Search

The Earned Income Tax Credit (EITC) is the largest poverty alleviation program for families with children in the US, and it has well-documented health effects. However, not all eligible families receive benefits. The Assessing California Communities' Experiences with Safety Net Supports (ACCESS) Study interviewed 411 EITC-eligible Californians with young children to understand low take-up of the federal EITC and California's supplemental CalEITC. Interviews were conducted in English and Spanish in 2020 and 2021 to gather information on sociodemographic characteristics, tax filing, and EITC receipt (verified via tax forms). Among those eligible for the EITC or CalEITC, 9 percent of participants did not file taxes; among those who did file taxes, about 84 percent received the EITC, and 83 percent received the CalEITC. Lower likelihood of federal EITC receipt among those eligible and filing taxes was associated with being younger, not speaking English, and not having prior knowledge of the EITC. Lower likelihood of CalEITC receipt among those eligible and filing taxes was associated with not speaking English. These findings can inform policies and community interventions to increase EITC take-up and thereby help address health equity.

Early child development has been influenced directly and indirectly by the COVID-19 pandemic, and these effects are exacerbated in contexts of poverty. This study estimates effects of the pandemic and subsequent population lockdowns on mental health, caregiving practices, and freedom of movement among female caregivers of children 6-27months (50% female), in rural Bangladesh. A cohort (N=517) was assessed before and during the pandemic (May-June, 2019 and July-September, 2020). Caregivers who experienced more food insecurity and financial loss during the pandemic reported larger increases in depressive symptoms (0.26 SD, 95% CI 0.08-0.44; 0.21 SD, 0.04-0.40) compared to less affected caregivers. Stimulating caregiving and freedom of movement results were inconsistent. Increases in depressive symptoms during the pandemic may have consequences for child development.

BackgroundThe COVID-19 pandemic and efforts to mitigate transmission resulted in sudden and widespread socioeconomic disruptions including school and child care closures, unemployment and underemployment, and housing precarity. Understanding the extent to which these disruptions may have contributed to adverse health outcomes is critical for establishing policy priorities that can mitigate further harm.MethodsWe explored the associations between pandemic-related child care, employment, and housing disruptions with depressive symptoms, self-rated health, and food security status among a sample of economically disadvantaged and racially diverse female caregivers of young children (n=464). Data were derived from the Assessing California Communities’ Experiences with Safety Net Supports (ACCESS) study, which conducted survey-based interviews with California caregivers with low-income from August 2020 – May 2021. We implemented a series of multivariable Poisson regressions with robust standard errors to assess the potency of each exposure, independently and within the context of one another.ResultsMost caregivers experienced disruptions to child care (70%) and employment (63%); few experienced major housing disruptions (8%). Women that experienced child care and housing disruptions had greater depressive symptoms, lower self-rated health, and greater food insecurity, although the relationships for housing and depressive symptoms were modified by the timing of participants’ interviews. Employment disruptions were not associated with any of the examined adverse health outcomes.ConclusionIn the wake of socioeconomic stressors brought about by the COVID-19 pandemic, attending to structural deficits in the child care system and increasing housing supports may be critical for protecting the health of caregivers.

In 2020, the COVID-19 pandemic led to significant declines in cancer screening, including among women served by the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). This study examined the spatial association between state-based COVID-19 test percent positivity and proportional change in NBCCEDP screening volume.Using the COVID-19 Diagnostic Laboratory Testing dataset, we calculated state-based monthly COVID-19 test percent positivity from July through December 2020 and categorized rates into low, medium, and high groups. We used data from 48 NBCCEDP state awardees to calculate the state-based monthly proportional change in screening volume and compared data for July-December 2020 with the previous 5-year average for those months. We categorized changes in screening volume into large decrease, medium decrease, and minimal change and created maps of the associations between variable subgroups by using bivariate mapping in QGIS.Bivariate relationships between COVID-19 test percent positivity and proportional change in cancer screening volume varied over time and geography. In 5 of 6 months, 4 states had high COVID-19 test percent positivity and minimal change in breast or cervical cancer screening volume; 2 states had high COVID-19 test percent positivity and minimal change in breast and cervical cancer screening volume.Some states maintained pre-COVID-19 screening volumes despite high COVID-19 test percent positivity. Follow-up research will be conducted to determine how these states differ from those with consistent decreases in screening volume and identify factors that may have contributed to differences. This information could be useful for planning to maximize NBCCEDP awardees' ability to maintain screening volume during future public health emergencies.

Pityriasis rubra pilaris is a papulosquamous inflammatory dermatosis that can be associated with HIV, autoimmunity, infections, certain medications, and neoplasms. Paraneoplastic pityriasis rubra pilaris has previously been reported in association with solid organ malignancies and once with leukemia. Herein, we present an elderly man with paraneoplastic pityriasis rubra pilaris, heralding the diagnosis of low-grade papillary urothelial carcinoma. Our patient's pityriasis rubra pilaris resolved after surgical resection of the tumor.

Summary Background Early childhood development (ECD) programmes can help address early disadvantages for the 43% of children younger than 5 years in low-income and middle-income countries who have compromised development. We aimed to test the effectiveness of two group-based delivery models for an integrated ECD responsive stimulation and nutrition education intervention using Kenya's network of community health volunteers. Methods We implemented a multi-arm, cluster-randomised community effectiveness trial in three rural subcounties across 60 villages (clusters) in western Kenya. Eligible participants were mothers or female primary caregivers aged 15 years or older with children aged 6–24 months at enrolment. If married or in established relationships, fathers or male caregivers aged 18 years or older were also eligible. Villages were randomly assigned (1:1:1) to one of three groups: group-only delivery with 16 fortnightly sessions; mixed delivery combining 12 group sessions with four home visits; and a comparison group. Villages in the intervention groups were randomly assigned (1:1) to invite or not invite fathers and male caregivers to participate. Households were surveyed at baseline and immediately post-intervention. Assessors were masked. Primary outcomes were child cognitive and language development (score on the Bayley Scales of Infant Development third edition), socioemotional development (score on the Wolke scale), and parental stimulation (Home Observation for Measurement of the Environment inventory). Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov , NCT03548558 . Findings Between Oct 1 and Nov 12, 2018, 1152 mother–child dyads were enrolled and randomly assigned (n=376 group-only intervention, n=400 mixed-delivery intervention, n=376 comparison group). At the 11-month endline survey (Aug 5–Oct 31, 2019), 1070 households were assessed for the primary outcomes (n=346 group only, n=373 mixed delivery, n=351 comparison). Children in group-only villages had higher cognitive (effect size 0·52 SD [95% CI 0·21–0·83]), receptive language (0·42 SD [0·08–0·77]), and socioemotional scores (0·23 SD [0·03–0·44]) than children in comparison villages at endline. Children in mixed-delivery villages had higher cognitive (0·34 SD [0·05–0·62]) and socioemotional scores (0·22 SD [0·05–0·38]) than children in comparison villages; there was no difference in language scores. Parental stimulation also improved for group-only (0·80 SD [0·49–1·11]) and mixed-delivery villages (0·77 SD [0·49–1·05]) compared with the villages in the comparison group. Including fathers in the intervention had no measurable effect on any of the primary outcomes. Interpretation Parenting interventions delivered by trained community health volunteers in mother–child groups can effectively promote child development in low-resource settings and have great potential for scalability. Funding Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health

Approximately 15.5 million cancer survivors were alive in the United States in 2016 with expected growth to 26.1 million by 2040 (1). Cancer survivors are living longer because of advances in early detection and treatment, but face psychosocial, cognitive, financial, and physical challenges (1,2). Physical challenges include cardiovascular complications, partly because cancer and cardiovascular disease (CVD) share some cumulative risk factors including tobacco use, physical inactivity, obesity, poor diet, hypertension, diabetes, and dyslipidemia (3). In addition, many cancer treatments damage the heart, and some cancer types increase risk for developing CVD (4). The recognition and management of heart disease in cancer survivors has given rise to the discipline of cardio-oncology, which focuses on the cardiovascular health of this population (5). CVD risk has been previously estimated using prediction models, and studies suggest that physician-patient communication using predicted heart age rather than predicted 10-year risk has led to a more accurate perception of excess heart age, encouraged actions to adopt a healthy lifestyle, and improved modifiable CVD risk factors (6,7). Using the nonlaboratory-based Framingham Risk Score (FRS) to estimate 10-year risk for developing CVD, predicted heart age is estimated from the 10-year risk of CVD (predicted by age, sex, diabetes status, smoking status, systolic blood pressure, hypertension treatment status, and body mass index); it is the age of an otherwise healthy person with the same predicted risk, with all other risk factors included in the prediction model at the normal level (systolic blood pressure of 125 mmHg, no hypertension treatment, body mass index of 22.5, nonsmoker, and nondiabetic) (6). Using data from the Behavioral Risk Factor Surveillance System (BRFSS), this study estimates predicted heart age, excess heart age (difference between predicted heart age and actual age), and racial/ethnic and sociodemographic disparities in predicted heart age among U.S. adult cancer survivors and noncancer participants aged 30-74 years using previously published methods (7). A total of 22,759 men and 46,294 women were cancer survivors with a mean age of 48.7 and 48.3 years, respectively. The predicted heart age and excess heart age among cancer survivors were 57.2 and 8.5 years, respectively, for men and 54.8 and 6.5 years, respectively, for women, and varied by age, race/ethnicity, education and income. The use of predicted heart age by physicians to encourage cancer survivors to improve modifiable risk factors and make heart healthy choices, such as tobacco cessation, regular physical activity, and a healthy diet to maintain a healthy weight, can engage survivors in informed cancer care planning after diagnosis.

