Mobile Phone Apps for Intimate Partner and Sexual Violence Prevention and Response: Systematic Search on App Stores

Background

Since the 2008 advent of the smartphone, more than 180 billion copies of apps have been downloaded from Apple App Store, with more than 2.6 million apps available for Android and 2.2 million apps available for iOS. Many violence prevention and response apps have been developed as part of this app proliferation.

Objective

This study aims to evaluate the prevalence and quality of freely available mobile phone apps targeting intimate partner violence (IPV) and sexual violence (SV) prevention and response.

Methods

We conducted a systematic search of violence prevention and response mobile phone apps freely available in Apple App Store (iOS; March 2016) and Google Play Store (Android; July 2016). Search terms included violence prevention, sexual assault, domestic violence, intimate partner violence, sexual violence, forensic nursing, wife abuse, and rape. Apps were included for review if they were freely available, were available in English, and had a primary purpose of prevention of or response to SV or IPV regardless of app target end users.

Results

Using the Mobile Application Rating Scale (MARS), we evaluated a total of 132 unique apps. The majority of included apps had a primary purpose of sharing information or resources. Included apps were of low-to-moderate quality, with the overall subjective quality mean for the reviewed apps being 2.65 (95% CI 2.58-2.72). Quality scores for each of the 5 MARS categories ranged from 2.80 (engagement) to 4.75 (functionality). An incidental but important finding of our review was the difficulty in searching for apps and the plethora of nonrelated apps that appear when searching for keywords such as “rape” and “domestic violence” that may be harmful to people seeking help.

Conclusions

Although there are a variety of mobile apps available designed to provide information or other services related to SV and IPV, they range greatly in quality. They are also challenging to find, given the current infrastructure of app store searches, keyword prioritization, and highlighting based on user rating. It is important for providers to be aware of these resources and be knowledgeable about how to review and recommend mobile phone apps to patients, when appropriate.

A mixed-methods evaluation of college student and provider perspectives on a smartphone application for help-seeking after violence

To elicit feedback on the acceptability, usability, and dissemination options for the bMOREsafe smartphone application (app). Participants: Forty-nine students and six service-providers provided feedback on the bMOREsafe app between April 2015 and March 2016. Methods: Students responded to an anonymous online survey and providers participated in semi-structured interviews. Descriptive and thematic analyses were completed. Results: Students rated the app as useful, however less applicable to themselves and their peers. Students stated they would be most receptive to recommendations about the app from peers and social media. Qualitative data from service providers fell into three main categories: trauma-informed aspects; inclusivity vs. specificity; and within an app, language matters. Conclusions: Smartphone technology can provide confidential information and resources to help students make decisions related to sexual assault or intimate partner violence care. While students and providers identified apps as a useful strategy for sharing this information, dissemination challenges remain.

Effect of iron supplementation on cognition in Greek preschoolers

OBJECTIVE

To examine effects of iron supplementation on vigilance, attention and conceptual learning in preschool children in Greece.

DESIGN

Randomized Double-Blind Placebo Controlled trial of iron. Randomization stratified by iron status and day care center (DCC).

SETTING

Nine public DCCs in Athens, Greece.

SUBJECTS

In all, 49 3-4-y olds (21 anemic, 28 good iron status) with birth weight not less than 2500 g, currently healthy; benign past medical history, IQ > or =1 s.d. below the age-adjusted mean, serum Pb < or =200 ppb (none exceeded 50 ppb), and height, weight and head circumference for age > or =10th percentile. Anemia defined as: (1) pretreatment Hgb <112 g/l and TS <16% and ferritin <12 microg/L OR (2) Hgb rise of >10 g/l (T2-T0) with iron supplementation. Good iron status was defined as baseline levels of Hgb >120 g/l and either TS >20% or serum ferritin >12 microg/l.

INTERVENTION

The intervention consisted of a 2-month supplementation of 15 mg iron (and MV) vs placebo (MV alone).

RESULTS

After iron treatment, the anemic subjects made significantly fewer errors of commission (14% higher specificity, P<0.05), exhibited 8% higher accuracy (P<0.05) and were significantly more efficient (mean difference=1.09, P<0.05) than those given placebo. These effects of iron were not found among preschoolers with good iron status. No effects of iron treatment were found on the Oddity Learning task.

CONCLUSIONS

This study demonstrated that iron supplementation of iron-deficient anemic preschoolers results in an improvement in discrimination, specifically selective attention.

Effects of iron supplementation and anthelmintic treatment on motor and language development of preschool children in Zanzibar: double blind, placebo controlled study

OBJECTIVE

To measure the effects of iron supplementation and anthelmintic treatment on iron status, anaemia, growth, morbidity, and development of children aged 6-59 months.

DESIGN

Double blind, placebo controlled randomised factorial trial of iron supplementation and anthelmintic treatment.

SETTING

Community in Pemba Island, Zanzibar.

PARTICIPANTS

614 preschool children aged 6-59 months.

MAIN OUTCOME MEASURES

Development of language and motor skills assessed by parental interview before and after treatment in age appropriate subgroups.

RESULTS

Before intervention, anaemia was prevalent and severe, and geohelminth infections were prevalent and light-Plasmodium falciparum infection was nearly universal. Iron supplementation significantly improved iron status, but not haemoglobin status. Iron supplementation improved language development by 0.8 (95% confidence interval 0.2 to 1.4) points on the 20 point scale. Iron supplementation also improved motor development, but this effect was modified by baseline haemoglobin concentrations (P=0.015 for interaction term) and was apparent only in children with baseline haemoglobin concentrations <90 g/l. In children with a baseline haemoglobin concentration of 68 g/l (one standard deviation below the mean value), iron treatment increased scores by 1.1 (0.1 to 2.1) points on the 18 point motor scale. Mebendazole significantly reduced the number and severity of infections caused by Ascaris lumbricoides and Trichuris trichiura, but not by hookworms. Mebendazole increased development scores by 0.4 (-0.3 to 1.1) points on the motor scale and 0.3 (-0.3 to 0.9) points on the language scale.

CONCLUSIONS

Iron supplementation improved motor and language development of preschool children in rural Africa. The effects of iron on motor development were limited to children with more severe anaemia (baseline haemoglobin concentration <90 g/l). Mebendazole had a positive effect on motor and language development, but this was not statistically significant.

