Deworming and micronutrient status by community open defecation prevalence: An observational study using nationally representative data from India, 2016-2018

BACKGROUND

Micronutrient deficiencies are widespread in India. Soil-transmitted helminth (STH) infections are acquired by interaction with soil and water contaminated by human feces and lead to blood loss and poor micronutrient absorption. The current recommendation for control of STH-related morbidity is targeted deworming, yet little is known about the effectiveness of deworming on micronutrient status in varying sanitation contexts. Ranging between 1% and 40% prevalence across Indian states, open defecation (OD) remains high despite India's investments at elimination by promoting community-wide sanitation. This variation provides an opportunity to study the relationship between deworming, micronutrient status, and OD at-scale.

METHODS AND FINDINGS

Cross-sectional datasets that were representative for India were obtained the Comprehensive National Nutrition Survey in 2016 to 2018 (n = 105,060 individuals aged 1 to 19 years). Consumption of deworming medication was described by age and community OD level. Logistic regression models were used to examine the relationship between deworming, cluster OD, and their interactions, with anemia and micronutrient deficiencies (iron, zinc, vitamin A, folate, and vitamin B12), controlling for age, sex, wealth, diet, and seasonality. These regression models further allowed us to identify a minimum OD rate after which deworming becomes ineffective. In sensitivity analyses, the association between deworming and deficiencies were tested in subsamples of communities classified into 3 OD levels based on statistical tertiles: OD free (0% of households in the community practicing OD), moderate OD (>0% and <30%), or high OD (at least 30%). Average deworming coverage and OD prevalence in the sample were 43.4% [IQR 26.0, 59.0] and 19.1% [IQR 0, 28.5], respectively. Controlling for other determinants of nutritional status, adolescents living in communities with higher OD levels had lower coverage of deworming and higher prevalence of anemia, zinc, vitamin A, and B12 deficiencies. Compared to those who were not dewormed, dewormed children and adolescents had lower odds of anemia (adjusted odds ratio 0.72, (95% CI [0.67, 0.78], p < 0.001) and deficiencies of iron 0.78, (95% CI [0.74, 0.82], p < 0.001) and folate 0.69, (95% CI [0.64,0.74], p<0.001)) in OD free communities. These protective effects remained significant for anemia but diminished for other micronutrient deficiencies in communities with moderate or high OD. Analysis of community OD indicated a threshold range of 30% to 60%, above which targeted deworming was no longer significantly associated with lower anemia, iron, and folate deficiency. The primary limitations of the study included potential for omitted variables bias and inability to capture longitudinal effects.

CONCLUSIONS

Moderate to high rates of OD significantly modify the association between deworming and micronutrient status in India. Public health policy could involve sequencing interventions, with focus on improving deworming coverage in communities that have achieved minimum thresholds of OD and re- triggering sanitation interventions in high OD communities prior to deworming days, ensuring high coverage for both. The efficacy of micronutrient supplementation as a complementary strategy to improve nutritional outcomes alongside deworming and OD elimination in this age group needs further study.

"I'll meet you at our bench": adaptation, innovation and resilience among VCSE organisations who supported marginalised and minoritised communities during the Covid-19 pandemic in Northern England - a qualitative focus group study

BACKGROUND

The Covid-19 pandemic has exacerbated pre-existing inequalities and increased adversity and challenges for vulnerable and marginalised communities worldwide. In the UK, the Voluntary Community and Social Enterprise (VCSE) sector play a vital role in supporting the health and wellbeing of people who are marginalised or experiencing multiple complex needs. However, only a small number of studies have focused on the impact that Covid-19 had on the VCSE sector.

METHODS

As part of a Health Inequalities Impact Assessment (HIIA), we conducted qualitative focus groups with staff and volunteers from five organisations to examine short, medium and longer-term impacts of Covid-19 upon the VCSE sector in Northern England. Nine online focus groups were conducted between March and July 2021.

FINDINGS

Focus group transcripts were analysed using Framework Analysis and yielded three central themes: (1) exacerbation of pre-existing inequalities, adversity and challenges for vulnerable and marginalised populations; (2) the 'price' of being flexible, innovative and agile for VCSE staff and volunteers; and (3) the voluntary sector as a 'lifeline' - organisational pride and resilience.

CONCLUSIONS

While the voluntary sector 'adapted at pace' to provide support during Covid-19 and in its continued aftermath, this resilience has potentially come at the cost of workforce and volunteer wellbeing, compounded by political obstacles and chronic shortage in funding and support. The VCSE sector has a vital role to play in the post-lockdown 'levelling up' agenda. The expertise, capacity and resilience of VCSE organisations, and their ability to respond to Covid-19, should be celebrated, recognised and supported adequately to maintain its resilience. To not do so threatens the sector's sustainability and risks jeopardising attempts to involve the sector in addressing the social determinants of health.

Food Insecurity and Perceived Effects of COVID-19 on Livelihoods in Rural Sri Lanka

BACKGROUND

Little is known about how the COVID-19 pandemic has affected food security and livelihoods in Sri Lanka.

OBJECTIVE

This article aims to assess food insecurity, perceived effects of COVID-19, and coping mechanisms among agriculture-based households in rural Sri Lanka.

METHODS

We used 2 rounds of panel data from phone surveys (n = 1057 households) conducted in 5 districts. Food insecurity (30-day recall), perceived impacts of COVID-19 (6-month recall), and coping mechanisms (6-month recall) were assessed using a household questionnaire. To assess food insecurity, we used the 8-item Food Insecurity Experience Scale. We tested for differences between T1 (baseline: December 2020-February 2021) and T2 (follow-up: July 2021-September 2021) and explored the association between food insecurity and the perceived effect of COVID-19 on income using a logistic regression model.

RESULTS

Food insecurity was highly prevalent (T1: 75%, T2: 80%) but varied across districts. Most respondents were affected by COVID-19 and/or COVID-19-associated mitigation measures (T1: 84%, T2: 89%). Among affected households, commonly reported impacts included those on income (T1: 77%, T2: 76%), food costs (T1: 84%, T2: 83%), and travel (∼90% in both rounds). Agricultural activities were also adversely affected (T1: 64%, T2: 69%). About half of COVID-19-affected households reported selling livestock or assets to meet basic needs. Households whose income was impacted by COVID-19 were more likely to be food insecure (adjusted odds ratio: 2.56, P < .001).

CONCLUSIONS

Households in rural Sri Lanka experienced food insecurity and livelihood disturbances during the COVID-19 pandemic. Additional surveys are needed to assess recovery post-COVID-19 and to understand if programs that support livelihoods have been protective.

Near-surface magma flow instability drives cyclic lava fountaining at Fagradalsfjall, Iceland

Lava fountains are a common manifestation of basaltic volcanism. While magma degassing plays a clear key role in their generation, the controls on their duration and intermittency are only partially understood, not least due to the challenges of measuring the most abundant gases, H2O and CO2. The 2021 Fagradalsfjall eruption in Iceland included a six-week episode of uncommonly periodic lava fountaining, featuring ~ 100-400 m high fountains lasting a few minutes followed by repose intervals of comparable duration. Exceptional conditions on 5 May 2021 permitted close-range (~300 m), highly time-resolved (every ~ 2 s) spectroscopic measurement of emitted gases during 16 fountain-repose cycles. The observed proportions of major and minor gas molecular species (including H2O, CO2, SO2, HCl, HF and CO) reveal a stage of CO2 degassing in the upper crust during magma ascent, followed by further gas-liquid separation at very shallow depths (~100 m). We explain the pulsatory lava fountaining as the result of pressure cycles within a shallow magma-filled cavity. The degassing at Fagradalsfjall and our explanatory model throw light on the wide spectrum of terrestrial lava fountaining and the subsurface cavities associated with basaltic vents.

Evidencing general acceptability of open-label placebo use for tackling overtreatment in primary care: a mixed methods study

BACKGROUND

Overtreatment poses a challenge to healthcare systems due to harmful consequences of avoidable side-effects and costs. This study presents the first account for examining the feasibility of placebo use for reducing overtreatment in primary care, including whether public attitudes support the use of different placebo types in place of inappropriate prescriptions of antibiotics, antidepressants, or analgesics.

METHODS

We used a multi-study, mixed-methods design, including patient and public (PPI) consultations, focus groups (Study 1) and two pre-registered online experiments (Studies 2 and 3).