Delivery of interventions through group sessions allows for in-depth discussions and creates opportunities for group members to work together to identify and solve common problems. However, low attendance may limit impact. We explored factors affecting attendance, active participation, and behavior change in an integrated group-based child development and maternal and child health intervention in Bangladesh. Community health workers (CHWs) facilitated two sessions a month including material on child stimulation; water, sanitation, and hygiene; nutrition, maternal depression, and lead exposure prevention. Sessions were conducted with 320 pregnant women and mothers with children younger than 24 months, in 16 villages in Kishoreganj district. After 4 and 9 months of intervention, we conducted focus group discussions and in-depth interviews with mothers (n = 55 and n = 48) to identify determinants of attendance and behavior change, and to examine potential for intervention scale-up. Recruiting family members to assist with childcare resulted in improved attention during sessions. Adopting a storytelling format for presentation of session materials resulted in more engaged participation during courtyard sessions. Session attendance and behavior change, especially purchasing decisions, were difficult for participants without the support of male heads of the household. Selecting a rotating leader from among the group members to remind group members to attend sessions and support CHWs in organizing the sessions was not successful. Facilitating self-appraisals and planning for water and sanitation allowed participants to identify areas for improvement and track their progress. Key determinants of a participant’s attendance were identified, and the resulting intervention shows promise for future implementation at scale.

In this article, we present a variety of measures that quantify equity in cancer mortality outcomes, demonstrate how the measures perform with various cancer types, and identify counties, or “bright spots,” that meet the criteria of those measures. Using county-level age-adjusted mortality rates for 2007–2016 from the National Center for Health Statistics, we identified counties that had both equitable and optimal outcomes for Black and White death rates across 5 types of cancer: cancers of the lung/bronchus, prostate, female breast, colorectum, and liver. The number of counties that met the criteria ranged from 0 to 442, depending on cancer type and measure used. Prostate cancer and male liver cancer consistently had the lowest number of “bright spots,” with a maximum of 3 counties meeting the most lenient criteria. This paper presents several ways to examine equity, using rate ratios and standard error measures, in cancer mortality outcomes. It highlights areas with positive progress toward equity and areas with a potential need for equity-focused cancer-control planning. Examining local areas of positive deviance can inform cancer-control programming and planning around health equity.

While the prevalence of undernutrition in children has decreased in many low- and middle-income countries since the 1990s, prevalences of overweight and obesity have increased. Frequent consumption of sugar-sweetened food might have contributed to this change, although very little is known about sugar-sweetened food consumption in early life.The objective of this study was to explore the associations between individual, household, and maternal factors and the prevalence of sugar-sweetened food consumption in 6- to 24-month-old children in Bangladesh.Multistage sampling was used to select households with children aged 6-24 months in rural Chatmohar, a subdistrict of Bangladesh (n = 1635). Research assistants conducted a 24-hour qualitative dietary recall questionnaire with the enrolled child's primary caregiver to measure maternal and child dietary patterns. We examined factors associated with the prevalence of child sugar-sweetened food consumption with multivariate logistic regression models. We conducted tests of heterogeneity to explore differential associations between the child sugar-sweetened food consumption prevalence and household income by maternal nutrition knowledge and wealth.Primary caregivers reported that 62% of toddlers had consumed sugar-sweetened food in the past 24 hours. A higher prevalence of child sugar-sweetened food consumption was associated with both a higher dietary diversity score (OR, 1.19; 95% CI, 1.09-1.29) and a higher prevalence of maternal sugar-sweetened food consumption (OR, 2.54; 95% CI, 1.97-3.28). At higher levels of maternal nutrition knowledge and wealth, more household income was associated with a lower prevalence of child sugar-sweetened food consumption.Almost two-thirds of 6- to 24-month-old children in rural Chatmohar, Bangladesh, had consumed sugar-sweetened food in the last day. This is a high and concerning prevalence, and the associated factors identified in this study should be investigated further to identify potential areas of intervention to decrease the prevalence of child sugar consumption in Bangladesh.

Objectives Breastfeeding and complementary feeding practices in India do not meet recommendations. Community health care workers (CHWs) are often the primary source of information for pregnant and postpartum women about Infant and Young Child Feeding (IYCF) practices. While existing research has evaluated the effectiveness of content and delivery of information through CHWs, little is known about the quality of the interpersonal communication (respectful care). We analyzed the effect of respectful interactions on recommended IYCF practices. Methods We use data from evaluation of an at-scale mHealth intervention in India that serves as a job aid to the CHWs (n = 3266 mothers of children Results About half of women reported positive, respectful interactions with CHWs. Interactions that are more respectful were associated with better recall of appropriate health messages. Interactions that are more respectful were associated with a greater likelihood of adopting all child-feeding behaviors except timely initiation of breastfeeding. After including recall in the model, the effect of respectful interactions alone reduced. Conclusions Respectful care from CHWs appears to be significantly associated with some behaviors around infant feeding, with the primary pathway being through better recall of messages. Focusing on improving social and soft skills of CHWs that can translate into better CHW-beneficiary interactions can pay rich dividends. Funding This study is funded by Grant No. OPP1158231 from Bill and Melinda Gates Foundation. Trial registration number: https://doi.org/10.1186/ISRCTN83902145

Background Hundreds of millions of children living in poverty worldwide are not reaching their full, developmental potential. Programs to promote nurturing and responsive caregiving, such as those in which community health workers (CHWs) conduct home visits to support optimal early childhood development (ECD), have been effective in small trials, but have not achieved similar success at scale. This study will explore two approaches to scale-up: converting a home-visiting model to a group-based model; and integrating the ECD curriculum into an existing government program. The objectives of the study are to: 1) Measure how the integration of ECD activities affects time and task allocation of CHWs and CHW psychosocial wellbeing; 2) Examine how the integration of ECD activities affects caregiver-child dyad participation in standard health and nutrition activities; and 3) Explore how the availability of age-appropriate play materials at home affects caregiver-child dyad participation rates in a group-based ECD program. Methods We will randomize 75 communities in rural Madagascar into three arms: 1) [C], which is the status quo (community-based health and nutrition program); 2) [T], which is C + ECD group sessions [T]; and 3) [T +], which is T with the addition of an enhanced play materials package for home use. All children between 6–30 months old at the time of the intervention launch will be eligible to participate in group activities. The intervention will last 12 months and is comprised of fortnightly group sessions in which the CHWs provide caregiver-child dyads with information relating to ECD; CHWs will also include structured time for caregivers to practice the play and child stimulation activities they have learned. We will administer monthly surveys to measure CHW time use and task allocation, and we will leverage administrative data to measure caregiver-child dyad participation in the group sessions. Discussion The results from the trial will provide the evidence base required to implement an integrated package of nutrition, health and ECD promotion activities at scale in Madagascar, and findings may be relevant in other low-income countries. Trial registration This trial is registered on the AEA Social Science Registry (AEARCTR-0004704) on November 15, 2019 and on ClinicalTrials.gov (NCT05129696) on November 22, 2021.