The developmental and probabilistic nature of the functional consequences of iron-deficiency anemia in children

It is often assumed that the psychometric tools currently available measure accurately the effects of iron-deficiency anemia (IDA) on cognition in young children and that such effects are rooted in cerebral changes. It is also assumed that snapshots of development within a clinical trial can document such effects. I challenge these assumptions on the basis of four considerations. The first is that there are multiple biological, physical and social-psychological factors that reorient the trajectory of different psychobiological domains in early life after intense and prolonged stress. Further, psychobiological development changes are not necessarily caused by brain changes; there are other mechanisms that also affect development (e.g., biomechanics). A second consideration focuses on intraindividual, interindividual and intergroup differences concerning the nature of the effect of IDA and the response to iron treatment. Individual and group factors can moderate the effects of IDA; for example, different stages of iron deficiency involve different systemic changes, which in turn affect different psychobiological domains. The third consideration is that differences in the time of measurement of an intervention within a randomized trial could lead to detecting effects in different domains or effects of different intensity within the same domain. Finally, developmental assessments with the traditional developmental scales during the first 18 mo of life yield equivocal findings. Snapshots of development will overlook the course of effects of a nutrition intervention over time. Repeated measures over time within the same domain are considered particularly useful to draw the course of development.

A developmental view of the undernourished child: background and purpose of the study in Pangalengan, Indonesia

OBJECTIVES

This is the first of a series of reports published in this supplement of an experimental study to test the validity of a conceptual model about the intellectual delay of undernourished children. This paper describes the model and outlines its empirical and theoretical basis. The model provides a conceptual framework for the multiple relationships among growth and developmental domains presumably affected by malnutrition. It allows for a statistical statement regarding the goodness of fit between data and theory. The model also identifies particular hypotheses regarding multiple distinct pathways of human development. The following questions were addressed: (1) what are the effects of early supplementary feeding on the physical growth, motor development and activity, mental development and behavior of infants and toddlers who are nutritionally at risk? (2) What are the effects of a micronutrient supplement in the presence and absence of a high-energy supplement? (3) What are the moderating effects of developmental level and timing of the intervention.

DESIGN

The study was a randomized clinical trial involving two cohorts (12 and 18 months old) of nutritionally-at-risk children living in Pangalengan, West Java, Indonesia and three types of supplements: condensed milk + micronutrients; skimmed milk + micronutrients; and skimmed milk. The children were tested every 2 months for a period of 12 months.

Nutritional intake of an undernourished infant population receiving an energy and micronutrient supplement in Indonesia

OBJECTIVES

This paper reports the dietary intake (home, day care centers, supplement and breast milk) of the children in the clinical trial in Pangalengan.

DESIGN

Two cohorts of children were randomly assigned to three treatments: E = 1171 kJ + 12 mg iron; M = 209 kJ + 12 mg iron; S = 104 kJ. Supplementation was given for 12 months.

SETTING

The sites were six tea plantations in Pangalengan, West Java.

SUBJECTS

A 12-month-old (n = 53) and an 18-month-old (n = 83) cohort were recruited from day-care-centers. Twenty children who received S belong to the 12- and 18-month-old cohorts. Inclusion criteria were: no chronic disease; length-for-age < or = -1 standard deviation (s.d.) and weight-for-length between -1 and -2 s.d. of the median of the reference of the World Health Organization.

METHODS

E = 1171 kJ + 12 mg iron; M = 209 kJ + 12 mg iron; S = 104 kJ. Supplementation was given for 12 months. Evaluations of intake were made at baseline and every 2 months thereafter.

RESULTS

For the 12-month-old cohort the mean increase in daily energy intake approximately 2931 kJ for E, approximately 1675 kJ for M, and approximately 837 kJ increase over the 6 months for the S group. For the 18-month-old cohort the changes were approximately 2512 kJ for E approximately 1675 for the M group and approximately 1047 for the S group.

Effects of an energy and micronutrient supplement on skeletal maturation in undernourished children in Indonesia

OBJECTIVES

This paper reports the effects of an energy and micronutrient supplement on skeletal maturation of nutritionally at risk infants and toddlers in Pangalengan, Indonesia.

DESIGN

Two cohorts of children were randomly assigned to three treatments: E = 1171 kJoule + 12 mg iron; M = 12 mg iron + 209 kJ; S = 104 kJ. Supplementation was given for 12 months.

SETTING

The sites were six tea plantations in Pangalengan, West Java.

SUBJECTS

A 12-month-old (n = 53) and an 18-month-old (n = 83) cohort were recruited from day-care-centers. Twenty children that received S belonged to the 12- and 18-month-old cohorts. Inclusion criteria were: no chronic disease; length-for-age < or = -1 standard deviation (s.d.) and weight-for-length between -1 and -2 s.d. of the median of the reference of the World Health Organization.

METHODS

Skeletal maturation was measured by X-ray of the left hand and wrist. The number of ossified centers and two different measures of skeletal age (Skel-1 and Skel-2) were the outcome variables measured.

RESULTS

In the 12-month-old cohort, there were intergroup differences 6 and 12 months after baseline. First, the children in the E group were about 2 months more advanced in ossified centers than the children in the S group (P < 0.10). At 12 months, the children in the E group were about 3 months more advanced in skeletal age than the children in the M group. M group children were about 2.5 months behind the children in the S group.

Effects of an energy and micronutrient supplement on play behavior in undernourished children in Indonesia

OBJECTIVES

This paper reports the effects of an energy and micronutrient supplementation on quantitative and qualitative aspects of play among poorly nourished children. At issue is whether the supplement led to a progression in complexity of play.

DESIGN

Two cohorts of children were randomly assigned to three treatments: E = 1171 kJ + 12 mg iron; M = 12 mg iron + 209 kJ; S = 104 kJ. Supplementation was given for 6 months. Evaluations of play behavior were repeated four times.

SETTING

The sites were six tea plantations in Pangalengan, West Java.

SUBJECTS

The present study utilized a subsample of 55 children recruited for the larger Pangalengan project 6 months into the study. Thirty-eight children were recruited late enough to allow for longitudinal observations. The remaining cases were used for cross sectional observations only. Inclusion criteria were: no chronic disease; length-for-age < or = -1 standard deviation (s.d.) and weight-for-length between -1 and -2 s.d. of the median of the reference of the World Health Organization.

