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Association between Malaria Infection and Early Childhood Development Mediated by Anemia in Rural Kenya. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17030902. [PMID: 32024214 PMCID: PMC7037381 DOI: 10.3390/ijerph17030902] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 01/24/2020] [Accepted: 01/24/2020] [Indexed: 02/08/2023]
Abstract
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’s optimal development, particularly in light of projections of continued high malaria transmission in Kenya and Africa.
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Adu-Afarwuah S, Young RR, Lartey A, Okronipa H, Ashorn P, Ashorn U, Oaks BM, Dewey KG. Supplementation with Small-Quantity Lipid-Based Nutrient Supplements Does Not Increase Child Morbidity in a Semiurban Setting in Ghana: A Secondary Outcome Noninferiority Analysis of the International Lipid-Based Nutrient Supplements (iLiNS)-DYAD Randomized Controlled Trial. J Nutr 2020; 150:382-393. [PMID: 31603205 PMCID: PMC7722352 DOI: 10.1093/jn/nxz243] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/26/2019] [Accepted: 09/11/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Adequate knowledge about the safety of consumption of small-quantity lipid-based nutrient supplements (SQ-LNSs) is needed. OBJECTIVE We aimed to test the hypothesis that SQ-LNS consumption is noninferior to control with respect to child morbidity. METHODS Women (n = 1320) ≤20 wk pregnant were assigned to iron and folic acid until delivery with no supplementation for offspring; or multiple micronutrient supplements until 6 mo postpartum with no supplementation for offspring; or SQ-LNSs until 6 mo postpartum, and SQ-LNSs for offspring (6 mg Fe/d) from 6 to 18 mo of age [the lipid-based nutrient supplement (LNS) group]. We assessed noninferiority (margin ≤20%) between any 2 groups during 0-6 mo of age, and between the non-LNS and LNS groups during 6-18 mo of age for caregiver-reported acute respiratory infection, diarrhea, gastroenteritis, fever/suspected malaria, poor appetite, and "other illnesses." RESULTS During 0-6 mo of age, 1197 infants contributed 190,503 infant-days. For all morbidity combined, overall mean incidence (per 100 infant-days) was 3.3 episodes, overall mean prevalence (percentage of infant-days) was 19.3%, and the 95% CIs of the incidence rate ratio (IRR) and longitudinal prevalence rate ratio (LPRR) between any 2 groups were ≤1.20. During 6-18 mo, there were 240,097 infant-days for the non-LNS group and 118,698 for the LNS group. For all morbidity combined, group mean incidences were 4.3 and 4.3, respectively (IRR: 1.0; 95% CI: 1.0, 1.1), and mean prevalences were 28.2% and 29.3%, respectively (LPRR: 1.0; 95% CI: 1.0, 1.1). Noninferiority was inconclusive for diarrhea, fever/suspected malaria, and poor appetite. CONCLUSIONS SQ-LNS consumption does not increase reported overall child morbidity in this population compared with the 2 other treatments.This trial was registered at clinicaltrials.gov as NCT00970866.
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Affiliation(s)
- Seth Adu-Afarwuah
- department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana
| | - Rebecca R Young
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, CA, USA
| | - Anna Lartey
- department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana
| | - Harriet Okronipa
- department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, CA, USA
| | - Per Ashorn
- Centre for Child Health Research, Tampere University Faculty of Medicine and Health Sciences and Tampere University Hospital, Tampere, Finland; and
| | - Ulla Ashorn
- Centre for Child Health Research, Tampere University Faculty of Medicine and Health Sciences and Tampere University Hospital, Tampere, Finland; and
| | - Brietta M Oaks
- Department of Nutrition and Food Sciences, University of Rhode Island, Kingston, RI, USA
| | - Kathryn G Dewey
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, CA, USA
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Wessells KR, Hinnouho GM, Barffour MA, Arnold CD, Kounnavong S, Kewcharoenwong C, Lertmemongkolchai G, Schuster GU, Stephensen CB, Hess SY. Impact of Daily Preventive Zinc or Therapeutic Zinc Supplementation for Diarrhea on Plasma Biomarkers of Environmental Enteric Dysfunction among Rural Laotian Children: A Randomized Controlled Trial. Am J Trop Med Hyg 2020; 102:415-426. [PMID: 31889508 PMCID: PMC7008314 DOI: 10.4269/ajtmh.19-0584] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 11/11/2019] [Indexed: 12/18/2022] Open
Abstract
Environmental enteric dysfunction (EED) may be ameliorated by zinc supplementation. The objective of this study was to investigate the impact of different forms of zinc supplementation on biomarkers of EED (i.e., plasma citrulline, kynurenine, and tryptophan concentrations and the kynurenine:tryptophan [KT] ratio) among young Laotian children. In a double-blind randomized controlled trial, 3,407 children aged 6-23 months were randomized into one of four groups: daily preventive zinc dispersible tablets (PZ; 7 mg zinc), daily multiple micronutrient powders (MNP; 10 mg zinc, 6 mg iron, and 13 other micronutrients), therapeutic zinc supplements for diarrhea treatment (TZ; 20 mg/day for 10 days), or daily placebo powder, and followed up for ∼36 weeks. Plasma samples at baseline and endline for 359 children were analyzed for citrulline, kynurenine, and tryptophan concentrations. At baseline, the prevalence of stunting and zinc deficiency was 37% and 76.5%, respectively. The mean plasma citrulline, kynurenine, and tryptophan concentrations were 24.6 ± 5.4 µmol/L, 3.27 ± 0.83 µmol/L, and 72.3 ± 12.9 µmol/L, respectively; the mean KT ratio (×1,000) was 45.9 ± 12.0. At endline, neither plasma citrulline, kynurenine, or tryptophan concentrations, nor the KT ratio differed among intervention groups (P > 0.05). In this population, PZ, MNP, and TZ had no overall effect on plasma concentrations of citrulline, kynurenine, and tryptophan, or the KT ratio. The need remains to better understand the etiology of EED, and the development of biomarkers to diagnose EED and evaluate the impact of interventions.
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Affiliation(s)
- K. Ryan Wessells
- Department of Nutrition, Institute for Global Nutrition, University of California, Davis, Davis, California
| | - Guy-Marino Hinnouho
- Department of Nutrition, Institute for Global Nutrition, University of California, Davis, Davis, California
| | - Maxwell A. Barffour
- Department of Nutrition, Institute for Global Nutrition, University of California, Davis, Davis, California
- Public Health Program, College of Health and Human Services, Missouri State University, Springfield, Missouri
| | - Charles D. Arnold
- Department of Nutrition, Institute for Global Nutrition, University of California, Davis, Davis, California
| | - Sengchanh Kounnavong
- Lao Tropical and Public Health Institute, Vientiane, Lao People’s Democratic Republic
| | - Chidchamai Kewcharoenwong
- Mekong Health Science Research Institute, Khon Kaen University, Khon Kaen, Thailand
- Faculty of Associated Medical Sciences, The Centre for Research and Development of Medical Diagnostic Laboratories, Khon Kaen University, Khon Kaen, Thailand
| | - Ganjana Lertmemongkolchai
- Mekong Health Science Research Institute, Khon Kaen University, Khon Kaen, Thailand
- Faculty of Associated Medical Sciences, The Centre for Research and Development of Medical Diagnostic Laboratories, Khon Kaen University, Khon Kaen, Thailand
| | - Gertrud U. Schuster
- Department of Nutrition, Institute for Global Nutrition, University of California, Davis, Davis, California
- Agricultural Research Service, Western Human Nutrition Research Center, US Department of Agriculture, Davis, California
| | - Charles B. Stephensen
- Department of Nutrition, Institute for Global Nutrition, University of California, Davis, Davis, California
- Agricultural Research Service, Western Human Nutrition Research Center, US Department of Agriculture, Davis, California
| | - Sonja Y. Hess
- Department of Nutrition, Institute for Global Nutrition, University of California, Davis, Davis, California
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254
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Gough EK, Moulton LH, Mutasa K, Ntozini R, Stoltzfus RJ, Majo FD, Smith LE, Panic G, Giallourou N, Jamell M, Kosek P, Swann JR, Humphrey JH, Prendergast AJ. Effects of improved water, sanitation, and hygiene and improved complementary feeding on environmental enteric dysfunction in children in rural Zimbabwe: A cluster-randomized controlled trial. PLoS Negl Trop Dis 2020; 14:e0007963. [PMID: 32059011 PMCID: PMC7046282 DOI: 10.1371/journal.pntd.0007963] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 02/27/2020] [Accepted: 11/27/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Environmental enteric dysfunction (EED) may be an important modifiable cause of child stunting. We described the evolution of EED biomarkers from birth to 18 months in rural Zimbabwe and tested the independent and combined effects of improved water, sanitation, and hygiene (WASH), and improved infant and young child feeding (IYCF), on EED. METHODOLOGY AND FINDINGS The Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial was a 2x2 factorial cluster-randomised trial of improved IYCF and improved WASH on child stunting and anaemia at 18 months of age. 1169 infants born to HIV-negative mothers provided plasma and faecal specimens at 1, 3, 6, 12, and 18 months of age. We measured EED biomarkers that reflect all domains of the hypothesized pathological pathway. Markers of intestinal permeability and intestinal inflammation declined over time, while markers of microbial translocation and systemic inflammation increased between 1-18 months. Markers of intestinal damage (I-FABP) and repair (REG-1β) mirrored each other, and citrulline (a marker of intestinal epithelial mass) increased from 6 months of age, suggesting dynamic epithelial turnover and regeneration in response to enteric insults. We observed few effects of IYCF and WASH on EED after adjustment for multiple comparisons. The WASH intervention decreased plasma IGF-1 at 3 months (β:0.89, 95%CI:0.81,0.98) and plasma kynurenine at 12 months (β: 0.92, 95%CI:0.87,0.97), and increased plasma IGF-1 at 18 months (β:1.15, 95%CI:1.05,1.25), but these small WASH effects did not translate into improved growth. CONCLUSIONS Overall, we observed dynamic trends in EED but few effects of IYCF or WASH on biomarkers during the first 18 months after birth, suggesting that these interventions did not impact EED. Transformative WASH interventions are required to prevent or ameliorate EED in low-income settings.
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Affiliation(s)
- Ethan K. Gough
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Lawrence H. Moulton
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Kuda Mutasa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Robert Ntozini
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Rebecca J. Stoltzfus
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, United States of America
| | - Florence D. Majo
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Laura E. Smith
- Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, United States of America
| | - Gordana Panic
- Department of Metabolism, Digestion and Reproduction, Division of Digestive Diseases, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Natasa Giallourou
- Department of Metabolism, Digestion and Reproduction, Division of Digestive Diseases, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Mark Jamell
- Pain Care Specialists of Oregon, Eugene, OR, United States of America
| | - Peter Kosek
- Pain Care Specialists of Oregon, Eugene, OR, United States of America
| | - Jonathan R. Swann
- Department of Metabolism, Digestion and Reproduction, Division of Digestive Diseases, Faculty of Medicine, Imperial College London, London, United Kingdom
- Department of Neuroscience, Karolinska Institute, Solna, Sweden
| | - Jean H. Humphrey
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Andrew J. Prendergast
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, London, United Kingdom
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Valcourt N, Javernick-Will A, Walters J, Linden K. System Approaches to Water, Sanitation, and Hygiene: A Systematic Literature Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17030702. [PMID: 31973179 PMCID: PMC7037755 DOI: 10.3390/ijerph17030702] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 01/09/2020] [Accepted: 01/14/2020] [Indexed: 01/25/2023]
Abstract
Endemic issues of sustainability in the water, sanitation, and hygiene (WASH) sector have led to the rapid expansion of ‘system approaches’ for assessing the multitude of interconnected factors that affect WASH outcomes. However, the sector lacks a systematic analysis and characterization of the knowledge base for systems approaches, in particular how and where they are being implemented and what outcomes have resulted from their application. To address this need, we conducted a wide-ranging systematic literature review of systems approaches for WASH across peer-reviewed, grey, and organizational literature. Our results show a myriad of methods, scopes, and applications within the sector, but an inadequate level of information in the literature to evaluate the utility and efficacy of systems approaches for improving WASH service sustainability. Based on this analysis, we propose four recommendations for improving the evidence base including: diversifying methods that explicitly evaluate interconnections between factors within WASH systems; expanding geopolitical applications; improving reporting on resources required to implement given approaches; and enhancing documentation of effects of systems approaches on WASH services. Overall, these findings provide a robust survey of the existing landscape of systems approaches for WASH and propose a path for future research in this emerging field.
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Affiliation(s)
- Nicholas Valcourt
- Department of Civil, Environmental, and Architectural Engineering, University of Colorado Boulder, Boulder, CO 80309, USA; (A.J.-W.); (K.L.)
- USAID Sustainable WASH Systems Learning Partnership, United State Agency for International Development, Washington, DC 20004, USA;
- Correspondence:
| | - Amy Javernick-Will
- Department of Civil, Environmental, and Architectural Engineering, University of Colorado Boulder, Boulder, CO 80309, USA; (A.J.-W.); (K.L.)
- USAID Sustainable WASH Systems Learning Partnership, United State Agency for International Development, Washington, DC 20004, USA;
| | - Jeffrey Walters
- USAID Sustainable WASH Systems Learning Partnership, United State Agency for International Development, Washington, DC 20004, USA;
- College of Engineering, George Fox University, Newberg, OR 97132, USA
| | - Karl Linden
- Department of Civil, Environmental, and Architectural Engineering, University of Colorado Boulder, Boulder, CO 80309, USA; (A.J.-W.); (K.L.)
- USAID Sustainable WASH Systems Learning Partnership, United State Agency for International Development, Washington, DC 20004, USA;
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Tam E, Keats EC, Rind F, Das JK, Bhutta ZA. Micronutrient Supplementation and Fortification Interventions on Health and Development Outcomes among Children Under-Five in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis. Nutrients 2020; 12:E289. [PMID: 31973225 PMCID: PMC7071447 DOI: 10.3390/nu12020289] [Citation(s) in RCA: 103] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 01/10/2020] [Accepted: 01/19/2020] [Indexed: 12/20/2022] Open
Abstract
Micronutrient deficiencies continue to be widespread among children under-five in low- and middle-income countries (LMICs), despite the fact that several effective strategies now exist to prevent them. This kind of malnutrition can have several immediate and long-term consequences, including stunted growth, a higher risk of acquiring infections, and poor development outcomes, all of which may lead to a child not achieving his or her full potential. This review systematically synthesizes the available evidence on the strategies used to prevent micronutrient malnutrition among children under-five in LMICs, including single and multiple micronutrient (MMN) supplementation, lipid-based nutrient supplementation (LNS), targeted and large-scale fortification, and point-of-use-fortification with micronutrient powders (MNPs). We searched relevant databases and grey literature, retrieving 35,924 papers. After application of eligibility criteria, we included 197 unique studies. Of note, we examined the efficacy and effectiveness of interventions. We found that certain outcomes, such as anemia, responded to several intervention types. The risk of anemia was reduced with iron alone, iron-folic acid, MMN supplementation, MNPs, targeted fortification, and large-scale fortification. Stunting and underweight, however, were improved only among children who were provided with LNS, though MMN supplementation also slightly increased length-for-age z-scores. Vitamin A supplementation likely reduced all-cause mortality, while zinc supplementation decreased the incidence of diarrhea. Importantly, many effects of LNS and MNPs held when pooling data from effectiveness studies. Taken together, this evidence further supports the importance of these strategies for reducing the burden of micronutrient malnutrition in children. Population and context should be considered when selecting one or more appropriate interventions for programming.