RESULTS

Study 1 (N = 16) explored everyday conceptions and practicalities of potential placebo use in the context of respiratory infections. Findings highlighted the importance of trusting doctor-patient relationships and safety-netting. Study 2 employed a randomised experiment with a representative UK sample (N = 980), investigating attitudes towards 5 different treatment options for respiratory infections: (1) blinded + pure placebo, (2) open-label + pure placebo, (3) open-label + impure placebo, (4) antibiotic treatment, and (5) no treatment. Study 2 also examined how attitudes varied based on wording and individual differences. Findings indicated general support (ηp2 = .149, large effect size) for replacing inappropriate antibiotics with open-label + impure placebos, although personal placebo acceptability was lower. Also, older people, individuals suffering from chronic illness or those showing higher levels of health anxiety appeared less amenable to placebo use. Study 3 (N = 1177) compared attitudes towards treatment options across three clinical scenarios: respiratory infection, depression and pain. Findings suggested significant differences in the acceptability of placebo options based on the clinical context. In the infection scenario, options for open-label + pure placebos, open-label + impure placebos and no treatment were rated significantly more acceptable (ηp2 = .116, medium effect size) compared to the depression and pain scenarios. Again, general support for placebos was higher than placebo acceptability for personal use.

CONCLUSIONS

Findings from PPI and three studies indicate general support for combatting overprescribing in primary care through clinical placebo use. This is an indicator for wider UK public support for a novel, behavioural strategy to target a long-standing healthcare challenge. General acceptability appears to be highest for the use of open-label + impure placebos in the context of antibiotic overprescribing.

Concurrent Undernutrition and Overnutrition within Indian Families between 2006 and 2021

Background

The double burden of malnutrition (DBM), characterized by concurrent undernutrition and overnutrition, is a growing global concern. Families share resources and eating behaviors and programs often target households, yet evidence of the DBM at the family level is scarce.

Objectives

This study examined trends and inequality in the intrahousehold DBM in India between 2006 and 2021.

Methods

Data were from 3 waves of India's National Family Health Survey (NFHS 2006, 2016, and 2021). We examined 3 types of household member (with children aged <5 y) combinations: mother-child (N = 328,039 across 3 waves), father-child, and parent (mother and father)-child (N = 47,139 for each pair). The DBM was defined as one or more individuals with undernutrition (either wasting or stunting in children or underweight in adults) and one or more overweight individuals within the same household. DBM was examined over time, at national and subnational levels, and by residence and wealth.

Results

Nearly all DBM was in the form of an overweight parent and an undernourished weight or stunted child. The prevalence of parent-child DBM increased from 15% in 2006 to 26% in 2021. Father-child pairs experienced the most rapid DBM increase, from 12% in 2006 to 22% in 2021, an 83% increase, driven by increasing overweight among men. In 2021, the DBM was highest in North-Eastern and Southern states, and among relatively rich households from urban areas. The increase in the DBM was faster in rural areas and among poor households compared with that in urban areas and rich households. Urban-rural and rich-poor inequalities in the DBM have decreased over time.

Conclusions

The intrahousehold DBM has increased over time, affecting 1 in 4 households in India in 2021. Family-based interventions that can simultaneously address child underweight and parent overweight are required to address India's increasing intrahousehold DBM.

The community engagement course and action network: strengthening community and academic research partnerships to advance health equity

Background

Historically Black Colleges and Universities and Minority Serving Institutions are uniquely positioned to implement community-campus research partnerships based on a history of service, the pursuit of community trustworthiness and student demographics often similar to surrounding marginalized communities. The Morehouse School of Medicine Prevention Research Center collaborates with members of Historically Black Colleges and Universities, Minority Serving Institutes, and community organizations on the Community Engaged Course and Action Network. This network is the first of its kind and aims to strengthen members' ability to implement Community-Based Participatory Research (CBPR) principles and partnerships. Projects address public health priorities including mental health among communities of color, zoonotic disease prevention, and urban food deserts.

Materials and methods

To assess the effectiveness of the network, a Participatory Evaluation framework was implemented to conduct process evaluation which included review of partnership structures, operations, project implementation processes, and preliminary outcomes of the research collaborations. A focus group of Community Engagement Course and Action Network members (community and academic) was also conducted to identify benefits and challenges of the network with emphasis on key areas for improvement to further enhance the relationships between partners and to facilitate their subsequent community-campus research.

Results

Network improvements were tied to themes strengthening community-academic partnerships including sharing and fellowship, coalition building and collaboration, and greater connections and awareness of community needs through their current community-academic partnerships. The need to conduct ongoing evaluation during and after implementation, for determining the early adoption of CBPR approaches was also identified.

Conclusion

Evaluation of the network's processes, infrastructure, and operation provides early lessons learned to strengthen the network. Ongoing assessment is also essential for ensuring continuous quality improvement across partnerships such as determining CBPR fidelity, assessing partnership synergy, and dynamics, and for quality improvement of research protocol. The implications and potential for advancing implementation science through this and similar networks are great towards advancing leadership in modeling how foundations in community service can advance to CBPR partnership formation and ultimately, health equity approaches, that are local defined and assessed.

More is not enough: High quantity and high quality antenatal care are both needed to prevent low birthweight in South Asia

Antenatal care (ANC) is an opportunity to receive interventions that can prevent low birth weight (LBW). We sought to 1) estimate LBW prevalence and burden in South Asia, 2) describe the number of ANC visits (quantity) and interventions received (quality), and 3) explore associations between ANC quantity, quality and LBW. We used Demographic and Health Survey (DHS) data from Afghanistan (2015), Bangladesh (2018), India (2016), Nepal (2016), Pakistan (2018) and Sri Lanka (2016) (n = 146,284 children <5y). Women were categorized as follows: 1) low quantity (<4 ANC visits) and low quality (<5 of 10 interventions received during ANC), 2) low quantity and high quality (≥5 of 10 interventions), 3) high quantity (≥4 visits) and low quality, 4) high quantity and high quality. We used fixed effect logistic regressions to examine associations between ANC quality/quantity and LBW (<2500 grams). LBW prevalence was highest in Pakistan (23%) and India (18%), with India accounting for two-thirds of the regional burden. Only 8% of women in Afghanistan received high quantity and high quality ANC, compared to 42-46% in Bangladesh, India, and Pakistan, 65% in Nepal and 92% in Sri Lanka. Compared to the low quantity/quality reference group, children of women with high quantity/quality ANC had lower odds of LBW in India (Adjusted Odds Ratio 0.84, 95% CI 0.78-0.89), Nepal (0.57, 0.35-0.94), Pakistan (0.45, 0.23-0.86), and Sri Lanka (0.73, 0.57-0.92). Low quantity but high quality ANC was protective in India (0.90, 0.84-0.96), Afghanistan (0.53, 0.27-1.05) and Pakistan (0.49, 0.23-1.05). High quantity but low quality ANC was protective in Sri Lanka (0.76, 0.61-0.93). Neither frequent ANC without appropriate interventions nor infrequent ANC with appropriate interventions are sufficient to prevent LBW in most South Asian countries, though quality may be more important than quantity. Consistent measurement of interventions during ANC is needed.

'How I'm feeling today, I probably won't be feeling tomorrow'. Using I-Poems to explore young people's changing emotions during the Covid-19 pandemic - A qualitative, longitudinal study

Background

Relatively little published qualitative research has explored children and young people's (CYP) prolonged or longitudinal experiences of the pandemic, and their emotional responses to such unreserved change to everyday life. As part of a broader, qualitative longitudinal study, this paper explores change and continuity in young people's emotions over time during the Covid-19 pandemic in North East England.

Methods

I-Poems were curated for each of the 26 young people in this study from serial interview transcripts and diary entries, collected over the course of 16 months. Creation of I-Poems require researchers to focus on sentences made by the interviewee that include the word "I," and without changing the order of those sentences, to present them in poetic stanzas.

Findings

Young people's voices and experiences became more poignant and powerful when their 'I' narrative was centralised, silencing the presence of the researcher. Further, presenting the data in this way allowed us to see how the following emotions shifted over time: grief, sadness, frustration, anger, anxiety, joy, pleasure, excitement. We contend that young people experienced significant rupture and change over the course of our 16 month project, with both positive and negative repercussions for their emotional wellbeing.

