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We evaluated the impact of reimbursement for non-face-to-face chronic care management (NFFCCM) on healthcare utilization among Medicare beneficiaries with type 2 diabetes in Louisiana.We implemented group-based trajectory balancing and propensity score matching to obtain comparable treatment (with NFFCCM) and control (without NFFCCM) groups at baseline. Patients with diabetes with Medicare as their primary payer at baseline were extracted using electronic health records of 3 health systems from Research Action for Health Network, a Clinical Research Network. The study period is from 2013 to early 2020. Our outcomes include general healthcare utilization (outpatient, emergency department, and inpatient encounters) and health utilization related to diabetic complications. We tested each of these outcomes according to multiple treatment definitions and different subgroups.Receiving any NFFCCM was associated with an increase in outpatient visits of 657 (95% confidence interval [CI] 626-687; P.001) per 1000 patients per month, a decrease in inpatient admissions of 5 (95% CI 2-7; P.001) per 1000 patients per month, and a decrease in emergency department visits of 4 (95% CI 1-7; P = .005) per 1000 patients per month after 24-month follow-up from initial NFFCCM encounter. Both complex and noncomplex NFFCCM significantly increased visits to outpatient services and inpatient admissions per month. Receiving NFFCCM has a dose-response association with increasing outpatient visits per month.Patients with diabetes in Louisiana who received NFFCCM had more low-cost primary healthcare and less high-cost healthcare utilization in general. The cost savings of NFFCCM in diabetes management could be further explored in the future.

Alessandra N Bazzano,1 Yaoyao Sun,2,3 Yuanhao Zu,4 Julia M Fleckman,1 Emma A Blackson,1 Tejal Patel,1 Angie Shorty-Belisle,5 Keith H Liederman,6 Cody Roi7 1Tulane University School of Public Health and Tropical Medicine, Department of Social, Behavioral, and Population Sciences, New Orleans, LA, USA; 2Peking University, Institute of Mental Health, Sixth Hospital, Beijing, People’s Republic of China; 3NHC Key Laboratory of Mental Health. National Clinical Research Center for Mental Disorders, Peking University, Beijing, People’s Republic of China; 4Tulane University School of Public Health and Tropical Medicine, Department of Biostatistics, New Orleans, LA, USA; 5Educare New Orleans, New Orleans, LA, USA; 6Kingsley House, New Orleans, LA, USA; 7Louisiana State University Health Science Center, Department of Child and Adolescent Psychiatry, New Orleans, LA, USACorrespondence: Alessandra N Bazzano, Email abazzano@tulane.eduBackground: Early childhood is the key life course period for development of social-emotional skills, providing the foundation for school readiness and resilience in later life. Age-appropriate yoga and mindfulness programs may contribute to the development of critical skills in children. Young children from minoritized communities that face structural racism and health disparities may benefit from programs that support social-emotional development and contribute to future academic success. Systematic reviews of yoga interventions for young children have indicated the potential for effectiveness in supporting social-emotional development, executive function, and physical activity. However, studies of yoga and mindfulness with non-White children are sparse and, overall, the evidence base to date for such programs remains limited by non-controlled studies and the variable quality of studies evaluating programs in early childhood settings.Methods: The analysis of data from a non-randomized, controlled intervention aimed to assess the effect of exposure to a yoga and mindfulness program for early childhood development of social-emotional skills in a majority Black/African American urban preschool setting in southeastern US. Children in the intervention received group yoga and mindfulness led by a certified children’s yoga teacher who also had training and experience as a school teacher. Intervention participants engaged in activities for 20 minutes once per week for 32 weeks, while the control group had no yoga. The final sample included 579 in the historical control group and 122 in the intervention group.Results: Results indicated that children who participated in the yoga and mindfulness program had higher total protective factor (TPF) subscores on the Devereux Early Childhood Assessment over time than children who did not receive yoga and mindfulness programming, and that the difference was statistically significant (P< 0.05). Participation in the intervention group significantly predicted increases in initiative score, self-control score, and TPF score, as well as a decrease in the behavioral concerns.Discussion: School based yoga and mindfulness programming can support social-emotional skills and resilience in young children. Additional studies with larger sample sizes and randomization are needed on use of yoga and mindfulness in young children for social-emotional development, particularly for Black/African American children and others from minoritized communities.Keywords: child development, psychological resilience, child health, behavior

The present study aimed to examine the interrelationships of prenatal psychopathology (specifically symptom cluster), dispositional mindfulness, and rumination using network analysis. Network analysis estimates the links between symptoms and can evaluate the presence and strength of the links. A total of 1122 pregnant women were recruited from a tertiary hospital in China. Psychopathology symptoms (including anxiety, depression, stress, fatigue, sleep, fear of childbirth [FOC], and memory problems) were assessed and used along with mindfulness and rumination to construct networks of association using R. Results illustrated five communities within the network. Anxiety resulted in the highest strength of centrality followed by two symptoms: FOC and retrospective memory. Paths showed that mindfulness was directly connected to depression, prospective memory, retrospective memory, and lack of positive anticipation in FOC, whereas mindfulness was connected indirectly through rumination to anxiety, fatigue, stress, and sleep problems. The findings reinforce that anxiety is a key symptom of prenatal psychopathology and requires priority consideration. The direct associations between mindfulness and prenatal psychopathology symptoms provide potential targets for future mindfulness-based interventions, and mindfulness reducing rumination thus in turn decrease anxiety, suggesting potential mediating mechanism of mindfulness.