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Affiliation(s)
- Emily Tam
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; (E.T.); (E.C.K.)
| | - Emily C. Keats
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; (E.T.); (E.C.K.)
| | - Fahad Rind
- Centre of Excellence in Women and Child’s Health, Aga Khan University, Karachi 74800, Pakistan;
| | - Jai K. Das
- Division of Women and Child Health, Aga Khan University, Karachi 74800, Pakistan;
| | - Zulfiqar A. Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; (E.T.); (E.C.K.)
- Centre of Excellence in Women and Child’s Health, Aga Khan University, Karachi 74800, Pakistan;
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257
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Hamzah L, Boehm AB, Davis J, Pickering AJ, Wolfe M, Mureithi M, Harris A. Ruminant Fecal Contamination of Drinking Water Introduced Post-Collection in Rural Kenyan Households. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E608. [PMID: 31963600 PMCID: PMC7027003 DOI: 10.3390/ijerph17020608] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 01/07/2020] [Accepted: 01/14/2020] [Indexed: 12/25/2022]
Abstract
In sub-Saharan Africa, many families travel to collect water and store it in their homes for daily use, presenting an opportunity for the introduction of fecal contamination. One stored and one source water sample were each collected from 45 households in rural Kenya. All 90 samples were analyzed for fecal indicator bacteria (E. coli and enterococci) and species-specific contamination using molecular microbial source tracking assays. Human (HF183), avian (GFD), and ruminant (BacR) contamination were detected in 52, two, and four samples, respectively. Stored water samples had elevated enterococci concentrations (p < 0.01, Wilcoxon matched pairs test) and more frequent BacR detection (89% versus 27%, p < 0.01, McNemar's exact test) relative to source water samples. fsQCA (fuzzy set qualitative comparative analysis) was conducted on the subset of households with no source water BacR contamination to highlight combinations of factors associated with the introduction of BacR contamination to stored water supplies. Three combinations were identified: (i) ruminants in the compound, safe water extraction methods, and long storage time, (ii) ruminants, unsafe water extraction methods, and no soap at the household handwashing station, and (iii) long storage time and no soap. This suggests that multiple pathways contribute to the transmission of ruminant fecal contamination in this context, which would have been missed if data were analyzed using standard regression techniques.
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Affiliation(s)
- Latifah Hamzah
- Department of Civil and Environmental Engineering, Stanford University, Stanford, CA 94305, USA; (L.H.); (A.B.B.); (J.D.); (M.W.)
| | - Alexandria B. Boehm
- Department of Civil and Environmental Engineering, Stanford University, Stanford, CA 94305, USA; (L.H.); (A.B.B.); (J.D.); (M.W.)
- Woods Institute for the Environment, Stanford University, Stanford, CA 94305, USA
| | - Jennifer Davis
- Department of Civil and Environmental Engineering, Stanford University, Stanford, CA 94305, USA; (L.H.); (A.B.B.); (J.D.); (M.W.)
- Woods Institute for the Environment, Stanford University, Stanford, CA 94305, USA
| | - Amy J. Pickering
- Department of Civil and Environmental Engineering, Tufts University, Medford, MA 01255, USA;
| | - Marlene Wolfe
- Department of Civil and Environmental Engineering, Stanford University, Stanford, CA 94305, USA; (L.H.); (A.B.B.); (J.D.); (M.W.)
- Innovations for Poverty Action, Nairobi, Kenya;
| | | | - Angela Harris
- Department of Civil, Construction, and Environmental Engineering, NC State University, Raleigh, NC 27695, USA
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McGuinness SL, O'Toole J, Ayton D, Giriyan A, Gaonkar CA, Vhaval R, Cheng AC, Leder K. Barriers and Enablers to Intervention Uptake and Health Reporting in a Water Intervention Trial in Rural India: A Qualitative Explanatory Study. Am J Trop Med Hyg 2020; 102:507-517. [PMID: 31933461 DOI: 10.4269/ajtmh.19-0486] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Consumption of unsafe drinking water contributes to the global disease burden, necessitating identification and implementation of effective, acceptable, and sustainable water interventions in resource-limited settings. In a quantitative stepped-wedge cluster randomized trial of a community-based water intervention in rural India, we identified low rates of intervention uptake and reported diarrhea. To better understand and explain these findings, we performed a qualitative study examining barriers and enablers to intervention uptake and health reporting using the COM-B model, where capabilities, opportunities, and motivators interact to generate behavior. We conducted 20 focus groups and one semi-structured interview with participants and four focus groups with data collectors. Multifactorial barriers to intervention uptake included distorted perceptions of water-related health effects, implementation issues that reduced treated water availability; convenience of, and preference for, alternative drinking water sources; delivery of water to plastic storage tanks (perceived as affecting water quality and taste); and resistance to change. Enablers included knowledge of water-related health risks, proximity to tanks, and social opportunity. Barriers to health reporting included variability in interpretation of illness, suspicion regarding the consequences of reporting disease, weariness with repeated questions, and perceived inaction on health data already provided; low survey implementation fidelity was also important. Enablers included surveyor initiatives to encourage reporting and a sense of social responsibility. This qualitative explanatory study allowed better understanding of our quantitative results. It also identified obstacles and facilitators to implementing and evaluating community water interventions, providing insight on how to achieve better intervention uptake and health reporting in future studies.
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Affiliation(s)
- Sarah L McGuinness
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Joanne O'Toole
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Darshini Ayton
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Asha Giriyan
- The Energy and Resources Institute (TERI), Panaji, India
| | | | | | - Allen C Cheng
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Karin Leder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Troeger CE, Khalil IA, Blacker BF, Biehl MH, Albertson SB, Zimsen SRM, Rao PC, Abate D, Ahmadi A, Ahmed MLCB, Akal CG, Alahdab F, Alam N, Alene KA, Alipour V, Aljunid SM, Al-Raddadi RM, Alvis-Guzman N, Amini S, Anber NH, Anjomshoa M, Antonio CAT, Arabloo J, Aremu O, Atalay HT, Atique S, Avokpaho EFGA, Awad S, Awasthi A, Badawi A, Balakrishnan K, Banoub JAM, Barac A, Bassat Q, Bedi N, Bennett DA, Bhattacharyya K, Bhutta ZA, Bijani A, Car J, Carvalho F, Castañeda-Orjuela CA, Christopher DJ, Dandona L, Dandona R, Daryani A, Demeke FM, Deshpande A, Djalalinia S, Dubey M, Dubljanin E, Duken EE, El Sayed Zaki M, Endries AY, Fernandes E, Fischer F, Fullman N, Gardner WM, Geta B, Ghadiri K, Gorini G, Goulart AC, Guo Y, Hailu GB, Haj-Mirzaian A, Haj-Mirzaian A, Hamidi S, Hassen HY, Hoang CL, Hostiuc M, Hussain Z, Irvani SSN, James SL, Jha RP, Jonas JB, Karch A, Kasaeian A, Kassa TD, Kassebaum NJ, Kefale AT, Khader YS, Khan EA, Khan MN, Khang YH, Khoja AT, Kimokoti RW, Kisa A, Kisa S, Kissoon N, Kochhar S, Kosen S, Koyanagi A, Kuate Defo B, Kumar GA, Lal DK, Leshargie CT, Li S, Lodha R, Macarayan ERK, Majdan M, Mamun AA, Manguerra H, Melese A, Memish ZA, Mengistu DT, Meretoja TJ, Mestrovic T, Miazgowski B, Mirrakhimov EM, Moazen B, Mohammad KA, Mohammed S, Monasta L, Moore CE, Mosser JF, Mousavi SM, Murthy S, Mustafa G, Nazari J, Nguyen CT, Nguyen LH, Nisar MI, Nixon MR, Ogbo FA, Okoro A, Olagunju AT, Olagunju TO, P A M, Pakhale S, Postma MJ, Qorbani M, Quansah R, Rafiei A, Rahim F, Rahimi-Movaghar V, Rai RK, Rezai MS, Rezapour A, Rios-Blancas MJ, Ronfani L, Rosettie K, Rothenbacher D, Safari S, Saleem Z, Sambala EZ, Samy AM, Santric Milicevic MM, Sartorius B, Sawhney M, Seyedmousavi S, Shaikh MA, Sheikh A, Shigematsu M, Smith DL, Soriano JB, Sreeramareddy CT, Stanaway JD, Sufiyan MB, Teklu TGE, Temsah MH, Tessema B, Tran BX, Tran KB, Ullah I, Updike RL, Vasankari TJ, Veisani Y, Wada FW, Waheed Y, Weaver M, Wiens KE, Wiysonge CS, Yimer EM, Yonemoto N, Zaidi Z, Zar HJ, Zarghi A, Lim SS, Vos T, Mokdad AH, Murray CJL, Kyu HH, Hay SI, Reiner RC. Quantifying risks and interventions that have affected the burden of diarrhoea among children younger than 5 years: an analysis of the Global Burden of Disease Study 2017. THE LANCET. INFECTIOUS DISEASES 2020; 20:37-59. [PMID: 31678029 PMCID: PMC7340495 DOI: 10.1016/s1473-3099(19)30401-3] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 05/13/2019] [Accepted: 07/05/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Many countries have shown marked declines in diarrhoeal disease mortality among children younger than 5 years. With this analysis, we provide updated results on diarrhoeal disease mortality among children younger than 5 years from the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017) and use the study's comparative risk assessment to quantify trends and effects of risk factors, interventions, and broader sociodemographic development on mortality changes in 195 countries and territories from 1990 to 2017. METHODS This analysis for GBD 2017 had three main components. Diarrhoea mortality was modelled using vital registration data, demographic surveillance data, and verbal autopsy data in a predictive, Bayesian, ensemble modelling tool; and the attribution of risk factors and interventions for diarrhoea were modelled in a counterfactual framework that combines modelled population-level prevalence of the exposure to each risk or intervention with the relative risk of diarrhoea given exposure to that factor. We assessed the relative and absolute change in diarrhoea mortality rate between 1990 and 2017, and used the change in risk factor exposure and sociodemographic status to explain differences in the trends of diarrhoea mortality among children younger than 5 years. FINDINGS Diarrhoea was responsible for an estimated 533 768 deaths (95% uncertainty interval 477 162-593 145) among children younger than 5 years globally in 2017, a rate of 78·4 deaths (70·1-87·1) per 100 000 children. The diarrhoea mortality rate ranged between countries by over 685 deaths per 100 000 children. Diarrhoea mortality per 100 000 globally decreased by 69·6% (63·1-74·6) between 1990 and 2017. Among the risk factors considered in this study, those responsible for the largest declines in the diarrhoea mortality rate were reduction in exposure to unsafe sanitation (13·3% decrease, 11·2-15·5), childhood wasting (9·9% decrease, 9·6-10·2), and low use of oral rehydration solution (6·9% decrease, 4·8-8·4). INTERPRETATION Diarrhoea mortality has declined substantially since 1990, although there are variations by country. Improvements in sociodemographic indicators might explain some of these trends, but changes in exposure to risk factors-particularly unsafe sanitation, childhood growth failure, and low use of oral rehydration solution-appear to be related to the relative and absolute rates of decline in diarrhoea mortality. Although the most effective interventions might vary by country or region, identifying and scaling up the interventions aimed at preventing and protecting against diarrhoea that have already reduced diarrhoea mortality could further avert many thousands of deaths due to this illness. FUNDING Bill & Melinda Gates Foundation.
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Stewart CP, Wessells KR, Arnold CD, Huybregts L, Ashorn P, Becquey E, Humphrey JH, Dewey KG. Lipid-based nutrient supplements and all-cause mortality in children 6-24 months of age: a meta-analysis of randomized controlled trials. Am J Clin Nutr 2020; 111:207-218. [PMID: 31697329 DOI: 10.1093/ajcn/nqz262] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 09/23/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Undernutrition is associated with an elevated risk of mortality among children in low- and middle-income countries. Small-quantity lipid-based nutrient supplements (LNS) have been evaluated as a method to prevent undernutrition and improve infant development, but the effects on mortality are unknown. OBJECTIVE Our objective was to evaluate the effect of LNS on all-cause mortality among children 6-24 mo old. METHODS We conducted a systematic review and meta-analysis of randomized controlled trials of LNS designed to prevent undernutrition, with or without other interventions. Literature was searched in May 2019 and trials were included if they enrolled children between 6 and 24 mo old and the period of supplementation lasted ≥6 mo. We extracted data from participant flow diagrams and contacted study investigators to request data. We conducted a meta-analysis to produce summary RR estimates. RESULTS We identified 18 trials conducted in 11 countries that enrolled 41,280 children and reported 586 deaths. The risk of mortality was lower in the LNS arms than in the non-LNS comparison arms (RR: 0.73; 95% CI: 0.59, 0.89; 13 trials). Estimates were similar when trials with maternal LNS intervention arms were added or when alternative formulations of LNS were excluded. The results appeared stronger in trials in which LNS were compared with passive control arms. Excluding these contrasts and only comparing multicomponent arms with LNS groups and comparison groups that contained all the same components without LNS attenuated the effect estimate (RR: 0.82; 95% CI: 0.61, 1.10). CONCLUSIONS LNS provided for the prevention of undernutrition may reduce the risk of mortality, but more trials with appropriate comparison groups allowing isolation of the effect of LNS alone are needed.This study was registered at www.crd.york.ac.uk/PROSPERO as CRD42019128718.
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Affiliation(s)
- Christine P Stewart
- Institute for Global Nutrition, University of California, Davis, Davis, CA, USA
| | - K Ryan Wessells
- Institute for Global Nutrition, University of California, Davis, Davis, CA, USA
| | - Charles D Arnold
- Institute for Global Nutrition, University of California, Davis, Davis, CA, USA
| | - Lieven Huybregts
- International Food Policy Research Institute, Washington, DC, USA
| | - Per Ashorn
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Elodie Becquey
- International Food Policy Research Institute, Washington, DC, USA
| | - Jean H Humphrey
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kathryn G Dewey
- Institute for Global Nutrition, University of California, Davis, Davis, CA, USA
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261
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Contreras JD, Eisenberg JN. Does Basic Sanitation Prevent Diarrhea? Contextualizing Recent Intervention Trials through a Historical Lens. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 17:E230. [PMID: 31905628 PMCID: PMC6981821 DOI: 10.3390/ijerph17010230] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 12/19/2019] [Accepted: 12/25/2019] [Indexed: 12/14/2022]
Abstract
Three of four recent major sanitation intervention trials found no effect on diarrhea. These results conflicted with longstanding beliefs from decades of literature. To understand this discordance, we placed recent trials into the historical context that preceded them in two ways. First, we evaluated the history of published literature reviews on sanitation and diarrhea. Second, we conducted meta-analyses on studies from the most recent systematic review to uncover features that predict effectiveness. We found that 13 literature reviews dating to 1983 consistently estimated a significant protective effect of sanitation against diarrhea. However, these were marred by flawed studies and inappropriately averaged effects across widely heterogeneous interventions and contexts. Our meta-analyses highlight that the overall effect of sanitation on diarrhea was largely driven by sewerage and interventions that improved more than sanitation alone. There is no true overall effect of sanitation because variability between intervention types and implementation contexts is too complex to average. Ultimately, the null effects of recent latrine interventions are not surprising. Instead, the one trial that found a strong relative reduction in diarrhea is the historical outlier. The development of transformative sanitation interventions requires a better understanding of the social and environmental contexts that determine intervention effectiveness.