Conclusions

Large scale (quantitative and qualitative) studies remain much needed to focus on the long-term impacts of the pandemic on young people's social, emotional and cultural lives. Longitudinal and creative qualitative approaches (such as I-Poems) have the potential to centralise participant voice, break down power dynamics, and allow exploration of shifting experiences and emotions over time.

The role of hospital antimicrobial and infectious diseases pharmacists in the UK: a theoretically underpinned exploration

Objectives

We sought to characterise the role of hospital infection pharmacists in the UK and to understand the core challenges being faced, future role development desires and the required support to address these.

Methods

We developed a questionnaire underpinned by the theoretical domains framework exploring the barriers and enablers to pharmacists fulfilling their perceived roles and responsibilities. Any pharmacist whose role included 'specialist antimicrobial' or 'infectious diseases' was invited to complete a questionnaire sent via national infection and pharmacy groups/networks. Descriptive statistics were used to report responses to each item, and a content analysis was undertaken to summarize the key messages from an extended response option.

Results

Of the 102 respondents, 91 (89.2%) were from English hospitals. Fifty-three (52%) were from district general hospitals and 45 (45.1%) from teaching hospitals. Most (97, 95%) respondents were of a senior grade. The need for a comprehensive educational programme, recognition of research as core to the role and integration with infection/microbiology departments were key requirements along with protected time to engage with the activities. Highlights of the role were opportunities to teach, making a significant contribution to patient care and scope to contribute to strategy and vision. The COVID-19 pandemic negatively impacted on respondents' capacity to undertake their perceived roles and responsibilities.

Conclusions

Our study delineates the need for UK infection and pharmacy policy makers to review hospital infection pharmacist developmental pathways and roles. Joint learning, and closer working, with infection/microbiology departments may be an efficient strategy to address the issues raised.

Letter to the Editor Regarding: Evolving Business Models in Orthotics by Schneider, N

The purpose of this letter is to continue the dialogue regarding the paper "Evolving business models in Orthotics" in the Canadian Prosthetics & Orthotics Journal Volume 4, Issue2, No.3, 2021. In it we present the perspective of the current Alberta Association of Orthotists and Prosthetists (AAOP) and provide additional context and information on historical events. Finally, we provide additional clarity on how costing is approached in the Province of Alberta (Canada) and the purported inequity in compensation between the two disciplines.

Underweight, overweight or obesity, diabetes, and hypertension in Bangladesh, 2004 to 2018

Background and objectives

Bangladesh is experiencing a nutrition transition with an increase in the double burden of malnutrition and non-communicable diseases (NCDs). This study sought to: 1) examine trends and differences in underweight, overweight/obesity, hypertension and diabetes by gender, area of residence, and wealth in Bangladesh from 2004 to 2018, 2) assess what factors contributed to changes in these outcomes.

Methods

We used data from five rounds of the Bangladesh Demographic and Health Surveys (n = 76,758 women 15-49y and 10,900 men 18-95y in total). We calculated differences, slope index of inequality (SII) and concentration index (CIX) to examine trends over time and differences in outcomes by wealth and residence. We identified determinants and estimated drivers of changes in outcomes using regression-based decomposition.

Results

Between 2004 and 2018, underweight prevalence decreased in both women (33% to 12%) and men (26% to 18%), whereas overweight/obesity increased (17% to 49% in women and 21% to 34% in men). Hypertension also increased in both women (31% to 44%) and men (19% to 33%) while diabetes changed marginally (11% to 14%). In all years, underweight was concentrated in poorer and rural households while overweight/obesity, diabetes and hypertension were concentrated in wealthier and urban households. Wealth inequity decreased over time for underweight, changed little for overweight/obesity, and increased for hypertension and diabetes among men. Increases in wealth explained 35% to 50% of the reduction in underweight and 30% to 57% of the increase in overweight/obesity.

Conclusion

Our findings imply that double duty actions are required to sustain the decrease in undernutrition and slow the increase in overweight/obesity and NCDs across diverse socioeconomic sections of the population in Bangladesh.

Variation on a theme: the structures and biosynthesis of specialized fatty acid natural products in plants

Plants are able to construct lineage-specific natural products from a wide array of their core metabolic pathways. Considerable progress has been made toward documenting and understanding, for example, phenylpropanoid natural products derived from phosphoenolpyruvate via the shikimate pathway, terpenoid compounds built using isopentyl pyrophosphate, and alkaloids generated by the extensive modification of amino acids. By comparison, natural products derived from fatty acids have received little attention, except for unusual fatty acids in seed oils and jasmonate-like oxylipins. However, scattered but numerous reports show that plants are able to generate many structurally diverse compounds from fatty acids, including some with highly elaborate and unique structural features that have novel bioproduct functionalities. Furthermore, although recent work has shed light on multiple new fatty acid natural product biosynthesis pathways and products in diverse plant species, these discoveries have not been reviewed. The aims of this work, therefore, are to (i) review and systematize our current knowledge of the structures and biosynthesis of fatty acid-derived natural products that are not seed oils or jasmonate-type oxylipins, specifically, polyacetylenic, very-long-chain, and aromatic fatty acid-derived natural products, and (ii) suggest priorities for future investigative steps that will bring our knowledge of fatty acid-derived natural products closer to the levels of knowledge that we have attained for other phytochemical classes.

Chicken liver and eggshell crackers as a safe and affordable animal source food for overcoming micronutrient deficits during pregnancy and lactation in Indonesia: a double-blind, randomised placebo-controlled trial (SISTIK Growth Study)

Background: Indonesia ranks fifth in terms of the number of stunted children and there has been little change in the stunting prevalence in the last decade. In earlier observational studies conducted in 2014-2015, we identified several key underlying problems with the potential to impact stunting in Sumedang district, West Java, Indonesia. Deficits in intakes of growth-limiting micronutrients were observed, most notably calcium, iron, zinc, and vitamin A, emphasizing the need for a food-based intervention to overcome these micronutrient deficits in the diets of mothers and their infants.

Methods: A double-blind placebo-controlled cluster randomised trial comparing the effect of daily consumption of 75 grams of locally produced micronutrient-enriched crackers (MEC) (intervention group) compared to placebo crackers (control group) by mothers at two-time intervals: (i) from the 8-14 weeks of pregnancy to delivery (i.e., 28-34 weeks of consumption of MEC) on birth length, and (ii) from the 8-14 weeks of pregnancy to 5 months post-partum on attained linear growth and linear growth velocity of breast-fed infants. A total of 324 pregnant women from 28 clusters (villages) located in 3 sub-districts in Sumedang district, West Java, Indonesia, will be randomly assigned to either intervention (n=14 villages) or control (n=14 villages).

Discussion: This will be the first study in Indonesia to use crackers based on powdered eggshells and chicken liver, in a form which is acceptable, safe, and has a long shelf life. If daily consumption of MEC for 6 months during pregnancy can enhance birth length, or their continued daily consumption for 5 months postpartum improves both attained and incremental linear growth at 5 months of age, then scaling-up in Indonesia may be considered.

Trial Registration: https://clinicaltrials.gov/ct2/show/NCT04564222; 25 ^th September 2020

A good investment: longer-term cost savings of sensitive parenting in childhood

Introduction

Good quality parenting in early childhood is reliably associated with positive mental and physical health over the lifespan.

Objectives

The hypothesis that early parenting quality has significant long-term financial benefits has not been previously tested.

Methods

Design: Longitudinal study with follow-up from 2012 to 2016; UK multicentre study cohort. Participants: 174 young people drawn from 2 samples, one at moderate risk of poor outcomes and one at high risk, assessed aged 4–6 years then followed up in early adolescence (mean age 12.1 years). Measures: The primary outcome was total costs: health, social care, extra school support, out-of-home placements and family-born expenditure, determined through semistructured economic interviews. Early parenting quality was independently assessed through direct observation of parent–child interaction.

Results

Costs were lower for youths exposed to more sensitive parenting (most sensitive quartile mean £1,619, least sensitive quartile mean £21,763; p < .001). Costs were spread across personal family expenditure and education, health, social and justice services. The cost difference remained significant after controlling for several potential confounders. These included demographic variables (family poverty, parental education); exposure to child abuse; and child/young person variables including level of antisocial behaviour in both childhood and adolescence, IQ and attachment security.