Background Nutrition-sensitive agriculture is an effective multi-sectoral approach to address the underlying causes of malnutrition. However, successful implementation requires the involvement of different sectors to jointly plan, monitor, and evaluate key activities, which is often challenged by contextual barriers. Previous studies in Ethiopia have not adequately explored these contextual barriers. Hence, the current study aimed to qualitatively explore the challenges to joint planning, monitoring, and evaluation for nutrition-sensitive agriculture among sectors in Ethiopia. Methods A qualitative exploratory study was conducted in Tigray and Southern Nations, Nationalities, and Peoples (SNNP) of Ethiopia regional states in 2017. Ninety-four key informants were purposively selected from government agencies primarily in health and agriculture, from local (kebele) to national levels, and ranging from academic organizations, research institutions, and implementing partners. Researchers developed a semi-structured guide and conducted key informant interviews which were audiotaped, transcribed verbatim in local language, and translated to English. All transcriptions were imported into ATLAS.ti Version 7.5 software for coding and analysis. The data analysis followed an inductive approach. Transcriptions were coded line by line; then similar codes were grouped into categories. Subsequently, non-repetitive themes were identified from the categories using thematic analysis methodology. Results The following themes were identified as challenges that hinder joint planning, monitoring, and evaluation to link nutrition to agriculture: (1) limited capacity, (2) workload in home sector (agriculture or nutrition), (3) lack of attention to nutrition interventions, (4) inadequate supportive supervision, (5) problematic reporting system, and (6) weak technical coordinating committees. Conclusions and recommendations Gaps in human and technical resources, limited attention from different sectors, and absence of routine monitoring data hindered joint planning, monitoring, and evaluation activities for nutrition-sensitive agriculture in Ethiopia. Short-term and long-term training for experts and intensification of supportive supervision may address gaps in capacity. Future studies should address whether routine monitoring and surveillance in nutrition-sensitive multi-sectoral activities provides long-term improvement in outcomes.

BACKGROUND Health inequalities are rooted in historically unjust differences in economic opportunities, environment, access to health care services, and other social determinants. Owing to these health inequalities, the COVID-19 pandemic has disproportionately affected underserved populations, notably people of color, incarcerated and formerly incarcerated individuals, and those unable to physically distance themselves from others. However, people most strongly impacted by health disparities, and the pandemic, are not frequently engaged in research, either as researchers or as participants, resulting in slow progress toward improving health equity. Establishing ways to foster the engagement of historically excluded people is crucial to improving health equity through patient-centered health research. OBJECTIVE This study aimed to assess the use of equity-centered design thinking (EDT) for engaging community members in research prioritization related to COVID-19. The co-design methods and subsequent production of a toolkit that can be used for engagement were assessed through process evaluation and qualitative methods. METHODS Process evaluation and qualitative inquiry, using reflexive thematic analysis, were undertaken to examine the use of EDT. Patient community members and stakeholders remotely partnered with design and health researchers in a year-long digital process to cocreate capacity-building tools for setting agenda for research regarding the impact of COVID-19 on health outcomes. Through a series of 3 workshops, 5 community partners engaged in EDT activities to identify critical challenges for the health and well-being of their communities. The subsequent tools were tested with 10 health researchers who provided critical input over the course of 2 workshops. Interviews with co-designers, project materials, and feedback sessions were used in the process evaluation and finalization of an equity-centered toolkit for community engagement in research. Data from the co-design process, meetings, workshops, and interviews were analyzed using reflexive thematic analysis to identify salient themes. RESULTS Process evaluation illustrated how the EDT co-design process offered an approach to engage patient partners and community stakeholders in health-related research around COVID-19. The participants expressed satisfaction with design thinking approaches, including creative activities and iterative co-design, as a means of working together. Thematic analysis identified 3 key themes: the value of authentic partnerships, building trust and empathy through design, and fostering candid dialogue around health and social issues impacting historically underrepresented and underinvested communities. CONCLUSIONS The project addressed the need to test EDT strategies for fostering inclusive community engagement in health research agenda setting and provided an alternative to traditional top-down models. Despite the increasing use of human-centered design in health, few projects explicitly include equity in design thinking approaches. The use of methods and tools to intentionally engage underrepresented stakeholders in the process of research agenda setting and equitably sharing power between researchers and community members may improve health research, ultimately improving health equity.