METHODS

The children were videotaped during play. These tapes were coded for eight mutually exclusive categories of activities. Four activities coded represented manipulative, relational, functional and symbolic play.

RESULTS

Treatment did not affect qualitative play. Girls that received E increased functional play but boys showed the opposite effect. Children in the S group were breastfed more during play as compared to the E group. Children in the E group waited less to begin play.

Effects of an energy and micronutrient supplement on motor development and motor activity in undernourished children in Indonesia

OBJECTIVES

This paper reports the effects of an energy and micronutrient supplement on the motor development, motor milestones and motor activity of nutritionally at risk infants and toddlers in Pangalengan, Indonesia.

DESIGN

Two cohorts of children were randomly assigned to three treatments E = 1171 kJ + 12 mg iron; M = 209 kJ + 12 mg iron; S = 104 kJ. Supplementation was given for 12 months.

SETTING

The sites were six tea plantations in Pangalengan, West Java.

SUBJECTS

A 12-month-old (n = 53) and an 18-month-old (n = 83) cohort were recruited from day-care-centers. Twenty children that received S belonged to the 12- and 18-month-old cohorts. Inclusion criteria were: no chronic disease; length-for-age < or = -1 standard deviation (s.d.) and weight-for-length between -1 and -2 s.d. of the median of the reference of the World Health Organization.

METHODS

Evaluations of intake were made at baseline and every 2 months thereafter. Motor development was assessed with the Bayley Scale and with a custom-made scale to assess gross motor development leading to bipedal locomotion. Motor activity was assessed through 4 h continuous observations of the child's interaction with the social and physical environment.

RESULTS

In the 12-month-old cohort, as compared to the M and S groups the children that received the E supplement walked at an earlier age, had higher scores in the Bayley Scale and were motorically more active. Similar intergroup differences were observed in the 18-month-old cohort in the total motor activity score.

Effects of an energy and micronutrient supplement on iron deficiency anemia, physical activity and motor and mental development in undernourished children in Indonesia

OBJECTIVES

This paper reports the effects of an energy and micronutrient supplementation on mental and motor development, activity and behavior under natural conditions of children classified as iron deficient anemic and iron replete.

DESIGN

Children were randomly assigned to two different nutritional supplements: (1) 12 mg iron + either 1171 or 209 kJ; (2) 104 kJ + 0 iron. Treatment lasted for 6 months.

SETTING

The sites were six tea plantations in Pangalengan, West Java.

SUBJECTS

Eighteen anemic subjects (hemoglobin < 110 g/L; transferrin saturation (TS) < 16%) and 18 matched (sex and age) controls (hemoglobin > 110 g/L; TS > 16%) were selected from a pool of children with the following characteristics: no chronic disease; length-for-age < or = -1 standard deviation (s.d.) and weight-for-length between -1 and -2 s.d. of the median of the reference of the World Health Organization.

METHODS

Hemoglobin, ferritin, transferrin saturation and erythrocyte protoporphyrin were evaluated before and 6 months after treatment. The following psychological measurements were obtained at baseline and 2, 4 and 6 months later. Mental and motor development was evaluated with the Bayley Scale. Motor activity was measured by 4 h continuous observations at home and at day care centers. The interactions between the child and its social and physical environment were also evaluated during 4 h of observations.

RESULTS

Anemic children showed faster motor development and greater physical activity than the control children did. None of the other tests showed inter-group differences.

Community-level determinants of child growth in an Indonesian tea plantation

OBJECTIVES

The paper presents the results of an ecological-economic approach to identifying community-level factors that influence the physical growth of young children.

DESIGN

A cross-sectional design was used to obtain both the anthropometry and the ecological-economic data.

SETTING

The sites were 24 communities located in a tea plantation near Bandung, West Java, Indonesia.

SUBJECTS

415 children between the ages of 6 and 18 months.

METHODS

Epidemiological and ethnographic methods were used to measure community infrastructure and services related to child growth. Anthropometry was used to measure child growth. Econometric methods, including probit and ordinary least squares regression, were used to analyze the effect of community-level factors on child growth.

RESULTS

Community vaccination programs, child care services, environmental sanitation and latrines were associated with better child growth. We concluded that community-level goods and services substantially contributed to health in early childhood.

Effects of an energy and micronutrient supplement on mental development and behavior under natural conditions in undernourished children in Indonesia

OBJECTIVES

This paper reports the effects of an energy and micronutrient supplement on mental development and on the social cognitive and emotionally regulatory behaviors of nutritionally at risk infants and toddlers in Pangalengan, Indonesia.

DESIGN

Two cohorts of children were randomly assigned to three treatments: E = 1171 kJ + 12 mg iron; M = 12 mg iron + 209 kJ; S = 104 kJoule. Supplementation was given for 12 months.

SETTING

The sites were six tea plantations in Pangalengan, West Java.

SUBJECTS

A 12-month-old (N = 53) and an 18-month-old (N = 83) cohort were recruited from day-care-centers. Twenty children who received S belonged to the 12- and 18-month-old cohort. Inclusion criteria were: no chronic disease; length-for-age < or = -1 standard deviation (s.d.) and weight-for-length between -1 and -2 s.d. of the median of the reference of the World Health Organization.

METHODS

Evaluations of intake were made at baseline and every 2 months thereafter. Motor development was assessed with the Bayley Scale and with a custom-made scale to assess gross motor development leading to bipedal locomotion. Four hours of continuous observations were made of the child's interaction with the social and physical environment.

RESULTS

In the 12-month-old cohort, as compared with the M and S groups, the children who received the E supplement walked at an earlier age, had higher scores in the Bayley Scale and showed more mature social-cognitive and emotional regulatory behaviors. Similar intergroup differences were observed in the 18-month-old cohort in social cognition and regulation of emotions.

A preliminary test of a developmental model for the study of undernourished children in Indonesia

OBJECTIVES

Structural equation modeling of an abbreviated version of the conceptual model of the effects of micronutrient and energy supplementation on growth and development of undernourished children in West Java. The study focused on the baseline data from the Pangalengan longitudinal project.

