-onset, acute, and chronic .Pre-onset stage factors include culprit drugs , gender, common cold symptoms before onset, and age at onset of SJS/TEN. Cold medicines include over-the-counter and hospital-prescribed acetaminophen and NSAIDs. Medicines started after day 0 were excluded. If several medications were taken simultaneously, all applicable classifications were included in the analysis.Acute stage factors include severe conjunctivitis, ocular surface epithelial erosions, pseudomembranes, eyelid alopecia, onychopathy, and vesiculobullous lesions of the oral cavity and lips. The presence of onychopathy at the acute stage was defined if the item of “nail deformation” and/or “lost nail at acute or subacute stage”  was checChronic stage factors include dry eye, trichiasis, and symblepharon or conjunctivalization of the cornea . The preThe numbers and percentages of each factor stratified by country were tallied except the age at onset, for which mean and standard deviation were calculated.For each pre-onset factor, the odds ratio and 95% confidence interval for the presence of each acute factor were estimated by country. For each pre-onset factor, the odds ratio and 95% confidence interval for the presence of each chronic factor were estimated by country. For each acute factor, the odds ratio and 95% confidence interval for the presence of each chronic factor were estimated by country. The age at onset was converted into a binary variable with 30 years of age as the cutoff value. For odds ratios that included 0 in any of the presence/absence categories, Woolf’s correction was performed, and 0.5 was added to all the categories to estimate the odds ratio and 95% confidence interval .p < 0.05)   and if tThe participant flow is shown in There was a statistically significant association in the nine combinations between pre-onset factors and acute stage factors. Of these, one combination was excluded for the presence of heterogeneity by the Breslow–Day test, leaving eight combinations.Pre-onset common cold symptoms were positively correlated with severe conjunctivitis  and ocular surface erosion  in the acute stage. There was a statistically significant association in the seven combinations between the pre-onset factors and the chronic stage factors. The intake of cold medicine was positively correlated with trichiasis  and symblepharon or conjunctivalization of the cornea  in the chronic stage. Pre-onset common cold symptoms were positively correlated with trichiasis  and symblepharon or conjunctivalization of the cornea  in the chronic stage. Anticonvulsants were negatively correlated with trichiasis . There was a statistically significant association in 14 combinations between acute stage factors and chronic stage factors. Of these, two combinations related to alopecia were excluded due to the presence of heterogeneity by the Breslow–Day test. One combination for vesiculobullous lesion was excluded due to its small sample size, leaving 12 significant combinations. Between the acute and chronic stage factors, severe conjunctivitis, ocular surface erosion, pseudomembrane, and onychopathy were positively correlated with all three factors in the chronic stage. In all, data from 682 patients were obtained  from sevRegarding the association of medications with acute and chronic findings, ingestion of cold medications was significantly positively correlated with trichiasis (IOR = 1.73) and symblepharon or conjunctivalization of the cornea (IOR = 1.93) in the chronic stage. Dry eye was not statistically significantly associated, but showed a positive correlation trend (IOR = 1.49), although it was not significantly associated. The association between cold medicines and findings in the acute stage such as severe conjunctivitis, ocular surface erosion, and pseudomembrane were not significantly correlated. However, this study revealed that cold medicine-associated SJS/TEN is significantly more likely to result in ocular sequelae such as trichiasis and symblepharon or conjunctivalization of the cornea in the chronic stage of SJS/TEN. Therefore, those who take cold medications and develop SJS/TEN should be even more closely monitored for ocular findings because of the possibility of the high incidence of ocular sequela.The use of antibiotics prior to disease onset was not correlated with dry eye, trichiasis, symblepharon, and/or conjunctivalization of the cornea in the chronic stage. The use of antibiotics before the onset of SJS/TEN was not significantly associated with acute or chronic findings. However, the association between antibiotics and all findings in the chronic stage tends to show a negative correlation. Ocular findings may be less likely to occur in SJS/TEN caused by antibiotics before the onset of SJS/TEN compared to those caused by cold medications. This result was consistent with the previous report by Sotozono et al. . Thus, cTaking anticonvulsants before the onset of SJS/TEN was significantly negatively correlated with conjunctivitis (IOR = 0.33) and with oral mucosal findings (IOR = 0.21) in the acute stage. A significant negative correlation was also found between anticonvulsants and trichiasis in the chronic-stage findings (IOR = 0.41). Ocular findings may be less likely to occur in SJS/TEN caused by anticonvulsants before the onset of SJS/TEN compared to cold medications. This result was consistent with a previous report by Ma et al. .Interestingly, the onset with anticonvulsant drugs tended to be about 2 weeks after medication , whereasOf the 643 patients with data for the presence or absence of common cold symptoms such as sore throat, fatigue, and slight fever, 437 (68.0%) had common cold symptoms before the onset of