ObjectiveTo examine patient/caregiver preference for key attributes of treatments for spinal muscular atrophy (SMA).BackgroundIn the rapidly evolving SMA treatment landscape, it is critically important to understand how attributes of potential treatments may impact patient/caregiver choices.Design/methodsA discrete choice experiment survey was developed based on qualitative interviews. Patients with SMA (≥ 18 years) and caregivers of patients were recruited through a U.S. patient organization. Respondents made choices in each of 12 sets of hypothetical treatments. The relative importance of five treatment characteristics was compared (measured by regression coefficients [RC] of conditional logit models): (1) improvement or stabilization of motor function, (2) improvement or stabilization of breathing function, (3) indication for all ages or pediatric patients only, (4) route of administration [repeated intrathecal (IT) injections, one-time intravenous (IV) infusion, daily oral delivery] and (5) potential harm (mild, moderate, serious/life threatening).ResultsPatient ages ranged from less than 1 to 67 years (n = 101, 65 self-reported and 36 caregiver-reported) and 64 were female. Total SMA subtypes included: type 1 (n = 21), type 2 (n = 48), type 3 (n = 29), other (n = 3). Prior spinal surgery was reported in 47 patients. Nusinersen and onasemnogene abeparvovec-xioi use were reported in 59 and 10 patients, respectively. Improvement in motor and breathing function was highly valued [RC: 0.65, 95% confidence interval (CI): 0.47–0.83 and RC: 0.79, 95% CI: 0.60–0.98, respectively]. Oral medication and one-time infusion were strongly preferred over repeated IT injections (RC: 0.80, 95% CI: 0.60–0.98 and RC: 0.51, 95% CI: 0.30–0.73, respectively). Patients least preferred an age-restricted label/approved use (≤ 2 years of age) (RC: − 1.28, 95% CI: − 1.47 to − 1.09). Cross-attributes trade-off decision suggested a lower willingness for a high-risk therapy despite additional efficacy gain. For some patients, there may be willingness to trade off additional gains in efficacy for a change in route of administration from repeated intrathecal administration to oral medication.ConclusionsImprovements in motor/breathing function, broad indication, oral or one-time infusion, and minimal risk were preferred treatment attributes. Treatment decisions should be made in clinical context and be tailored to patient needs.

AIM To compare the cardiovascular risks between users and non-users of sodium-glucose co-transporter-2 (SGLT2) inhibitors based on electronic medical record data from a large integrated healthcare system in South Louisiana. MATERIALS AND METHODS Demographic, anthropometric, laboratory and medication prescription information for patients with type 2 diabetes who were new users of SGLT2 inhibitors, either as initial treatments or as add-on treatments, were obtained from electronic health records. Mediation analysis was performed to evaluate the association of use of SGLT2 inhibitors and changes of metabolic risk factors with the risk of incident ischaemic heart disease. RESULTS A total of 5338 new users of SGLT2 inhibitors were matched with 13 821 non-users. During a mean follow-up of 3.26 years, 2302 incident cases of ischaemic heart disease were defined. After adjusting for multiple confounding factors, patients using SGLT2 inhibitors had a lower risk of incident ischaemic heart disease compared to patients not using SGLT2 inhibitors (hazard ratio [HR] 0.63, 95% confidence interval [CI] 0.54-0.73). Patients using SGLT2 inhibitors also had a lower risk of incident ischaemic heart disease within 6 months (HR 0.36, 95% CI 0.25-0.44), 12 months (HR 0.40, 95% CI 0.32-0.49), 24 months (HR 0.53, 95% CI 0.43-0.60) and 36 months (HR 0.65, 95% CI 0.54-0.73), respectively. Reductions in systolic blood pressure partly mediated lowering risk of ischaemic heart disease among patients using SGLT2 inhibitors. CONCLUSIONS The real-world data in the present study show the contribution of SGLT2 inhibitors to reducing risk of ischaemic heart disease, and their benefits beyond glucose-lowering.

The objective of this qualitative study was to address existing gaps in the literature by gathering parent perspectives on both health and school readiness in regard to neighborhood context, specifically parents’ perceived level of neighborhood safety and support, on physical health and the behavioral and cognitive domains of school readiness. Focus groups were conducted with a total of 28 parents or caregivers whose children attended Early Head Start/Head Start Centers or who received Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) services in New Orleans, Louisiana during fall 2015. Parents discussed concepts of school readiness, neighborhood, the intersection between the two, and parental stress, however, few expressed a clear connection between their concerns about safety, their own stress, and their child’s readiness for school. Disparities in both health and school readiness exist between both racial and socioeconomic groups in the United States, and this study offers a unique and enhanced understanding of the impact of non-academic factors on the well-being and development of young children.

Patients with diabetes have a 10-fold higher risk of lower-extremity amputation (LEA) than people without diabetes (1). LEA is associated with the greatest reduction in quality of life and the greatest increase in mortality and medical costs in all diabetes complications. Previous studies suggested that the mean hemoglobin A1c (HbA1c) level was associated with an increased LEA risk among patients with type 2 diabetes (2). However, emerging evidence indicates that long-term glycemic variability evaluated by clinical visit-to-visit HbA1c variability may be a better predictor of diabetes complications (3). So far, the definitions of long-term HbA1c variability are inconsistent. In most studies, standard deviation of serial HbA1c measurements (HbA1c SD) and the intrapersonal coefficient of variation of HbA1c (HbA1c CV) are often used to represent HbA1c variability. In the current study, we added a new marker—HbA1c variability score (HVS) (4)—which is more easily applied to clinical practice. We collected data from electronic health records for patients with type 2 diabetes between 2013 and 2019 in the Louisiana Experiment Assessing Diabetes outcomes (LEAD) cohort study (5). We excluded patients who had LEA diagnosis before entry and within 2 years after the first date of diabetes diagnosis, those with incomplete baseline data, those who did not have at least four HbA1c tests within 2 …

Background: Management of diabetes may be uniquely challenging for older individuals with multiple chronic conditions. Health systems and policymakers have attempted to reduce barriers to chronic care management (CCM) through incentives to provide non-face-to-face care. This qualitative study aimed to investigate and present views on non-face-to-face care management held by elderly patients with diabetes and other chronic conditions in order to contribute to improved programming for this population. Materials and methods: Semi-structured interviews were conducted with patients over the age of 64 who have been diagnosed with diabetes and at least one other chronic health condition. Interview recordings were transcribed and analyzed by experienced researchers using a thematic analytic approach, and an illustrative case study was developed. Results: Thirty individuals participated in this study. Participants were drawn from three health systems in south Louisiana, an area with high rates of morbidity and mortality related to chronic diseases. We identified themes related to lived experiences with diabetes and other medical conditions, perception of personal health status, perceived value of non-face-to-face programs, and support needs for future programming. Additionally, we present one case study describing in detail an individual patient's experience with non-face-to-face CCM. Conclusion: Health systems should consider intentionally recruiting participants who would benefit most from non-face-to-face care, including higher-need, less self-sufficient patients with resource constraints, while continuing to offer in-person services. Future research should examine whether tailoring non-face-to-face programming and support to address unique barriers can further enhance diabetes care at the population level.