DESIGN

This trial included two cohorts of children classified as nutritionally-at-risk who were randomly assigned to three treatments (condensed milk + micronutrients (E); skimmed milk + micronutrients (M); skimmed milk (S)). Supplements were given for a period of up to 12 months.

SETTING

The sites were six tea plantations in Pangalengan.

SUBJECTS

A 12-month-old (n=53) and an 18-month-old (n=83) cohort were recruited from 24 day care centers. Twenty children that received the S supplement were part of the 12- and 18-month-old cohorts. Criteria for inclusion were: no chronic disease; length-for-age < -1 standard deviation (s.d.) and weight-for-length between -1 and -2 s.d. of the median of the reference of the World Health Organization.

VARIABLES

Indicators of socioeconomic status were economic and educational resources; length-for-age and weight-for-length were used as indicators of nutritional status; motor development and motor activity were measured with custom-made procedures; and carrying by caretaker and manipulation of objects were used as indicators of caretaking and exploratory behavior.

RESULTS

The model fitted the data of the older but not of the younger cohort (chi2 statistic and three other indices of goodness to fit). However, there were no differences between cohorts in the estimation of the models.

A developmental view of the effects of an energy and micronutrient supplement in undernourished children in Indonesia

OBJECTIVES

This paper presents the results of a structural equation model testing whether the longitudinal data of the Pangalengan subjects fit the theoretical model regarding the intellectual delay of undernourished children.

DESIGN

Two cohorts of children were randomly assigned to three treatments: E = 1171 kJ + 12 mg iron; M = 12 mg iron + 209 kJ; S = 104 kJ. Supplementation was given for 6 months.

SETTING

The sites were six tea plantations in Indonesia.

SUBJECTS

A 12-month-old (n = 53) and an 18-month-old (n = 83) cohort were recruited from day-care-centers. Inclusion criteria were: no chronic disease; length-for-age = < 1 standard deviation (s.d.) and weight-for-length between -1 and -2 s.d. of the median of the reference of the World Health Organization.

METHODS

Twenty-four-hour dietary intakes were assessed using the weighted individual inventory technique. Body weight and length were obtained using standard procedures; motor development was assessed with the Bayley Scale and with a custom made scale for motor development leading to bipedal locomotion. Four-hour observations were made of the child's interactions with the environment. Carrying a child in the arms and exploratory behavior were used as indicators of caregiving and exploration. All measurements were obtained every 2 months.

RESULTS

The original model did not fit the data. The model was then modified with the inclusion of two new pathways: from activity and from motor development to mental development. Following these adjustments the model fit the data for each cohort and for both cohorts combined.

The eco-cultural context of the undernourished children in a study on the effects of early supplementary feeding in Indonesia

OBJECTIVES

This paper describes the ecological and cultural backdrop of the subjects enrolled in an experimental study to test the validity of a conceptual model about the intellectual delay of undernourished children.

DESIGN

The experiment was a 12-month clinical, randomized trial on the effects of early supplementary feeding on two cohorts of children classified as nutritionally-at-risk. Three different supplements (condensed milk + micronutrients; skimmed milk + micronutrients; skimmed milk) were given to the children during 6 or 12 months of the study.

SETTING

The plantations are 1500-1800 m above sea level in Pangalengan, 50 km south of Bandung, West Java. Temperature fluctuates from 10 to 17 degrees C. A high yearly precipitation is approximately 3000 mm. Communities are laid out at 5-15 km from one another. Living conditions are modest.

SUBJECTS

The 156 subjects were recruited from 24 day-care-centers (DCC) that serviced families of 24 communities in six tea plantations. The 12- and 18-month-old cohorts included 73 and 83 children, respectively; each cohort included three subgroups that received distinct supplements.

OBSERVATIONS

The interactions of the caretakers with the children in the DCCs were consistent with the socialization for survival mode. A primary concern was the physical growth, health, cleanliness, sanitation and safety of the children. Stimulating children, providing toys and initiating play or other activities that would emphasize educational development had a low priority.

Effects of an energy and micronutrient supplement on growth and development in undernourished children in Indonesia: methods

OBJECTIVES

To describe the methodologies of a clinical trial on the effects of an energy and micronutrient supplement on the growth and development of undernourished children.

DESIGN

This trial included two cohorts of children classified as nutritionally-at-risk who were randomly assigned to three treatments (condensed milk + micronutrients (E); skimmed milk + micronutrients (M); skimmed milk (S)). Supplements were given for a period up to 12 months.

SETTING

Six tea plantations in Pangalengan, West Java were the site for this study.

SUBJECTS

A 12-month-old (N=53) and an 18-month-old (N=83) cohort were recruited from 24 day-care-centers (DCC). Twenty children that received the S supplement were part of the 12- and 18 month-old cohort. Criteria for case inclusion were absence of chronic disease; length-for-age < or = -1 standard deviation (s.d.) and weight-for-length between -1 and -2 s.d. of the median of the reference of the World Health Organization.

VARIABLES

Social variables included assessment of health facilities, childcare, housing, income and parental education. Nutrition and growth variables included dietary intake measured over a 24 hr period every 2 months; hemoglobin and three iron indicators measured at baseline, 6 and 12 months; anthropometry measured every 2 months and skeletal maturation measured every 6 months. Cognition and behavior included the assessment of mental and motor development and the behavior of the child under natural conditions.

DATA ANALYSIS

An ANOVA was the statistic most frequently used to test inter-group differences and structural equation modeling was used to test the internal validity of the conceptual model of the study.

Effects of an energy and micronutrient supplement on anthropometry in undernourished children in Indonesia

OBJECTIVES

This paper reports the effects of early supplementary feeding on body weight, length, head circumference and arm circumference among the children in the Pangalengan study.

DESIGN

Two cohorts of children were randomly assigned to three treatments: E = 1171 kJ + 12 mg iron; M = 209 kJ + 12 mg iron; S = 104 kJ. Supplementation was given for 12 months.

SETTING

The sites were six tea plantations in Pangalengan, West Java.

