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Background Breastfeeding is known to reduce risk of enteropathogen infections, but protection from specific enteropathogens is not well characterized. Objective To estimate the association between full breastfeeding (days fed breast milk exclusively or with non-nutritive liquids) and enteropathogen detection. Design 2,145 newborns were enrolled in eight sites, of whom 1,712 had breastfeeding and key enteropathogen data through 6 months. We focused on eleven enteropathogens: adenovirus 40/41, norovirus, sapovirus, astrovirus, and rotavirus, enterotoxigenic Escherichia coli (ETEC), Campylobacter spp, and typical enteropathogenic E. coli as well as entero-aggregative E. coli, Shigella and Cryptosporidium. Logistic regression was used to estimate the risk of enteropathogen detection in stools and survival analysis to estimate the timing of first detection of an enteropathogen. Results Infants with 10% more days of full breastfeeding within the preceding 30 days of a stool sample were less likely to have the three E. Coli and Campylobacter spp detected in their stool (mean odds 0.92���0.99) but equally likely (0.99���1.02) to have the viral pathogens detected in their stool. A 10% longer period of full breastfeeding from birth was associated with later first detection of the three E. Coli, Campylobacter, adenovirus, astrovirus, and rotavirus (mean hazard ratios of 0.52���0.75). The hazards declined and point estimates were not statistically significant at 3 months. Conclusions In this large multi-center cohort study, full breastfeeding was associated with lower likelihood of detecting four important enteric pathogens in the first six months of life. These results also show that full breastfeeding is related to delays in the first detection of some bacterial and viral pathogens in the stool. As several of these pathogens are risk factors for poor growth during childhood, this work underscores the importance of exclusive or full breastfeeding during the first six months of life to optimize early health., Accepted for publication in AJCN

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Background: Environmental enteropathy (EE), the adverse impact of frequent and numerous enteric infections on the gut resulting in a state of persistent immune activation and altered permeability, has been proposed as a key determinant of growth failure in children in low- and middle-income populations. A theory-driven systems model to critically evaluate pathways through which enteropathogens, gut permeability, and intestinal and systemic inflammation affect child growth was conducted within the framework of the Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) birth cohort study that included children from eight countries. Methods: Non-diarrheal stool samples (N = 22,846) from 1253 children from multiple sites were evaluated for a panel of 40 enteropathogens and fecal concentrations of myeloperoxidase, alpha-1-antitrypsin, and neopterin. Among these same children, urinary lactulose:mannitol (L:M) (N = 6363) and plasma alpha-1-acid glycoprotein (AGP) (N = 2797) were also measured. The temporal sampling design was used to create a directed acyclic graph of proposed mechanistic pathways between enteropathogen detection in non-diarrheal stools, biomarkers of intestinal permeability and inflammation, systemic inflammation and change in length- and weight- for age in children 0–2 years of age. Findings: Children in these populations had frequent enteric infections and high levels of both intestinal and systemic inflammation. Higher burdens of enteropathogens, especially those categorized as being enteroinvasive or causing mucosal disruption, were associated with elevated biomarker concentrations of gut and systemic inflammation and, via these associations, indirectly associated with both reduced linear and ponderal growth. Evidence for the association with reduced linear growth was stronger for systemic inflammation than for gut inflammation; the opposite was true of reduced ponderal growth. Although Giardia was associated with reduced growth, the association was not mediated by any of the biomarkers evaluated. Interpretation: The large quantity of empirical evidence contributing to this analysis supports the conceptual model of EE. The effects of EE on growth faltering in young children were small, but multiple mechanistic pathways underlying the attribution of growth failure to asymptomatic enteric infections had statistical support in the analysis. The strongest evidence for EE was the association between enteropathogens and linear growth mediated through systemic inflammation. Funding: Bill & Melinda Gates Foundation.

The home environment provides the context for much of a child's early development. Examples of important aspects of the home environment include safety, cleanliness, and opportunities for cognitive stimulation. This study sought to examine the psychometric properties of an adapted form of the Home Observation for the Measurement of the Environment (HOME; Caldwell & Bradley, 1984, 2003) across the eight international sites of the MAL-ED project (Dhaka, Bangladesh; Vellore, India; Bhakatapur, Nepal; Naushahro Feroze, Pakistan; Fortaleza, Brazil; Loreto, Peru; Venda, South Africa; Haydom, Tanzania), to identify a factor structure that fit the data at all sites, and to derive a subset of items that could be used to examine home environmental characteristics across sites. A three-factor structure (i.e., Emotional and Verbal Responsivity; Clean and Safe Environment; Child Cleanliness) was identified, and partial measurement equivalence/invariance across sites was supported. Overall, these findings lend support for the use of portions of this abbreviated and adapted version of the HOME for use among heterogeneous, cross-cultural groups in low- and middle-income nations.