Author(s): Dewey, Kathryn G; Wessells, K Ryan; Arnold, Charles D; Prado, Elizabeth L; Abbeddou, Souheila; Adu-Afarwuah, Seth; Ali, Hasmot; Arnold, Benjamin F; Ashorn, Per; Ashorn, Ulla; Ashraf, Sania; Becquey, Elodie; Bendabenda, Jaden; Brown, Kenneth H; Christian, Parul; Colford, John M; Dulience, Sherlie JL; Fernald, Lia CH; Galasso, Emanuela; Hallamaa, Lotta; Hess, Sonja Y; Humphrey, Jean H; Huybregts, Lieven; Iannotti, Lora L; Jannat, Kaniz; Lartey, Anna; Port, Agnes Le; Leroy, Jef L; Luby, Stephen P; Maleta, Kenneth; Matias, Susana L; Mbuya, Mduduzi NN; Mridha, Malay K; Nkhoma, Minyanga; Null, Clair; Paul, Rina R; Okronipa, Harriet; Ouedraogo, Jean-Bosco; Pickering, Amy J; Prendergast, Andrew J; Ruel, Marie; Shaikh, Saijuddin; Weber, Ann M; Wolff, Patricia; Zongrone, Amanda; Stewart, Christine P | Abstract: ABSTRACTBackgroundMeta-analyses have demonstrated that small-quantity lipid-based nutrient supplements (SQ-LNS) reduce stunting and wasting prevalence among infants and young children. Identification of subgroups who benefit most from SQ-LNS may facilitate program design.ObjectiveOur objective was to identify study-level and individual-level modifiers of the effect of SQ-LNS on child growth outcomes.MethodsWe conducted a two-stage meta-analysis of individual participant data from 14 randomized controlled trials of SQ-LNS provided to children 6 to 24 months of age in low- and middle-income countries (n=37,066). We generated study-specific and subgroup estimates of SQ-LNS vs. control and pooled the estimates using fixed-effects models, with random-effects models as sensitivity analyses. We used random effects meta-regression to examine study-level effect modifiers. Heterogeneity was assessed using I2 and Tau2 statistics. Sensitivity analyses were conducted to examine whether results differed depending on inclusion criteria for arms within trials and types of comparisons.ResultsSQ-LNS provision decreased stunting (length-for-age z-score l −2) by 12% (relative reduction), wasting (weight-for-length (WLZ) z-score l −2) by 14%, low mid-upper arm circumference (MUAC l 125 mm or MUACZ l −2) by 18%, acute malnutrition (WLZ l −2 or MUAC l 125 mm) by 14%, underweight (weight-for-age z-score l −2) by 13%, and small head size (head-circumference z-score l −2) by 9%. Effects of SQ-LNS on growth outcomes generally did not differ by study-level characteristics including region, stunting burden, malaria prevalence, sanitation, water quality, duration of supplementation, frequency of contact or average reported compliance with SQ-LNS. Effects of SQ-LNS on stunting, wasting, low MUAC and small head size were greater among girls than among boys; effects on stunting, underweight and low MUAC were greater among later-born (vs. first-born) children; and effects on wasting and acute malnutrition were greater among children in households with improved (vs. unimproved) sanitation. Results were similar across sensitivity analyses.ConclusionsThe positive impact of SQ-LNS on growth is apparent across a wide variety of study-level contexts. Policy-makers and program planners should consider including SQ-LNS in the mix of interventions to prevent both stunting and wasting. This study was registered at www.crd.york.ac.uk/PROSPERO as CRD42019146592.

Background:Previously, we demonstrated that a water, sanitation, handwashing, and nutritional intervention improved linear growth and was unexpectedly associated with shortened childhood telomere length (TL) (Lin et al., 2017). Here, we assessed the association between TL and growth.Methods:We measured relative TL in whole blood from 713 children. We reported differences between the 10th percentile and 90th percentile of TL or change in TL distribution using generalized additive models, adjusted for potential confounders.Results:In cross-sectional analyses, long TL was associated with a higher length-for-age Z score at age 1 year (0.23 SD adjusted difference in length-for-age Z score [95% CI 0.05, 0.42; FDR-corrected p-value = 0.01]). TL was not associated with other outcomes.Conclusions:Consistent with the metabolic telomere attrition hypothesis, our previous trial findings support an adaptive role for telomere attrition, whereby active TL regulation is employed as a strategy to address ‘emergency states’ with increased energy requirements such as rapid growth during the first year of life. Although short periods of active telomere attrition may be essential to promote growth, this study suggests that a longer overall initial TL setting in the first 2 years of life could signal increased resilience against future telomere erosion events and healthy growth trajectories.Funding:Funded by the Bill and Melinda Gates Foundation.Clinical trial number:NCT01590095

OBJECTIVE: Evaluate how coverage and quality of primary health care (PHC) and a conditional cash transfer (CCT) program associate with child mortality in Brazil. METHODS: Multivariate linear regression models and least absolute shrinkage and selection estimator (LASSO) were utilized with the municipal level child mortality rate as the key dependent variable. PHC quality with PHC and CCT coverage were the independent variables. The quality of the Brazilian PHC was assessed using the Brazilian National Program for Access and Quality Improvement in PHC data. PHC and CCT coverage were calculated based on Brazilian official databases. Human developmental index (HDI), municipality size, and country region were used as control variables. A total of 3441 municipalities were evaluated. RESULTS: We found that ESF (Estratégia Saúde da Família) quality variables PLANNING [Family Health Team Planning activities], CITYSUPPORT [municipality support for Family Health Strategy activities], EXAMS [exams offered and priority groups seen by the family health team], and PRENATAL [prenatal care and exams provided by the family health team], as well as HDI, percentage of PHC coverage, percentage of CCT coverage, and population size have significant and negative relationships with 1-year-old child mortality. LASSO regression results confirmed these associations. Quality is an important element of effective social service provision. CONCLUSION: This exploration represents one of the first investigations into the role of PHC system quality, and how it is related to health outcomes, while also considering PHC and conditional cash transfer program coverage. Quality of PHC, measured by work process variables, plays an important role in child mortality. Efforts on PHC quality and coverage, as well as on CCT program coverage, are important to child mortality reduction. Therefore, this is an important finding to other PHC public health services. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.17269/s41997-019-00246-9) contains supplementary material, which is available to authorized users.

Community Health Workers (CHWs) can effectively implement maternal and child health interventions, but there is paucity of evidence on how to integrate child stimulation into these interventions, and their delivery at scale. In rural Bangladesh, CHWs implemented an intervention integrating psychosocial stimulation, nutrition, maternal mental health, water, sanitation, hygiene (WASH) and lead exposure prevention. In each of 16 intervention villages, one CHW worked with 20 households. CHWs bi-weekly held group meetings or alternated group meetings and home visits with pregnant women and lactating mothers. We assessed the intervention through five focus groups, four interviews and one group discussion with CHWs and their supervisors to explore success factors of implementation. CHWs’ training, one-on-one supervision and introduction by staff to their own community, and adoption of tablet computers as job aids, enabled successful session delivery to convey behavioral recommendations. CHWs reported difficulties delivering session due to the complexity of behavioral recommendations and struggled with age-specific intervention material. Young children’s attendance in group sessions generated distractions that undermined content delivery. We identified ways to minimize the difficulties to strengthen intervention-delivery during implementation, and scale-up. Iterative revisions of similarly integrated interventions based on qualitative evaluation findings could be delivered feasibly by CHWs and allow for implementation at scale.

Introduction Community health workers (CHWs) deliver services at-scale to reduce maternal and child undernutrition, but often face inadequate support from the health system to perform their job well. Supportive supervision is a promising intervention that strengthens the health system and can enable CHWs to offer quality services. Objectives We examined if greater intensity of supportive supervision as defined by monitoring visits to Anganwadi Centre, CHW-supervisor meetings, and training provided by supervisors to CHWs in the context of Integrated Child Services Development (ICDS), a national nutrition program in India, is associated with higher performance of CHWs. Per program guidelines, we develop the performance of CHWs measure by using an additive score of nutrition services delivered by CHWs. We also tested to see if supportive supervision is indirectly associated with CHW performance through CHW knowledge. Methods We used longitudinal survey data of CHWs from an impact evaluation of an at-scale technology intervention in Madhya Pradesh and Bihar. Since the inception of ICDS, CHWs have received supportive supervision from their supervisors to provide services in the communities they serve. Mixed-effects logistic regression models were used to test if higher intensity supportive supervision was associated with improved CHW performance. The model included district fixed effects and random intercepts for the sectors to which supervisors belong. Results Among 809 CHWs, the baseline proportion of better performers was 45%. Compared to CHWs who received lower intensity of supportive supervision, CHWs who received greater intensity of supportive supervision had 70% higher odds (AOR 1.70, 95% CI 1.16, 2.49) of better performance after controlling for their baseline performance, CHW characteristics such as age, education, experience, caste, timely payment of salaries, Anganwadi Centre facility index, motivation, and population served in their catchment area. A test of mediation indicated that supportive supervision is associated indirectly with CHW performance through improvement in CHW knowledge. Conclusion Higher intensity of supportive supervision is associated with improved CHW performance directly and through knowledge of CHWs. Leveraging institutional mechanisms such as supportive supervision could be important in improving service delivery to reach beneficiaries and potentially better infant and young child feeding practices and nutritional outcomes. Trial registration : Trial registration number: https://doi.org/10.1186/ISRCTN83902145