SUBJECTS

A 12-month-old (n = 53) and an 18-month-old (n = 83) cohort were recruited from day-care centers. Twenty children that received S belonged to the 12- and 18-month cohorts. Inclusion criteria were: no chronic disease; length-for-age < or = -1 standard deviation (s.d.) and weight-for-length between -1 and -2 s.d. of the median of the reference of the World Health Organization.

METHODS

Length was measured with a portable measuring board; a Detecto scale with an accuracy of 0.1 kg was used for the measurement of body weight. Arm and head circumferences were measured using similar fiberglass tapes.

RESULTS

Body weight showed effects on both cohorts at 2, 8 and 12 months; head circumference showed effects at 4 months in the 12-month-old cohort and at 10 months among the females of the 18-month-old cohort; and arm circumference showed effects across cohorts at 2, 8 and 12 months. In general the benefits are clearer for females and for the 12-month-old cohort.

Effects of an energy and micronutrient supplement on growth and activity, correcting for non-supplemental sources of energy input in undernourished children in Indonesia

OBJECTIVES

This paper investigates simultaneously the growth and activity of children that received an early energy and micronutrient supplement, adjusting for all non-supplemental energy intakes. Any additional change in growth and activity after this adjustment was then compared across supplements at three points felt to be representative of the study.

DESIGN

Two cohorts of children were randomly assigned to three treatments: E = 1171 kJ + 12 mg iron; M = 209 kJ + 12 mg iron; S = 104 kJ. Supplementation was given for 12 months.

SETTING

The sites were six tea plantations in Pangalengan, West Java.

SUBJECTS

A 12-month-old (n = 53) and an 18-month-old (n = 83) cohort were recruited from day-care-centers. Twenty children that received S belonged to the 12- and 18-month-old cohorts. Inclusion criteria were: no chronic disease; length-for-age < or = -1 standard deviation (s.d.) and weight-for-length between -1 and -2 s.d. of the median of the reference of the World Health Organization.

METHODS

Length was measured with a portable measuring board; a Detecto scale with an accuracy of 0.1 kg was used for the measurement of body weight. Arm and head circumferences were measured using similar fiberglass tapes. Motor activity was assessed through continuous 4 h observations at home and at day care centers. Anthropometry and activity were measured every two months over 12 months.

RESULTS

After correcting for non-supplemental sources of energy intake, the effects of the supplement on weight and activity were observed at 2 months; effects on length and activity were observed at 6 months; and effects on weight alone were observed at 12 months.

Developmental sequel from early nutritional deficiencies: conclusive and probability judgements

Results from quasi-experimental longitudinal studies of children and from experimental research with animal models have led several investigators to state that early iron deficiency anemia leaves a permanent cognitive deficit. However, neither source of information provides a basis for such a claim. Some key confounders were not controlled by the quasi-experimental studies, and the external validity of the animal data is questionable. Further, three decades of research on the functional consequences of protein-energy malnutrition have shown that the social environment moderates the effects of an early nutritional insult; it can keep such effect unchanged, or increase or decrease its severity. The prediction of later life on the basis of a particular nutritional event carries a large error factor, which suggests that the search would be more fruitful if we tracked probability statements.

Nucleotide sequence of the 4.3 kbp BamHI-N fragment of fowlpox virus FP9

Nucleotide sequence analysis of the 4.3 kbp BamHI-N fragment of the fowlpox virus (FPV) genome revealed that it encodes 7 proteins with homology to vaccinia virus (VV) E11L, E10R, O1L, O3L, I1L, I2L and I3L encoded proteins. No evidence of FPV homolog of VV O2L could be found.

When science and politics listen to each other: good prospects from a new school breakfast program in Peru

This article provides an overview of a school breakfast program implemented in 1993 in the Peruvian Andes. The program, designed by the Instituto de Investigación Nutricional in Lima and supported by the government of Peru, constitutes a clear departure from previous school feeding programs, which were heavily politicized and poorly documented. From the program's inception, nutritionists, managers, and social scientists have collaborated to produce a sound nutritional design, efficient distribution mechanisms, and effective evaluation methods. During the program's first year, controlled evaluations conducted in several Andean regions documented improved dietary intake and a significant decline in the prevalence of anemia. An educational evaluation also found improved verbal skills, higher school attendance, and lower dropout rates among recipients of the school breakfast. The results have prompted the Peruvian government to continue supporting the program, thus setting a new standard for the effective management of social expenditure in the context of economic adjustment.

Fasting and cognition in well- and undernourished schoolchildren: a review of three experimental studies

This paper reviews three experiments on the effects of an overnight and morning fast on attention and memory processes among 9-11-y-old children. Two of the experiments focused on middle-class, well-nourished boys and girls in the United States: the third involved boys from low-income families with and without nutritional risk in Huaraz, Peru. All experiments used the same crossover design and followed similar experimental procedures to control the subjects' intakes and motor activity during the study period. The children were admitted to a research center on two different evenings, approximately 7 d apart. After arrival the children ate dinner, played table games or watched television, and went to bed. They were awakened at 0730 and, by design, were either served breakfast (approximately 2301 kJ) or not. At 1100 they took psychologic tests that assessed recall from working memory and competence in discriminating visual stimuli. At 1200 the children were discharged. The consequences of the overnight and morning fast, particularly among the children who were nutritionally at risk, included slower stimulus discrimination, increased errors, and slower memory recall. We propose that these alterations result from a state of metabolic stress in which homeostatic mechanisms work to maintain circulating glucose concentrations.

Breakfast and cognition: an integrative summary

In this supplement, the papers presented at the International Symposium on Breakfast and Performance in Napa, CA in 1995 are summarized and integrated with data published since that time. In particular, the focus is on issues of research design, measurements, mechanisms, potential effect modifiers (eg, age), and relevance for public policy. No definitive conclusions can be drawn from the existing data on either the long- and short-term benefits of breakfast on cognition and school learning or the mechanisms that mediate this relation. The pooled data suggest that omitting breakfast interferes with cognition and learning, an effect that is more pronounced in nutritionally at-risk children than in well-nourished children. At the very least, breakfast consumption improves school attendance and enhances the quality of the students' diets.