Conclusions

This study is the first showing that more sensitive early parental care predicts lower costs to society many years later, independent of poverty, child and youth antisocial behaviour levels and IQ. The findings provide novel evidence for the public health impact of early caregiving quality and likely financial benefits of improving it.

Disclosure

No significant relationships.

A Quasi-Experimental Evaluation of a Nutrition Behavior Change Intervention Delivered Through Women's Self-Help Groups in Rural India: Impacts on Maternal and Young Child Diets, Anthropometry, and Intermediate Outcomes

Background

Women's self-help groups (SHGs) have become one of the largest institutional platforms serving the poor. Nutrition behavior change communication (BCC) interventions delivered through SHGs can improve maternal and child nutrition outcomes.

Objectives

The objective was to understand the effects of a nutrition BCC intervention delivered through SHGs in rural India on intermediate outcomes and nutrition outcomes.

Methods

We compared 16 matched blocks where communities were supported to form SHGs and improve livelihoods; 8 blocks received a 3-y nutrition intensive (NI) intervention with nutrition BCC, and agriculture- and rights-based information, facilitated by a trained female volunteer; another 8 blocks received standard activities (STD) to support savings/livelihoods. Repeated cross-sectional surveys of mother-child pairs were conducted in 2017-2018 (n = 1609 pairs) and 2019-2020 (n = 1841 pairs). We matched treatment groups over time and applied difference-in-difference regression models to estimate impacts on intermediate outcomes (knowledge, income, agriculture/livelihoods, rights, empowerment) and nutrition outcomes (child feeding, woman's diet, woman and child anthropometry). Analyses were repeated on households with ≥1 SHG member.

Results

Forty percent of women were SHG members and 50% were from households with ≥1 SHG member. Only 10% of women in NI blocks had heard of intervention content at endline. Knowledge improved in both NI and STD groups. There was a positive NI impact on knowledge of timely introduction of animal-sourced foods to children (P < 0.05) but not on other intermediate outcomes. No impacts were observed for anthropometry or diet indicators except child animal-source food consumption (P < 0.01). In households with ≥1 SHG member, there was a positive NI impact on child unhealthy food consumption (P < 0.05).

Conclusions

Limited impacts could be due to limited exposure or skills of volunteers, and a concurrent national nutrition campaign. Our findings add to a growing literature on SHG-based BCC interventions and the conditions necessary for their success.

Language used to describe medication review activities: does it require standardisation? A narrative synthesis

Introduction

Medication review (MR) is a health care professional’s systematic assessment of a patient’s medications with recommendations for improvement (1). To enable comparison between different evaluations of medication review-based interventions to determine whether the nature of activity differs, it is important that standardised language is used. Currently, there is no accepted international taxonomy for describing medication review activities. Therefore, we undertook a systematic review of literature with narrative synthesis to determine whether standardisation may be appropriate.

Aim

To determine the range of terms used to describe medication review activities.

Method

A PROSPERO registered systematic review (CRD 42020215992) was performed using search terms according to the Population, Intervention, Comparison and Outcome (PICO) framework. ‘Population’ & ‘Comparison’ were not used. Synonyms for medication review activities were used for both ‘Intervention’ and ‘Outcomes’, e.g., stop, start, change, alter. We included all papers reporting medication review activities in English with empirical data. Papers not using language to describe medication review activities were excluded. Two researchers reviewed all titles, abstracts, and full-text papers independently; discussion resolved any disagreement. Data extraction was carried out independently as per Cochrane Effective Practice and Organisation of Care (EPOC) as follows:

The papers were assessed using the Mixed Method Appraisal Tool (MMAT). The research team themed the extracted terms.

Results

After deleting duplicates, 9746 titles were screened. Twenty-one studies were included: eight quantitative non-randomised trials, eight randomised controlled trials, and five quantitative descriptive studies. The studies covered the UK, Netherlands, Australia, Sweden, Norway, Belgium, Canada, and Jordan. The table summarises the medication review activities reported in these papers.

Conclusion

Various authors reported medication review activities. ‘Alter’ and ‘adaptation’ are examples of ambiguous terms. Determining whether actions are related with activities to reduce or increase doses is difficult due to such terminology. As a result, comparing medication review approaches may be difficult. Limiting the search strategy to English-language only may have missed some studies. A taxonomy to describe and define medication review activities, thereby standardising MR reporting, should improve the presentation of data from process evaluations and the ability to compare activity between studies.

Reference

(1) Christensen M, Lundh A. Medication review in hospitalised patients to reduce morbidity and mortality. Cochrane Database Syst Rev [Internet]. 2016 Feb 20; Available from: https://doi.wiley.com/10.1002/14651858.CD008986.pub3

Changes in anemia and anthropometry during adolescence predict learning outcomes: findings from a 3-year longitudinal study in India

BACKGROUND

Anemia and poor physical growth during adolescence have far-ranging consequences, but limited longitudinal evidence exists on how changes in these factors relate to changes in learning skills as adolescents mature.

OBJECTIVES

We examined the association between changes in anemia and physical growth during adolescence and learning outcomes.

METHODS

We used longitudinal data from the Understanding the Lives of Adolescents and Young Adults (UDAYA) project, which surveyed adolescents aged 10-19 y in northern India in 2015-2016 and 2018-2019 (n = 5963). We used multilevel mixed-effects logistic regression models to examine associations between changes in anemia/thinness/stunting status (4 groups: never, improved, new, and persistent) and reading (ability to read a story) and math proficiency (ability to solve division problems) at follow-up.

RESULTS

Persistent anemia and stunting were higher among girls than among boys (46% compared with 8% and 37% compared with 14%, respectively), but persistent thinness was lower (7% compared with 16%). Improvement in anemia, thinness, and stunting was 1.4-1.7 times higher among boys than among girls. Boys who were anemic in both waves were 74% [adjusted odds ratio (AOR): 0.26; 95% CI: 0.12, 0.59] and 65% (AOR: 0.35; 95% CI: 0.16, 0.76) less likely to be able to read a story and solve division problems, respectively, than boys who were nonanemic in both waves. Persistent thinness in boys was negatively associated with both reading (AOR: 0.37; 95% CI: 0.21, 0.66) and math proficiency (AOR: 0.27; 95% CI: 0.16, 0.46). Persistent stunting contributed to lower reading and math proficiency in boys and girls (AORs: 0.29-0.46). Boys whose anemia or thinness status improved and girls whose stunting status improved had similar learning skills at follow-up as those who were never anemic/thin/stunted.

CONCLUSIONS

Persistent anemia, thinness, and short stature during adolescence were associated with poor learning. Programs targeted at adolescents should contribute to nurturing environments that foster healthy growth and learning.

Unequal coverage of nutrition and health interventions for women and children in seven countries

Objective

To examine inequalities and opportunity gaps in co-coverage of health and nutrition interventions in seven countries.

Methods

We used data from the most recent (2015–2018) demographic and health surveys of mothers with children younger than 5 years in Afghanistan (n = 19 632), Bangladesh (n = 5051), India (n = 184 641), Maldives (n = 2368), Nepal (n = 3998), Pakistan (n = 8285) and Sri Lanka (n = 7138). We estimated co-coverage for a set of eight health and eight nutrition interventions and assessed within-country inequalities in co-coverage by wealth and geography. We examined opportunity gaps by comparing coverage of nutrition interventions with coverage of their corresponding health delivery platforms.

Findings

Only 15% of 231 113 mother–child pairs received all eight health interventions (weighted percentage). The percentage of mother–child pairs who received no nutrition interventions was highest in Pakistan (25%). Wealth gaps (richest versus poorest) for co-coverage of health interventions were largest for Pakistan (slope index of inequality: 62 percentage points) and Afghanistan (38 percentage points). Wealth gaps for co-coverage of nutrition interventions were highest in India (32 percentage points) and Bangladesh (20 percentage points). Coverage of nutrition interventions was lower than for associated health interventions, with opportunity gaps ranging from 4 to 54 percentage points.

Conclusion

Co-coverage of health and nutrition interventions is far from optimal and disproportionately affects poor households in south Asia. Policy and programming efforts should pay attention to closing coverage, equity and opportunity gaps, and improving nutrition delivery through health-care and other delivery platforms.