IntroductionIn low- and middle-income countries, children experience multiple risks for delayed development. We evaluated a multicomponent, group-based early child development intervention including behavioural recommendations on responsive stimulation, nutrition, water, sanitation, hygiene, mental health and lead exposure prevention.MethodsWe conducted a 9-month, parallel, multiarm, cluster-randomised controlled trial in 31 rural villages in Kishoreganj District, Bangladesh. Villages were randomly allocated to: group sessions (‘group’); alternating groups and home visits (‘combined’); or a passive control arm. Sessions were delivered fortnightly by trained community members. The primary outcome was child stimulation (Family Care Indicators); the secondary outcome was child development (Ages and Stages Questionnaire Inventory, ASQi). Other outcomes included dietary diversity, latrine status, use of a child potty, handwashing infrastructure, caregiver mental health and knowledge of lead. Analyses were intention to treat. Data collectors were independent from implementers.ResultsIn July–August 2017, 621 pregnant women and primary caregivers of childrenConclusionOur findings suggest that group-based, multicomponent interventions can be effective at improving child development outcomes in rural Bangladesh, and that they have the potential to be delivered at scale.Trial registration numberThe trial is registered in ISRCTN (ISRCTN16001234).

BackgroundSmall-quantity lipid-based nutrient supplements (SQ-LNS) reduce child stunting and provide many of the fatty acids and micronutrients that are necessary for rapid brain development that occurs during infancy and early childhood. Positive effects of SQ-LNS on developmental outcomes have been found in some trials, but not others.ObjectivesOur objectives were to generate pooled estimates of the effect of SQ-LNS, compared to control groups that received no intervention or an intervention without any nutritional supplement, on developmental outcomes (language, social-emotional, motor, and executive function), and to identify study-level and individual-level modifiers of these effects.MethodsWe conducted a two-stage meta-analysis of individual participant data from 14 intervention versus control group comparisons in 13 randomized trials of SQ-LNS provided to infants and young children age 6 to 24 months in 9 low- or middle-income countries (total n=30,024). We generated study-specific estimates of SQ-LNS vs. control groups (including main effects and subgroup estimates for individual-level effect modifiers) and pooled the estimates using fixed-effects models. We used random effects meta-regression to examine potential study-level effect modifiers.ResultsIn 11-13 intervention versus control group comparisons (n=23,588-24,561), SQ-LNS increased mean language (mean difference: 0.07 standard deviations; 95% CI: 0.04, 0.10), social-emotional (0.08; 0.05, 0.11), and motor scores (0.08; 0.05, 0.11) and reduced the prevalence of children in the lowest decile of these scores by 17% (prevalence ratio: 0.83, 95% CI 0.76, 0.91), 19% (0.81; 0.74, 0.90), and 16% (0.84; 0.77, 0.92), respectively. SQ-LNS also increased the prevalence of children walking without support at 12 months by 9% (1.09; 1.05, 1.14). Effects of SQ-LNS on language, social-emotional, and motor outcomes were larger among study populations with a higher burden (≥ 35%) of child stunting at 18 months (mean difference 0.11-0.13 SD; 8-9 comparisons) than in populations with lower stunting burden (estimates near zero). At the individual level, greater effects of SQ-LNS were found on language among children who were acutely malnourished (mean difference: 0.31) at baseline; on language (0.12), motor (0.11), and executive function (0.06) among children in households with lower socio-economic status; and on motor development among later-born children (0.11), children of older mothers (0.10), and children of mothers with lower education (0.11).ConclusionsSQ-LNS provided daily to children in the range of 6-24 months of age can be expected to result in modest, but potentially important, developmental gains, particularly in populations with high child stunting burden. Certain groups of children who experience higher risk environments, such as those from poor households or with poor baseline nutritional status, have greater potential to benefit from SQ-LNS in developmental outcomes. This study was registered at www.crd.york.ac.uk/PROSPERO as CRD42020159971.

Background Over recent decades, Vietnam has experienced rapid economic growth, a nutrition transition from the traditional diet to highly-processed and calorie-dense foods and beverages, and an increasing prevalence of childhood overweight/obesity (ow/ob). The goal of this study is to describe the patterns of ow/ob in a longitudinal sample of Vietnamese children from ages 1 to 8, and the sociodemographic and behavioral factors associated with ow/ob at age 8. Methods This study is a secondary data analysis of a geographically-representative, longitudinal cohort of 1961 Vietnamese children from the Young Lives Cohort Study from 2002 to 2009. Thirty-one communities were selected with oversampling in rural communities, and children age 1 were recruited from each community using simple random sampling. Surveys of families and measurements of children were collected at child ages 1, 5, and 8. Our specified outcome measure was childhood ow/ob at age 8, defined by the World Health Organization’s thresholds for body-mass-index (BMI) for age Z-scores. Associations between early and concurrent socio-behavioral factors, childhood nutrition and physical activity variables were analyzed using STATA 15. Bivariate and multivariable analyses were completed utilizing logistic regression models. Results The prevalence of ow/ob increased from 1.1% in both sexes at age 1 to 7% in females and 13% in males at age 8. Bivariate analyses show greater likelihood of ow/ob at age 8 was significantly associated with early life sociodemographic factors (at age 1), male sex (OR = 2.2, 1.6–3.1), higher wealth (OR = 1.1–1.4), and urban residence (OR = 4.3, 3–6). In adjusted analyses, ow/ob at age 8 was associated with early nutrition practices at age 5, including frequent consumption of powdered milk (OR = 2.8, 1.6–4.6), honey/sugar (OR = 2.7, 1.8–4.1), prepared restaurant/fast foods (OR = 4.6, 2.6–8.2), and packaged sweets (OR = 3.4, 2.3–4.9). In addition, breastfeeding for 6 months or longer was protective against obesity at age 8 (OR = 0.3, 0.1–0.9). Conclusions We found that increased consumption of powdered milk, honey/sugar, packaged sweets, and prepared restaurants/fast foods are associated with childhood ow/ob. In contrast, breastfeeding for 6 months or longer was protective against childhood ow/ob. These findings suggest that public health programs and campaigns aimed to prevent childhood ow/ob in Vietnam should target early feeding practices.

ObjectiveTo determine the magnitude of relationships of early life factors with child development in low/middle-income countries (LMICs).DesignMeta-analyses of standardised mean differences (SMDs) estimated from published and unpublished data.Data sourcesWe searched Medline, bibliographies of key articles and reviews, and grey literature to identify studies from LMICs that collected data on early life exposures and child development. The most recent search was done on 4 November 2014. We then invited the first authors of the publications and investigators of unpublished studies to participate in the study.Eligibility criteria for selecting studiesStudies that assessed at least one domain of child development in at least 100 children under 7 years of age and collected at least one early life factor of interest were included in the study.AnalysesLinear regression models were used to assess SMDs in child development by parental and child factors within each study. We then produced pooled estimates across studies using random effects meta-analyses.ResultsWe retrieved data from 21 studies including 20 882 children across 13 LMICs, to assess the associations of exposure to 14 major risk factors with child development. Children of mothers with secondary schooling had 0.14 SD (95% CI 0.05 to 0.25) higher cognitive scores compared with children whose mothers had primary education. Preterm birth was associated with 0.14 SD (–0.24 to –0.05) and 0.23 SD (–0.42 to –0.03) reductions in cognitive and motor scores, respectively. Maternal short stature, anaemia in infancy and lack of access to clean water and sanitation had significant negative associations with cognitive and motor development with effects ranging from −0.18 to −0.10 SDs.ConclusionsDifferential parental, environmental and nutritional factors contribute to disparities in child development across LMICs. Targeting these factors from prepregnancy through childhood may improve health and development of children.