Three-month nutritional supplementation in Indonesian infants and toddlers benefits memory function 8 y later

Does short-term supplementary feeding during infancy and childhood have long-lasting effects? In 1986, 334 children aged 6-60 mo living on rural tea plantations in West Java, Indonesia, participated in a 3-mo randomized trial to test the effects of a dietary supplement providing approximately 1672 kJ (400 kcal) energy/d, with about the same nutrient density as local foods. We returned to the same communities in 1994 and enrolled 231 (125 supplemented, 106 control) of the original subjects in a follow-up study of the long-term effects of supplementation. We assessed these subjects by using several measures: anthropometry, iron status, information processing, Peabody Picture Vocabulary Test, word fluency, and an arithmetic test. The supplemented group showed no differences from those in the control group. However, when the analysis was limited to subjects who had received the supplement before the age of 18 mo (n = 73), the supplemented children performed better than control children on the Sternberg test of working memory (decision time intercept: probe absent, P = 0.002; probe present, P = 0.053). After considering possible confounders, we concluded that the supplementation during infancy was responsible for the difference. This finding shows that supplementation can have long-lasting effects on a specific domain if the child receives it at the appropriate stage of development.

Iron deficiency and educational deficiency

Existing data suggest that iron deficiency anemia (IDA) is a risk factor for poor educational performance in schoolchildren. The synergistic effect of IDA in combination with other forms of malnutrition and other risk factors may affect educational performance more strongly. Thus, IDA and its effect on educational performance should be studied in the context of other risk factors.

"Stupidity or worms": do intestinal worms impair mental performance?

The title of a 1930s article asked the question, "Stupidity or Hookworm?" In this article, the authors discuss research that attempts to answer the question of whether intestinal worms--namely, hookworm, whipworm, and roundworm--harm the mental performance of their hosts. After introducing the biology and epidemiology of intestinal worms, the authors present the historical background to the problem. They review research from the 1910s through the 1990s; there is evidence that high intensities of worms can affect mental performance, but not all dewormed children show improved performance. They discuss the mechanisms of how worms might affect the mind.

The effects of high energy and micronutrient supplementation on iron status in nutritionally at risk infants

The study assessed the effects of supplementary feeding over 180 consecutive days on iron status of infants and toddlers at six tea plantation in West Java, Indonesia. The design used was a clinical trial: two eohorts (i.e., 12 and 18 months old children) and three treatment groups (i.e., energy + micronutrient, micronutrient alone, and placebo) per cohort. Every day except Sunday, the infants attended day-care centers. Twenty four centers and 136 infants were selected. The infants were screened for weight and length and those meeting the criteria (i.e., < -1 SD of length-for-age, and between -1 and -2 SD of weight-for-length of the NCHS reference) were included. The experimental unit was the day-care centers (DCC), where each DCC was randomly assigned to one of the three treatment. As expected, groups of energy + micronutrient and micronutrient alone of the 12 months cohort experienced a significant upward shift in hemoglobin, ferritin and TS and a downward change in FEP, while the values for the group of placebo remain about the same as at base line. In the first 6 month of treatments, the ANOVA for each iron indicator yielded significant main effects of treatment (P < 0.01) and for Hb with (P = 0.059) on 12 months cohort. On the other hand, the main effects of treatment on hemoglobin, TS, ferritin and FEP were not significant for the 18 months cohort. In the second 6 months of treatments, the only significant of the treatment effect (P < 0.01) was in serum ferritin on 18-month cohort. Under these circumstances, energy has a positive role in improving iron stores. It is likely that the equilibrium of hemoglobin and each iron indicators were reached in 6 months of treatment except ferritin still continued to increase up to 12 month. The effects of treatment on the improvement of iron status was stronger in 12 months than in 18 months.

Effect of removing Ascaris on the growth of Guatemalan schoolchildren

OBJECTIVE

To determine whether successful deworming for 6 months in children with high levels of Ascaris improves physical growth.

SUBJECTS

Two hundred twenty-eight children (mean age, 9.7 years) in a highland Indian town in Guatemala.

DESIGN

Children were randomly assigned to receive albendazole or placebo at baseline and 12 weeks. Children and field workers were both blind to the group assignment.

OUTCOME MEASURES

Children's heights, weights, and mid-upper-arm circumferences were measured at baseline and 12 and 24 weeks. Fecal egg counts were taken at 0, 2, 12, 14, and 24 weeks to estimate the helminth burden (eggs per gram of feces [epg]).

RESULTS

Baseline helminth prevalences were Ascaris, 91%, and Trichuris, 82%. Ascaris intensities were high: half of the children had moderate burdens (10 000 to 50 000 epg), and 25% had heavy burdens ( > 50 000 epg). Trichuris burdens were light (72% < 1000 epg). The albendazole and placebo groups did not differ at baseline in epg, age, anthropometry, or socioeconomic status. The two rounds of treatment successfully reduced the Ascaris burdens but had less effect on Trichuris. At 6 months the treatment group showed a small gain in weight (0.18 kg) compared with the placebo group but no improvement in height or mid-upper-arm circumference.

CONCLUSIONS

The successful removal of ascaris in a population of school-aged children with relatively high loads may have modest effects on weight gain. Ascaris is one of the most common infections in school-aged children, but its effect on the host may be less than that of other helminths.

Does schooling buffer the effects of early risk?

The data presented here come from a 20-year study conducted in a rural area of Guatemala. Data on early biological indicators, graduated parameters of social structure, and preschool cognition were combined into a risk scale and analyzed in relation to primary school grade attainment and adolescent psychoeducational test performance. Similar to empirical relations reported in industrialized countries, performance declined as the number of risk factors to which a subject was exposed increased. More important, primary education was observed to buffer the effects of early risk for a subset of subjects. Subjects at high risk who stayed in school performed significantly better than subjects with similar levels of risk who completed fewer than 4 years of primary school.

The effects of deworming on indicators of school performance in Guatemala

Intestinal helminths are among the most common infections in school-age children. Of 246 children, aged 7-12 years, attending school in rural Guatemala, 91% carried Ascaris lumbricoides and 82% carried Trichuris trichiura. These children were randomly assigned to receive either albendazole or placebo at 0 and 12 weeks in a 'double-blind' study of the effects of deworming on indicators of school performance. Albendazole successfully rid the children of Ascaris but it was less effective against Trichuris. The children's performance in tests of reading and vocabulary were measured at 0 and 24 weeks, the Peabody picture vocabulary test was given at 24 weeks, and attendance was measured throughout the school year. Comparison of the treated and placebo groups showed no positive effect of deworming. The treated children were largely free of Ascaris for at least 6 months, but during that period we could not detect any improvement in reading, vocabulary, or attendance. The effects of being Trichuris-free were not examined because of the limited effectiveness of albendazole against this worm at the dosage used.