Exploring young people's perspectives of inequalities in health: a qualitative study

Background

Reducing inequalities in health is an enduring global public health challenge. Worryingly in England, inequalities across some groups and places are worsening, highlighted and exacerbated by the Covid-19 pandemic. While there has been growing interest in exploring public understandings of health inequalities, few studies have explored the views of young people. Our study seeks to redress this by exploring young people's perspectives of inequalities in health.

Methods

Working with existing youth organisations, we recruited young people (aged 13-21) from six youth groups in areas of high deprivation across three geographical locations in England. Each group took part in three interlinked focus groups (n = 18), the majority of which were run online using video conferencing platforms. Focus groups were co-delivered with partnering youth organisations during 2021. They involved participatory concept mapping activities, and the discussion of health related news articles.

Results

Key themes emerged around young people's perspectives of: i) factors influencing health within their local area; ii) understandings of inequalities in health; and iii) key messages to convey to those with a role in addressing health inequalities at a place level.

Conclusions

Our study highlights the importance of exploring and understanding young people's perspectives of inequalities in order to better shape policies which are supported by the communities and people they impact.

Key messages

Young people have a nuanced, experiential understanding of key factors influencing their health and inequalities in health within their local areas. Building upon young people’s understandings of inequalities in health provides opportunities to mobilise support for policies seeking to change the distribution of key social determinants.

A Nutrition Behaviour Change Intervention Delivered Through Women's Self-Help Groups in India Is Protective Against Depression and Reduces Time Spent in Market Work

Objectives

Women's self-help groups (SHGs), which operate at large scale in India, are an important platform for delivering behaviour change communication (BCC) and social support interventions to rural women. Little is known about how such group-based interventions affect women's mental health and time use.

Methods

The Women Improving Nutrition through Group-based Strategies (WINGS) study was a quasi-experimental impact evaluation, comparing 16 blocks (8 matched pairs) with SHG formation support; 8 blocks received a 3-year nutrition intervention (NI) with BCC topics such as nutrition, home-gardens and women's well-being, facilitated by a trained female volunteer; the other 8 received standard activities (STD) to support savings & livelihoods. We conducted repeated cross-sectional surveys of mother-child pairs in 2017–18 (n = 1609) and 2019–20 (n = 1841). We matched treatment groups over time and applied difference-in-difference (DID) regression models to estimate NI impacts. Outcomes assessed: (1) common mental disorder symptoms (CMD) (Self Reporting Questionnaire (SRQ) score, 8 or higher) and (2) time use, constructed using 24-hour recall data. Time indicators were the proportion of time spent on productive work (employed, agricultural work), reproductive work (cooking, caring for children etc.), and time spent on social-leisure activities (hobbies, socializing).

Results

Overall, women were 25 years old with 5 years of education and worked 10.7 hours/day. CMD were reported by 17% of women. DID estimates showed that CMD prevalence doubled over time among women in STD areas but did not change in NI areas (P &lt; 0.01). Compared to STD areas, women in NI areas reported a larger decrease in time spent on productive work (DID: −5 percentage points (pp); P &lt; 0.01) and larger increases in time spent on reproductive work (DID: +5 pp; P &lt; 0.01) and on social-leisure activities (DID: +22 minutes, P &lt; 0.01).

Conclusions

A BCC intervention delivered through SHGs in rural India protected against a secular trend in declining mental health and shifted women's time from market work to domestic and social-leisure activities. These findings add to a growing evidence base on the effectiveness of group-based interventions to improve women's wellbeing in developing countries.

Funding Sources

Bill & Melinda Gates Foundation.

Effects of Persistent Undernutrition During Adolescence on Learning Skills: Findings From a Longitudinal Study of 16,000 Adolescents in India

Objectives

Limited evidence exists on longitudinal impacts of undernutrition on learning skills as adolescents mature. This study aimed to examine the effect of undernutrition in early adolescence on learning skills in late adolescence.

Methods

We used longitudinal data from a project called UDAYA that surveyed 16,929 adolescents aged 10–19 years from Bihar and Uttar Pradesh, India in 2015–16 (wave 1) and again in 2018–19 (wave 2). Adolescents’ ability to read a story and solve division problems at age 19–22 years was assessed using the Annual Status of Education Report tools. We characterized adolescents’ nutrition status into 4 groups: never undernourished (e.g., not stunted in wave 1 and 2), recovered (e.g., stunted in in wave 1 but not stunted in wave 2), faltered (e.g., not stunted in wave 1 but stunted in wave 2), and persistent (e.g., stunted in both waves). These 4 groups were created for stunting, thinness, and anemia. We used multivariable logistic regression models adjusted for key demographics, environmental factors, and sampling design.

Results

Undernutriton was high (51% were anemic, 19% thin, and 36% stunted) in both survey rounds. Nearly one third of adolescents had persistent stunting or anemia, and 11% had persistent thinness. Compared to those who were never stunted, adolescents with persistent stunting had poorer reading (adjusted odds ratio: 0.66, 95% confidence interval: 0.53–0.83) and math (0.70, 0.56–0.89) skills. Reading ability was also poorer in adolescents who experienced growth faltering (0.61, 0.42–0.90) or who were stunted in wave 1 but not stunted in wave 2 (0.64, 0.44–0.93). Persistent thinness was negatively associated with reading (0.71, 0.54–0.93) but not math skills. Persistent anemia was also negatively associated with reading skills, but the association did not remain significant in the fully adjusted model.

Conclusions

In a high poverty sample of Indian adolescents, persistent undernutrition during adolescence was associated with poor learning skill. Promisingly, most of those who recovered from undernutrition in the 2–3 year period between surveys showed catch-up in learning. Ensuring appropriate nutrition during this period of rapid physical and cognitive maturation will yield long-term dividends for wellbeing.

Funding Sources

Bill & Melinda Gates Foundation.

Food Insecurity Among Farmers in Rural Sri Lanka and the Perceived Impacts of COVID-19

Objectives

Little is known about how the COVID-19 pandemic (C19) has affected food security and farmers’ livelihoods in Sri Lanka. In this study, we assessed food security, perceived impacts of C19 and coping mechanisms to deal with these impacts.

Methods

As part of a baseline survey for an evaluation of the World Food Programme's Nutrition-Sensitive Food Assistance for Assets Program in Sri Lanka, we conducted ∼1300 quantitative household phone surveys across five districts between December 2020 and February 2021. Food insecurity was assessed using the 8-item Food Insecurity Experience Scale and categorized as moderate or severe using the Rasch model. Perceived impacts of C19 and the coping mechanisms used to deal with these shocks were assessed via questionnaire. Additionally, we explored how these experiences varied by wealth quintile, highest attained education level in the household, and district.

Results

Despite having had a relatively low burden of C19 cases in Sri Lanka compared to other countries, 85% of respondents in our sample reported being affected in some way by C19 or its associated control measures. Reported impacts include those on income (77% overall, 89% in lowest quintile, 62% in highest quintile) and agriculture activities (76% overall, 65% in lowest quintile, 87% in highest quintile), among others. Normal crop cultivation and harvesting was adversely impacted due to being advised to stay home (42%), being unable to purchase inputs (33%) and poor demand in the market (56%). In response to COVID shocks, about 30% of respondents in the lowest two wealth quintiles reported selling their livestock and about 20% of respondents across all wealth quintiles reported selling other assets. Half of the households interviewed were either moderately (36%) or severely (14%) food insecure. The proportion of households experiencing food insecurity varied by wealth quintile (mod: 55%-21%; sev: 27%-5%) and district (mod: 46%-29%; sev: 21%-10%).

Conclusions

High levels of food insecurity and disruptions across domains such as income, asset ownership, and agriculture could have short- and long-term effects on people's health, nutrition and well-being. Control measures enacted in Sri Lanka should consider the potentially devastating effects on smallholder farmers and introduce measures to mitigate these issues in those most affected.

Funding Sources

A4NH and WFP

'Well-leg' compartment syndrome associated with gynaecological surgery: a perioperative risk-reduction protocol and checklist

'Well-leg' compartment syndrome (WLCS) is an uncommon, but potentially devastating, complication associated with prolonged patient positioning for abdomino-pelvic surgery. Gynaecologists, anaesthetists and the wider theatre team share a responsibility to minimise the risk of this highly morbid, and even fatal, postoperative complication. This article provides an overview of WLCS related to gynaecological surgery - raising awareness amongst gynaecologists and highlighting the time-critical nature of diagnosis and management. Given the potential litiginous nature of this complication, we also present a perioperative checklist and risk-reduction protocol to suggest a standardised approach to prevention and relevant documentation. TWEETABLE ABSTRACT: Gynaecologists share a responsibility to minimise the risk of postoperative 'well-leg' compartment syndrome.