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Abstract
The human body grows in length from conception to the maximal adult height over two decades. The shortest male population averages ∼150 cm and the tallest ∼183 cm. Nonetheless the dimensions of head and trunk are highly comparable, with the vast difference in the leg length. Stunting is a personal condition in which an individual has a standing height-for-age (HAZ) of less than two standard deviations of the standard curve median. It is associated with increased mortality, morbidity, and functional deficits. The process of losing relative stature is known as linear growth retardation, first attributed to chronic protein deficiency, then to an assortment of micronutrient deficiencies, and most recently to inflammation from unhygienic environmental conditions. Public health intervention trials responding to each of these possibilities have failed to produce true reversal responses measured in the 10s of centimeters. As to biological insights, there is no convenient way to separate weight from length growth with sonographic monitoring, but a third of infants can be born stunted. Normative growth (standard curves) competes with epigenetic adaptation (programming) as the beacon for in utero growth. Major investments into field trials allow us to discard multiple micronutrients and water/sanitation/hygiene interventions as measures to reverse established stunting. The preponderance of evidence is against catch-up growth during puberty. Future publications will be in the conceptual domain, resolving metrics, while the full range of stimuli and exposures impeding growth will be elucidated. Advances in measurement techniques in anthropometry and immunology and endocrinology will be mobilized to the literature.
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Affiliation(s)
- Noel W. Solomons
- Center for Studies of Sensory Impairment, Aging and Metabolism (CeSSIAM), Guatemala City, Guatemala
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263
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Reese H, Routray P, Torondel B, Sinharoy SS, Mishra S, Freeman MC, Chang HH, Clasen T. Assessing longer-term effectiveness of a combined household-level piped water and sanitation intervention on child diarrhoea, acute respiratory infection, soil-transmitted helminth infection and nutritional status: a matched cohort study in rural Odisha, India. Int J Epidemiol 2019; 48:1757-1767. [PMID: 31363748 PMCID: PMC6929523 DOI: 10.1093/ije/dyz157] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Open defecation is widespread in rural India, and few households have piped water connections. While government and other efforts have increased toilet coverage in India, and evaluations found limited immediate impacts on health, longer-term effects have not been rigorously assessed. METHODS We conducted a matched cohort study to assess the longer-term effectiveness of a combined household-level piped water and sanitation intervention implemented by Gram Vikas (an Indian NGO) in rural Odisha, India. Forty-five intervention villages were randomly selected from a list of those where implementation was previously completed at least 5 years before, and matched to 45 control villages. We conducted surveys and collected stool samples between June 2015 and October 2016 in households with a child <5 years of age (n = 2398). Health surveillance included diarrhoea (primary outcome), acute respiratory infection (ARI), soil-transmitted helminth infection, and anthropometry. RESULTS Intervention villages had higher improved toilet coverage (85% vs 18%), and increased toilet use by adults (74% vs 13%) and child faeces disposal (35% vs 6%) compared with control villages. There was no intervention association with diarrhoea [adjusted OR (aOR): 0.94, 95% confidence interval (CI): 0.74-1.20] or ARI. Compared with controls, children in intervention villages had lower helminth infection (aOR: 0.44, 95% CI: 0.18, 1.00) and improved height-for-age z scores (HAZ) (+0.17, 95% CI: 0.03-0.31). CONCLUSIONS This combined intervention, where household water connections were contingent on community-wide household toilet construction, was associated with improved HAZ, and reduced soil-transmitted helminth (STH) infection, though not reduced diarrhoea or ARI. Further research should explore the mechanism through which these heterogenous effects on health may occur.
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Affiliation(s)
- Heather Reese
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Parimita Routray
- Environmental Health Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Belen Torondel
- Environmental Health Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Sheela S Sinharoy
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Samir Mishra
- Kalinga Institute of Industrial Technology, Bhubaneswar, India
| | - Matthew C Freeman
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Howard H Chang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Thomas Clasen
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Environmental Health Group, London School of Hygiene and Tropical Medicine, London, UK
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Reese H, Sinharoy SS, Clasen T. Using structural equation modelling to untangle sanitation, water and hygiene pathways for intervention improvements in height-for-age in children <5 years old. Int J Epidemiol 2019; 48:1992-2000. [PMID: 31598725 PMCID: PMC6929540 DOI: 10.1093/ije/dyz202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 09/09/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Despite a strong theoretical rationale for combining water, sanitation and hygiene (WaSH) interventions to improve child health, study findings are heterogeneous with little understanding of the mechanisms for these effects. Our study objective was to demonstrate the utility of structural equation modeling (SEM) to assess intervention effects on height-for-age z score (HAZ) through the complex system of WaSH pathways. METHODS We used data from a matched cohort effectiveness evaluation of a combined on-premise piped water and improved sanitation intervention in rural Odisha, India. Height/length was measured in children 0-59 months old (n = 1826) from 90 matched villages in February-June 2016. WaSH behaviours and infrastructure were assessed through household surveys and observation, respectively. We used SEM to calculate the standardized path coefficients and the total contributions of WaSH pathways to HAZ. RESULTS Intervention improvements on HAZ were through the sanitation pathway (coverage → use β: 0.722; use → HAZ β: 0.116), with piped water coverage indirectly affecting HAZ through improved sanitation use (β: 0.148). Although the intervention had a positive association with handwashing station coverage, there was no evidence of a total hygiene pathway effect on HAZ or further direct effects through the water pathways. CONCLUSIONS This study demonstrates the utility of SEM to assess the mechanisms through which combined WaSH interventions impact HAZ as a system of pathways, providing a more nuanced assessment than estimation of the total intervention effect. Our finding, that water impacts HAZ through the sanitation pathway, is an important and actionable insight for WaSH programming.
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Affiliation(s)
- Heather Reese
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Thomas Clasen
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
- London School of Hygiene and Tropical Medicine, London, UK
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Tickell KD, Atlas HE, Walson JL. Environmental enteric dysfunction: a review of potential mechanisms, consequences and management strategies. BMC Med 2019; 17:181. [PMID: 31760941 PMCID: PMC6876067 DOI: 10.1186/s12916-019-1417-3] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 08/27/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Environmental enteric dysfunction (EED) is an acquired enteropathy of the small intestine, characterized by enteric inflammation, villus blunting and decreased crypt-to-villus ratio. EED has been associated with poor outcomes, including chronic malnutrition (stunting), wasting and reduced vaccine efficacy among children living in low-resource settings. As a result, EED may be a valuable interventional target for programs aiming to reduce childhood morbidity in low and middle-income countries. MAIN TEXT Several highly plausible mechanisms link the proposed pathophysiology underlying EED to adverse outcomes, but causal attribution of these pathways has proved challenging. We provide an overview of recent studies evaluating the causes and consequences of EED. These include studies of the role of subclinical enteric infection as a primary cause of EED, and efforts to understand how EED-associated systemic inflammation and malabsorption may result in long-term morbidity. Finally, we outline recently completed and upcoming clinical trials that test novel interventions to prevent or treat this highly prevalent condition. CONCLUSIONS Significant strides have been made in linking environmental exposure to enteric pathogens and toxins with EED, and in understanding the multifactorial mechanisms underlying this complex condition. Further insights may come from several ongoing and upcoming interventional studies trialing a variety of novel management strategies.
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Affiliation(s)
- Kirkby D Tickell
- Department of Global Health, University of Washington, 325 9th Avenue (Box 359931), Seattle, WA, 98104, USA. .,Department of Epidemiology, University of Washington, 1959 NE Pacific Street, Health Sciences Bldg, F-262, Box 357236, Seattle, WA, 98195, USA. .,The Childhood Acute Illness and Nutrition Network (CHAIN), Nairobi, Kenya.
| | - Hannah E Atlas
- Department of Global Health, University of Washington, 325 9th Avenue (Box 359931), Seattle, WA, 98104, USA
| | - Judd L Walson
- Department of Global Health, University of Washington, 325 9th Avenue (Box 359931), Seattle, WA, 98104, USA.,Department of Epidemiology, University of Washington, 1959 NE Pacific Street, Health Sciences Bldg, F-262, Box 357236, Seattle, WA, 98195, USA.,The Childhood Acute Illness and Nutrition Network (CHAIN), Nairobi, Kenya.,Department of Allergy and Infectious Disease, University of Washington, 325 9th Avenue (Box 359931), Seattle, WA, 98104, USA.,Department of Pediatrics, University of Washington, 325 9th Avenue (Box 359931), Seattle, WA, 98104, USA
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266
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Abstract
The term 'double burden of malnutrition' is usually interpreted in terms of the physical status of children: stunted and wasted children on the one hand and overweight/obese children on the other. There is a third category of malnutrition that can occur at either end of the anthropometric spectrum or, indeed, in children whose physical size may be close to ideal. This third type is most commonly articulated with the phrase 'hidden hunger' and is often illustrated by micronutrient deficiencies; thus, we refer to it here as 'undernutrition'. As understanding of such issues advances, we realise that there is a myriad of factors that may be influencing a child's road to nutritional health. In this BMC Medicine article collection we consider these influences and the impact they have, such as: the state of the child's environment; the effect this has on their risk of, and responses to, infection and on their gut; the consequences of poor nutrition on cognition and brain development; the key drivers of the obesity epidemic across the globe; and how undernourishment can affect a child's body composition. This collection showcases recent advances in the field, but likewise highlights ongoing challenges in the battle to achieve adequate nutrition for children across the globe.
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Affiliation(s)
| | - Andrew M Prentice
- MRC Unit The Gambia at London School of Hygiene & Tropical Medicine, Atlantic Boulevard, Fajara, Banjul, The Gambia.
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267
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Brander RL, Pavlinac PB, Walson JL, John-Stewart GC, Weaver MR, Faruque ASG, Zaidi AKM, Sur D, Sow SO, Hossain MJ, Alonso PL, Breiman RF, Nasrin D, Nataro JP, Levine MM, Kotloff KL. Determinants of linear growth faltering among children with moderate-to-severe diarrhea in the Global Enteric Multicenter Study. BMC Med 2019; 17:214. [PMID: 31767012 PMCID: PMC6878715 DOI: 10.1186/s12916-019-1441-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 10/08/2019] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Moderate-to-severe diarrhea (MSD) in the first 2 years of life can impair linear growth. We sought to determine risk factors for linear growth faltering and to build a clinical prediction tool to identify children most likely to experience growth faltering following an episode of MSD. METHODS Using data from the Global Enteric Multicenter Study of children 0-23 months old presenting with MSD in Africa and Asia, we performed log-binomial regression to determine clinical and sociodemographic factors associated with severe linear growth faltering (loss of ≥ 0.5 length-for-age z-score [LAZ]). Linear regression was used to estimate associations with ΔLAZ. A clinical prediction tool was developed using backward elimination of potential variables, and Akaike Information Criterion to select the best fit model. RESULTS Of the 5902 included children, mean age was 10 months and 43.2% were female. Over the 50-90-day follow-up period, 24.2% of children had severe linear growth faltering and the mean ΔLAZ over follow-up was - 0.17 (standard deviation [SD] 0.54). After adjustment for age, baseline LAZ, and site, several factors were associated with decline in LAZ: young age, acute malnutrition, hospitalization at presentation, non-dysenteric diarrhea, unimproved sanitation, lower wealth, fever, co-morbidity, or an IMCI danger sign. Compared to children 12-23 months old, those 0-6 months were more likely to experience severe linear growth faltering (adjusted prevalence ratio [aPR] 1.97 [95% CI 1.70, 2.28]), as were children 6-12 months of age (aPR 1.72 [95% CI 1.51, 1.95]). A prediction model that included age, wasting, stunting, presentation with fever, and presentation with an IMCI danger sign had an area under the ROC (AUC) of 0.67 (95% CI 0.64, 0.69). Risk scores ranged from 0 to 37, and a cut-off of 21 maximized sensitivity (60.7%) and specificity (63.5%). CONCLUSION Younger age, acute malnutrition, MSD severity, and sociodemographic factors were associated with short-term linear growth deterioration following MSD. Data routinely obtained at MSD may be useful to predict children at risk for growth deterioration who would benefit from interventions.
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Affiliation(s)
- Rebecca L Brander
- Department of Epidemiology, University of Washington, Seattle, WA, USA.
| | | | - Judd L Walson
- Department of Epidemiology, Global Health, Pediatrics, Medicine, Childhood Acute Illness and Nutrition Network, University of Washington, Seattle, WA, USA
| | - Grace C John-Stewart
- Department of Epidemiology, Global Health, Pediatrics, Medicine, University of Washington, Seattle, WA, USA
| | - Marcia R Weaver
- Department of Global Health, Health Services, Health Metrics Sciences, University of Washington, Seattle, WA, USA
| | - Abu S G Faruque
- International Centre for Diarrhoeal Disease Research, Mohakhali, Dhaka, Bangladesh
| | - Anita K M Zaidi
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan.,Present Address: Enteric and Diarrheal Diseases Program, Bill and Melinda Gates Foundation, Seattle, WA, USA
| | - Dipika Sur
- National Institute of Cholera and Enteric Diseases, Kolkata, India.,Present Address: Translational Health Science and Technology Institute, Faridabad, India
| | - Samba O Sow
- Centre pour le Développement des Vaccines, Bamako, Mali
| | - M Jahangir Hossain
- Medical Research Council Unit, The Gambia at London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Pedro L Alonso
- Centro de Investigação em Saúde da Manhiça, Maputo, Mozambique.,Present Address: Global Malaria Programme, World Health Organization, Geneva, Switzerland
| | - Robert F Breiman
- Global Disease Detection Division, Kenya Office of the US Centers for Disease Control and Prevention, Nairobi, Kenya.,Present Address: Global Health Institute Emory University, Atlanta, GA, USA
| | - Dilruba Nasrin
- Center for Vaccine Development, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - James P Nataro
- Center for Vaccine Development, Department of Medicine, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA.,Present Address: Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Myron M Levine
- Center for Vaccine Development and Global Health, Department of Pediatrics and Medicine, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Karen L Kotloff
- Center for Vaccine Development and Global Health, Department of Pediatrics and Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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268
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Park JJH, Harari O, Siden E, Dron L, Zannat NE, Singer J, Lester RT, Thorlund K, Mills EJ. Interventions to improve linear growth during complementary feeding period for children aged 6-24 months living in low- and middle-income countries: a systematic review and network meta-analysis. Gates Open Res 2019; 3:1660. [PMID: 32259047 PMCID: PMC7096089 DOI: 10.12688/gatesopenres.13083.1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2019] [Indexed: 08/29/2023] Open
Abstract
Background: Optimizing linear growth in children during complementary feeding period (CFP) (6-24 months) are critical for their development. Several interventions, such as micronutrient and food supplements, deworming, maternal education, and water, sanitation and hygiene (WASH), could potentially be provided to prevent stunting, but their comparative effectiveness is currently unclear. In this study, we evaluated comparative effectiveness of interventions under these domains on child linear growth outcomes of height-for-age z-score (HAZ) and stunting (HAZ <-2SD) Methods: For this study, we searched for low- and middle-income country (LMIC)-based randomized clinical trials (RCTs) of aforementioned interventions provided to children during CFP. We searched for reports published until September 17, 2019 and hand-searched bibliographies of existing reviews. We performed random-effects network meta-analysis (NMA) for HAZ and stunting. Results: The evidence base for our NMA was based on 79 RCTs (96 papers) involving 81,786 children. Among the micronutrients, compared to standard-of-care, iron + folic acid (IFA) (mean difference =0.08; 95% credible interval [CrI]: 0.01, 0.15) and multiple micronutrients (MMN) (mean difference =0.06; 95%CrI: 0.01, 0.11) showed improvements for HAZ; MMN also reduced the risks for stunting (RR=0.86; 95%Crl: 0.73, 0.98), whereas IFA did not (RR=0.92; 95%Crl: 0.64, 1.23). For food supplements, flour in the caloric range of 270-340 kcal (RR=0.73; 95%Crl: 0.51, 1.00) and fortified lipid-based nutrient supplements (LNS) containing 220-285 kcal (RR=0.80; 95%Crl: 0.66, 0.97) decreased the risk of stunting compared to standard-of-care, but these interventions and other food supplements did not show improvements for HAZ. Deworming, maternal education, and WASH interventions did not show improvements for HAZ nor stunting. Conclusion: While we found micronutrient and food supplements to be effective for HAZ and/or stunting, the evidence base for other domains in this life stage was limited, highlighting the need for more investigation. Registration: PROSPERO CRD42018110449; registered on 17 October 2018.