Background and Purpose— Few studies have assessed the association of HDL (high-density lipoprotein) cholesterol with stroke risk among patients with type 2 diabetes mellitus. We aimed to investigate the association of HDL cholesterol with total and type-specific stroke risk in patients with type 2 diabetes mellitus. Methods— We performed a retrospective cohort study of 27 113 blacks and 40 431 whites with type 2 diabetes mellitus. Cox proportional hazards regression models were used to estimate the association of different levels of HDL cholesterol with stroke risk. Results— During a mean follow-up period of 3.0 years, 8496 patients developed stroke (8048 ischemic and 448 hemorrhagic). Multivariable-adjusted hazard ratios across levels of HDL at baseline (P trend P trend P trend =0.021) for hemorrhagic stroke, respectively. When we used an updated mean value of HDL cholesterol, the inverse association of HDL cholesterol with stroke risk did not change. This inverse association was consistent among patients of different ages, races, sexes, body mass index, hemoglobin A1c levels, never and past or current smokers, and patients with and without using glucose-lowering, cholesterol-lowering, or antihypertensive agents. Conclusions— The present study found consistent inverse associations between HDL cholesterol and the risk of total, ischemic and hemorrhagic stroke among patients with type 2 diabetes mellitus.

Mental health conditions in childhood and adolescence are increasing in the U.S. population and require early intervention, as highlighted by a recent Surgeon General’s Advisory on Protecting Youth Mental Health. These health issues, which have been exacerbated by the COVID-19 pandemic, impair functioning, and may lead to longer term reductions in quality of life. Young adolescents are likely to experience stressors including academic pressure, feelings of loneliness and isolation, and excessive exposure to social media, all of which have been made worse by the pandemic and associated disruptions. Universal preventive programs at school serve as an important strategy for equipping youth with coping skills to address current and future social and emotional challenges. Yoga and mindfulness programs have emerged as a promising preventive approach for schools and have proven feasible and acceptable. The current study evaluated a universal, school-based mindfulness and yoga program among youth aged 11–14 in a racially diverse, urban setting in the United States. Outcomes of interest included symptoms of anxiety and depression. Anxiety and depression symptoms decreased in the intervention group, although these differences were not statistically significant. In the control group, anxiety symptoms decreased but depression symptoms increased. The resulting time effect indicated a significant decrease in anxiety symptoms, while the time by group effect revealed a strong trend in depression symptoms. Future research should investigate the utility of yoga and mindfulness interventions for early adolescents in a larger population, and the differences in intervention effect among subgroups, with attention to longer term outcomes.

IntroductionThe prevalence of diabetes self-management education and support (DSME/S) use among patients with newly diagnosed type 2 diabetes mellitus (T2DM) and patients with insulin prescription has not been evaluated. It is also unclear what demographic, behavioral, and clinical factors associated with use of DSME/S.Research design and methodsThis retrospective analysis was based on electronic health records from the Research Action for Health Network (2013–2019). Patients with newly diagnosed T2DM were identified as 35–94 year-olds diagnosed with T2DM≥1 year after the first recorded office visit. Patients with insulin were identified by the first insulin prescription records. DSME/S (Healthcare Common Procedure Coding System G0108 and G0109) codes that occurred from 2 months before the ‘new diagnosis date’ or first insulin prescription date through 1 year after were defined as use of DSME/S. Age-matched controls (non-users) were identified from the Electronic Health Records (EHR). The date of first DSME/S record was selected as the index date. Logistic regression was used to estimate the associations between patient factors and use of DSME/S.ResultsThe prevalence of DSME/S use was 6.5% (8909/137 629) among patients with newly diagnosed T2DM and 32.7% (13,152/40,212) among patients with diabetes taking insulin. Multivariable analysis found that among patients with newly diagnosed T2DM, black and male patients were less likely to use DSME/S, while in patients with insulin, they were more likely to use the service compared with white and female counterparts, respectively. Among patients taking insulin, those with private insurance or self-pay status were significantly less likely, while those with Medicaid were more likely to use the service compared with their Medicare counterparts. A strong positive association was found between HbA1c, obesity, and DSME/S use in both cohorts, while hypertension was negatively associated with DSME/S in both cohorts.ConclusionWe showed a low rate of DSME/S use in Louisiana, especially in patients with newly diagnosed T2DM. Our findings demonstrated heterogeneity in factors influencing DSME/S use between patients with newly diagnosed T2D and patients with insulin.