Teenage Birth Leads to Short Stature and Anemia: Evidence From a Longitudinal Study of 10,000 Girls in India

Objectives

Home to one in five adolescents globally and a tradition of marrying young, India faces a huge challenge of teenage births. Early birth can be detrimental to the health and wellbeing of the teenage mother and her child, but few studies have followed teenage girls over time to understand these effects. We assessed the impact of early birth on female adolescents' undernutrition status.

Methods

We used longitudinal data collected under a project called UDAYA that surveyed adolescent girls in northern India (Uttar Pradesh and Bihar) in 2015–16, with a follow-up round in 2018–19. Girls with no prior birth in round one were grouped as follows: still no birth in round two (reference group; n = 7,197), birth at age &lt; 19 years by round two (early birth group; EB; n = 1,192), and birth at age &gt; = 19 years by round two (later birth group; LB; n = 1,474). Using multivariate logistic and ordinary least square regression models, we examined whether EB or LB predicted height for age z-score (HAZ), stunting, BMI for age z-score (BMIZ), thinness, hemoglobin (Hb), and anemia. Models were controlled for cluster sampling design and individual and household characteristics.

Results

The prevalence of undernutrition was higher in the EB group (stunting: 53%, thinness: 23%, anemia: 77%) and the LB group (stunting: 55%, thinness: 29%, anemia: 64%) compared to the reference group (stunting: 35%, thinness: 16%, anemia: 63%). The EB group was more likely to be short for their age (adjusted odds ratio (AOR): 1.30, 95% confidence interval (95%CI): 0.96,1.76), thin (AOR: 1.09, 95%CI: 0.68, 1.75), and anemic (AOR: 2.01, 95%CI: 1.39, 2.90) compared to the reference group. HAZ and Hb levels were on average 0.16 SD (95%CI: –0.30, –0.03) and 0.49 gm/DL (95%CI: –0.76, –0.22) lower, respectively, and BMIZ level was 0.22 SD (95%CI: 0.00, 0.43) higher for the EB group. Similar findings were observed for the LB group but were non-significant. The impact of EB on stunting and thinness was non-significant.

Conclusions

In adolescent girls, early birth can contribute to stunting and anemia. Policy initiatives to increase age at marriage and at birth would likely also benefit nutritional outcomes in adolescents.

Funding Sources

Bill & Melinda Gates Foundation.

Vulvar Aphthous Ulcer in an Adolescent With COVID-19

BACKGROUND

Vulvar aphthous ulcers have been associated with various prodromal viral illnesses. We describe the case of an adolescent girl who developed vulvar aphthous ulcers during infection with Coronavirus, SARS-CoV-2.

CASE

A 19-year-old girl presented to the emergency department with cough, sore throat, fevers, and rash, and tested positive for COVID-19. She re-presented 2 days later with vulvar pain and was found to have a vulvar aphthous ulcer. She was admitted for pain control and treated with oral steroids. Improvement in her vulvar pain was noted, along with resolution of fevers, cough, and rash.

SUMMARY AND CONCLUSION

This case illustrates the novel association of COVID-19 with vulvar aphthous ulcers in adolescents. Use of oral steroids for symptomatic management of COVID-19 led to rapid clinical improvement.

Adolescent birth and child undernutrition: an analysis of demographic and health surveys in Bangladesh, 1996-2017

Adolescent birth is a major global concern owing to its adverse effects on maternal and child health. We assessed trends in adolescent birth and examined its associations with child undernutrition in Bangladesh using data from seven rounds of Demographic and Health Surveys (1996–2017, n = 12,006 primiparous women with living children <5 years old). Adolescent birth (10–19 years old) declined slowly, from 84% in 1996 to 71% in 2017. Compared with adult mothers (≥20 years old), young adolescent mothers (10–15 years old) were more likely to be underweight (+11 pp), have lower education (−24 pp), have less decision‐making power (−10 pp), live in poorer households (−0.9 SD) with poorer sanitation (−15 pp), and have poorer feeding practices (10 pp), and were less likely to access health and nutrition services (−3 to −24 pp). In multivariable regressions controlled for known determinants of child undernutrition, children born to adolescents had lower height‐for‐age Z‐scores (−0.29 SD for young and −0.10 SD for old adolescents (16–19 years old)), weight‐for‐age Z‐score (−0.18 and −0.06 SD, respectively) as well as higher stunting (5.9 pp) and underweight (6.0 pp) than those born to adults. In conclusion, birth during adolescence, a common occurrence in Bangladesh, is associated with child undernutrition. Policies and programs to address poverty and improve women's education can help delay marriage, reduce early childbearing, and improve child growth.

6 Improving Patient Flow in a Multi-Specialty Assessment Area by Introducing Referral Pathways for Orthopaedics and Plastic Surgery during the COVID-19 Pandemic

Introduction

The COVID-19 pandemic has seen fundamental organisational changes to emergency departments internationally. Specialties throughout the hospital setting have been asked to change their working practice, often with the aim of adapting to new processes in emergency departments. Early in the pandemic, the orthopaedic team at one district general hospital were required to provide 24/7 onsite cover in a multi-specialty area. Confusion over the referral pathways of two specialties (orthopaedics and plastic surgery) led to increase waiting times, constrained patient flow and poor patient and staff satisfaction.

Method

This quality improvement project occurred over three cycles of data collection and intervention over a two-month period. A novel referral pathway was developed and implemented after discussion with consultants in orthopaedics, plastics, and emergency medicine. Interventions included staff teaching, clarifying of roles at morning meetings and the deployment of posters.

Results

In cycle 1, 39% of orthopaedic referrals were inappropriately referred. By cycle 3, 0% of orthopaedic patients were inappropriately referred. Average time in department for patients referred to orthopaedics improved from 124 minutes to 88 minutes. Staff reported increased satisfaction, with appreciation for the clarification on referral criteria.

Conclusions

This QUIP demonstrates how simple interventions during times of crisis can solve complex organisational issues.

Functional mutants of Azospirillum brasilense elicit beneficial physiological and metabolic responses in Zea mays contributing to increased host iron assimilation

Iron (Fe), an essential element for plant growth, is abundant in soil but with low bioavailability. Thus, plants developed specialized mechanisms to sequester the element. Beneficial microbes have recently become a favored method to promote plant growth through increased uptake of essential micronutrients, like Fe, yet little is known of their mechanisms of action. Functional mutants of the epiphytic bacterium Azospirillum brasilense, a prolific grass-root colonizer, were used to examine mechanisms for promoting iron uptake in Zea mays. Mutants included HM053, FP10, and ipdC, which have varying capacities for biological nitrogen fixation and production of the plant hormone auxin. Using radioactive iron-59 tracing and inductively coupled plasma mass spectrometry, we documented significant differences in host uptake of Fe2+/3+ correlating with mutant biological function. Radioactive carbon-11, administered to plants as 11CO2, provided insights into shifts in host usage of 'new' carbon resources in the presence of these beneficial microbes. Of the mutants examined, HM053 exhibited the greatest influence on host Fe uptake with increased plant allocation of 11C-resources to roots where they were transformed and exuded as 11C-acidic substrates to aid in Fe-chelation, and increased C-11 partitioning into citric acid, nicotianamine and histidine to aid in the in situ translocation of Fe once assimilated.