Item does not contain fulltext BACKGROUND: Gastrointestinal angiodysplasias are vascular malformations that often cause red blood cell transfusion-dependent anaemia. Several studies suggest that somatostatin analogues might decrease rebleeding rates, but the true effect size is unknown. We therefore aimed to investigate the efficacy of somatostatin analogues on red blood cell transfusion requirements of patients with gastrointestinal angiodysplasias and to identify subgroups that might benefit the most from somatostatin analogue therapy. METHODS: We did a systematic review and individual patient data meta-analysis. We searched MEDLINE, Embase, and Cochrane on Jan 15, 2016, with an updated search on April 25, 2021. All published randomised controlled trials and cohort studies that reported on somatostatin analogue therapy in patients with gastrointestinal angiodysplasias were eligible for screening. We excluded studies without original patient data, single case reports, small case series (ie

Author(s): Wessells, K Ryan; Arnold, Charles D; Stewart, Christine P; Prado, Elizabeth L; Abbeddou, Souheila; Adu-Afarwuah, Seth; Arnold, Benjamin F; Ashorn, Per; Ashorn, Ulla; Becquey, Elodie; Brown, Kenneth H; Byrd, Kendra A; Campbell, Rebecca K; Christian, Parul; Fernald, Lia CH; Fan, Yue-Mei; Galasso, Emanuela; Hess, Sonja Y; Huybregts, Lieven; Jorgensen, Josh M; Kiprotich, Marion; Kortekangas, Emma; Lartey, Anna; Le Port, Agnes; Leroy, Jef L; Lin, Audrie; Maleta, Kenneth; Matias, Susana L; Mbuya, Mduduzi NN; Mridha, Malay K; Mutasa, Kuda; Naser, Abu Mohd; Paul, Rina R; Okronipa, Harriet; Ouedraogo, Jean-Bosco; Pickering, Amy J; Rahman, Mahbubur; Schulze, Kerry; Smith, Laura E; Weber, Ann M; Zongrone, Amanda; Dewey, Kathryn G | Abstract: ABSTRACTBackgroundSmall-quantity lipid-based nutrient supplements (SQ-LNS) have been shown to reduce the prevalence of anemia and iron deficiency among infants and young children, but effects on other micronutrients are less well known. Identifying subgroups who may experience greater benefits from SQ-LNS, or who are more likely to respond to the intervention, may facilitate the development of public health policies and programs.ObjectiveOur objective was to identify study-level and individual-level modifiers of the effect of SQ-LNS on child hematological and micronutrient status outcomes.MethodsWe conducted a two-stage meta-analysis of individual participant data from 13 randomized controlled trials of SQ-LNS provided to children 6 to 24 months of age in low- and middle-income countries (n = 15,946). Outcomes were hemoglobin (Hb), inflammation-adjusted plasma ferritin, soluble transferrin receptor, zinc, retinol and retinol binding protein (RBP), and erythrocyte zinc protoporphyrin, and respective dichotomous outcomes indicative of anemia and micronutrient deficiency. We generated study-specific estimates of SQ-LNS vs. control, including main effects and subgroup estimates for individual-level effect modifiers, and pooled the estimates using fixed-effects models. We used random effects meta-regression to examine potential study-level effect modifiers.ResultsProvision of SQ-LNS decreased the prevalence of anemia (Hb l 110 g/L) by 16% (relative reduction), iron deficiency (plasma ferritin l 12 µg/L) by 56% and iron deficiency anemia (IDA; Hb l 110 g/L and plasma ferritin l 12 µg/L) by 64%. We observed positive effects of SQ-LNS on hematological and iron status outcomes within all subgroups of the study-level and individual-level effect modifiers, but effects were larger in certain subgroups. For example, effects of SQ-LNS on anemia and iron status were greater in trials that provided SQ-LNS for g 12 months and provided 9 mg/d vs. l 9 mg iron/d, and among later-born (vs. first-born) children. There was no effect of SQ-LNS on plasma zinc or retinol, but there was a 7% increase in plasma RBP and a 56% reduction in vitamin A deficiency (RBP l 0.70 µmol/L), with little evidence of effect modification by individual-level characteristics.ConclusionsSQ-LNS provided to infants and young children 6-24 months of age can substantially reduce the prevalence of anemia, iron deficiency, and IDA across a range of individual, population and study design characteristics. Policy-makers and program planners should consider SQ-LNS within intervention packages to prevent anemia and iron deficiency. This study was registered at www.crd.york.ac.uk/PROSPERO as CRD42020156663.

The aim of this systematic review was to examine the prevalence of burnout-related symptoms in Brazilian schoolteachers who work in public schools. The literature search was conducted using the following databases: PubMed-MEDLINE, Scopus, and Web of Science. Peer-reviewed studies published in English, Spanish, or Portuguese were considered for inclusion. A total of 2106 records were identified through database searching and 7 additional studies were identified through other sources. Based on the inclusion and exclusion criteria, 19 studies were included in the systematic review. Burnout syndrome prevalence was assessed through seven distinct questionnaires. Overall, the majority of the studies presented high methodological quality. Brazilian schoolteachers exhibited high levels of emotional exhaustion (21–69%), high or moderate degrees of depersonalization (8–32%), and high levels of personal realization and enthusiasm toward the job (30–90%). From these data, it is possible to infer that Brazilian schoolteachers are, in general, affected by burnout syndrome. However, and, surprisingly, they seem to be motivated and idealistic, as demonstrated by their high levels of personal realization and enthusiasm toward the job (30–90%). This likely favors the implementation of programs designed to avoid or reduce burnout, deal with stress, and enhance teaching quality.

BackgroundAnganwadi Workers (AWWs) are a group of 1.4 million community health workers that operate throughout rural India as a part of the Integrated Child Development Services program. AWWs are responsible for disseminating key health information regarding nutrition, family planning, and immunizations to the women and children in their catchment area, while maintaining detailed registers that track key beneficiary data, updates on health status, and supply inventory beneficiaries. There is a need to understand how AWWs spend their time on all of these activities given all of their responsibilities, and the factors that are associated with their time use.MethodsThis cross-sectional study conducted in Madhya Pradesh, collected time use data from AWWs using a standard approach in which we asked participants how much time they spent on various activities. Additionally, we estimated a logistic regression model to elucidate what AWW characteristics are associated with time use.ResultsWe found that AWWs spend substantial amounts of time on administrative tasks, such as filling out their paper registers. Additionally, we explored the associations between various AWW characteristics and their likelihood of spending the expected amount of time on preschool work, filling out their registers, feeding children, and conducting home visits. We found a positive significant association between AWW education and their likelihood of filling out their registers.ConclusionsAWWs spend substantial amounts of time on administrative tasks, which could take away from their ability to spend time on providing direct care. Additionally, future research should explore why AWW characteristics matter and how such factors can be addressed to improve AWWs’ performance and should explore the associations between Anganwadi Center characteristics and AWW time use.

Summary Background Scant data are available about global patterns of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spread and global epidemiology of early confirmed cases of COVID-19 outside mainland China. We describe the global spread of SARS-CoV-2 and characteristics of COVID-19 cases and clusters before the characterisation of COVID-19 as a pandemic. Methods Cases of COVID-19 reported between Dec 31, 2019, and March 10, 2020 (ie, the prepandemic period), were identified daily from official websites, press releases, press conference transcripts, and social media feeds of national ministries of health or other government agencies. Case characteristics, travel history, and exposures to other cases were abstracted. Countries with at least one case were classified as affected. Early cases were defined as those among the first 100 cases reported from each country. Later cases were defined as those after the first 100 cases. We analysed reported travel to affected countries among the first case reported from each country outside mainland China, demographic and exposure characteristics among cases with age or sex information, and cluster frequencies and sizes by transmission settings. Findings Among the first case reported from each of 99 affected countries outside of mainland China, 75 (76%) had recent travel to affected countries; 60 (61%) had travelled to China, Italy, or Iran. Among 1200 cases with age or sex information, 874 (73%) were early cases. Among 762 early cases with age information, the median age was 51 years (IQR 35–63); 25 (3%) of 762 early cases occurred in children younger than 18 years. Overall, 21 (2%) of 1200 cases were in health-care workers and none were in pregnant women. 101 clusters were identified, of which the most commonly identified transmission setting was households (76 [75%]; mean 2·6 cases per cluster [range 2–7]), followed by non-health-care occupational settings (14 [14%]; mean 4·3 cases per cluster [2–14]), and community gatherings (11 [11%]; mean 14·2 cases per cluster [4–36]). Interpretation Cases with travel links to China, Italy, or Iran accounted for almost two-thirds of the first reported COVID-19 cases from affected countries. Among cases with age information available, most were among adults aged 18 years and older. Although there were many clusters of household transmission among early cases, clusters in occupational or community settings tended to be larger, supporting a possible role for physical distancing to slow the progression of SARS-CoV-2 spread. Funding None.