Children with severe acute malnutrition (SAM) are identified for admission to outpatient therapeutic programs using mid-upper-arm circumference (MUAC) or weight for height (WHZ). However, MUAC and WHZ do not identify the same children, and such observed differences might have programmatic implications of missed nutrition therapy if only MUAC is used to identify children with SAM. The objective of the study was to assess any difference in prevalence and degree of agreement between MUAC and WHZ in identifying SAM affected children. A cross-sectional study was conducted in South Gondar Zone, Ethiopia, among 17 districts, with 3 districts and 10 health centers with their clustered health posts selected randomly. A total of 2,040 children were recruited, and data were collected using a parent questionnaire then entered into EpiData and analyzed using SPSS v 20. A total of 1,980 respondents (97.1%) were interviewed, all of whom were female and rural residents. Children’s mean age in months was 23.2 (SD ± 9.7), and 54% were male children. The prevalence of SAM based on MUAC

AIM: To investigate the association between visit-to-visit HbA1c variability and the risk of cardiovascular disease in patients with type 2 diabetes. MATERIALS AND METHODS: We performed a retrospective cohort study of 29 260 patients with at least four HbA1c measurements obtained within 2 years of their first diagnosis of type 2 diabetes. Different HbA1c variability markers were calculated, including the standard deviation (SD), coefficient of variation (CV) and adjusted SD. Cox proportional hazards regression models were used to estimate the association of these HbA1c variability markers with incident cardiovascular disease. RESULTS: During a mean follow-up of 4.18 years, a total of 3746 incident cardiovascular disease cases were diagnosed. Multivariate-adjusted hazard ratios for cardiovascular disease across the first, second, third and fourth quartiles of HbA1c SD values were 1.00, 1.30 (95% confidence interval [CI] 1.18–1.42), 1.40 (95% CI 1.26–1.55) and 1.59 (95% CI 1.41–1.77) (P for trend

Even though current prescribing trends reveal that high-dose opioid prescribing and opioid prescribing in general has decreased, sustained efforts are needed to help providers adopt and maintain safe prescribing behaviors. The purpose of this four-year type 2 effectiveness-implementation hybrid stepped wedge cluster randomized trial is to: (1) compare the clinical and cost effectiveness of electronic medical record-based clinical decision support [EMR-CDS] versus additional integrated, collaborative behavioral health [EMR-CDS + BHI-CCM] for opioid management of patients with co-morbid chronic non-cancer pain with depression or anxiety; and (2) examine facilitators and barriers to implementing these interventions within 35 primary care clinics in a integrated delivery health system. The EMR-CDS alerts providers to employ opioid risk mitigation and safe prescribing practices at the point of care. The BHI-CCM consists of primary care embedded community health workers for case management; licensed clinical social workers for cognitive behavioral therapy, and a clinical pharmacist for medication management who provide care management via telemedicine (virtual video or audio only visits) under the guidance of a consulting psychiatrist. The primary outcome is reduction in the percentage of patients with average daily opioid dose ≥50 mg morphine equivalent. Secondary outcomes include changes in service utilization, patient reported outcomes and processes of care. The investigators anticipate that study results will elucidate the role of technology versus care team optimization in changing opioid prescribing behaviors. The investigators further anticipate that integrated mental/behavioral health care will increase value-based care and the efficiency with which guideline concordant care is delivered.

Chronic diseases impact 117 million adults in the United States and account for $3.3 trillion in health care spending. This qualitative study investigated experiences with reimbursement structure for non-face-to-face (NFF) chronic care management (CCM) through diverse health system approaches in primary care settings in Southeastern Louisiana. In-depth interviews were conducted with 16 purposively selected key informants, and reflexive thematic analysis was utilized to explore findings. Variation in health system approaches for implementing and quality of NFF CCM programs were identified. Results included differences in health system motivation and methods for financial structuring and quality of third-party vendor and alternative models.

Children with severe acute malnutrition (SAM) are identified for admission to outpatient therapeutic programs using mid-upper-arm circumference (MUAC) or weight for height (WHZ). However, MUAC and WHZ do not identify the same children, and such observed differences might have programmatic implications of missed nutrition therapy if only MUAC is used to identify children with SAM. The objective of the study was to assess any difference in prevalence and degree of agreement between MUAC and WHZ in identifying SAM affected children. A cross-sectional study was conducted in South Gondar Zone, Ethiopia, among 17 districts, with 3 districts and 10 health centers with their clustered health posts selected randomly. A total of 2,040 children were recruited, and data were collected using a parent questionnaire then entered into EpiData and analyzed using SPSS v 20. A total of 1,980 respondents (97.1%) were interviewed, all of whom were female and rural residents. Children's mean age in months was 23.2 (SD ± 9.7), and 54% were male children. The prevalence of SAM based on MUAC