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Affiliation(s)
- Jay J. H. Park
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
| | - Ofir Harari
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
| | - Ellie Siden
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
| | - Louis Dron
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
| | | | - Joel Singer
- School of Population and Public Health, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Data and Methodology Program, CIHR Canadian HIV Trials Network, Vancouver, BC, V6Z 1Y6, Canada
| | - Richard T. Lester
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
| | - Kristian Thorlund
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada
| | - Edward J. Mills
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada
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Khalid H, Gill S, Fox AM. Global aid for nutrition-specific and nutrition-sensitive interventions and proportion of stunted children across low- and middle-income countries: does aid matter? Health Policy Plan 2019; 34:ii18-ii27. [DOI: 10.1093/heapol/czz106] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2019] [Indexed: 11/13/2022] Open
Abstract
AbstractDevelopment assistance for health (DAH) has increased dramatically over the past two decades, and this increase has led to a debate on the benefits and perverse effects of scaling-up vs scaling back DAH, and the type of interventions DAH should support. Nutrition remains a contested category viewed as essential to achieving primary healthcare objectives but as falling outside of the direct ambit of the health system. Thus, despite the increase in DAH, it continues to remain an underfunded area and little is known about the relationship between aid for nutrition-specific and nutrition-sensitive interventions and the proportion of stunted children across low- and middle-income countries. We hypothesize that as nutrition-specific aid targets local needs of countries and is less fungible than nutrition-sensitive aid, it will contribute more to a reduction in the proportion of stunted children, with the steepest gains among countries that have the highest burden of malnutrition. We use fixed-effects regressions to examine the relationship between the proportion of stunted children and aid for nutrition interventions (specific and sensitive) to 116 low- and middle-income countries (2002–16). We construct our panel using the Creditor Reporting System, Institute of Health Metrics and Evaluation, Food and Agriculture Organization, World Health Organization and World Development indicators databases. We find a one-dollar increase in per capita nutrition-specific aid is associated with a reduction in the proportion of stunted children by 0.004 (P < 0.05). When stratified by burden of malnutrition, a one-dollar increase in per capita nutrition-specific aid to countries with the highest burden of malnutrition is associated with sharper reductions in the proportion of stunted children (0.013, P < 0.01). We also find a significant association for per capita nutrition-sensitive aid and proportion of stunted children when per capita aid for nutrition is lagged by 3 and 4 years (0.0002, P < 0.05), suggesting a long-run association between nutrition-sensitive aid and proportion of stunted children. Our findings suggest that in spite of criticisms that development assistance fails to adequately reach its intended beneficiaries, aid for nutrition has been successful at reducing the proportion of stunted children. Our findings imply a need to scale-up nutrition funding and improve targeting of aid.
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Affiliation(s)
- Hina Khalid
- School of Humanities and Social Sciences, Information Technology University, Arfa Software Technology Park, Ferozepur Road Lahore, Pakistan
| | - Sitara Gill
- School of Humanities and Social Sciences, Information Technology University, Arfa Software Technology Park, Ferozepur Road Lahore, Pakistan
| | - Ashley M Fox
- Rockefeller College of Public Affairs and Policy, University at Albany, State University of New York, Albany, NY, USA
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Louis-Auguste J, Besa E, Zyambo K, Munkombwe D, Banda R, Banda T, Watson A, Mayneris-Perxachs J, Swann J, Kelly P. Tryptophan, glutamine, leucine, and micronutrient supplementation improves environmental enteropathy in Zambian adults: a randomized controlled trial. Am J Clin Nutr 2019; 110:1240-1252. [PMID: 31504110 PMCID: PMC6821547 DOI: 10.1093/ajcn/nqz189] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 07/18/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Environmental enteropathy (EE) refers to villus blunting, reduced absorption, and microbial translocation in children and adults in tropical or deprived residential areas. In previous work we observed an effect of micronutrients on villus height (VH). OBJECTIVE We aimed to determine, in a randomized controlled trial, if amino acid (AA) or multiple micronutrient (MM) supplementation can improve intestinal structure or barrier dysfunction in Zambian adults with EE. METHODS AA (tryptophan, leucine, and glutamine) and/or MM supplements were given for 16 wk in a 2 × 2 factorial comparison against placebo. Primary outcomes were changes in VH, in vivo small intestinal barrier dysfunction assessed by confocal laser endomicroscopy (CLE), and mechanistic (or mammalian) target of rapamycin complex 1 (MTORC1) nutrient responsiveness in lamina propria CD4+ lymphocytes. RESULTS Over 16 wk AA, but not MM, supplementation increased VH by 16% (34.5 μm) compared with placebo (P = 0.04). Fluorescein leak, measured by CLE, improved only in those allocated to both AA and MM supplementation. No effect was seen on MTORC1 activation, but posttreatment MTORC1 and VH were correlated (ρ = 0.51; P = 0.001), and change in MTORC1 was correlated with change in VH in the placebo group (ρ = 0.63; P = 0.03). In secondary analyses no effect was observed on biomarkers of microbial translocation. Metabolomic analyses suggest alterations in a number of microbial- and host-derived metabolites including the leucine metabolite β-hydroxy-β-methylbutyrate, which was increased by AA supplementation and correlated with VH. CONCLUSIONS In this phase 2 trial, AA supplementation protected against a decline in VH over the supplementation period, and improved barrier function when combined with micronutrients. Leucine and MTORC1 metabolism may be involved in the mechanism of effect. This trial was registered at www.pactr.org as PACTR201505001104412.
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Affiliation(s)
- John Louis-Auguste
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom,Tropical Gastroenterology & Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Ellen Besa
- Tropical Gastroenterology & Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Kanekwa Zyambo
- Tropical Gastroenterology & Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Derick Munkombwe
- Department of Pharmacy, School of Health Sciences, University of Zambia, Lusaka, Zambia
| | - Rosemary Banda
- Tropical Gastroenterology & Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Themba Banda
- Tropical Gastroenterology & Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | | | - Jordi Mayneris-Perxachs
- Department of Diabetes, Endocrinology, and Nutrition, Girona Biomedical Research Institute, Dr Josep Trueta University Hospital, Centre for Physiopathology of Obesity and Nutrition (CIBEROBN), Girona, Spain,Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona, Spain,Division of Integrative Systems Medicine and Digestive Diseases, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Jonathan Swann
- Division of Integrative Systems Medicine and Digestive Diseases, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Paul Kelly
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom,Tropical Gastroenterology & Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia,Address correspondence to PK (e-mail: )
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271
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Sullivan PB. Environmental enteric dysfunction: a socioeconomic problem looking for a medical solution? Am J Clin Nutr 2019; 110:1051-1052. [PMID: 31667510 DOI: 10.1093/ajcn/nqz225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Peter B Sullivan
- University of Oxford, Department of Pediatrics, Children's Hospital, Oxford, United Kingdom
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272
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Wells JCK, Briend A, Boyd EM, Berkely JA, Hall A, Isanaka S, Webb P, Khara T, Dolan C. Beyond wasted and stunted-a major shift to fight child undernutrition. THE LANCET. CHILD & ADOLESCENT HEALTH 2019; 3:831-834. [PMID: 31521500 DOI: 10.1016/s2352-4642(19)30244-5] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 06/08/2019] [Accepted: 06/28/2019] [Indexed: 12/30/2022]
Abstract
Child undernutrition refers broadly to the condition in which food intake is inadequate to meet a child's needs for physiological function, growth, and the capacity to respond to illness. Since the 1970s, nutritionists have categorised undernutrition in two major ways, either as wasted (ie, low weight for height, or small mid-upper arm circumference) or stunted (ie, low height for age). This approach, although useful for identifying populations at risk of undernutrition, creates several problems: the focus is on children who have already become undernourished, and this approach draws an artificial distinction between two idealised types of undernourished children that are widely interpreted as indicative of either acute or chronic undernutrition. This distinction in turn has led to the separation of programmatic approaches to prevent and treat child undernutrition. In the past 3 years, research has shown that individual children are at risk of both conditions, might be born with both, pass from one state to the other over time, and accumulate risks to their health and life through their combined effects. The current emphasis on identifying children who are already wasted or stunted detracts attention from the larger number of children undergoing the process of becoming undernourished. We call for a major shift in thinking regarding how we assess child undernutrition, and how prevention and treatment programmes can best address the diverse causes and dynamic biological processes that underlie undernutrition.
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Affiliation(s)
- Jonathan C K Wells
- Childhood Nutrition Research Centre, Population, Policy and Practice Research and Teaching Department, University College London Great Ormond Street Institute of Child Health, London, UK.
| | - André Briend
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Frederiksberg, Denmark; Centre for Child Health Research, Faculty of Medicine and Medical Technology, Tampere University, Tampere, Finland
| | - Erin M Boyd
- US Agency for International Development's Office of US Foreign Disaster Assistance, Washington, DC, USA
| | - James A Berkely
- Kenya Medical Research Institute, Wellcome Trust Research Programme, Kilifi, Kenya; Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK; The Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
| | | | - Sheila Isanaka
- Department of Nutrition, Harvard T H Chan School of Public Health, Boston, MA, USA; Research Department, Epicentre, Paris, France
| | - Patrick Webb
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | | | - Carmel Dolan
- Childhood Nutrition Research Centre, Population, Policy and Practice Research and Teaching Department, University College London Great Ormond Street Institute of Child Health, London, UK
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273
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Capone D, Adriano Z, Berendes D, Cumming O, Dreibelbis R, Holcomb DA, Knee J, Ross I, Brown J. A localized sanitation status index as a proxy for fecal contamination in urban Maputo, Mozambique. PLoS One 2019; 14:e0224333. [PMID: 31652287 PMCID: PMC6814227 DOI: 10.1371/journal.pone.0224333] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 10/10/2019] [Indexed: 11/24/2022] Open
Abstract
Sanitary surveys are used in low- and middle-income countries to assess water, sanitation, and hygiene conditions, but have rarely been compared with direct measures of environmental fecal contamination. We conducted a cross-sectional assessment of sanitary conditions and E. coli counts in soils and on surfaces of compounds (household clusters) in low-income neighborhoods of Maputo, Mozambique. We adapted the World Bank's Urban Sanitation Status Index to implement a sanitary survey tool specifically for compounds: a Localized Sanitation Status Index (LSSI) ranging from zero (poor sanitary conditions) to one (better sanitary conditions) calculated from 20 variables that characterized local sanitary conditions. We measured the variation in the LSSI with E. coli counts in soil (nine locations/compound) and surface swabs (seven locations/compound) in 80 compounds to assess reliability. Multivariable regression indicated that a ten-percentage point increase in LSSI was associated with 0.05 (95% CI: 0.00, 0.11) log10 fewer E. coli/dry gram in courtyard soil. Overall, the LSSI may be associated with fecal contamination in compound soil; however, the differences detected may not be meaningful in terms of public health hazards.
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Affiliation(s)
- Drew Capone
- Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, Georgia, United States of America
| | - Zaida Adriano
- WE Consult, Maputo, Mozambique
- Departamento de Geografia, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - David Berendes
- Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging Zoonotic and Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Oliver Cumming
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Robert Dreibelbis
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - David A. Holcomb
- Department of Environmental Sciences and Engineering, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Jackie Knee
- Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, Georgia, United States of America
| | - Ian Ross
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Joe Brown
- Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, Georgia, United States of America
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274
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Setty K, Cronk R, George S, Anderson D, O'Flaherty G, Bartram J. Adapting Translational Research Methods to Water, Sanitation, and Hygiene. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E4049. [PMID: 31652610 PMCID: PMC6843932 DOI: 10.3390/ijerph16204049] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 10/04/2019] [Accepted: 10/06/2019] [Indexed: 12/20/2022]
Abstract
Translational research applies scientific techniques to achieve practical outcomes, connecting pure research and pure practice. Many translational research types have arisen since the mid-1900s, reflecting the need to better integrate scientific advancement with policy and practice. Water, sanitation, and hygiene (WaSH) development efforts have aimed to reduce morbidity and mortality and improve service delivery; thus, associated research has a strong orientation toward applied studies that use diverse methods to support decision-making. Drawing from knowledge that emerged to support other professional fields, such as manufacturing and clinical healthcare, we characterize different types of translational research and clarify nomenclature and principles. We describe study approaches relevant to translational research questions, and offer overarching recommendations, specific examples, and resources for further study as practical advice to professionals who seek to apply translational methods to WaSH problems. To enhance collective outcomes, professionals should mindfully align projects within the translational spectrum. We further recommend overarching good practices such as documenting intervention adaptations, overtly considering contextual factors, and better distinguishing efficacy from effectiveness research by replicating studies in different contexts. By consciously improving the compatibility and linkages between WaSH science and practice, this guide can accelerate urgently needed progress toward global development goals.
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Affiliation(s)
- Karen Setty
- The Water Institute at UNC and Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 166 Rosenau Hall, CB #7431 Chapel Hill, NC 27599-7431, USA.
| | - Ryan Cronk
- The Water Institute at UNC and Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 166 Rosenau Hall, CB #7431 Chapel Hill, NC 27599-7431, USA.
| | - Shannan George
- The Water Institute at UNC and Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 166 Rosenau Hall, CB #7431 Chapel Hill, NC 27599-7431, USA.
| | - Darcy Anderson
- The Water Institute at UNC and Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 166 Rosenau Hall, CB #7431 Chapel Hill, NC 27599-7431, USA.
| | - Għanja O'Flaherty
- The Water Institute at UNC and Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 166 Rosenau Hall, CB #7431 Chapel Hill, NC 27599-7431, USA.
| | - Jamie Bartram
- The Water Institute at UNC and Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 166 Rosenau Hall, CB #7431 Chapel Hill, NC 27599-7431, USA.
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275
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Budge S, Hutchings P, Parker A, Tyrrel S, Tulu T, Gizaw M, Garbutt C. Do domestic animals contribute to bacterial contamination of infant transmission pathways? Formative evidence from Ethiopia. JOURNAL OF WATER AND HEALTH 2019; 17:655-669. [PMID: 31638018 DOI: 10.2166/wh.2019.224] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Child stunting is associated with poor water, sanitation and hygiene (WASH), partly due to the effect of infection on intestinal nutrient absorption. WASH interventions, however, show little effect on growth. A hypothesis is that bacterial contamination of hands and floors from domestic animals and their faeces, and subsequent ingestion via infant hand-to-mouth behaviours, may explain this. This formative study used microbial testing and survey and observational data from 20 households in Ethiopia to characterise principle bacterial transmission pathways to infants, considering WASH facilities and practices, infant behaviours and animal exposure. Microbial swabbing showed the contamination of hands and floor surfaces from thermotolerant coliform bacteria. Animal husbandry practices, such as keeping animals inside, contributed significantly (all p < 0.005). There was no evidence that latrine facilities mitigated contamination across infant (p = 0.76) or maternal (p = 0.86) hands or floor surfaces (p = 0.36). This small study contributes to the evidence that animal faeces are an important source of domestic bacterial contamination. The results imply that interventions aiming to reduce pathogen transmission to infants should think beyond improving WASH and also consider the need to separate infants and animals in the home. Intervention studies will be required to determine whether this reduces infant infection and improves linear growth.