The aim of this study was to determine the main characteristics of a “good teacher” through the use of questionnaires designed to assess teaching skills and competences, considering the point of view of teachers, principals, and students. In total, 82 teachers, 14 principals, and 625 middle-school students from 5 public schools in Sao Paulo state participated in this study. Two questionnaires were applied, one designed for teachers and principals and the other for students. First, teachers and principals completed their specific questionnaire, after which the other questionnaire was applied to the students. Both questionnaires contained multiple choice questions related to eight distinct subsections. The questions were answered through the use of a Likert scale, varying from 1 (“totally disagree”) to 5 (“totally agree”). The comparisons of the frequency of responses among all questionnaire subsections between teachers and principals were analyzed using a Chi-Square and the z-test, with P-values adjusted to the Bonferroni method. The statistical significance level was set as P < 0.05. The subsection “class atmosphere” presented the highest percentage of response “totally agree”, closely followed by “professional engagement”. Significant differences (P < 0.05) in responses were observed between teachers and principals for “teaching planning and practice”, “use of time and material resources to develop classes”, and “professional engagement” domains. In summary, it was demonstrated that some teaching characteristics might be more important than others, with some of these characteristics exhibiting significant differences between groups. Nevertheless, it is crucial to emphasize that all assessed educational domains may be recognized as critical teaching qualities, as all of them presented high levels of “totally agree” responses.

Supporting caregivers&rsquo, mental wellbeing and ability to provide psychosocial stimulation may promote early childhood development. This paper describes the systematic approach of developing an integrated stimulation intervention, identifying the feasibility and challenges faced throughout the period. We developed an integrated curriculum by culturally adapting three interventions (Reach Up, Thinking Healthy, and general nutrition advice) and piloted this curriculum (Mar&ndash, April 2017) in courtyard groups sessions and individual home visits with pregnant women (n = 11) and lactating mothers (of children &lt, 24 months) (n = 29). We conducted qualitative interviews with the participants (n = 8) and the community health workers who delivered the intervention (n = 2). Most participants reported willingness to attend the sessions if extended for 1 year, and recommended additional visual cues and interactive role-play activities to make the sessions more engaging. Participants and community health workers found it difficult to understand the concept of &ldquo, unhealthy thoughts&rdquo, in the curriculum. This component was then revised to include a simplified behavior-focused story. Community health workers reported difficulty balancing the required content of the integrated curriculum but were able to manage after the contents were reduced. The revised intervention is likely feasible to deliver to a group of pregnant and lactating mothers in a low-resource setting.

BackgroundIron deficiency anemia affects hundreds of millions of women and children worldwide and is associated with impaired infant outcomes. Small-quantity lipid-based nutrient supplement (LNS) have been found to reduce the prevalence of anemia and iron deficiency in some trials.ObjectivesWe evaluated the effectiveness of daily LNS supplementation on child anemia and micronutrient status in Madagascar within the context of an existing, scaled-up nutrition program.MethodsWe cluster-randomized 125 communities to (T0) a routine program with monthly growth monitoring and nutrition education; (T1) T0+home visits for intensive nutrition counselling; (T2) T1+LNS for children aged 6-18mo; (T3) T2+LNS for pregnant/lactating women; or (T4) T1+parenting messages. Pregnant women and infants aged

Malaria is a leading cause of morbidity and mortality among children under five years of age, with most cases occurring in Sub-Saharan Africa. Children in this age group in Africa are at greatest risk worldwide for developmental deficits. There are research gaps in quantifying the risks of mild malaria cases, understanding the pathways linking malaria infection and poor child development, and evaluating the impact of malaria on the development of children under five years. We analyzed the association between malaria infection and gross motor, communication, and personal social development in 592 children age 24 months in rural, western Kenya as part of the WASH Benefits environmental enteric dysfunction sub-study. Eighteen percent of children had malaria, 20% were at risk for gross motor delay, 21% were at risk for communication delay, and 23% were at risk for personal social delay. Having a positive malaria test was associated with increased risk for gross motor, communication, and personal social delay while adjusting for child characteristics, household demographics, study cluster, and intervention treatment arm. Mediation analyses suggested that anemia was a significant mediator in the pathway between malaria infection and risk for gross motor, communication, and personal social development delays. The proportion of the total effect of malaria on the risk of developmental delay that is mediated by anemia across the subscales was small (ranging from 9% of the effect on gross motor development to 16% of the effect on communication development mediated by anemia). Overall, malaria may be associated with short-term developmental delays during a vulnerable period of early life. Therefore, preventative malaria measures and immediate treatment are imperative for children&rsquo, s optimal development, particularly in light of projections of continued high malaria transmission in Kenya and Africa.

Purpose The purpose of the study was to examine whether access to an at-scale, group-based parenting education program ("Educacion Inicial") had differential effects on parenting behaviors and child cognitive development according to mother's age at the birth of her first child, with a focus on adolescent mothers in rural Mexico. Methods This was a secondary analysis of a cluster-randomized controlled trial (n = 728 households, n = 106 communities). We conducted intent-to-treat analyses and examined the interaction between treatment group and mother's age at first birth. The primary outcomes were parenting behaviors (Family Care Indicators) and children's cognitive development (McCarthy Scales of Children's Abilities) at ages 3–5 years. Results We found that children of mothers who began childbearing in adulthood (20–30 years) scored higher on tests of cognitive development when randomized to weekly parenting support than their counterparts in the comparison group. Whereas, the children of mothers who began childbearing in adolescence (≤16 years) did not have higher scores associated with the parenting program (difference in magnitude of associations: Verbal=−8.19; 95% CI=−15.50 to −.88; p = .03; Memory=−7.22; 95% CI=−14.31 to −.14; p = .05). The higher scores among the children of mothers who began childbearing in adulthood were only significant when Educacion Inical was supported by Prospera, the conditional cash transfer program. Conclusions Our study results suggest that the Educacion Inicial parenting intervention did not adequately address the needs of women who began childbearing in adolescence. One reason may be that adolescent mothers are more socially marginalized and less able to benefit from parenting programs.

This article looks at both nutrition and early childhood stimulation interventions as part of an integrated life cycle approach to development. We build on recent systematic reviews of child development, which are comprehensive in regard to what is currently known about outcomes reported in key studies. We then focus particularly on implementation, scaling, and economic returns, drawing mainly on experience in low- and middle-income countries where undernutrition and poor child development remain significant public health challenges with implications across the life course.

Understanding feedbacks between human and environmental health is critical for the millions who cope with recurrent illness and rely directly on natural resources for sustenance. Although studies have examined how environmental degradation exacerbates infectious disease, the effects of human health on our use of the environment remains unexplored. Human illness is often tacitly assumed to reduce human impacts on the environment. By this logic, ill people reduce the time and effort that they put into extractive livelihoods and, thereby, their impact on natural resources. We followed 303 households living on Lake Victoria, Kenya over four time points to examine how illness influenced fishing. Using fixed effect conditional logit models to control for individual-level and time-invariant factors, we analyzed the effect of illness on fishing effort and methods. Illness among individuals who listed fishing as their primary occupation affected their participation in fishing. However, among active fishers, we found limited evidence that illness reduced fishing effort. Instead, ill fishers shifted their fishing methods. When ill, fishers were more likely to use methods that were illegal, destructive, and concentrated in inshore areas but required less travel and energy. Ill fishers were also less likely to fish using legal methods that are physically demanding, require travel to deep waters, and are considered more sustainable. By altering the physical capacity and outlook of fishers, human illness shifted their effort, their engagement with natural resources, and the sustainability of their actions. These findings show a previously unexplored pathway through which poor human health may negatively impact the environment.