SJS/TEN. This indicates that common cold symptoms often precede the onset of SJS/TEN with SOC. Regarding the association of common cold symptoms with acute and chronic findings, common cold symptoms prior to the onset of SJS/TEN were significantly positively correlated with acute conjunctivitis (IOR = 3.23), and ocular surface erosions (IOR = 3.15). In addition, common cold symptoms before the onset of SJS/TEN were significantly positively correlated with trichiasis (IOR = 1.80) and symblepharon or conjunctivalization of the cornea (IOR = 1.58) in the chronic stage. Previously, Ueta et al. suspected that SJS/TEN might be caused when people with an unusual genetic predisposition took cold remedies for infections such as viruses. In this study, of 437 patients with confirmed common cold symptoms, 278 (63.6%) were taking common cold remedies, suggesting that both cold remedies, as well as microbial infections, may be involved in the pathogenesis of SJS/TEN .Among the 682 patients, 423 were female (62.0%). This indicates that patients with SJS/TEN who presented with SOC tended to be female. The mean age of onset for the 672 patients for whom the age of onset was known was 29.1 years (SD 19.4 years). Regarding the association of age with acute and chronic findings, age more than 30 years was negatively associated with acute conjunctivitis (IOR = 0.42), ocular surface erosions (IOR = 0.43), pseudomembrane (IOR = 0.25) in the acute stage, and nail disorders (IOR = 0.61), trichiasis (IOR = 0.58), and symblepharon or conjunctivalization of the cornea (IOR = 0.50) in the chronic stage. This indicates that the age of onset of SJS/TEN of less than 30 years is more likely to result in SOC in the acute and chronic stages of SJS/TEN. Thus, children who develop SJS/TEN should be continuously monitored for ocular findings not only in the acute stage but also in the chronic stage, because of the possibility of high incidence of SOC.Based on combined ophthalmology collaborative data from seven countries, acute findings of severe conjunctivitis were observed in 92.3% (383/415), ocular surface erosions in 86.1% (273/317), pseudomembranes in 86.2% (163/189), onychopathy in 77.5% (505/652), alopecia in 59.6% (212/356), and vesiculobullous lesion of the oral cavity and lips were present in 98.8% (559/566). Chronic ocular sequelae included dry eye in 90.6% (465/513), trichiasis in 73.2% (447/611), and symblepharon or conjunctivalization to the cornea in 74.9% (466/622). Regarding the association of acute stage findings with chronic stage findings, severe conjunctivitis in the acute stage was significantly positively correlated with dry eye (IOR = 4.69), trichiasis (IOR = 7.77), and symblepharon or conjunctivalization of the cornea (IOR = 10.4). Ocular surface erosions were significantly positively correlated with dry eye (IOR = 6.12), trichiasis (IOR = 4.27), and symblepharon or conjunctivalization to the cornea (IOR = 10.7). Pseudomembrane had a significant positive correlation with dry eye (IOR = 7.09), trichiasis (IOR = 4.12), and symblepharon or conjunctivalization to the cornea (IOR = 7.94).These findings indicate that acute ocular findings such as severe conjunctivitis with ocular surface erosion and pseudomembrane in the acute stage are likely to cause ocular sequelae in the chronic stage. Thus, the SJS/TEN patients with SOC in the acute stage should be continuously monitored for ocular findings in their chronic stage, due to the high incidence of ocular sequelae.Onychopathy was significantly positively correlated with dry eye (IOR = 3.96), trichiasis (IOR = 5.21), and symblepharon or conjunctivalization of the cornea (IOR = 6.64). Onychopathy in the acute stage was, therefore, likely to be associated with ocular sequelae in the chronic stage.There are several limitations to our study. First, in many hospitals, acute ocular findings are not recorded. Of the 682 patients, only 170 (24.9%) records reflected the presence or absence of the full range of acute findings we sought in the study. For many of the patients in the study, an ophthalmologist was not called on in the acute stage. Another limitation is that paracetamol (acetaminophen) is available as an over-the-counter drug in the UK, the US, and Thailand, and it may not be reflected as a causative agent in some of the clinical reports.Other confounding factors such as management in the acute stage and chronic stage were not taken into account in the analysis. The treatments in the acute stage such as steroid pulse therapy and amniotic membrane transplantation might affect the chronic ocular findings of the SJS/TEN patients . PreviouMoreover, in this study, we did not include the findings of lid-related disorders of SJS/TEN with SOC. Further investigations including them are also needed in the future.In summary, this study assimilates worldwide data from patients with ocular SJS/TEN and shows that patients with SOC in the acute stage are more likely to have ocular sequelae in the chronic stage. It has been reported that ocular sequelae are less likely to occur if pulsed intravenous corticosteroid is administered within 4 days of onset , or amniThe original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by KPUM. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.MU planned the study design. MU, CS, MK, TW, PJ, HS, SR, DM, KY, VP, CB, SA, KS, C-KJ, JG, JC, and SK were involved in the data collection. MU, CI, MN, and ST were involved in the data interpretation and data analysis. MU, CI, MN, ST, HS, CB, and JC wrote the manuscript. All authors critically revised the report, commented on drafts of the manuscript, and approved the final report.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.