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Affiliation(s)
| | - Paul Hutchings
- Water Science, Cranfield Water Science Institute, Cranfield University, Vincent Building, Cranfield, Bedford MK43 0AL, UK E-mail:
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276
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Hyun C, Burt Z, Crider Y, Nelson KL, Sharada Prasad CS, Rayasam SDG, Tarpeh W, Ray I. Sanitation for Low-Income Regions: A Cross-Disciplinary Review. ANNUAL REVIEW OF ENVIRONMENT AND RESOURCES 2019; 44:287-318. [PMID: 32587484 PMCID: PMC7316187 DOI: 10.1146/annurev-environ-101718-033327] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Sanitation research focuses primarily on containing human waste and preventing disease; thus, it has traditionally been dominated by the fields of environmental engineering and public health. Over the past 20 years, however, the field has grown broader in scope and deeper in complexity, spanning diverse disciplinary perspectives. In this article, we review the current literature in the range of disciplines engaged with sanitation research in low- and middle-income countries (LMICs). We find that perspectives on what sanitation is, and what sanitation policy should prioritize, vary widely. We show how these diverse perspectives augment the conventional sanitation service chain, a framework describing the flow of waste from capture to disposal. We review how these perspectives can inform progress toward equitable sanitation for all [i.e., Sustainable Development Goal (SDG) 6]. Our key message is that both material and nonmaterial flows-and both technological and social functions-make up a sanitation "system." The components of the sanitation service chain are embedded within the flows of finance, decision making, and labor that make material flows of waste possible. The functions of capture, storage, transport, treatment, reuse, and disposal are interlinked with those of ensuring equity and affordability. We find that a multilayered understanding of sanitation, with contributions from multiple disciplines, is necessary to facilitate inclusive and robust research toward the goal of sanitation for all.
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Affiliation(s)
- Christopher Hyun
- Energy and Resources Group, University of California, Berkeley, California 94720, USA
| | - Zachary Burt
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Yoshika Crider
- Energy and Resources Group, University of California, Berkeley, California 94720, USA
| | - Kara L Nelson
- Department of Civil and Environmental Engineering, College of Engineering, University of California, Berkeley, California 94720, USA
| | - C S Sharada Prasad
- School of Development, Azim Premji University, Bengaluru, Karnataka 560100, India
| | | | - William Tarpeh
- Chemical Engineering, Stanford University, Stanford, California 94305, USA
| | - Isha Ray
- Energy and Resources Group, University of California, Berkeley, California 94720, USA
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277
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Wilson-Jones M, Smith K, Jones D, Hamilton H, Richardson L, Macintyre A, Gautam OP, Harvey E, Northover H. Response to 'The implications of three major new trials for the effect of water, sanitation and hygiene on childhood diarrhea and stunting: a consensus statement' by Cumming et al. BMC Med 2019; 17:183. [PMID: 31554508 PMCID: PMC6761719 DOI: 10.1186/s12916-019-1414-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 08/20/2019] [Indexed: 12/19/2022] Open
Abstract
Please see related article: https://doi.org/10.1186/s12916-019-1410-x.
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Affiliation(s)
| | - Kyla Smith
- WaterAid UK, 47-49 Durham St, Vauxhall, London, SE11 5JD, UK.
| | - Dan Jones
- WaterAid UK, 47-49 Durham St, Vauxhall, London, SE11 5JD, UK
| | - Helen Hamilton
- WaterAid UK, 47-49 Durham St, Vauxhall, London, SE11 5JD, UK
| | | | - Alison Macintyre
- WaterAid Australia, Level 9, 176 Wellington Parade, East Melbourne, VIC, 3002, Australia
| | | | - Erik Harvey
- WaterAid UK, 47-49 Durham St, Vauxhall, London, SE11 5JD, UK
| | - Henry Northover
- WaterAid UK, 47-49 Durham St, Vauxhall, London, SE11 5JD, UK
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278
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Majorin F, Torondel B, Ka Seen Chan G, Clasen T. Interventions to improve disposal of child faeces for preventing diarrhoea and soil-transmitted helminth infection. Cochrane Database Syst Rev 2019; 9:CD011055. [PMID: 31549742 PMCID: PMC6757260 DOI: 10.1002/14651858.cd011055.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Diarrhoea and soil-transmitted helminth (STH) infections represent a large disease burden worldwide, particularly in low-income countries. As the aetiological agents associated with diarrhoea and STHs are transmitted through faeces, the safe containment and management of human excreta has the potential to reduce exposure and disease. Child faeces may be an important source of exposure even among households with improved sanitation. OBJECTIVES To assess the effectiveness of interventions to improve the disposal of child faeces for preventing diarrhoea and STH infections. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL, MEDLINE, Embase, and 10 other databases. We also searched relevant conference proceedings, contacted researchers, searched websites for organizations, and checked references from identified studies. The date of last search was 27 September 2018. SELECTION CRITERIA We included randomized controlled trials (RCTs) and non-randomized controlled studies (NRS) that compared interventions aiming to improve the disposal of faeces of children aged below five years in order to decrease direct or indirect human contact with such faeces with no intervention or a different intervention in children and adults. DATA COLLECTION AND ANALYSIS Two review authors selected eligible studies, extracted data, and assessed the risk of bias. We used meta-analyses to estimate pooled measures of effect where appropriate, or described the study results narratively. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS Sixty-three studies covering more than 222,800 participants met the inclusion criteria. Twenty-two studies were cluster RCTs, four were controlled before-and-after studies (CBA), and 37 were NRS (27 case-control studies (one that included seven study sites), three controlled cohort studies, and seven controlled cross-sectional studies). Most study sites (56/69) were in low- or lower middle-income settings. Among studies using experimental study designs, most interventions included child faeces disposal messages along with other health education messages or other water, sanitation, and hygiene (WASH) hardware and software components. Among observational studies, the main risk factors relevant to this review were safe disposal of faeces in the latrine or defecation of children under five years of age in a latrine.Education and hygiene promotion interventions, including child faeces disposal messages (no hardware provision)Four RCTs found that diarrhoea incidence was lower, reducing the risk by an estimated 30% in children under six years old (rate ratio 0.71, 95% confidence interval (CI) 0.59 to 0.86; 2 trials, low-certainty evidence). Diarrhoea prevalence measured in two other RCTs in children under five years of age was lower, but evidence was low-certainty (risk ratio (RR) 0.93, 95% CI 0.84 to 1.04; low-certainty evidence).Two controlled cohort studies that evaluated such an intervention in Bangladesh did not detect a difference on diarrhoea prevalence (RR 0.91, 95% CI 0.64 to 1.28; very low-certainty evidence). Two controlled cross-sectional studies that evaluated the Health Extension Package in Ethiopia were associated with a lower two-week diarrhoea prevalence in 'model' households than in 'non-model households' (odds ratio (OR) 0.26, 95% CI 0.16 to 0.42; very low-certainty evidence).Programmes to end open defecation by all (termed community-led total sanitation (CLTS) interventions plus adaptations)Four RCTs measured diarrhoea prevalence and did not detect an effect in children under five years of age (RR 0.92, 95% CI 0.79 to 1.07; moderate-certainty evidence). The analysis of two trials did not demonstrate an effect of the interventions on STH infection prevalence in children (pooled RR 1.03, 95% CI 0.64 to 1.65; low-certainty evidence).One controlled cross-sectional study compared the prevalence of STH infection in open defecation-free (ODF) villages that had received a CLTS intervention with control villages and reported a higher level of STH infection in the intervention villages (RR 2.51, 95% CI 1.74 to 3.62; very low-certainty evidence).Sanitation hardware and behaviour change interventions, that included child faeces disposal hardware and messagingTwo RCTs had mixed results, with no overall effect on diarrhoea prevalence demonstrated in the pooled analysis (RR 0.79, 95% CI 0.49 to 1.26; very low-certainty evidence).WASH hardware and education/behaviour change interventionsOne RCT did not demonstrate an effect on diarrhoea prevalence (RR 1.15, 95% CI 0.93 to 1.41; very low-certainty evidence).Two CBAs reported that the intervention reduced diarrhoea incidence by about a quarter in children under five years of age, but evidence was very low-certainty (rate ratio 0.77, 95% CI 0.71 to 0.84). Another CBA reported that the intervention reduced the prevalence of STH in an intervention village compared to a control village, again with GRADE assessed at very low-certainty (OR 0.17, 95% CI 0.02 to 0.73).Case-control studiesPooled results from case-control studies that presented data for child faeces disposal indicated that disposal of faeces in the latrine was associated with lower odds of diarrhoea among all ages (OR 0.73, 95% CI: 0.62 to 0.85; 23 comparisons; very low-certainty evidence). Pooled results from case-control studies that presented data for children defecating in the latrine indicated that children using the latrine was associated with lower odds of diarrhoea in all ages (OR 0.54, 95% CI 0.33 to 0.90; 7 studies; very low-certainty evidence). AUTHORS' CONCLUSIONS Evidence suggests that the safe disposal of child faeces may be effective in preventing diarrhoea. However, the evidence is limited and of low certainty. The limited research on STH infections provides only low and very-low certainty evidence around effects, which means there is currently no reliable evidence that interventions to improve safe disposal of child faeces are effective in preventing such STH infections.While child faeces may represent a source of exposure to young children, interventions generally only address it as part of a broader sanitation initiative. There is a need for RCTs and other rigorous studies to assess the effectiveness and sustainability of different hardware and software interventions to improve the safe disposal of faeces of children of different age groups.
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Affiliation(s)
- Fiona Majorin
- London School of Hygiene & Tropical MedicineFaculty of Infectious and Tropical DiseasesKeppel StreetLondonUKWC1E 7HT
| | - Belen Torondel
- London School of Hygiene & Tropical MedicineFaculty of Infectious and Tropical DiseasesKeppel StreetLondonUKWC1E 7HT
| | - Gabrielle Ka Seen Chan
- London School of Hygiene & Tropical MedicineFaculty of Infectious and Tropical DiseasesKeppel StreetLondonUKWC1E 7HT
| | - Thomas Clasen
- Rollins School of Public Health, Emory UniversityDepartment of Environmental Health1518 Clifton Road NEAtlantaGAUSA30322
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Olney DK, Marshall Q, Honton G, Ogden K, Hambayi M, Piccini S, Go A, Gelli A, Bliznashka L. Leveraging an Implementation– Research Partnership to Improve Effectiveness of Nutrition-Sensitive Programs at the World Food Programme. Food Nutr Bull 2019; 41:18-37. [DOI: 10.1177/0379572119874273] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Nutrition-sensitive programs can accelerate progress in addressing malnutrition. However, evidence gaps exist related to their effectiveness and how to optimize program design and implementation. Objective: We present the process the International Food Policy Research Institute and the World Food Programme (WFP) used to develop nutrition-sensitive program guidance and plans for improving program effectiveness and contributing to the evidence base through rigorous evaluations. Methods: A 5-step process, using principles of design thinking (a systematic, iterative analytical approach to problem solving), was used to develop, test, and refine WFP’s nutrition-sensitive guidance. The guidance focuses on improving nutrition outcomes for nutritionally vulnerable groups across the life cycle: women and children in the first 1000 days, preschoolers, schoolchildren, and adolescents. Results: Through iterative consultations, we created WFP’s nutrition-sensitive guidance that includes harmonized theories of change across WFP’s programs; 7 opportunities to enhance the programs’ nutrition-sensitivity; and mapping of these opportunities to WFP programs and key evidence gaps. This guidance has been rolled out to WFP’s offices worldwide to support improved nutrition outcomes. Finally, several evaluation designs have been proposed to fill identified evidence gaps. Conclusions: By leveraging our implementation–research partnership, we expect that WFP’s programs will be more effective and cost effective for improving nutrition. This can be assessed through coupling newly designed nutrition-sensitive programs with rigorous evaluations. Evaluation results will be used to refine WFP’s nutrition-sensitive guidance and improve their programs globally. This guidance, and creation process, could be useful for others interested in designing nutrition-sensitive programs and increasing program effectiveness for nutrition.
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Affiliation(s)
- Deanna K. Olney
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | - Quinn Marshall
- Nutrition Division, World Food Programme (WFP), Rome, Italy
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | - Kathryn Ogden
- Nutrition Division, World Food Programme (WFP), Rome, Italy
| | | | - Sarah Piccini
- Nutrition Division, World Food Programme (WFP), Rome, Italy
| | - Ara Go
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | - Aulo Gelli
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | - Lilia Bliznashka
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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280
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Child-Sensitive WASH Composite Score and the Nutritional Status in Cambodian Children. Nutrients 2019; 11:nu11092142. [PMID: 31500268 PMCID: PMC6770572 DOI: 10.3390/nu11092142] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 08/09/2019] [Accepted: 08/19/2019] [Indexed: 12/12/2022] Open
Abstract
Progress in health has occurred in the past decades in Cambodia, in terms of health service access and interventions, but several indicators, including the prevalence of malnourished children, remain alarming. The causes of undernutrition are often linked to inadequate access to water, sanitation and hygiene services but limited evidence exists on the direct association between poor WASH practices and children's' nutritional statuses. This study investigates the relationship between water, sanitation and hygiene practices, defined as the child-sensitive composite score, and the nutritional status of children under five years old, measured as the weight-for-height z-score, mid-upper arm circumference or height-for-age z-score in six districts of Cambodia. The analysis used data from a longitudinal study, comprising extensive data collection on anthropometry, health, nutrition, WASH, and cognitive development. Chronological trends in wasting and stunting were described cross-sectionally, whereas the effect of WASH practices on the nutritional status of children over up to three consecutive study visits was examined with a linear mixed-effects model. The prevalence of wasting decreased during the study while stunting prevalence increased. A small, but significant, association was found between the WASH child-sensitive composite scores and the wasting child anthropometry indicators: weight-for-height z-score or mid-upper arm circumference. Evidence for an association with height-for-age z-score, detecting stunted children, was found when the independent variable was quantified according to global, but not national, guidelines. This study reinforces discordant existing evidence towards a direct association between WASH practices and children's nutritional status, suggesting the need to align nutrition and WASH programmes.
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281
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Geere JAL, Hunter PR. The association of water carriage, water supply and sanitation usage with maternal and child health. A combined analysis of 49 Multiple Indicator Cluster Surveys from 41 countries. Int J Hyg Environ Health 2019; 223:238-247. [PMID: 31488359 DOI: 10.1016/j.ijheh.2019.08.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/12/2019] [Accepted: 08/15/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Millions of people carry water home from off-plot sources each day and lack improved sanitation. Research on the health outcomes associated with water fetching is limited, and with usage of improved sanitation is inconclusive. OBJECTIVES To analyse the association of water fetching, unimproved water supplies, and usage of improved sanitation facilities with indicators of women's and children's health. METHODS 49 Multiple Indicator Cluster Surveys from 41 countries were merged, creating a data set of 2,740,855 people from 539,915 households. Multilevel, multivariable analyses were conducted, using logistic regression for binary outcomes, negative binomial regression for count data and ordinary linear regression for linear data. We adjusted for confounding factors and accounted for clustering at survey, cluster and household level. RESULTS Compared to households in which no-one collects water, water fetching by any household member is associated with reduced odds of a woman giving birth in a health care facility (OR 0.88 to 0.90). Adults collecting water is associated with increased relative risk of childhood death (RR 1.04 to 1.05), children collecting water is associated with increased odds of diarrheal disease (OR 1.10 to 1.13) and women or girls collecting water is associated with reduced uptake of antenatal care (β-0.04 to -0.06) and increased odds of leaving a child under five alone for one or more hours, one or more days per week (OR 1.07 to 1.16). Unimproved water supply is associated with childhood diarhhoea (OR 1.05), but not child deaths, or growth scores. When the percentage of people using improved sanitation is more than 80% an association with reduced childhood death and stunting was observed, and when more than 60%, usage of improved sanitation was associated with reduction of diarhhoea and acute undernutrition. CONCLUSION Fetching water is associated with poorer maternal and child health outcomes, depending on who collects water. The percentage of people using improved sanitation seems to be more important than type of toilet facility, and must be high to observe an association with reduced child deaths and diarhhoea. Water access on premises, and near universal usage of improved sanitation, is associated with improvements to maternal and child health.