Early marriage and early childbearing in South Asia: trends, inequalities, and drivers from 2005 to 2018

Early marriage (EM) and early childbearing (ECB) have far-reaching consequences. This study describes the prevalence, trends, inequalities, and drivers of EM and ECB in South Asia using eight rounds of Demographic and Health Survey data across 13 years. We report the percentage of ever-married women aged 20-24 years (n = 105,150) married before 18 years (EM) and with a live birth before 20 years (ECB). Relative trends were examined using average annual rate of reduction (AARR). Inequalities were examined by geography, marital household wealth, residence, and education. Sociodemographic drivers of changes for EM were assessed using regression decomposition analyses. We find that EM/ECB are still common in Bangladesh (69%/69%), Nepal (52%/51%), India (41%/39%), and Pakistan (37%/38%), with large subnational variation in most countries. EM has declined fastest in India (AARR of -3.8%/year), Pakistan (-2.8%/year), and Bangladesh (-1.5%/year), but EM elimination by 2030 will not occur at these rates. Equity analyses show that poor, uneducated women in rural areas are disproportionately burdened. Regression decomposition analysis shows that improvements in wealth and education explained 44% (India) to 96% (Nepal) of the actual EM reduction. Investments across multiple sectors are required to understand and address EM and ECB, which are pervasive social determinants of maternal and child wellbeing.

A comparison of gastric gas volumes measured by computed tomography after high-flow nasal oxygen therapy or conventional facemask ventilation. Anaesthesia 2021;76:1184-1189. [PMID: 33651914 DOI: 10.1111/anae.15433]

High-flow nasal oxygen therapy is increasingly used to improve peri-intubation oxygenation. However, it is unknown whether it may cause or exacerbate insufflation of gas into the stomach. High-flow nasal oxygen therapy is now standard practice in our hospital for adult patients undergoing percutaneous thermal ablation of liver cancer under general anaesthesia with tracheal intubation. We compared gastric gas volumes measured from computed tomography images that had been acquired immediately after intubation in two series of patients: 50 received peri-intubation high-flow nasal oxygen therapy and another 50 received conventional facemask pre-oxygenation and ventilation before intubation and before high-flow nasal oxygen therapy became standard practice in our unit. Median (IQR [range]) gastric gas volume was 24.0 (14.2-59.9 [3-167]) cm³ in the high-flow nasal oxygen therapy group and 23.8 (12.6-38.8 [0-185]) cm³ in the facemask group. There was no difference between the two groups in the volume of gastric gas measured by computed tomography imaging (Mann-Whitney U-test, U = 1136, p = 0.432, n₁  = n₂  = 50). Our results demonstrate that a small volume of gastric gas is commonly present after induction of anaesthesia, but that the use of peri-intubation high-flow nasal oxygen therapy for pre-oxygenation and during apnoea does not increase this volume compared with conventional facemask pre-oxygenation and ventilation. This is clinically relevant, as high-flow nasal oxygen therapy is increasingly being used in a peri-intubation context and in patients at higher risk of aspiration.

The double burden of malnutrition in India: Trends and inequalities (2006-2016)

Rapid urban expansion has important health implications. This study examines trends and inequalities in undernutrition and overnutrition by gender, residence (rural, urban slum, urban non-slum), and wealth among children and adults in India. We used National Family Health Survey data from 2006 and 2016 (n = 311,182 children 0-5y and 972,192 adults 15-54y in total). We calculated differences, slope index of inequality (SII) and concentration index to examine changes over time and inequalities in outcomes by gender, residence, and wealth quintile. Between 2006 and 2016, child stunting prevalence dropped from 48% to 38%, with no gender differences in trends, whereas child overweight/obesity remained at ~7–8%. In both years, stunting prevalence was higher in rural and urban slum households compared to urban non-slum households. Within-residence, wealth inequalities were large for stunting (SII: -33 to -19 percentage points, pp) and declined over time only in urban non-slum households. Among adults, underweight prevalence decreased by ~13 pp but overweight/obesity doubled (10% to 21%) between 2006 and 2016. Rises in overweight/obesity among women were greater in rural and urban slum than urban non-slum households. Within-residence, wealth inequalities were large for both underweight (SII -35 to -12pp) and overweight/obesity (+16 to +29pp) for adults, with the former being more concentrated among poorer households and the latter among wealthier households. In conclusion, India experienced a rapid decline in child and adult undernutrition between 2006 and 2016 across genders and areas of residence. Of great concern, however, is the doubling of adult overweight/obesity in all areas during this period and the rise in wealth inequalities in both rural and urban slum households. With the second largest urban population globally, India needs to aggressively tackle the multiple burdens of malnutrition, especially among rural and urban slum households and develop actions to maintain trends in undernutrition reduction without exacerbating the rapidly rising problems of overweight/obesity.

[Recommendations for the Protocol of functional examination of the anorectal zone and disorders classification: the International Anorectal Physiology Working Group consensus and Russian real-world practice]

This manuscript summarizes consensus reached by the International Anorectal Physiology Working Group (IAPWG) for the performance, terminology used, and interpretation of anorectal function testing including anorectal manometry (focused on high-resolution manometry), the rectal sensory test, and the balloon expulsion test. Based on these measurements, a classification system for disorders of anorectal function is proposed. Aim to provide information about methods of diagnosis and new classification of functional anorectal disorders to a wide range of specialists general practitioners, therapists, gastroenterologists, coloproctologists all who face the manifestations of these diseases in everyday practice and determine the diagnostic and therapeutic algorithm. Current paper provides agreed statements of IAPWG Consensus and comments (in italics) of Russian experts on real-world practice, mainly on methodology of examination. These comments in no way intended to detract from the provisions agreed by the international group of experts. We hope that these comments will help to improve the quality of examination based on the systematization of local experience with the use of the methods discussed and the results obtained. Key recommendations: the International Anorectal Physiology Working Group protocol for the performance of anorectal function testing recommends a standardized sequence of maneuvers to test rectoanal reflexes, anal tone and contractility, rectoanal coordination, and rectal sensation. Major findings not seen in healthy controls defined by the classification are as follows: rectoanal areflexia, anal hypotension and hypocontractility, rectal hyposensitivity, and hypersensitivity. Minor and inconclusive findings that can be present in health and require additional information prior to diagnosis include anal hypertension and dyssynergia.

Infection and mortality of healthcare workers worldwide from COVID-19: a systematic review

OBJECTIVES

To estimate COVID-19 infections and deaths in healthcare workers (HCWs) from a global perspective during the early phases of the pandemic.

DESIGN

Systematic review.

METHODS

Two parallel searches of academic bibliographic databases and grey literature were undertaken until 8 May 2020. Governments were also contacted for further information where possible. There were no restrictions on language, information sources used, publication status and types of sources of evidence. The AACODS checklist or the National Institutes of Health study quality assessment tools were used to appraise each source of evidence.

OUTCOME MEASURES

Publication characteristics, country-specific data points, COVID-19-specific data, demographics of affected HCWs and public health measures employed.

RESULTS

A total of 152 888 infections and 1413 deaths were reported. Infections were mainly in women (71.6%, n=14 058) and nurses (38.6%, n=10 706), but deaths were mainly in men (70.8%, n=550) and doctors (51.4%, n=525). Limited data suggested that general practitioners and mental health nurses were the highest risk specialities for deaths. There were 37.2 deaths reported per 100 infections for HCWs aged over 70 years. Europe had the highest absolute numbers of reported infections (119 628) and deaths (712), but the Eastern Mediterranean region had the highest number of reported deaths per 100 infections (5.7).

CONCLUSIONS

COVID-19 infections and deaths among HCWs follow that of the general population around the world. The reasons for gender and specialty differences require further exploration, as do the low rates reported in Africa and India. Although physicians working in certain specialities may be considered high risk due to exposure to oronasal secretions, the risk to other specialities must not be underestimated. Elderly HCWs may require assigning to less risky settings such as telemedicine or administrative positions. Our pragmatic approach provides general trends, and highlights the need for universal guidelines for testing and reporting of infections in HCWs.

Demographic, nutritional, social and environmental predictors of learning skills and depression in 20,000 Indian adolescents: Findings from the UDAYA survey

OBJECTIVES

Adolescent wellbeing is critical to breaking the intergenerational cycle of poverty and one in five of the world's adolescents live in India. We explored predictors of learning skills and depression in Indian adolescents.

METHODS

Data on adolescents aged 10-19y (three groups: 5,840 unmarried males, 8,953 unmarried females, 4,933 married females) were available from the state-representative Understanding the Lives of Adolescents and Young Adults survey in Uttar Pradesh and Bihar. Multivariable logistic regression models adjusted for cluster sampling design and state fixed effects were used to examine factors (demographic, health/nutrition, social, and environmental) associated with three outcomes: reading proficiency, math proficiency, and depressive symptoms.