BACKGROUND Despite potential for benefit, mindfulness remains an emergent area in perinatal mental health care, and evidence of smartphone-based mindfulness training for perinatal depression is especially limited. OBJECTIVE The objective of this study was to evaluate the effectiveness of a smartphone-based mindfulness training intervention during pregnancy on perinatal depression and other mental health problems with a randomized controlled design. METHODS Pregnant adult women who were potentially at risk of perinatal depression were recruited from an obstetrics clinic and randomized to a self-guided 8-week smartphone-based mindfulness training during pregnancy group or attention control group. Mental health indicators were surveyed over five time points through the postpartum period by online self-assessment. The assessor who collected the follow-up data was blind to the assignment. The primary outcome was depression as measured by symptoms, and secondary outcomes were anxiety, stress, affect, sleep, fatigue, memory, and fear. RESULTS A total of 168 participants were randomly allocated to the mindfulness training (n=84) or attention control (n=84) group. The overall dropout rate was 34.5%, and 52.4% of the participants completed the intervention. Mindfulness training participants reported significant improvement of depression (group × time interaction χ24=16.2, P=.003) and secondary outcomes (χ24=13.1, P=.01 for anxiety; χ24=8.4, P=.04 for positive affect) compared to attention control group participants. Medium between-group effect sizes were found on depression and positive affect at postintervention, and on anxiety in late pregnancy (Cohen d=0.47, –0.49, and 0.46, respectively). Mindfulness training participants reported a decreased risk of positive depressive symptom (Edinburgh Postnatal Depression Scale [EPDS] score>9) compared to attention control participants postintervention (odds ratio [OR] 0.391, 95% CI 0.164-0.930) and significantly higher depression symptom remission with different EPDS reduction scores from preintervention to postintervention (OR 3.471-27.986). Parity did not show a significant moderating effect; however, for nulliparous women, mindfulness training participants had significantly improved depression symptoms compared to nulliparous attention control group participants (group × time interaction χ24=18.1, P=.001). CONCLUSIONS Smartphone-based mindfulness training is an effective intervention in improving maternal perinatal depression for those who are potentially at risk of perinatal depression in early pregnancy. Nulliparous women are a promising subgroup who may benefit more from mindfulness training. CLINICALTRIAL Chinese Clinical Trial Registry ChiCTR1900028521; http://www.chictr.org.cn/showproj.aspx?proj=33474

Aims: This study compares the cardiovascular benefits between SGLT2 inhibitors and other glucose-lowering drugs (oGLDs) based on electronic medical record data from a large integrated delivery health system in South Louisiana. Materials and Methods: Demographic, anthropometric, laboratory and medication prescription information for patients with type 2 diabetes who were new users of SGLT2 inhibitors either as initial treatments or as add-on treatments were obtained from electronic health records. Mediation analysis was performed in demonstrating the association of use of SGLT2 inhibitors and changes of metabolic risk factors with the risk of incident coronary heart disease. Results: A total of 5,338 new users of SGLT2 inhibitors were matched with 13,821 patients using oGLDs. During a mean follow up of 3.26 years, 2,303 incident cases of coronary heart disease were defined. After adjusting for multiple confounding factors, patients using SGLT2 inhibitors had a lower risk of incident coronary heart disease compared to patients using oGLDs (hazard ratio [HR] 0.63; 95% confidence interval [CI] 0.55-0.72). Patients using SGLT2 inhibitors also had a lower risk of incident coronary heart disease within 6 months (HR 0.32; 95% CI 0.23-0.43), 12 months (HR 0.38; 95% CI0.31-0.48), 24 months (HR 0.49; 95% CI 0.41-0.59) and 36 months (HR 0.59; 95% CI 0.51-0.69), respectively. Reductions in systolic blood pressure attributed the lower risk of coronary heart disease among patients using SGLT2 inhibitors. Conclusions: Evidence from real world data indicated the contribution of SGLT2 inhibitors to reducing risk of coronary heart disease, as well as the benefits beyond glucose-lowering. Disclosure Y. Shen: None. J. Zhou: None. L. Shi: None. E. Nauman: None. P.T. Katzmarzyk: None. E.G. Price-Haywood: None. S. Chu: None. S. Yang: None. A.N. Bazzano: None. S. Nigam: None. G. Hu: None.

Maternal and under five-year-old mortality rates have reduced in the last two decades globally due to concerted effort, yet newborn deaths remain unacceptably prevalent. Behavior change is an important component of interventions to address newborn health problems in low-income countries. In Cambodia, maternal and newborn mortality has markedly decreased, and continued improvements will allow the country to achieve further reduction in newborn morbidity. The results of an implementation study of the Newborn Care and Infection Control Initiative using process evaluation are presented to provide insight into the trial implementation and context of the program that may have contributed to intervention results. The study utilized a mixed method process to explore the context, mechanisms, and implementation of intervention components: training of village health support group volunteers to provide home visits, training of midwives on infection prevention and control around the perinatal period, counseling on newborn care, and provision of training materials for counseling and intervention. Implementation was evaluated through quantitative and qualitative data collection including surveys, observation, semi-structured interviews, focus groups, and visual media. Descriptive statistics summarized the quantitative data and thematic analysis was used to explore the qualitative data. The evaluation identified several factors that might have influenced the outcomes of the trial: continuity of health center staff communication, timing and ability to complete home visits, and training quality. Additional support for parents in the perinatal period, preferably provided at the community level, will contribute to further improvement in health outcomes for newborns in this area. Researchers in this context should consider mechanisms to improve the coordination of health facility staff counseling while providing support and resources to ensure home visits to families with newborns are made on time. Attention to staffing, training, and quality of newborn health interventions is critical in planning for the scaling-up of newborn health programming.