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Affiliation(s)
- Jo-Anne L Geere
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, Norfolk, United Kingdom
| | - Paul R Hunter
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, Norfolk, United Kingdom; Department of Environmental Health, Tshwane University of Technology, Pretoria, South Africa.
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282
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Peletz R, Kisiangani J, Ronoh P, Cock-Esteb A, Chase C, Khush R, Luoto J. Assessing the Demand for Plastic Latrine Slabs in Rural Kenya. Am J Trop Med Hyg 2019; 101:555-565. [PMID: 31392946 PMCID: PMC6726948 DOI: 10.4269/ajtmh.18-0888] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 06/09/2019] [Indexed: 12/19/2022] Open
Abstract
Improving access to safe and affordable sanitation facilities is a global health priority that is essential for meeting the United Nation's Sustainable Development Goals. To promote the use of improved sanitation in rural and low-income settings, plastic latrine slabs provide a simple option for upgrading traditional pit latrines. The International Finance Corporation/World Bank Selling Sanitation program estimated that plastic slabs would have a 34% annual growth, with a market size of US$2.53 million in Kenya by 2017. In this study, we examined the commercial viability of these plastic latrine slabs in rural Kenya by evaluating a financing and distribution model intervention, documenting household slab sales to date, and assessing consumer exposure and perceptions. We also determined household willingness to pay through a real-money auction with 322 households. We found that no households in our study area had purchased the plastic slabs. The primary barriers to slab sales were limited marketing activities and low demand compared with the sales price: households were willing to pay an average of US$5 compared with a market price of US$16. Therefore, current household demand for the plastic latrine slabs in rural Kenya is too low to support commercial distribution. Further efforts are required to align the price of plastic latrine slabs with consumer demand in this setting, such as additional demand creation, product financing, and public sector investment.
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Affiliation(s)
| | | | | | | | | | | | - Jill Luoto
- Rand Corporation, Santa Monica, California
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283
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Cumming O, Arnold BF, Ban R, Clasen T, Esteves Mills J, Freeman MC, Gordon B, Guiteras R, Howard G, Hunter PR, Johnston RB, Pickering AJ, Prendergast AJ, Prüss-Ustün A, Rosenboom JW, Spears D, Sundberg S, Wolf J, Null C, Luby SP, Humphrey JH, Colford JM. The implications of three major new trials for the effect of water, sanitation and hygiene on childhood diarrhea and stunting: a consensus statement. BMC Med 2019; 17:173. [PMID: 31462230 PMCID: PMC6712663 DOI: 10.1186/s12916-019-1410-x] [Citation(s) in RCA: 122] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 08/15/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Three large new trials of unprecedented scale and cost, which included novel factorial designs, have found no effect of basic water, sanitation and hygiene (WASH) interventions on childhood stunting, and only mixed effects on childhood diarrhea. Arriving at the inception of the United Nations' Sustainable Development Goals, and the bold new target of safely managed water, sanitation and hygiene for all by 2030, these results warrant the attention of researchers, policy-makers and practitioners. MAIN BODY Here we report the conclusions of an expert meeting convened by the World Health Organization and the Bill and Melinda Gates Foundation to discuss these findings, and present five key consensus messages as a basis for wider discussion and debate in the WASH and nutrition sectors. We judge these trials to have high internal validity, constituting good evidence that these specific interventions had no effect on childhood linear growth, and mixed effects on childhood diarrhea. These results suggest that, in settings such as these, more comprehensive or ambitious WASH interventions may be needed to achieve a major impact on child health. CONCLUSION These results are important because such basic interventions are often deployed in low-income rural settings with the expectation of improving child health, although this is rarely the sole justification. Our view is that these three new trials do not show that WASH in general cannot influence child linear growth, but they do demonstrate that these specific interventions had no influence in settings where stunting remains an important public health challenge. We support a call for transformative WASH, in so much as it encapsulates the guiding principle that - in any context - a comprehensive package of WASH interventions is needed that is tailored to address the local exposure landscape and enteric disease burden.
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Affiliation(s)
- Oliver Cumming
- Department of Disease Control, Faculty of Infectious Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK.
| | - Benjamin F Arnold
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, CA, USA
| | - Radu Ban
- Bill and Melinda Gates Foundation, Seattle, WA, USA
| | - Thomas Clasen
- Department of Environmental Health, Rollins School of Public Health, Emory University, NE Atlanta, GA, USA
| | - Joanna Esteves Mills
- Department of Disease Control, Faculty of Infectious Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK
| | - Matthew C Freeman
- Department of Environmental Health, Rollins School of Public Health, Emory University, NE Atlanta, GA, USA
| | - Bruce Gordon
- Department of Public Health, World Health Organization, Geneva, Switzerland
| | - Raymond Guiteras
- Department of Agricultural and Resource Economics, North Carolina State University, Raleigh, NC, USA
| | - Guy Howard
- Department of Civil Engineering, University of Bristol, Queens Building, Bristol, UK
| | - Paul R Hunter
- The Norwich Medical School, University of East Anglia, Norwich, UK
| | - Richard B Johnston
- Department of Public Health, World Health Organization, Geneva, Switzerland
| | - Amy J Pickering
- Department of Civil and Environmental Engineering, Tufts University, Medford, MA, USA
| | | | | | | | - Dean Spears
- Department of Economics, The University of Texas at Austin, Austin, TX, USA
| | | | - Jennyfer Wolf
- Department of Public Health, World Health Organization, Geneva, Switzerland
| | - Clair Null
- Center for International Policy Research and Evaluation, Mathematica Policy Research, Washington, DC, USA
| | - Stephen P Luby
- Department of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - Jean H Humphrey
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - John M Colford
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, CA, USA
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284
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Developing a Contextually Appropriate Integrated Hygiene Intervention to Achieve Sustained Reductions in Diarrheal Diseases. SUSTAINABILITY 2019. [DOI: 10.3390/su11174656] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Diarrheal disease in under-five children remains high in Sub-Saharan Africa; primarily attributed to environmental pathogen exposure through poorly managed water, sanitation, and hygiene (WASH) pathways, including foods. This formative study in rural Malawi used a theoretical base to determine the personal, social, environmental, and psychosocial factors that are to be considered in the development of an integrated intervention for WASH and food hygiene. Using a mixed methods approach, a stakeholder analysis was followed by data collection pertaining to 1079 children between the ages of four to 90 weeks: observations (n = 79); assessment of risks, attitudes, norms and self-regulation (RANAS) model (n = 323); structured questionnaires (n = 1000); focus group discussions (n = 9); and, in-depth interviews (n = 9) (PACTR201703002084166). We identified four thematic areas for the diarrheal disease intervention: hand washing with soap; food hygiene; feces management (human and animal); and, water management. The contextual issues included: the high level of knowledge on good hygiene practices not reflected in observed habits; inclusion of all family members incorporating primary caregivers (female) and financial controllers (male); and, endemic poverty as a significant barrier to hygiene infrastructure and consumable availability. The psychosocial factors identified for intervention development included social norms, abilities, and self-regulation. The resulting eight-month context specific intervention to be evaluated is described.
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285
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Theory-driven formative research to inform the design of a national sanitation campaign in Tanzania. PLoS One 2019; 14:e0221445. [PMID: 31442255 PMCID: PMC6707585 DOI: 10.1371/journal.pone.0221445] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 08/06/2019] [Indexed: 02/07/2023] Open
Abstract
Introduction There are gaps in global understanding about how to design and implement interventions to improve sanitation. This formative study provided insights for the subsequent redesign of a government-led national sanitation campaign targeting rural populations in Tanzania. Methods The Behaviour Centred Design approach was used to investigate the determinants of toilet building, improvement and use. Varied, novel, and interactive research tools were employed in fifty-five households in two regions of rural Tanzania. Results were analysed to articulate a Theory of Change, which then informed intervention design. Results Participants valued hard work, enterprise, and improving their lives over many years. They wanted better toilets but felt no urgency to act quickly. A common emotional motivator for improving toilets was to protect children from disease (Nurture) but this was insufficient to drive rapid change. Disgust with traditional toilets meant they were built at a distance from the house: an ‘out of sight, out of mind’ attitude. Other powerful motives included the desire to improve living conditions (Create), and to become a modern Tanzanian (Status), albeit without ‘showing off’. Construction costs and water scarcity were the main stated barriers. Receiving information about realistic costs, support accessing materials, and visiting better latrines elsewhere were commonly reported reasons for improving latrines. Conclusions The resulting Theory of Change recommended that the intervention should surprise people with a novel conversation about toilets, promote toilets as a means of conferring status, and introduce a perceived urgency to ‘act now’. It should suggest that modest improvements would lead to a better life. Feelings of disgust and fear with poor quality toilets should be amplified, and barriers lessened through promoting transformational toilet improvements, and improving access to modern toilet products. This research provided considerable insight into sanitation behaviours in rural Tanzania, which informed creative intervention design.
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286
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Humphrey JH. Reducing the user burden in WASH interventions for low-income countries. LANCET GLOBAL HEALTH 2019; 7:e1158-e1159. [PMID: 31401991 DOI: 10.1016/s2214-109x(19)30340-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 07/22/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Jean H Humphrey
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe.
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287
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Huybregts L, Le Port A, Becquey E, Zongrone A, Barba FM, Rawat R, Leroy JL, Ruel MT. Impact on child acute malnutrition of integrating small-quantity lipid-based nutrient supplements into community-level screening for acute malnutrition: A cluster-randomized controlled trial in Mali. PLoS Med 2019; 16:e1002892. [PMID: 31454356 PMCID: PMC6711497 DOI: 10.1371/journal.pmed.1002892] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 07/23/2019] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Community-based management of acute malnutrition (CMAM) has been widely adopted to treat childhood acute malnutrition (AM), but its effectiveness in program settings is often limited by implementation constraints, low screening coverage, and poor treatment uptake and adherence. This study addresses the problem of low screening coverage by testing the impact of distributing small-quantity lipid-based nutrient supplements (SQ-LNSs) at monthly screenings held by community health volunteers (CHVs). Screening sessions included behavior change communication (BCC) on nutrition, health, and hygiene practices (both study arms) and SQ-LNSs (one study arm). Impact was assessed on AM screening and treatment coverage and on AM incidence and prevalence. METHODS AND FINDINGS A two-arm cluster-randomized controlled trial in 48 health center catchment areas in the Bla and San health districts in Mali was conducted from February 2015 to April 2017. In both arms, CHVs led monthly AM screenings in children 6-23 months of age and provided BCC to caregivers. The intervention arm also received a monthly supply of SQ-LNSs to stimulate caregivers' participation and supplement children's diet. We used two study designs: i) a repeated cross-sectional study (n = approximately 2,300) with baseline and endline surveys to examine impacts on AM screening and treatment coverage and prevalence (primary study outcomes) and ii) a longitudinal study of children enrolled at 6 months of age (n = 1,132) and followed monthly for 18 months to assess impact on AM screening and treatment coverage and incidence (primary study outcomes). All analyses were done by intent to treat. The intervention significantly increased AM screening coverage (cross-sectional study: +40 percentage points [pp], 95% confidence interval [CI]: 32, 49, p < 0.001; longitudinal study: +28 pp, 95% CI: 23, 33, p < 0.001). No impact on treatment coverage or AM prevalence was found. Children in the intervention arm, however, were 29% (95% CI: 8, 46; p = 0.017) less likely to develop a first AM episode (incidence) and, compared to children in comparison arm, their overall risk of AM (longitudinal prevalence) was 30% (95% CI: 12, 44; p = 0.002) lower. The intervention lowered CMAM enrollment by 10 pp (95% CI: 1.9, 18; p = 0.016), an unintended negative impact likely due to CHVs handing out preventive SQ-LNSs to caregivers of AM children instead of referring them to the CMAM program. Study limitations were i) the referral of AM cases by our research team (for ethical reasons) during monthly measurements in the longitudinal study might have interfered with usual CMAM activities and ii) the outcomes presented by child age also reflect seasonal variations because of the closed cohort design. CONCLUSIONS Incorporating SQ-LNSs into monthly community-level AM screenings and BCC sessions was highly effective at improving screening coverage and reducing AM incidence, but it did not improve AM prevalence or treatment coverage. Future evaluation and implementation research on CMAM should carefully assess and tackle the remaining barriers that prevent AM cases from being correctly diagnosed, referred, and adequately treated. TRIAL REGISTRATION ClinicalTrials.gov NCT02323815.
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Affiliation(s)
- Lieven Huybregts
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, DC, United States of America
| | - Agnes Le Port
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, DC, United States of America
| | - Elodie Becquey
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, DC, United States of America
| | - Amanda Zongrone
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, DC, United States of America
| | - Francisco M. Barba
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, DC, United States of America
| | - Rahul Rawat
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, DC, United States of America
| | - Jef L. Leroy
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, DC, United States of America
| | - Marie T. Ruel
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, DC, United States of America
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288
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Di Baldassarre G, Sivapalan M, Rusca M, Cudennec C, Garcia M, Kreibich H, Konar M, Mondino E, Mård J, Pande S, Sanderson MR, Tian F, Viglione A, Wei J, Wei Y, Yu DJ, Srinivasan V, Blöschl G. Sociohydrology: Scientific Challenges in Addressing the Sustainable Development Goals. WATER RESOURCES RESEARCH 2019; 55:6327-6355. [PMID: 32742038 PMCID: PMC7388443 DOI: 10.1029/2018wr023901] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 06/20/2019] [Accepted: 07/02/2019] [Indexed: 05/27/2023]
Abstract
The Sustainable Development Goals (SDGs) of the United Nations Agenda 2030 represent an ambitious blueprint to reduce inequalities globally and achieve a sustainable future for all mankind. Meeting the SDGs for water requires an integrated approach to managing and allocating water resources, by involving all actors and stakeholders, and considering how water resources link different sectors of society. To date, water management practice is dominated by technocratic, scenario-based approaches that may work well in the short term but can result in unintended consequences in the long term due to limited accounting of dynamic feedbacks between the natural, technical, and social dimensions of human-water systems. The discipline of sociohydrology has an important role to play in informing policy by developing a generalizable understanding of phenomena that arise from interactions between water and human systems. To explain these phenomena, sociohydrology must address several scientific challenges to strengthen the field and broaden its scope. These include engagement with social scientists to accommodate social heterogeneity, power relations, trust, cultural beliefs, and cognitive biases, which strongly influence the way in which people alter, and adapt to, changing hydrological regimes. It also requires development of new methods to formulate and test alternative hypotheses for the explanation of emergent phenomena generated by feedbacks between water and society. Advancing sociohydrology in these ways therefore represents a major contribution toward meeting the targets set by the SDGs, the societal grand challenge of our time.