Background: Child cognitive development is influenced by early-life insults and protective factors. To what extent these factors have a long-term legacy on child development and hence fulfillment of cognitive potential is unknown. Objective: The aim of this study was to examine the relation between early-life factors (birth to 2 y) and cognitive development at 5 y. Methods: Observational follow-up visits were made of children at 5 y, previously enrolled in the community-based MAL-ED longitudinal cohort. The burden of enteropathogens, prevalence of illness, complementary diet intake, micronutrient status, and household and maternal factors from birth to 2 y were extensively measured and their relation with the Wechsler Preschool Primary Scales of Intelligence at 5 y was examined through use of linear regression. Results: Cognitive T-scores from 813 of 1198 (68%) children were examined and 5 variables had significant associations in multivariable models: mean child plasma transferrin receptor concentration (β: −1.81, 95% CI: −2.75, −0.86), number of years of maternal education (β: 0.27, 95% CI: 0.08, 0.45), maternal cognitive reasoning score (β: 0.09, 95% CI: 0.03, 0.15), household assets score (β: 0.64, 95% CI: 0.24, 1.04), and HOME child cleanliness factor (β: 0.60, 95% CI: 0.05, 1.15). In multivariable models, the mean rate of enteropathogen detections, burden of illness, and complementary food intakes between birth and 2 y were not significantly related to 5-y cognition. Conclusions: A nurturing home context in terms of a healthy/clean environment and household wealth, provision of adequate micronutrients, maternal education, and cognitive reasoning have a strong and persistent influence on child cognitive development. Efforts addressing aspects of poverty around micronutrient status, nurturing caregiving, and enabling home environments are likely to have lasting positive impacts on child cognitive development. publishedVersion

Supplemental material, Appendix_A._MALED_Investigators_JPA for Assessing Early Childhood Fluid Reasoning in Low- and Middle-Income Nations: Validity of the Wechsler Preschool and Primary Scale of Intelligence Across Seven MAL-ED Sites by Linda Ruan-Iu, Laura L. Pendergast, Muneera Rasheed, Fahmida Tofail, Erling Svensen, Angelina Maphula, Reeba Roshan, Baitun Nahar, Rita Shrestha, Brittney Williams, Barbara A. Schaefer, Rebecca Scharf, Laura E. Caulfield, Jessica Seidman and Laura E. Murray-Kolb in Journal of Psychoeducational Assessment

In a multisite birth cohort study, we document a high burden of Campylobacter infection using enzyme immunoassay, demonstrate an association between Campylobacter and linear growth shortfalls and both increased intestinal permeability and intestinal and systemic inflammation, and identify potential interventions., Background. Enteropathogen infections have been associated with enteric dysfunction and impaired growth in children in low-resource settings. In a multisite birth cohort study (MAL-ED), we describe the epidemiology and impact of Campylobacter infection in the first 2 years of life. Methods. Children were actively followed up until 24 months of age. Diarrheal and nondiarrheal stool samples were collected and tested by enzyme immunoassay for Campylobacter. Stool and blood samples were assayed for markers of intestinal permeability and inflammation. Results. A total of 1892 children had 7601 diarrheal and 26 267 nondiarrheal stool samples tested for Campylobacter. We describe a high prevalence of infection, with most children (n = 1606; 84.9%) having a Campylobacter-positive stool sample by 1 year of age. Factors associated with a reduced risk of Campylobacter detection included exclusive breastfeeding (risk ratio, 0.57; 95% confidence interval, .47–.67), treatment of drinking water (0.76; 0.70–0.83), access to an improved latrine (0.89; 0.82–0.97), and recent macrolide antibiotic use (0.68; 0.63–0.74). A high Campylobacter burden was associated with a lower length-for-age Z score at 24 months (−1.82; 95% confidence interval, −1.94 to −1.70) compared with a low burden (−1.49; −1.60 to −1.38). This association was robust to confounders and consistent across sites. Campylobacter infection was also associated with increased intestinal permeability and intestinal and systemic inflammation. Conclusions. Campylobacter was prevalent across diverse settings and associated with growth shortfalls. Promotion of exclusive breastfeeding, drinking water treatment, improved latrines, and targeted antibiotic treatment may reduce the burden of Campylobacter infection and improve growth in children in these settings.