Background The purpose of this study was to report long‐term disease control and late radiation toxicity for patients reirradiated for head and neck cancer. Methods We conducted a retrospective analysis of 137 patients reirradiated with a prescribed dose ≥45 Gy between 1986 and 2013 for a recurrent or second primary malignancy. Endpoints were locoregional control, overall survival (OS), and grade ≥4 late complications according to European Organization for Research and Treatment of Cancer (EORTC)/Radiation Therapy Oncology Group (RTOG) criteria. Results Five‐year locoregional control rates were 46% for patients reirradiated postoperatively versus 20% for patients who underwent reirradiation as the primary treatment (p < .05). Sixteen cases of serious (grade ≥4) late toxicity were seen in 11 patients (actuarial 28% at 5 years). In patients reirradiated with intensity‐modulated radiotherapy (IMRT), a borderline improved locoregional control was observed (49% vs 36%; p = .07), whereas late complication rates did not differ. Conclusion Reirradiation should be considered for patients with a recurrent or second primary head and neck cancer, especially postoperatively, if indicated. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1122–1130, 2017

Author(s): Gopalakrishnan, Lakshmi; Buback, Laura; Fernald, Lia; Walker, Dilys; Diamond-Smith, Nadia; in addition to The CAS Evaluation Consortium | Abstract: BACKGROUND:mHealth technologies are proliferating globally to address quality and timeliness of health care delivery by Community Health Workers (CHWs). This study aimed to examine CHW and beneficiaries' perceptions of a new mHealth intervention (Common Application Software [CAS] for CHWs in India. The objectives of the study were to seek perspectives of CHWs and beneficiaries on the uptake of CAS, changes in CHW-beneficiary interactions since the introduction of CAS and potential barriers faced by CHWs in use of CAS. Further, important contextual factors related to CHW-beneficiary interface and dynamics that may have a bearing on CAS have been described. METHODS:A qualitative study was conducted in two states of India (Bihar and Madhya Pradesh) from March-April 2018 with CHWs (n = 32) and beneficiaries (n = 55). All interviews were conducted and recorded in Hindi, transcribed and translated into English, and coded and thematically analysed using Dedoose. FINDINGS:The mHealth intervention was acceptable to the CHWs who felt that CAS improved their status in the communities where they worked. Beneficiaries' views were a mix of positive and negative perceptions. The divergent views between CHWs and beneficiaries surrounding the use and impact of CAS highlight an underlying mistrust, socio-cultural barriers in engagement, and technological barriers in implementation. All these contextual factors can influence the perception and uptake of CAS. CONCLUSIONS:mHealth interventions targeting CHWs and beneficiaries have the potential to improve performance of CHWs, reduce barriers to information and potentially change the behaviors of beneficiaries. While technology is an enabler for CHWs to improve their service delivery, it does not necessarily help overcome social and cultural barriers that impede CHW-beneficiary interactions to bring about improvements in knowledge and health behaviors. Future interventions for CHWs including mHealth interventions should examine contextual factors along with the acceptability, accessibility, and usability by beneficiaries and community members.

Background The Quality-Adjusted Life Year (QALY) is internationally recognized as standard metric of health outcomes in cost-effectiveness analyses (CEAs) in healthcare. The ongoing debate concerning the appropriateness of its use for decision-making in palliative care has been recently mapped in a review. The aim was to report on and draw conclusions from two expert meetings that reflected on earlier mapped issues in order to reach consensus, and to advise on the QALY’s future use in palliative care. Methods A nominal group approach was used. In order to facilitate group decision making, three statements regarding the use of the QALY in palliative care were discussed in a structured way. Two groups of international policymakers, healthcare professionals and researchers participated. Data were analysed qualitatively using inductive coding. Results 1) Most experts agreed that the recommended measurement tool for the QALYs ‘Q’ component, the EuroQol-5D (EQ-5D), is inappropriate for palliative care. A more sensitive tool, which might be based on the capabilities approach, could be used or developed. 2) Valuation of time should be incorporated in the ‘Q’ part, leaving the linear clock time in the ‘LY’ component. 3) Most experts agreed that the QALY, in its current shape, is not suitable for palliative care. Conclusions 1) Although the EQ-5D does not suffice, a generic tool is needed for the QALY. As long as no suitable alternative is available, other tools can be used besides or serve as basis for the EQ-5D because of issues in conceptual overlap. 2) Future research should further investigate the valuation of time issue, and how best to integrate it in the ‘Q’ component. 3) A generic outcome measure of effectiveness is essential to justly allocate healthcare resources. However, experts emphasized, the QALY is and should be one of multiple criteria for choices in the healthcare insurance package.

The Supplemental Nutrition Assistance Program (SNAP) in the United States is a key element of the nation’s safety net. Yet, 12.5 million US children live in households that experience food insecurity, despite national spending of $65 billion on SNAP alone. In analyses integrating data from the 36 Organisation for Economic Co-operation and Development (OECD) countries, we found that child poverty and food insecurity are much higher in the United States than in most of the other OECD countries. The United States has higher total social spending than other OECD countries, but a lower rate of spending on children and families. This international comparison suggests that potentially effective solutions implemented in other countries might help further alleviate US childhood poverty and food insecurity. Broadly, we recommend increasing investments in families with children, particularly low-income families. Our specific recommendations include increasing SNAP benefits, establishing additional benefits to support low-income families with young children, and implementing a universal child allowance. Achieving substantial reductions in child poverty and food insecurity will require overcoming many challenges, including the current US political climate, a national history of underinvestment in social programs, a lack of political will, and a culture of structural racism.

Background Human capital (the knowledge, skills, and health that accumulate over life) can be optimized by investments in early childhood to promote cognitive and language development. Parents and caregivers play a crucial role in the promotion and support of cognitive development in their children. Thus, understanding caregiver perceptions of a child’s capabilities and attributes, including intelligence, may enhance investments early in life. To explore this question, we asked caregivers to rank their child’s intelligence in comparison with other children in the community, and compared this ranking with children’s scores on an assessment of developmental abilities across multiple domains. Methods Our study examined cross-sectional data of 3361 children aged 16–42 months in rural Madagascar. Child intelligence, as perceived by their caregiver, was captured using a ladder ranking scale based on the MacArthur Scale for Subjective Social Status. Children’s developmental abilities were assessed using scores from the Ages and Stages Questionnaire: Inventory (ASQ-I), which measures cognitive, language, and socio-emotional development. Ranked percentiles of the ASQ-I were generated within communities and across the whole sample. We created categories of under-estimation, matched, and over-estimation by taking the differences in rankings between caregiver-perceived child intelligence and ASQ-I. Child nutritional status, caregiver belief of their influence on child intelligence, and sociodemographic factors were examined as potential correlates of discordance between the measures using multinomial logistic regressions. Results We found caregiver perceptions of intelligence in Madagascar did not align consistently with the ASQ-I, with approximately 8% of caregivers under-estimating and almost 50% over-estimating their children’s developmental abilities. Child nutritional status, caregiver belief of their influence on child intelligence, caregiver education, and wealth were associated with under- or over-estimation of children’s developmental abilities. Conclusions Our findings suggest parents may not always have an accurate perception of their child’s intelligence or abilities compared with other children. The results are consistent with the limited literature on parental perceptions of child nutrition, which documents a discordance between caregiver perceptions and objective measures. Further research is needed to understand the common cues caregivers that use to identify child development milestones and how these may differ from researcher-observed measures in low-income settings. Trial registration Current Controlled Trials ISRCTN14393738. Registered June 23, 2015.

Summary: Background: Evidence from efficacy trials suggests that lipid-based nutrient supplementation (LNS) and home visits can be effective approaches to preventing chronic malnutrition and promoting child development in low-income settings. We tested the integration of these approaches within an existing, large-scale, community-based nutrition programme in Madagascar. Methods: We randomly allocated 125 programme sites to five intervention groups: standard-of-care programme with monthly growth monitoring and nutrition education (T0); T0 plus home visits for intensive nutrition counselling through an added community worker (T1); T1 plus LNS for children aged 6–18 months (T2); T2 plus LNS for pregnant or lactating women (T3); or T1 plus fortnightly home visits to promote and encourage early stimulation (T4). Pregnant women (second or third trimester) and infants younger than 12 months were enrolled in the trial. Primary outcomes were child growth (length-for-age and weight-for-length Z scores) and development at age 18–30 months. Analyses were by intention to treat. The trial was registered with the ISRCTN registry, number ISRCTN14393738. Findings: The study enrolled 3738 mothers: 1248 pregnant women (250 women in each of the T0, T1, T2, and T4 intervention groups and 248 in the T3 intervention group) and 2490 children aged 0–11 months (497 children in T0, 500 in T1, 494 in T2, 499 in T3, and 500 in T4) at baseline who were assessed at 1-year and 2-year intervals. There were no main effects of any of the intervention groups on any measure of anthropometry or any of the child development outcomes in the full sample. However, compared with children in the T0 intervention group, the youngest children (

Background Brazil is the most populous country with a public, universal and free health care system. The National Program for Access and Quality Improvement in Primary Care (PMAQ) was created to improve the quality of primary health care (PHC). Objective To evaluated whether progress generally has been made within Brazil’s PHC since PMAQ implementation, and if changes occurred uniformly in the country, while also identifying municipal characteristics that may have influenced the improvement. Methods This is an observational study using data from PMAQ external evaluation (2012 and 2014), a 1200-item survey used to evaluate Brazilian PHC quality. After confirming the groupings of items using factor analysis, we created 23 composed indexes (CIs) related to infrastructure and work process. Results On average, the large majority of CIs showed improvements between 2012 and 2014. Region and city size moderated changes in the PHC indices differently. Overall, there were better improvements in infrastructure in the Northeast compared with other country regions, and in smaller cities (10 000–20 000 people). Infrastructure indices appear to have improved equitably across the country. Work process improvements varied with city size and region. Conclusion Despite similar support of PMAQ across the country, improvements are not predictable nor homogeneous. Non-uniform improvements were seen in Brazil’s PHC. Though we do not directly evaluate the effectiveness of the PMAQ (financial reward) method, these initial findings suggest that it is a potentially useful tool to improve health systems, but additional support may be needed in regions that lag behind in quality improvements.