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Affiliation(s)
- Giuliano Di Baldassarre
- Department of Earth SciencesUppsala UniversityUppsalaSweden
- Centre of Natural Hazards and Disaster Science, CNDSUppsalaSweden
| | - Murugesu Sivapalan
- Department of Civil and Environmental EngineeringUniversity of Illinois at Urbana‐ChampaignUrbanaILUSA
- Department of Geography and Geographic Information ScienceUniversity of Illinois at Urbana‐ChampaignUrbanaILUSA
| | - Maria Rusca
- Department of Earth SciencesUppsala UniversityUppsalaSweden
- Centre of Natural Hazards and Disaster Science, CNDSUppsalaSweden
| | | | - Margaret Garcia
- School of Sustainable Engineering and the Built EnvironmentArizona State UniversityTempeAZUSA
| | - Heidi Kreibich
- GFZ German Research Centre for GeosciencesPotsdamGermany
| | - Megan Konar
- Department of Civil and Environmental EngineeringUniversity of Illinois at Urbana‐ChampaignUrbanaILUSA
| | - Elena Mondino
- Department of Earth SciencesUppsala UniversityUppsalaSweden
- Centre of Natural Hazards and Disaster Science, CNDSUppsalaSweden
| | - Johanna Mård
- Department of Earth SciencesUppsala UniversityUppsalaSweden
- Centre of Natural Hazards and Disaster Science, CNDSUppsalaSweden
| | - Saket Pande
- Faculty of Civil Engineering and GeosciencesDelft University of TechnologyDelftThe Netherlands
| | | | - Fuqiang Tian
- Department of Hydraulic EngineeringTsinghua UniversityBeijingChina
| | - Alberto Viglione
- Institute of Hydraulic Engineering and Water Resources ManagementVienna University of TechnologyAustria
- Department of EnvironmentLand and Infrastructure Engineering (DIATI), Politecnico di TorinoTurinItaly
| | - Jing Wei
- Department of Hydraulic EngineeringTsinghua UniversityBeijingChina
| | - Yongping Wei
- School of Earth and Environmental Sciences, University of QueenslandBrisbaneQueenslandAustralia
| | - David J. Yu
- Lyles School of Civil EngineeringPurdue UniversityWest LafayetteINUSA
- Department of Political SciencePurdue UniversityWest LafayetteINUSA
| | - Veena Srinivasan
- Ashoka Trust for Research in Ecology and the EnvironmentBangaloreIndia
| | - Günter Blöschl
- Institute of Hydraulic Engineering and Water Resources ManagementVienna University of TechnologyAustria
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Kothari MT, Coile A, Huestis A, Pullum T, Garrett D, Engmann C. Exploring associations between water, sanitation, and anemia through 47 nationally representative demographic and health surveys. Ann N Y Acad Sci 2019; 1450:249-267. [PMID: 31232465 PMCID: PMC6771505 DOI: 10.1111/nyas.14109] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 03/25/2019] [Accepted: 04/03/2019] [Indexed: 12/26/2022]
Abstract
Globally, no countries are on track to achieve the adopted global nutrition targets set for anemia in 2025. Given the linkages between water, sanitation, and hygiene (WASH) and nutrition, this secondary data analysis explores potential associations with anemia. Forty-seven demographic and health surveys were used to explore the association between unimproved water and sanitation and anemia in women and children with adjusted odds ratios (ORs) calculated by country and cumulatively. In over 60% of countries, children with off-premises water access had significantly increased odds of anemia. In over a quarter of countries, children exposed to surface water had higher odds of anemia. In Burundi, children were 1.65 times more likely to be anemic when reported to be living in households using surface water. However, in India, a protective effect was noted (adjusted OR: 0.70, P < 0.001) for surface water. In 60% and 65% of countries, women and children exposed to an open sanitation facility had higher odds of being anemic, respectively. There is evidence of an association between selected water and sanitation indicators and anemia. Promoting policies, practices and research that strengthen access to improved WASH should be considered for reducing anemia prevalence alongside standard nutrition interventions.
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Affiliation(s)
- Monica T. Kothari
- Maternal, Newborn, Child Health and Nutrition (MNCHN), PATHWashingtonDC
| | - Amanda Coile
- Maternal, Newborn, Child Health and Nutrition (MNCHN), PATHWashingtonDC
| | - Arja Huestis
- Maternal, Newborn, Child Health and Nutrition (MNCHN), PATHWashingtonDC
| | - Tom Pullum
- ICF, Demographic Health SurveysRockvilleMaryland
| | - Dean Garrett
- Maternal, Newborn, Child Health and Nutrition (MNCHN), PATHWashingtonDC
| | - Cyril Engmann
- Maternal, Newborn, Child Health and Nutrition (MNCHN), PATHWashingtonDC
- Departments of Pediatrics and Global Health, Schools of Medicine and Public HealthUniversity of WashingtonSeattleWashington
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290
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Prendergast AJ, Gharpure R, Mor S, Viney M, Dube K, Lello J, Berger C, Siwila J, Joyeux M, Hodobo T, Hurt L, Brown T, Hoto P, Tavengwa N, Mutasa K, Craddock S, Chasekwa B, Robertson RC, Evans C, Chidhanguro D, Mutasa B, Majo F, Smith LE, Hirai M, Ntozini R, Humphrey JH, Berendes D. Putting the "A" into WaSH: a call for integrated management of water, animals, sanitation, and hygiene. Lancet Planet Health 2019; 3:e336-e337. [PMID: 31439312 PMCID: PMC11287451 DOI: 10.1016/s2542-5196(19)30129-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 07/25/2019] [Indexed: 06/10/2023]
Affiliation(s)
- Andrew J Prendergast
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe; Blizard Institute, Queen Mary University of London, London E1 2AT, UK.
| | - Radhika Gharpure
- Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Siobhan Mor
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK; University of Liverpool, Liverpool, UK; International Livestock Research Institute, Addis Ababa, Ethiopia
| | - Mark Viney
- Institute of Integrative Biology, University of Liverpool, Liverpool, UK; University of Liverpool, Liverpool, UK
| | - Kululeko Dube
- Food and Agriculture Organization of the United Nations, Harare, Zimbabwe
| | - Joanne Lello
- College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Cedric Berger
- College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Joyce Siwila
- School of Veterinary Medicine, University of Zambia, Lusaka, Zambia
| | | | | | - Lisa Hurt
- College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Tim Brown
- School of Geography, Queen Mary University of London, London E1 2AT, UK
| | - Patience Hoto
- Food and Agriculture Organization of the United Nations, Harare, Zimbabwe
| | - Naume Tavengwa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Kuda Mutasa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Susan Craddock
- Department of Gender, Women, and Sexuality Studies, University of Minnesota, Minneapolis, MN, USA
| | - Bernard Chasekwa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | | | - Ceri Evans
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe; Blizard Institute, Queen Mary University of London, London E1 2AT, UK
| | | | - Batsirai Mutasa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Florence Majo
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Laura E Smith
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe; Department of Epidemiology and Environmental Health, University at Buffalo, Buffalo, NY, USA
| | | | - Robert Ntozini
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Jean H Humphrey
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David Berendes
- Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
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291
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Bauza V, Madadi V, Ocharo RM, Nguyen TH, Guest JS. Microbial Source Tracking Using 16S rRNA Amplicon Sequencing Identifies Evidence of Widespread Contamination from Young Children's Feces in an Urban Slum of Nairobi, Kenya. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2019; 53:8271-8281. [PMID: 31268313 DOI: 10.1021/acs.est.8b06583] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Child exposure to fecal contamination remains common in low- and middle-income countries after sanitation interventions. Unsafe disposal of children's feces may contribute to this continued exposure, but its relative importance to domestic fecal contamination is not well understood. To address this gap, we interviewed and collected environmental samples (drinking water, caregiver hands, child hands, surfaces, soil, open drainage ditches, standing water, streams) from 40 households in Kibera, an urban slum in Nairobi, Kenya. To track young children's feces (<3 years old) separately from other human-associated fecal sources, we validated distance-based and Bayesian (SourceTracker) microbial source tracking methods using amplicon-based sequencing of the 16S rRNA gene. Contamination by young children's feces could be identified and distinguished separately from older child/adult feces with high sensitivity and specificity in water and soil. Among environmental samples, young children's feces were almost always identified as the dominant source of human fecal contamination inside households (hands, surfaces) whereas older children/adult feces were often identified as the dominant source outside households (standing water, streams, soil). Markers for young children's feces were also detected in standing water and streams, and markers for both fecal sources were equally likely to be dominant in open ditches. These results establish motivation for sanitation interventions that directly address child feces management.
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Affiliation(s)
- Valerie Bauza
- Department of Civil and Environmental Engineering , University of Illinois at Urbana-Champaign , Urbana , Illinois 61801 , United States
| | - Vincent Madadi
- Department of Chemistry , University of Nairobi , Nairobi , 00100 , Kenya
| | - Robinson M Ocharo
- Department of Sociology and Social Work , University of Nairobi , Nairobi , 00100 , Kenya
| | - Thanh H Nguyen
- Department of Civil and Environmental Engineering , University of Illinois at Urbana-Champaign , Urbana , Illinois 61801 , United States
| | - Jeremy S Guest
- Department of Civil and Environmental Engineering , University of Illinois at Urbana-Champaign , Urbana , Illinois 61801 , United States
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292
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Abstract
The Engineer’s role in addressing global poverty challenges has often been confined to village and community-scale interventions, product design and development, or large-scale infrastructure design and construction. Yet despite fifty years of these approaches, over half the world’s population still lives on less than $5.50 a day, the global burden of disease in low-income countries is overwhelmingly attributable to environmental health contaminants, and climate change is already negatively affecting people in developing countries. The conventional community, product or infrastructure focuses of development engineering is insufficient to address these global drivers that perpetuate poverty. The emerging field of Global Engineering can work to identify and address these structural issues. Global Engineering should be concerned with the unequal and unjust distribution of access to basic services such as water, sanitation, energy, food, transportation and shelter, and place an emphasis on identifying the drivers, determinants and solutions favoring equitable access. Technology development and validation, data collection and impact evaluation can contribute to evidence-based influence on policies and practice. Global Engineering envisions a world in which everyone has safe water, sanitation, energy, food, shelter and infrastructure, and can live in health, dignity, and prosperity.
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293
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Park JJH, Fang ML, Harari O, Dron L, Siden EG, Majzoub R, Jeziorska V, Thorlund K, Mills EJ, Bhutta ZA. Association of Early Interventions With Birth Outcomes and Child Linear Growth in Low-Income and Middle-Income Countries: Bayesian Network Meta-analyses of Randomized Clinical Trials. JAMA Netw Open 2019; 2:e197871. [PMID: 31348509 PMCID: PMC6661710 DOI: 10.1001/jamanetworkopen.2019.7871] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 05/29/2019] [Indexed: 12/24/2022] Open
Abstract
Importance The first 1000 days of life represent a critical window for child development. Pregnancy, exclusive breastfeeding (EBF) period (0-6 months), and complementary feeding (CF) period (6-24 months) have different growth requirements, so separate considerations for intervention strategies are needed. No synthesis to date has attempted to quantify the associations of interventions under multiple domains of micronutrient and balanced energy protein and food supplements, deworming, maternal education, water sanitation, and hygiene across these 3 life periods with birth and growth outcomes. Objective To determine the magnitude of association of interventions with birth and growth outcomes based on randomized clinical trials (RCTs) conducted in low-income and middle-income countries (LMICs) using Bayesian network meta-analyses. Data Sources MEDLINE, Embase, and Cochrane databases were searched from their inception up to August 14, 2018. Study Selection Included were LMIC-based RCTs of interventions provided to pregnant women, infants (0-6 months), and children (6-24 months). Data Extraction and Synthesis Two independent reviewers used a standardized data extraction and quality assessment form. Random-effects network meta-analyses were performed for each life period. Effect sizes are reported as odds ratios (ORs) and mean differences (MeanDiffs) for dichotomous and continuous outcomes, with 95% credible intervals (CrIs). This study calculated probabilities of interventions being superior to standard of care by at least a minimal clinically important difference. Main Outcomes and Measures The study compared ORs on preterm birth and MeanDiffs on birth weight for pregnancy, length for age (LAZ) for EBF, and height for age (HAZ) for CF. Results Among 302 061 participants in 169 randomized clinical trials, the network meta-analyses found several nutritional interventions that demonstrated greater association with improved birth and growth outcomes compared with standard of care. For instance, compared with standard of care, maternal supplements of multiple micronutrients showed reduced odds for preterm birth (OR, 0.54; 95% CrI, 0.27-0.97) and improved mean birth weight (MeanDiff, 0.08 kg; 95% CrI, 0.00-0.17 kg) but not LAZ during EBF (MeanDiff, -0.02; 95% CrI, -0.18 to 0.14). Supplementing infants and children with multiple micronutrients showed improved LAZ (MeanDiff, 0.20; 95% CrI, 0.03-0.35) and HAZ (MeanDiff, 0.14; 95% CrI, 0.02-0.25). The study found that pregnancy interventions generally had higher probabilities of a minimal clinically importance difference than the interventions for the EBF or CF in the first 1000 days of life. Conclusions and Relevance These analyses highlight the importance of intervening early for child development, during pregnancy if possible. Results of this study suggest that there is a need to combine interventions from multiple domains and test for their effectiveness as a package.
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Affiliation(s)
- Jay J. H. Park
- Experimental Medicine, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- MTEK Sciences, Vancouver, British Columbia, Canada
| | - Mei Lan Fang
- MTEK Sciences, Vancouver, British Columbia, Canada
- School of Nursing and Health Sciences, University of Dundee, Dundee, United Kingdom
| | - Ofir Harari
- MTEK Sciences, Vancouver, British Columbia, Canada
| | - Louis Dron
- MTEK Sciences, Vancouver, British Columbia, Canada
| | | | - Reham Majzoub
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Kristian Thorlund
- MTEK Sciences, Vancouver, British Columbia, Canada
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Edward J. Mills
- MTEK Sciences, Vancouver, British Columbia, Canada
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Zulfiqar A. Bhutta
- Center of Excellence in Women and Child Health, The Aga Khan University, Karachi, Pakistan
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
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294
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Wichaidit W, Biswas S, Begum F, Yeasmin F, Nizame FA, Najnin N, Leontsini E, Winch PJ, Unicomb L, Luby SP, Ram PK. Effectiveness of a large‐scale handwashing promotion intervention on handwashing behaviour in Dhaka, Bangladesh. Trop Med Int Health 2019; 24:972-986. [DOI: 10.1111/tmi.13277] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Wit Wichaidit
- Department of Epidemiology and Environmental Health State University of New York Buffalo NY USA
| | - Shwapon Biswas
- Johns Hopkins University Baltimore MD USA
- International Centre for Diarrhoeal Disease Research Dhaka Bangladesh
| | - Farzana Begum
- International Centre for Diarrhoeal Disease Research Dhaka Bangladesh
| | - Farzana Yeasmin
- International Centre for Diarrhoeal Disease Research Dhaka Bangladesh
| | | | - Nusrat Najnin
- Department of Epidemiology and Preventive Medicine Monash University Melbourne Australia
| | - Elli Leontsini
- Johns Hopkins Bloomberg School of Public Health Baltimore MD USA
| | | | - Leanne Unicomb
- International Centre for Diarrhoeal Disease Research Dhaka Bangladesh
| | | | - Pavani K. Ram
- Department of Epidemiology and Environmental Health State University of New York Buffalo NY USA
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295
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Owino VO, Murphy‐Alford AJ, Kerac M, Bahwere P, Friis H, Berkley JA, Jackson AA. Measuring growth and medium- and longer-term outcomes in malnourished children. MATERNAL & CHILD NUTRITION 2019; 15:e12790. [PMID: 30690903 PMCID: PMC7199054 DOI: 10.1111/mcn.12790] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 11/13/2018] [Accepted: 12/12/2018] [Indexed: 12/26/2022]
Abstract
Severe and moderate acute malnutrition are among the leading causes of mortality among children in low- and middle-income countries. There is strong evidence that growth assessed anthropometrically from conception to 2 years of age marks later risk of ill health. This is central to the concept of the developmental origins of adult disease and is presumed to be related to modification of developmental processes during critical "window(s)" of vulnerability. Interventions to treat acute malnutrition have resulted in dramatic increase in the number of affected children surviving. Ensuring that these children thrive to fulfil their full physical and cognitive potential is a new challenge. Integral to this challenge is the need to be able to measure how earlier insults relate to the ability to survive and thrive to productive adulthood. Despite its obvious value, routine anthropometry does not adequately indicate how earlier adverse exposures affect more refined aspects of growth. Anthropometry is inadequate for predicting how disruption of healthy growth might modulate risk of disease or any subsequent interventions that correct this risk. A clear characterisation of healthy child growth is needed for determining which component best predicts later outcomes. The extent to which postnatal acute malnutrition is a consequence of maternal factors acting preconception or in utero and their relationship to postnatal health and long-term risk of non-communicable diseases is not clear. Body-composition measurement has significant untapped potential allowing us to translate and better understand the relationship between early insults and interventions on early growth in the short-term and long-term health outcomes.