Does breakfast make a difference in school?

This article reviews selectively the literature on the effects of breakfast on cognition and school performance. The focus is on studies published in refereed journals after 1978 that tested those effects on well-nourished and nutritionally at-risk children. In at-risk subjects (defined by clinical history and anthropometry), a morning and overnight fast had adverse effects on cognition, particularly the speed of information retrieval in working memory. Contradictions in the data from different studies prevent definitive conclusions on whether well-nourished children experience similar functional deficits. Nonetheless, available information suggests that brain function is sensitive to short-term variations in the availability of nutrient supplies. Moreover, well-conducted evaluations suggest that the availability of feeding programs in public schools throughout the academic year increases the probability that children will eat breakfast and improve their educational status.

Functional significance of the covariance between protein energy malnutrition and iron deficiency anemia

Most of the correlational and experimental studies that have tested the hypothesis that mild-to-moderate protein-energy malnutrition (PEM) has an adverse effect on cognitive development disregarded the potential confounder effect of micronutrients. This omission may have been a critical flaw in study design because it is now recognized that iron deficiency increases the probability of deviations in the trajectory of children's motor and mental development from a normal developmental path. This paper discusses two frequently cited studies on the effects of PEM on neurointegrative and cognitive development and proposes that neither study can discard the hypothesis that effects attributed to protein and energy deficiency are, instead, determined by iron deficiency.

Nutrition in early life and the fulfillment of intellectual potential

The effects of early supplementary feeding on cognition are investigated using data collected during two periods in four Guatemalan villages. The first was the Institute of Nutrition of Central America and Panama (INCAP) longitudinal study from 1969 to 1977 and the second was a cross-sectional follow-up of former participants carried out in 1988-1989. The principal objective of these studies was to assess the differential effect of two dietary supplements, Atole containing 163 kcal/682 kJ and 11.5 g protein per cup or 180 mL and Fresco containing 59 kcal/247 kJ and 0 g protein per cup, that were given to mothers, infants and young children. Performance was assessed on a battery of psychoeducational and information processing tests that were administered during adolescence. Consistent differences between groups were observed on psychoeducational tests. Subjects receiving Atole scored significantly higher on tests of knowledge, numeracy, reading and vocabulary than those given Fresco. Atole ingestion also was associated with faster reaction time in information processing tasks. In addition, there were significant interactions between type of dietary supplement and socioeconomic status (SES) of subjects. In Atole villages, there were no differences in performance between subjects in the lowest and highest SES categories. On the other hand, performance in Fresco villages was best in the highest compared with the lowest SES group. After close scrutiny of alternative hypotheses, it is concluded that dietary changes produced by supplementation provide the strongest explanation for the test performance differences observed in the follow-up between subjects exposed to Atole and those exposed to Fresco supplementation.

Growth improvements in children above 3 years of age: the Cali Study

The Cali Study involved the random assignment of 301 malnourished children to be exposed to one (CT1, n = 113), two (CT2, n = 64), three (CT3, n = 62) or four (CT4, n = 62) 9-mo periods of a multifocal day care-based intervention (i.e., education, health and nutrition). The ages at which the intervention was initiated for Groups CT4, CT3, CT2 and CT1 were 3.5, 4.2, 5.2 and 6.1 y, respectively. After the experimental phase, children were followed up in elementary school until they were 10.4 y old. Our secondary data analyses show that children who were exposed at an earlier age and for a longer period of time showed the highest degree (P < or = 0.05) of improvement in weight and linear growth during the pre-school period. These improvements in physical growth could no longer be detected 3 y after the termination of the intervention.

Adverse effect of iron supplementation on weight gain of iron-replete young children

The efficacy of iron supplementation for iron-deficient subjects is in no doubt. However, the assumption that iron supplementation of iron-replete subjects is harmless may not be valid. We have studied the effect of iron supplementation on growth rate in 47 iron-sufficient young children (12-18 months) in Indonesia. The children were randomly assigned either ferrous sulphate (3 mg/kg daily) or placebo every day for 4 months. Before treatment the length, weight, and arm circumference of the two groups were similar. During the 4 months of supplementation the rate of weight gain was significantly greater in the placebo group than in the iron-supplemented group (0.106 [SE 0.010] vs 0.070 [0.011] kg every 2 weeks, p = 0.02). The rates of gain in length and arm circumference did not differ significantly by treatment. There were no differences between the groups in rates of respiratory and gastrointestinal infections. These results suggest that iron supplementation of iron-replete children may retard their growth.

Poverty and child development: relevance of research in developing countries to the United States

Data from low-income countries are helpful in understanding the effects of poverty on child development in the U.S. Illustrative are 3 public health issues: (1) In the U.S., among poor African-American and Hispanic babies anemia is as high as 20%-24%, while in low-income countries, iron deficiency anemia (IDA) causes poor performance on mental and motor tests among babies and children. These data suggest that IDA is a major public health problem among poor minority children that requires prompt attention. (2) In 1993 the U.S. government appropriated $2.86 billion for the Special Supplemental Food Program for Women, Infants, and Children (WIC). Evaluations of WIC, however, have failed to yield conclusive information on the benefits of the program. In low-income countries, nutritional supplements targeted to at-risk groups have resulted in developmental benefits. Thus, WIC is likely to buffer intellectual development against the adverse effects of malnutrition observed among poor children. (3) Evidence from developing countries suggests that concurrent illnesses and poor nutrition interfere with schooling. However, in the U.S., attention to such issues has declined, while common illnesses have increased among the poor. A reappraisal of this issue is warranted to meet the education and health goals proposed for the year 2000 in the U.S.

Infant feeding policies in maternity wards and their effect on breast-feeding success: an analytical overview

OBJECTIVES

The purpose of this review is to examine the plausibility of a causal relationship between maternity ward practices and lactation success.