BackgroundCommunity-based management of acute malnutrition (CMAM) is an effective program to manage children with acute malnutrition, including both severe and moderate acute malnutrition. However, little is known about continued child nutritional status after discharge from community based management of acute malnutrition programs in Ethiopia.ObjectiveThe study aimed to identify factors associated with relapse of acute malnutrition among children 6-59 months after been discharged recovered from community based management program in South Gondar Zone, Northwest Ethiopia.MethodsA case-control study was conducted in three districts of South Gondar Zone by tracing children age 6-59 months who were reported as recovered from the community based management program. Sample size calculated for the first objective of assessing prevalence of severe acute malnutrition among children following discharge as recovery using Epi- Info version 7.1.3.3 StatCalc taking 95% CL, 17.8% post discharge relapse (Ashraf H, et al. (2012), 3% margin of error, design effect of 2 and adding 5% non-response rate was the largest sample size and used to this study. Children with Mid Upper Arm Circumference (MUAC) = 12.5cm served as controls. Data were collected from 10 November 2017 to 30 January 2018 using a survey questionnaire and families were asked to bring children to a health facility for anthropometric measurements, following which data were entered and analyzed. Bivariate and multivariable logistic regression models were utilized to measure association between the risk factors and acute malnutrition.ResultsOverall, 1,273 participants were interviewed. The mean age in months of children was 23.1 (±9.1 SD) for cases and 23.1 (±8.9 SD) for controls. About 40% of the cases and 50% of the controls were female children. The factors associated with acute malnutrition were: male children (AOR = 1.84, 95% CI: 1.42-2.39), living in a food insecure household (AOR = 1.67, 95% CI:1.15-2.44), non-receipt of Vitamin A supplement (AOR = 1.76, 95% CI: 1.28-2.41), prelacteal feeding (AOR = 2.81 (95%CI, 1.57-5.05), distance to water source more than 15 walk (AOR = 1.88, 95% CI:1.32-2.71), less frequent self-reported hand washing (AOR = 1.35, 95% CI:1.05-1.75), mother not having consumed extra food during this pregnancy/lactation (AOR = 1.36, 95% CI: 1.03-1.78), and respondent age above 30 years (AOR = 1.43, 95% CI:1.10-1.87).ConclusionThe key factors contributing to relapse of acute malnutrition were related to childcare and feeding practices. Social and behavior change communication strategies targeting families at risk of undernutrition, along with improved food security and integrated programming are recommended to prevent relapse of acute malnutrition.

Background: Newborn mortality in Cambodia remains high, with sepsis and complications of delayed care-seeking important contributing factors. Intervention study objectives were to improve infection control behavior by staff in health centers, improve referral of sick newborns, increase recognition of danger signs, and prompt care-seeking at an appropriate health facility, and appropriate referral for sick newborns by mothers and families of newborn infants. Methods: The stepped-wedge cluster-randomized controlled trial took place in rural Cambodia from February 2015 to November 2016. Sixteen clusters consisted of public health center catchment areas serving the community. The intervention included health center staff training and home visits to mothers by community health volunteers within 24 hours of birth and on days 3 and 7 after delivery, including assessment of newborns for danger signs and counselling mothers. The trial participants included women who had recently delivered a newborn who were visited in their homes in the first week, as well as health center staff and community volunteers who were trained in newborn care. Women in their last trimester of pregnancy greater than 18 years of age were recruited and were blinded to their group assignment. Mothers and caregivers (2494) received counseling on handwashing practices, breastfeeding, newborn danger signs, and prompt, appropriate referral to facilities. Results: Health center staff in the intervention group had increased likelihood of hand washing at recommended key moments when compared with the control group, increased knowledge of danger signs, and higher recall of at least three hygiene messages. Of mother/caregiver participants at 14 days after delivery, women in the intervention group were much more likely to know at least three danger signs and to have received messages on care-seeking compared with controls. Conclusions: The intervention improved factors understood to be associated with newborn survival and health. Well-designed training, followed by regular supervision, enhanced the knowledge and self-reported behavior of health staff and health volunteers, as well as mothers&rsquo, own knowledge of newborn danger signs. However, further improvement in newborn care, including care-seeking for illness and handwashing among mothers and families, will require additional involvement from broader stakeholders in the community.

BackgroundCommunity-based management of acute malnutrition has been reported effective in terms of recovery rate, but recovered children may be at increased risk of developing acute malnutrition after returning to the same household (HH) environment.ObjectiveCompare the magnitude and factors associated with acute malnutrition among recovered and never treated children in South Gondar Zone, Amhara Region, Ethiopia.MethodA comparative cross-sectional study was conducted in three districts of South Gondar Zone by tracing 720 recovered and an equal number of age matched children who were never treated for acute malnutrition. Parents were asked to bring children to health post for survey data collection, anthropometric measurements, and edema assessment. Data were collected using a survey questionnaire, entered in to EpiData and analyzed using SPSS v20. Anthropometric indices were generated according to the WHO’s 2006 Child Growth Standards using WHO Anthro software version 3.2.2. Bivariate and multivariable logistic regression was utilized. Values withP< 0.05 were considered statistically significant and Odds Ratio with 95% CI was used to measure strength of association.ResultA total of 1,440 parents were invited, of which 1,414 participated (98.2% response rate). Mean age in months of children (±SD) was 23.7 (±10.4) for recovered and 23.3 (±10.8) for comparison group. About 49% of recovered and 46% of comparison children were females. A significant difference was observed on magnitude of acute malnutrition between recovered (34.2% (95% CI [30.9–38.0]) and comparison groups (26.7% (95% CI [23.5–30.2]),P= 0.002. Factors associated with acute malnutrition among recovered were district of Ebnat (AOR = 3.7; 95% CI [1.9–7.2]), Tach-Gayint (AOR = 2.4; 95% CI [1.2–4.7]); male child (AOR = 1.4; 95% CI [1.0–2.0]); prelactal feeding (AOR = 2.6; 95% CI [1.3 –5.1]); not feeding colostrum (AOR = 1.5; 95% CI [1.1–2.3]); not consuming additional food during pregnancy/lactation (AOR = 1.6; 95% CI [1.1–2.3]); not given Vitamin A supplement (AOR = 2.1; 95% CI [1.4–3.2]); and safe child feces disposal practice (AOR = 1.7; 95% CI [1.2–2.5]) while district of Tach-Gayint (AOR = 2.5; 95% CI [1.3–4.8]); male child (AOR = 1.5; 95% CI [1.1–2.1]), not feeding colostrum (AOR = 1.7; 95% CI [1.2–2.5]), poor hand washing practice (AOR = 1.6; 95% CI [1.1–2.2]); food insecure HH (AOR = 1.6; 95% CI [1.1–2.4]), birth interval ConclusionRecovered children were more at risk of acute malnutrition than the comparison group. Nutrition programs should invest in improving nutrition counseling and education; as well as the hygienic practices to protect children against post-discharge relapse of acute malnutrition.