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Affiliation(s)
- Victor O. Owino
- Nutritional and Health Related Environmental Studies Section, Division of HealthInternational Atomic Energy AgencyViennaAustria
| | - Alexia J. Murphy‐Alford
- Nutritional and Health Related Environmental Studies Section, Division of HealthInternational Atomic Energy AgencyViennaAustria
| | - Marko Kerac
- Department of Population HealthLondon School of Hygiene and Tropical MedicineLondonUK
| | - Paluku Bahwere
- Valid InternationalOxfordUK
- Research Centre in Epidemiology, Biostatistics and Clinical Research, School of Public HealthFree University of BrusselsBrusselsBelgium
| | - Henrik Friis
- Department of Nutrition, Exercise and SportsUniversity of CopenhagenFrederiksbergDenmark
| | - James A. Berkley
- DirectorThe Childhood Acute Illness & Nutrition (CHAIN) NetworkNairobiKenya
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global HealthUniversity of OxfordOxfordUK
| | - Alan A. Jackson
- Human Nutrition, International Malnutrition Task ForceSouthampton General HospitalSouthamptonUK
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296
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Delea MG, Snyder JS, Belew M, Caruso BA, Garn JV, Sclar GD, Woreta M, Zewudie K, Gebremariam A, Freeman MC. Design of a parallel cluster-randomized trial assessing the impact of a demand-side sanitation and hygiene intervention on sustained behavior change and mental well-being in rural and peri-urban Amhara, Ethiopia: Andilaye study protocol. BMC Public Health 2019; 19:801. [PMID: 31226957 PMCID: PMC6588862 DOI: 10.1186/s12889-019-7040-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 05/23/2019] [Indexed: 12/25/2022] Open
Abstract
Background Unimproved water, sanitation, and hygiene (WASH) behaviors are key drivers of infectious disease transmission and influencers of mental well-being. While WASH is seen as a critical enabler of health, important knowledge gaps related to the content and delivery of effective, holistic WASH programming exist. Corresponding impacts of WASH on mental well-being are also underexplored. There is a need for more robust implementation research that yields information regarding whether and how community-based, demand-side interventions facilitate progressive and sustained adoption of improved sanitation and hygiene behaviors and downstream health impacts. The purpose of this protocol is to detail the rationale and design of a cluster-randomized trial evaluating the impact of a demand-side sanitation and hygiene intervention on sustained behavior change and mental well-being in rural and peri-urban Amhara, Ethiopia. Methods Together with partners, we developed a theoretically-informed, evidence-based behavioral intervention called Andilaye. We randomly selected and assigned 50 sub-districts (kebeles) from three purposively selected districts (woredas); half to receive the Andilaye intervention, and half the standard of care sanitation and hygiene programming (i.e., community-led total sanitation and hygiene [CLTSH]). During baseline, midline, and endline, we will collect data on an array of behavioral factors, potential moderators (e.g., water and sanitation insecurity, collective efficacy), and our primary study outcomes: sanitation and hygiene behaviors and mental well-being. We will perform a process evaluation to assess intervention fidelity and related attributes. Discussion While CLTSH has fostered sanitation and hygiene improvements in Ethiopia, evidence of behavioral slippage, or regression to unimproved practices in communities previously declared open defecation free exists. Other limitations of CLTSH, such as its focus on disgust, poor triggering, and over-saturation of Health Extension Workers have been documented. We employed rigorous formative research and practically applied social and behavioral theory to develop Andilaye, a scalable intervention designed to address these issues and complement existing service delivery within Ethiopia’s Health Extension Program. Evidence from this trial may help address knowledge gaps related to scalable alternatives to CLTSH and inform sanitation and hygiene programming and policy in Ethiopia and beyond. Trial registration This trial was registered with clinicaltrials.gov (NCT03075436) on March 9, 2017. Electronic supplementary material The online version of this article (10.1186/s12889-019-7040-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Maryann G Delea
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jedidiah S Snyder
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Bethany A Caruso
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Joshua V Garn
- School of Community Health Sciences, University of Nevada, Reno, NV, USA
| | - Gloria D Sclar
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Mulat Woreta
- Emory Ethiopia, Bahir Dar and Addis Ababa, Ethiopia
| | | | | | - Matthew C Freeman
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
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297
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Using Trials of Improved Practices to identify practices to address the double burden of malnutrition among Rwandan children. Public Health Nutr 2019; 22:3175-3186. [PMID: 31221234 DOI: 10.1017/s1368980019001551] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Low- and middle-income countries (LMIC) are increasingly experiencing the double burden of malnutrition. Studies to identify 'double-duty' actions that address both undernutrition and overweight in sub-Saharan Africa are needed. We aimed to identify acceptable behaviours to achieve more optimal feeding and physical activity practices among both under- and overweight children in Rwanda, a sub-Saharan LMIC with one of the largest recent increases in child overweight. DESIGN We used the Trials of Improved Practices (TIPs) method. During three household visits over 1·5 weeks, we used structured interviews and unstructured observations to collect data on infant and young child feeding practices and caregivers' experiences with testing recommended practices. SETTING An urban district and a rural district in Rwanda. PARTICIPANTS Caregivers with an under- or overweight child from 6 to 59 months of age (n 136). RESULTS We identified twenty-five specific recommended practices that caregivers of both under- and overweight children agreed to try. The most frequently recommended practices were related to dietary diversity, food quantity, and hygiene and food handling. The most commonly cited reason for trying a new practice was its benefits to the child's health and growth. Financial constraints and limited food availability were common barriers. Nearly all caregivers said they were willing to continue the practices and recommend them to others. CONCLUSIONS These practices show potential for addressing the double burden as part of a broader intervention. Still, further research is needed to determine whether caregivers can maintain the behaviours and their direct impact on both under- and overweight.
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298
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Chama M, Amadi BC, Chandwe K, Zyambo K, Besa E, Shaikh N, Ndao IM, Tarr PI, Storer C, Head R, Kelly P. Transcriptomic analysis of enteropathy in Zambian children with severe acute malnutrition. EBioMedicine 2019; 45:456-463. [PMID: 31229436 PMCID: PMC6642221 DOI: 10.1016/j.ebiom.2019.06.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/11/2019] [Accepted: 06/11/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Children with severe acute malnutrition (SAM), with or without diarrhoea, often have enteropathy, but there are few molecular data to guide development of new therapies. We set out to determine whether SAM enteropathy is characterised by specific transcriptional changes which might improve understanding or help identify new treatments. METHODS We collected intestinal biopsies from children with SAM and persistent diarrhoea. mRNA was extracted from biopsies, sequenced, and subjected to a progressive set of complementary analytical approaches: NOIseq, Gene Set Enrichment Analysis (GSEA), and correlation analysis of phenotypic data with gene expression. FINDINGS Transcriptomic profiles were generated for biopsy sets from 27 children of both sexes, under 2 years of age, of whom one-third were HIV-infected. NOIseq analysis, constructed from phenotypic group extremes, revealed 66 differentially expressed genes (DEGs) out of 21,386 mapped to the reference genome. These DEGs include genes for mucins and mucus integrity, antimicrobial defence, nutrient absorption, C-X-C chemokines, proteases and anti-proteases. Phenotype - expression correlation analysis identified 1221 genes related to villus height, including increased cell cycling gene expression in more severe enteropathy. Amino acid transporters and ZIP zinc transporters were specifically increased in severe enteropathy, but transcripts for xenobiotic metabolising enzymes were reduced. INTERPRETATION Transcriptomic analysis of this rare collection of intestinal biopsies identified multiple novel elements of pathology, including specific alterations in nutrient transporters. Changes in xenobiotic metabolism in the gut may alter drug disposition. Both NOIseq and GSEA identified gene clusters similar to those differentially expressed in pediatric Crohn's disease but to a much lesser degree than those identified in coeliac disease. FUND: Bill & Melinda Gates Foundation OPP1066118. The funding agency had no role in study design, data collection, data analysis, interpretation, or writing of the report.
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Affiliation(s)
- Mubanga Chama
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Beatrice C Amadi
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Kanta Chandwe
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Kanekwa Zyambo
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Ellen Besa
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Nurmohammad Shaikh
- Department of Pediatrics, Washington University School of Medicine, St Louis, MO, United States
| | - I Malick Ndao
- Department of Pediatrics, Washington University School of Medicine, St Louis, MO, United States
| | - Philip I Tarr
- Department of Pediatrics, Washington University School of Medicine, St Louis, MO, United States
| | - Chad Storer
- Department of Genetics, Washington University School of Medicine, St Louis, MO, United States
| | - Richard Head
- Department of Genetics, Washington University School of Medicine, St Louis, MO, United States
| | - Paul Kelly
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia; Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, 4 Newark Street, London, UK.
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299
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Chidziwisano K, Tilley E, Malolo R, Kumwenda S, Musaya J, Morse T. Risk Factors Associated with Feeding Children under 2 Years in Rural Malawi-A Formative Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E2146. [PMID: 31213008 PMCID: PMC6616994 DOI: 10.3390/ijerph16122146] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 05/27/2019] [Accepted: 05/30/2019] [Indexed: 12/16/2022]
Abstract
Diarrhoeal disease remains one of the leading causes of morbidity and mortality in the under-five population, particularly in low income settings such as sub-Saharan Africa. Despite significant progress in sanitation and water access, faecal-oral infections persist in these populations. Therefore, a better understanding of these transmission pathways, and how potential risk factors can be reduced within low income contexts is needed. This study, conducted in Southern Malawi from June to October 2017, used a mixed methods approach to collect data from household surveys (n = 323), checklists (n = 31), structured observations (n = 80), and microbiological food samples (n = 20). Results showed that food prepared for immediate consumption (primarily porridge for children) posed a low health risk. Poor hygiene practices increased the risk of contamination from shared family meals. Faecal and nosocomial bacteria were associated with poor hand hygiene and unhygienic eating conditions. Leftover food storage and inadequate pre-consumption heating increased the risk of contamination. Improvements in food hygiene and hand hygiene practices at critical points could reduce the risk of diarrhoeal disease for children under 2 years but must consider the contextual structural barriers to improved practice like access to handwashing facilities, soap, food and water storage.
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Affiliation(s)
- Kondwani Chidziwisano
- Centre for Water, Sanitation, Health and Appropriate Technology Development (WASHTED), Polytechnic, University of Malawi, Private Bag 303, Chichiri, Blantyre 3, Malawi.
- Department of Environmental Health, Polytechnic, University of Malawi, Private Bag 303, Chichiri, Blantyre 3, Malawi.
- Department of Civil and Environmental Engineering, University of Strathclyde, Level 5 James Weir Building, G1 1XQ, Glasgow, UK.
| | - Elizabeth Tilley
- Department of Environmental Health, Polytechnic, University of Malawi, Private Bag 303, Chichiri, Blantyre 3, Malawi.
- EAWAG: Swiss Federal Institute of Aquatic Science and Technology, 8600 Dübendorf, Switzerland.
| | - Rossanie Malolo
- Centre for Water, Sanitation, Health and Appropriate Technology Development (WASHTED), Polytechnic, University of Malawi, Private Bag 303, Chichiri, Blantyre 3, Malawi.
| | - Save Kumwenda
- Centre for Water, Sanitation, Health and Appropriate Technology Development (WASHTED), Polytechnic, University of Malawi, Private Bag 303, Chichiri, Blantyre 3, Malawi.
- Department of Environmental Health, Polytechnic, University of Malawi, Private Bag 303, Chichiri, Blantyre 3, Malawi.
| | - Janelisa Musaya
- Department of Pathology, College of Medicine, University of Malawi, P.O Box 360, Chichiri, Blantyre 3, Malawi.
| | - Tracy Morse
- Department of Civil and Environmental Engineering, University of Strathclyde, Level 5 James Weir Building, G1 1XQ, Glasgow, UK.
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Konyole SO, Omollo SA, Kinyuru JN, Skau JKH, Owuor BO, Estambale BB, Filteau SM, Michaelsen KF, Friis H, Roos N, Owino VO. Effect of locally produced complementary foods on fat-free mass, linear growth, and iron status among Kenyan infants: A randomized controlled trial. MATERNAL AND CHILD NUTRITION 2019; 15:e12836. [PMID: 31045329 DOI: 10.1111/mcn.12836] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 04/14/2019] [Accepted: 04/24/2019] [Indexed: 12/14/2022]
Abstract
The impact of quality complementary food products on infant growth and body composition has not been adequately investigated. This study evaluated the effect on fat-free mass (FFM) accrual, linear growth, and iron status of locally produced complementary food products comparing to a standard product. In a randomized, double-blind trial, 499 infants at 6 months received nine monthly rations of (a) WinFood Classic (WFC) comprising germinated amaranth (71%), maize (10.4%), small fish (3%), and edible termites (10%); (b) WinFood Lite (WFL) comprising germinated amaranth (82.5%), maize (10.2%), and multimicronutrient premix; or (c) fortified corn-soy blend plus (CSB+). Primary outcomes were changes in FFM, length, and plasma ferritin and transferrin receptors (TfR). FFM was determined using deuterium dilution. Analysis was by intention to treat, based on available cases. Compared with CSB+, there were no differences in change from 6 to 15 months in FFM for WFC 0.0 kg (95% CI [-0.30, 0.29]) and WFL 0.03 kg (95% CI [-0.25, 0.32]) and length change for WFC -0.3 cm (95% CI [-0.9, 0.4]) and WFL -0.3 cm (95% CI [-0.9, 0.3]). TfR increased in WFC group 3.3 mg L-1 (95% CI [1.7, 4.9]) and WFL group 1.7 mg L-1 (95% CI [0.1, 3.4]) compared with CSB+. Compared with the increase in Hb in CSB+ group, there was a reduction in Hb in WFC of -0.9 g dl-1 (95% CI [-1.3, -0.5]) and a lower increase in WFL -0.4 g dl-1 (95% CI [-0.8, 0.0]). In conclusion, the tested WinFoods had the same effect on FFM and length as CSB+, whereas Hb and iron status decreased, suggesting inhibited iron bioavailability from the amaranth-based WinFoods.
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Affiliation(s)
- Silvenus O Konyole
- Department of Nutritional Sciences, Masinde Muliro University of Science and Technology, Kakamega, Kenya
| | - Selina A Omollo
- Institute of Tropical and Infectious Diseases, University of Nairobi, Nairobi, Kenya
| | - John N Kinyuru
- Department of Food Science and Technology, Jomo Kenyatta University of Agriculture and Technology, Juja, Kenya
| | - Jutta K H Skau
- Department of Paediatrics, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Benson B Estambale
- Division of Research, Innovations and Outreach, Jaramogi Oginga Odinga University of Science and Technology, Bondo, Kenya
| | - Suzanne M Filteau
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Kim F Michaelsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Denmark
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Denmark
| | - Nanna Roos
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Denmark
| | - Victor O Owino
- Nutritional and Health Related Environmental Studies Section, International Atomic Energy Agency, Vienna, Austria
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