INTRODUCTION: In many developing areas in the world, a high burden of enteric pathogens in early childhood are associated with growth deficits. The tryptophan-kynurenine-niacin pathway has been linked to enteric inflammatory responses to intestinal infections. However, it is not known in these settings whether scheduled antimicrobial intervention to reduce subclinical enteric pathogen carriage or repletion of the tryptophan-kynurenine-niacin pathway improves linear growth and development.METHODS AND ANALYSIS: We are conducting a randomised, placebo-controlled, factorial intervention trial in the rural setting of Haydom, Tanzania. We are recruiting 1188 children within the first 14 days of life, who will be randomised in a 2×2 factorial design to administration of antimicrobials (azithromycin and nitazoxanide, randomised together) and nicotinamide. The nicotinamide is administered as a daily oral dose, which for breast-feeding children aged 0-6 months is given to the mother and for children aged 6-18 months is given to the child directly. Azithromycin is given to the child as a single oral dose at months 6, 9, 12 and 15; nitazoxanide is given as a 3-day course at months 12 and 15. Mother/child pairs are followed via monthly in-home visits. The primary outcome is the child's length-for-age Z-score at 18 months. Secondary outcomes for the child include additional anthropometry measures; stool pathogen burden and bacterial microbiome; systemic and enteric inflammation; blood metabolomics, growth factors, inflammation and nutrition; hydrogen breath assessment to estimate small-intestinal bacterial overgrowth and assessment of cognitive development. Secondary outcomes for the mother include breastmilk content of nicotinamide, other vitamins and amino acids; blood measures of tryptophan-kynurenine-niacin pathway and stool pathogens.ETHICS AND DISSEMINATION: This trial has been approved by the Tanzanian National Institute for Medical Research, the Tanzanian FDA and the University of Virginia IRB. Findings will be presented at national and international conferences and published in peer-review journals.PROTOCOL VERSION: 5.0, 4 December 2017.PROTOCOL SPONSOR: Haydom Lutheran Hospital, Haydom, Manyara, Tanzania.TRIAL REGISTRATION NUMBER: NCT03268902; Pre-results.

Most models of occupational stress propose that stressors in the work environment lead to negative psychological, physical, and behavioural changes in the individual employee (Jex & Bliese, 1999). This thesis focuses on three potential stressors in the work environment; downsizing, poor work environment in general, and poor leadership. What are the characteristics of these stressors, and can they be causes of ill health? Does a focus on the individual interpretation of the environment give a better understanding of the relation between work and health? The theoretical framework for these discussions is the Cognitive Activation Theory of Stress (CATS) (Ursin & Eriksen, 2004). This thesis consists of three papers, one for each of these three common causal explanations on the relation between work and health: Downsizing (Paper 1), poor work environment (Paper 2), and poor leadership (Paper 3). To study if an employee’s previous learning experience and characteristics of the working environment are associated with positive attitudes towards downsizing, a survey was done in the Norwegian branch of a global oil company (n=467). The results showed that when facing an organisational downsizing, 1/3 of the employees were positive to the coming change and 1/3 was not. There was a strong positive relation between employees’ perceptions of their work environment and their attitude to organisational change (43% explained variance). Statistical significant factors explaining attitude to organisational change were Corporate Social Responsibility (CSR), Involvement & Participation, Team leadership, and Team effectiveness, with CSR being the most important factor. Employees with leadership responsibilities were less positive to change compared to employees without leadership responsibilities and older employees were more positive than younger ones. Poor work environment and the relation to health was investigated in 5 organisations (total n=458). The results showed that subjective health complaints (SHC) were common, also among workers with high job satisfaction. Satisfied workers reported an average of 5-6 subjective health complaints which corresponds to the prevalence found in a Norwegian general population. Work environment explained 43% of the variance in job satisfaction and 9% of the variance in SHC. The relation between poor leadership and subordinate health was investigated with multilevel analysis of questionnaires from 2915 employees and their 322 leaders. Leadership behaviour was defined as being supportive, empowering and fair. Leadership behaviour (organisational level) was not related to sick leave. However, examining individual perception (individual level) of leadership showed that those who perceived their leader as not being supportive, empowering or fair, had more sick leave in a 1-year follow-up. Furthermore, individual perception of leadership explained 20% of the variance for work related exhaustion and 17% for job satisfaction. This was more than twice the variance explained by leadership behaviour (organisational level). For all outcomes individual perception of leadership explained more variance than leadership behaviour. The conclusion in this thesis is that a simple stressor-strain model where downsizing, poor work environment, or poor leadership inevitably leads to ill health is not correct. As postulated in CATS, the important factor is the individual perception of these potential stressors. This might explain why interventions at the individual level have better results than interventions at the organisational level (Reynolds, 1997).

LMS er en forkortelse for ”learning management system” og blir anvendt om systemer som administrerer nettbaserte undervisningstjenester for studenter, lærere og administratorer. Det Psykologiske Fakultet ved Universitetet i Bergen har satset på et kommersielt nettbasert læringssystem som har vært i bruk i 2 år. En grundig evaluering av bruk og nytteverdi gjenstår. Denne artikkelen omfatter en preliminær undersøkelse av studenters bruk og vurdering av læringssystemets nytteverdi og potensiale. Resultatene er utarbeidet ved hjelp av et skjema som dekker kvantitative og kvalitative data og som ble designet til dette formålet. Populasjonen bestod av profesjonsstudenter på 3. semester ved Det Psykologiske Fakultet. Av 23 studenter som var tilstede under utdeling av skjemaet kom det inn 23 svar. En kvantitativ analyse av materialet er utført ved hjelp av SPSS statistisk analyse. Kvalitativ undersøkelse er basert på en evaluering av studentenes skriftlige besvarelser. Konklusjon: Et flertall av studentene synes bruk av nettbasert læringsportal er et nyttig supplement til undervisningen. Bruk av diskusjonsforum må være basert på frivillig innsats og dekke relevante psykologiske tema.