Postpartum care is a critical element for ensuring survival and health of mothers and newborns but is often inadequate in low- and middle-income countries due to barriers to access and resource constraints. Newly delivered mothers and their families often rely on traditional forms of postnatal care rooted in social and cultural customs or may blend modern and traditional forms of care. This ethnographic study sought to explore use of biomedical and traditional forms of postnatal care. Data were collected through unstructured observation and in-depth interviews with 15 mothers. Participants reported embracing traditional understandings of health and illness in the post-partum period centered on heating the body through diet, steaming, and other applications of heat, yet also seeking injections from private health care providers. Thematic analysis explored concepts related to transitioning forms of postnatal care, valuing of care through different lenses, and diverse sources of advice on postnatal care. Mothers also described concurrent use of both traditional medicine and biomedical postnatal care, and the importance of adhering to cultural traditions of postnatal care for future health. Maternal and newborn health are closely associated with postnatal care, so ensuring culturally appropriate and high-quality care must be an important priority for stakeholders including understand health practices that are evolving to include injections.

Design has been applied increasingly to global health and the work of international agencies to improve health and well-being of people in lower income countries. Along with this interest comes a need for understanding how design is operationalized in the context of global health, how designers, global-health stakeholders, and those intended to benefit from global-health programs approach and receive this new synergy. This chapter explores the current state of design as applied to global health, models of how it is carried out, and some of the questions that arise for practitioners. A case study is presented to illustrate a large global-health project with design explicitly incorporated into the heart of the program.

Alessandra N Bazzano,1 Christopher E Anderson,2 Chelsea Hylton,3 Jeanette Gustat2 1Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA; 2Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA; 3Project Peaceful Warriors, New Orleans, LA, USA Objective: To assess the impact of a yoga curriculum in an elementary school on student quality of life, and to assess teacher and staff perception of potential barriers to, and benefits of, introducing yoga and mindfulness into the classroom.Methods: A randomized controlled trial was utilized to assess the impact of a brief intervention on third-grade students who screened positive for symptoms of anxiety. Students were randomized to an intervention group of 20 students receiving small-group yoga/mindfulness activities for 8 weeks between October 2016 and February 2017, and a control group of 32 students receiving care as usual. The Brief Multidimensional Students’ Life Satisfaction Scale-Peabody Treatment Progress Battery and the Pediatric Quality of Life Inventory (PedsQL) served as outcomes. Teachers were invited to participate in two professional development sessions about introducing yoga and mindfulness into the classroom, and completed a survey following each of the sessions.Results: In generalized estimating equation models adjusted for time, the yoga-based intervention was associated with a 14.17 unit increase in student emotional PedsQL (p-value 0.001) and a 7.43 unit increase in psychosocial PedsQL (p-value 0.01). Results were not attenuated by adjustment. Teachers and staff reported using yoga more frequently in the classroom following the second of two professional development sessions (p-value

Over the last two decades, as the disciplinary boundaries for the application of design have dissolved, public health has emerged as one area within the social sector where design thinking and human-centred design have been applied more frequently. With that increased activity comes a need to understand how, why, for whom, and with what level of impact design thinking has been used. Many health projects receive public funding, and those that include design thinking approaches may thus be subject to evaluation more typically used in traditional biomedical research, with the potential for errors in translation between disciplines. The present paper considers the limitations and potential to further incorporate the two disciplinary approaches in order to improve progress in achieving health equity and improving population-level health outcomes.

Policies on breastfeeding and possible mother-to-child transmission of Ebola Virus Disease (EVD) during the outbreak evolved depending on public health priorities and the evidence available at that particular time. To improve responses to future outbreaks, research on vertical transmission of EVD should be prioritized; infant and young child feeding experts should be integrated into the outbreak response; and a digital repository of national policies and associated messages should be created., Optimal breastfeeding is of vital importance to infant and child health and has been adopted by countries as a standard recommendation. However, in the context of an infectious disease outbreak, especially when the disease is poorly understood, policy makers must balance the benefits of breastfeeding against the risk of disease transmission through breastfeeding. During the 2014–2015 Ebola Virus Disease (EVD) outbreak in Sierra Leone, the development of correct and consistent messaging about infant feeding and nutrition programming was considerably delayed by numerous challenges. These challenges included a lack of sufficient information about the risk of transmission through human milk, numerous stakeholders, limited communication between coordination pillars, inconsistent and evolving messages from various stakeholders, and the public's distrust of the health system and international actors. For improved response to future disease outbreaks, research on vertical transmission of EVD should be prioritized, infant and young child feeding experts should be integrated into outbreak response collaboration, and a digital repository of potential and appropriately tailored messages should be created.