In many low- and middle-income countries, young children learn a mother tongue or indigenous language at home before entering the formal education system where they will need to understand and speak a country's official language(s). Thus, assessments of children before school age, conducted in a nation's official language, may not fully reflect a child's development, underscoring the importance of test translation and adaptation. To examine differences in vocabulary development by language of assessment, this study adapted and validated instruments to measure developmental outcomes, including expressive and receptive vocabulary. This study assessed 505 children ages 2 to 6 in rural communities in Western Kenya with comparable vocabulary tests in three languages: Luo (the local language or mother tongue), Swahili, and English (official languages) at two time points, five to six weeks apart, between September 2015 and October 2016. Younger children responded to the expressive vocabulary measure exclusively in Luo much more frequently than did older children: 44–59 percent of those ages 2 to 4, compared to 20–21 percent of those ages 5 to 6. Baseline receptive vocabulary scores in Luo and Swahili were strongly associated with receptive vocabulary in English at follow-up, even after controlling for English vocabulary at baseline: a multivariate regression of follow-up English vocabulary on standardized measures of receptive vocabulary in all three languages yields an estimate, for Luo, of β = 0.26, SE = 0.05, p < 0.001; and for Swahili, β = 0.10, SE = 0.05, p = 0.032. The study also found that parental Luo literacy at baseline was associated with child English vocabulary at follow-up, while parental English literacy at baseline was not: a multivariate regression on both measures, along with household controls, yielded, for Luo, β = 0.11, SE = 0.05, p = 0.045; the coefficient on English was not statistically significantly distinguishable from zero (p=0.18). The findings suggest that multilingual testing is essential to understanding the developmental environment and cognitive growth of multilingual children.

BACKGROUND Triple-negative breast cancer (TNBC) has been associated with a more aggressive histology, poorer prognosis, and nonresponsiveness to hormone therapy. It is imperative that cancer research identify factors that drive disparities and focus on prevention. METHODS Using the United States Cancer Statistics database, the authors examined differences between TNBCs compared with all other breast cancers with regard to age, race/ethnicity, and stage at diagnosis. RESULTS A total of 1,151,724 cases of breast cancer were identified from 2010 through 2014, with the triple-negative phenotype accounting for approximately 8.4% of all cases. In unadjusted analyses, non-Hispanic black women (odds ratio [OR], 2.27; 95% CI, 2.23-2.31) and Hispanic women (OR, 1.22; 95% CI, 1.19-1.25) had higher odds of diagnosis when compared with non-Hispanic white women. Women aged

Objective:We collected dietary records over the course of nine months to comprehensively characterize the consumption patterns of Malagasy people living in remote rainforest areas of north-eastern Madagascar.Design:The present study was a prospective longitudinal cohort study to estimate dietary diversity and nutrient intake for a suite of macronutrients, micronutrients and vitamins for 152 randomly selected households in two communities.Setting:Madagascar, with over 25 million people living in an area the size of France, faces a multitude of nutritional challenges. Micronutrient-poor staples, especially rice, roots and tubers, comprise nearly 80 % of the Malagasy diet by weight. The remaining dietary components (including wild foods and animal-source foods) are critical for nutrition. We focus our study in north-eastern Madagascar, characterized by access to rainforest, rice paddies and local agriculture.Participants:We enrolled men, women and children of both sexes and all ages in a randomized sample of households in two communities.Results:Although the Household Dietary Diversity Score and Food Consumption Score reflect high dietary diversity, the Minimum Dietary Diversity–Women indicator suggests poor micronutrient adequacy. The food intake data confirm a mixed nutritional picture. We found that the median individual consumed less than 50 % of his/her age/sex-specific Estimated Average Requirement (EAR) for vitamins A, B12, D and E, and Ca, and less than 100 % of his/her EAR for energy, riboflavin, folate and Na.Conclusions:Malnutrition in remote communities of north-eastern Madagascar is pervasive and multidimensional, indicating an urgent need for comprehensive public health and development interventions focused on providing nutritional security.

INTRODUCTION: Burden of disease is often defined by using epidemiologic measures. However, there may be latent aspects of disease burden that are not factored into these types of estimates. This study quantified environmental burden of disease by using population health indicators and exploratory factor analysis at the county level across the United States. METHODS: Ninety-nine variables drawn from public use data sets from 2010 to 2016 were used to create a multifactor index — the burden index. We applied principal components analysis with promax rotation to allow the factors to correlate. Correlation coefficients for each factor and the outcome of interest, age-adjusted cancer death rate, were calculated. We used both unadjusted and adjusted linear regression techniques. RESULTS: The final additive county-level index included 9 factors that explained 68.3% of the variance in the counties and county equivalents. The burden index had a moderate association with the age-adjusted cancer death rates (r =.48, P

Forty-three percent of children under five in low and middle-income countries (LMICs) experience compromised cognitive and psychosocial development. Early childhood development (ECD) interventions that promote parent-child psychosocial stimulation and nutrition activities can help remediate early disadvantages in child development and health outcomes, but are difficult to scale. Key questions are: 1) how to maximize the reach and cost-effectiveness of ECD interventions; 2) what pathways connect interventions to parental behavioral changes and child outcomes; and 3) how to sustain impacts long-term. Msingi Bora (“good foundation” in Swahili) is a multi-arm cluster randomized controlled trial across 60 villages and 1200 households in rural Western Kenya that tests different, potentially cost-effective and scalable models to deliver an ECD intervention in biweekly sessions lasting 7 months. The curriculum integrates child psychosocial stimulation with hygiene and nutrition education. The multi-arm study will test the cost-effectiveness of two models of delivery: a group-based model versus a mixed model combining group sessions with personalized home visits. Households in a third study arm will serve as a control group. Each arm will have 20 villages and 400 households with a child aged 6–24 months at baseline. Primary outcomes are child cognitive and socioemotional development and home stimulation practices. In a 2 × 2 design among the 40 treatment villages, we will also test the role of including fathers in the intervention. We will estimate intention-to-treat and local average treatment effects, and examine mediating pathways using Mediation Analysis. One treatment arm will receive quarterly booster visits for 6 months following the end of the sessions. A follow-up survey 2 years after the end of the main intervention period will examine sustainability of outcomes and any spillover impacts onto younger siblings. Study protocols have been approved by the Maseno Ethics Review Committee (MUERC) in Kenya (00539/18) and by RAND’s institutional review board. This study is funded by the National Institute for Child Health and Human Development (R01HD090045). Results can provide policymakers with rigorous evidence of how best to design ECD interventions in low-resource rural settings. Clinical Trial NCT03548558 registered June 7, 2018 at clinicaltrials.gov; AEA-RCT registry AEARCTR-0002913.

Scaling up integrated nutrition programmes from small, targeted interventions or pilot studies to large-scale government-run programmes can be challenging, with risks of changing the nature and quality of the interventions such that effectiveness is not sustained. In 1999, the Government of Madagascar introduced a nationwide, community-based, growth-monitoring and nutrition education programme, which was gradually scaled up throughout the country until 2011. Data from three nationally representative surveys, administered pre- and post-programme implementation, in participating and non-participating communities, were used to evaluate the effectiveness of the programme to reduce malnutrition in children under 5 after two phases of expansion (1999-2004 and 2004-2011). In our analyses, we compared "original" communities, who had initiated the programme during the first phase, and "new" communities, who initiated the programme during the second phase. "Original" communities demonstrated a significant effect on mean weight-for-age and on the prevalence of underweight by 2004; this effect was sustained at a reduced level through 2011. In contrast, "new" communities showed no benefits for any childhood nutritional outcomes. An explanation for these findings may be that community health workers in the "new" communities reported lower motivation and less use of key messages and materials than those in the "original" communities. Frontline workers reported increased workload and irregular pay across the board during the second phase of programme expansion. Our findings underscore the risk of losing effectiveness if programme quality is not maintained during scale-up. Key factors, such as training and motivation of frontline workers, are important to address when bringing a programme to scale.