METHODS

Studies were located with MEDLINE, from our personal files, and by contacting researchers working in this field. Of the 65 studies originally reviewed, 18 met our inclusion criteria (i.e., hospital-based intervention, experimental design with randomization procedures, or quasi-experimental design with adequate documentation).

RESULTS

Meta-analysis indicated that commercial discharge packs had an adverse effect on lactation performance. The impact of early mother-infant contact on lactation success was unclear. Rooming-in and breast-feeding guidance in a rooming-in context had a beneficial impact on breast-feeding among primiparae. Breast-feeding on demand was positively associated with lactation success. In-hospital formula supplementation of 48 mL per day was not associated with poor breast-feeding performance.

CONCLUSIONS

Hospital-based breast-feeding interventions can have a beneficial effect on lactation success, particularly among primiparous women.

Determinants of lactation performance across time in an urban population from Mexico

We identified determinants of breastfeeding and full breastfeeding among 165 healthy mothers from Hermosillo, Mexico who planned to breastfeed and delivered vaginally a healthy term infant. Deliveries took place in either a nursery (n = 58) or a rooming-in (n = 107) public hospital where formula supplementation was not allowed. Multivariate analyses indicated that at 1 week full breastfeeding was associated (P < or = 0.05) with early milk arrival, social support for full breastfeeding and planned breastfeeding duration. At 2 months, full breastfeeding was associated with social support for full breastfeeding and early milk arrival. Breastfeeding was positively associated with early milk arrival and inversely associated with early introduction of supplementary bottles, maternal employment, maternal body mass index and infant age. At 4 months, full breastfeeding was positively associated with social support for full breastfeeding and inversely associated with infant age. Breastfeeding was positively associated with planned breastfeeding duration and inversely associated with early introduction of a bottle and urban background. Rooming-in mothers reported that their milk came in earlier (P < or = 0.05) than did the nursery group. Milk arrival was later when a bottle was introduced in the first week; both of these variables might be important in explaining a positive effect of rooming-in on lactation performance.

Reversal of developmental delays in iron-deficient anaemic infants treated with iron

Iron-deficient anaemic infants perform worse in tests of mental and motor development than do iron-sufficient infants of a comparable age. A randomised, double-blind trial was done to monitor the effects of iron supplementation on performance in the Bayley scales of mental and motor development among 12-18-month-old infants in Indonesia. Iron-deficient anaemic infants (n = 50) were assigned randomly to receive dietary ferrous sulphate or placebo for 4 month. Similar treatment randomisation was done among nonanaemic iron-deficient (n = 29) and iron-sufficient (n = 47) infants. Before intervention, the mean mental and motor scores of the iron-deficient anaemic infants were significantly (p < 0.01) lower than those of the nonanaemic iron-deficient and iron-sufficient classes. After intervention, developmental delays were reversed among iron-deficient anaemic infants who had received iron but they remained the same among placebo-treated iron-deficient anaemic infants. Neither ferrous sulphate nor placebo had significant effects on the scores of the other two iron-status classes. The poor performance of 12-18-month-old iron-deficient anaemic infants in the Bayley scales of mental and motor development can be improved to the level of performance of iron-sufficient infants by treatment with ferrous sulphate.

Effect of the maternity ward system on the lactation success of low-income urban Mexican women

We compared the lactation performance of 165 healthy mothers who planned to breastfeed and gave birth by vaginal delivery, without complications to a healthy infant in either a nursery (NUR) (n = 58) or a rooming-in hospital where formula supplementation was not allowed. In the rooming-in hospital, women were randomly assigned to a group that received breastfeeding guidance during the hospital stay (RIBFG) (n = 53) or to a control group (RI) (n = 54). Women were interviewed in the hospital and at 8, 70 and 135 days post-partum (pp). The groups were similar in socio-economic, demographic, anthropometric, previous breastfeeding experience and prenatal care variables. Non-parametric survival analyses adjusting for potential confounding factors show that breastfeeding guidance had a positive impact (P < or = 0.05) on breastfeeding duration among primiparous women who delivered in the rooming-in hospital. Among primiparae, the RI and RIBFG groups had higher (P < or = 0.05) full breastfeeding rates than the NUR group in the short term. In the longer term, only the difference between the RIBFG and the NUR group remained statistically significant. The maternity ward system did not have a statistically significant effect on the lactation performance of multiparae.

Effects of an iron supplementation trial on the Fe status of Thai schoolchildren

A double-blind clinical trial was conducted among 9- to 11-year-old children in sixteen schools in the Chon Buri province of Thailand to assess the effects of an iron supplement combined with an anthelminthic agent (i.e. albendazole). In addition to the albendazole, Fe or placebo tablets were distributed to 2268 children enrolled in grades three to five without knowledge of the Fe status of the children. Criteria for case inclusion were: (a) absence of A E Bart's or haemoglobin (Hb) H disease, (b) absence of abnormal Hb EE, and (c) age, 108-144 months. The results showed a significant improvement in the Fe status of the children after 16 weeks of treatment. The increments were: Hb from 124 to 128 g/l, serum ferritin from 34.54 to 104.72 micrograms/l, transferrin saturation from 24.09 to 35.05%; free erythrocyte protoporphyrin decreased from 444.7 to 281.4 micrograms/l erythrocytes. These changes were significantly greater than in the control group that received only the anthelminthic agent. However, the administration of albendazole only also resulted in significant changes in the same Fe indicators.

Developmental effects of short-term supplementary feeding in nutritionally-at-risk Indonesian infants

This study assessed the developmental effects of supplementary feeding over 90 consecutive days on infants aged 6-20 mo at six tea plantations in West Java, Indonesia. Every day except Sunday, the infants attended day-care centers distributed throughout the plantations. Twenty centers and 113 infants were selected; the infants in 9 centers received a dietary supplement, while the infants in 11 centers served as control subjects. Supplements were given twice a day providing, on average, 10.66 kJ (400 kcal) and 5 g protein/d. Measurements of body growth, dietary intake, and mental and motor development were made on all infants. Supplementary feeding had significant effects on weight gain and on motor development. Changes in caloric intake were independently associated with changes in weight and in motor test scores. The data suggest that the effects of the supplement may not have followed a simple mechanistic relationship from intake to weight change to motor development, but, rather, intake may have affected both growth and development domains simultaneously.