FINDINGS

Learning skills were poor (28-61% lacked basic reading and math skills depending on adolescent group and outcome) and depression was common (8-26%). Better learning skills were predicted by greater household wealth (AOR 1.72-2.55 depending on group) and household head education (AOR 1.03-1.07 per year), being in school (AOR 4.19-18.65), parental support (AOR 1.11-1.39), having gender equal attitudes (AOR 1.56-2.67), number of food groups consumed at least weekly (unmarried females: AOR 1.11), and having an improved latrine (AOR 1.33-1.51). Poorer learning skills were predicted by family substance use (AOR 0.68-0.74), underweight (males: AOR 0.74), witnessing parental violence (AOR 0.66-0.78). Depressive symptoms were predicted by witnessing parental violence (AOR 1.51-1.92) and experiencing sexual abuse (AOR 2.30-6.16).

CONCLUSION

Factors across multiple life dimensions are associated with learning skills and depression in Indian adolescents. Adolescent-focused policies and programs should consider health/nutrition, social, and environmental aspects of life in vulnerable individuals.

Collateral damage: the impact on outcomes from cancer surgery of the COVID-19 pandemic

BACKGROUND

Cancer diagnostics and surgery have been disrupted by the response of health care services to the coronavirus disease 2019 (COVID-19) pandemic. Progression of cancers during delay will impact on patients' long-term survival.

PATIENTS AND METHODS

We generated per-day hazard ratios of cancer progression from observational studies and applied these to age-specific, stage-specific cancer survival for England 2013-2017. We modelled per-patient delay of 3 and 6 months and periods of disruption of 1 and 2 years. Using health care resource costing, we contextualise attributable lives saved and life-years gained (LYGs) from cancer surgery to equivalent volumes of COVID-19 hospitalisations.

RESULTS

Per year, 94 912 resections for major cancers result in 80 406 long-term survivors and 1 717 051 LYGs. Per-patient delay of 3/6 months would cause attributable death of 4755/10 760 of these individuals with loss of 92 214/208 275 life-years, respectively. For cancer surgery, average LYGs per patient are 18.1 under standard conditions and 17.1/15.9 with a delay of 3/6 months (an average loss of 0.97/2.19 LYGs per patient), respectively. Taking into account health care resource units (HCRUs), surgery results on average per patient in 2.25 resource-adjusted life-years gained (RALYGs) under standard conditions and 2.12/1.97 RALYGs following delay of 3/6 months. For 94 912 hospital COVID-19 admissions, there are 482 022 LYGs requiring 1 052 949 HCRUs. Hospitalisation of community-acquired COVID-19 patients yields on average per patient 5.08 LYG and 0.46 RALYGs.

CONCLUSIONS

Modest delays in surgery for cancer incur significant impact on survival. Delay of 3/6 months in surgery for incident cancers would mitigate 19%/43% of LYGs, respectively, by hospitalisation of an equivalent volume of admissions for community-acquired COVID-19. This rises to 26%/59%, respectively, when considering RALYGs. To avoid a downstream public health crisis of avoidable cancer deaths, cancer diagnostic and surgical pathways must be maintained at normal throughput, with rapid attention to any backlog already accrued.

Multidimensional predictors of common mental disorders among Indian mothers of 6- to 24-month-old children living in disadvantaged rural villages with women's self-help groups: A cross-sectional analysis

Common mental disorders (CMD) among mothers cause disability, negatively affect child development, and have high long-term economic costs. Little is known about how factors across multiple life dimensions, modeled together, are differentially related to maternal mental health in high poverty contexts. Further, there is limited evidence on determinants of CMD in areas where self-help groups (SHGs) exist to promote women's wellbeing. Filling this evidence gap is important given the high prevalence of CMD and the rapid expansion of SHGs in rural India. Cross-sectional data were collected from 1644 mother-infant pairs living in disadvantaged rural villages across five Indian states-Jharkhand, Madhya Pradesh, West Bengal, Odisha, and Chhattisgarh-surveyed in the Women Improving Nutrition through Group-based Strategies study. CMD were assessed using the 20-item Self Reporting Questionnaire (SRQ). We examined 31 factors across four life dimensions: work (work type, time spent in labor, domestic and caretaking activities), agency (SHG membership, decision-making, gender attitudes), health/nutrition (underweight, fertility, diet diversity, child illness), and household/environment (dependency ratio, wealth, food security, shocks, water, sanitation). Survey-adjusted multivariate logistic and ordinary least squares regression models were fit to examine predictors of CMD or SRQ score. On average, mothers were 26 (range 18-46) years old and their children were 15 (range 6-24) months old. CMD defined as ≥ 8 positive SRQ responses were reported by 262 women (16%). Protective factors included being engaged in agricultural labor as a main occupation relative to being a housewife (AOR 0.18, 95% CI 0.10-0.32), more time working (0.85, 0.77-0.93), higher decision-making (0.33, 0.16-0.69), SHG membership (0.73, 0.56-0.96), and having an improved toilet (0.49, 0.33-0.72). Risk factors included food insecurity (1.13, 1.07-1.20) and shocks to non-farm livelihoods (2.04, 1.10-3.78). Practitioners and policymakers should aim to improve food security, economic wellbeing and social capital, such as that created through SHG membership, to improve maternal mental health. Future research should aim to understand why working outside the home, albeit in agricultural work, appears to protect maternal mental health in this context.

South Asia Is Far from Achieving Universal Coverage of Essential Nutrition Interventions: Examining Coverage, Trends, and Inequities, 2005 to 2018

Objectives

South Asia carries the largest burden of malnutrition globally. Tracking coverage of nutrition interventions is a critical step in designing effective nutrition policies and monitoring progress in the region. This paper examines coverage, trends, and inequities in nutrition interventions in South Asia.

Methods

Data were from Demographic and Health Surveys in Afghanistan (2015), Bangladesh (2011, 2014), India (2006, 2015), Maldives (2009, 2017), Nepal (2011, 2016) and Pakistan (2013, 2018). We examined essential interventions spanning the continuum of care: 2 in the pre-conception period, 7 in pregnancy, 4 in postpartum and 9 in childhood. We calculated absolute changes, average annual change rates, and concentration indices to examine trends and inequalities in coverage and composite coverage index (CCI) over time by residence and wealth quintiles.

Results

Coverage of nutrition interventions has generally improved since 2005 but coverage levels remain low and varied. Improvements have occurred for consumption of iodized salt, institutional births, antenatal care, weight monitoring during pregnancy, zinc and ORS supplementation (16 to 34 percentage points, pp). However, coverage of some child-level interventions has decreased: full immunization, preventive deworming, vitamin A supplementation and postnatal care (−9 to −13 pp). Median regional coverage was below 75% for 17 of 22 interventions. Extremely low coverage persists for preventive deworming during pregnancy (10%) and daily Iron supplementation for children (5%), while high coverage (&gt;80%) exists for consumption of iodized salt, attendance by a trained provider during pregnancy and weight monitoring during pregnancy. Large coverage gaps were found for CCI by wealth (10–45pp higher in rich, except Maldives) and residence (3–22pp higher in urban), with the gap decreasing over time in most countries.

Conclusions

Despite improvements in nutrition intervention coverage since 2005, universal coverage is still far from optimal and unequally affects poor, rural women and children in South Asia. More work is needed to close coverage gaps and measure the quality of nutrition interventions.

Funding Sources

BMGF through DataDENT.

Interrelations Between School-Based Services, Dietary Intake and Micronutrient Deficiencies Among School-Going Children and Adolescents Aged 5–19 Years in India

Objectives

India is home to 119 million children (CH; 5–9 y) and 253 million adolescents (AD; 10–19 y), a majority of whom suffer from multiple micronutrient deficiencies (MND). Given high school enrolment levels in India (90% of CH and 75% of AD) schools are a good platform for services and behavior change interventions targeted toward this age group. We sought to analyze the prevalence and predictors of MND in school going CH and AD in India.

Methods

Data from India's Comprehensive National Nutrition Survey 2016–18 were analyzed separately for CH aged 5–9 y (n = 10,640), AD aged 10–14 y (n = 5390) and AD aged 15–19 y (n = 3693). Serum/plasma concentrations of ferritin, retinol, B12, erythrocyte folate, 25-hydroxyvitamin D, zinc and C-reactive protein were measured. We assessed the weighted prevalence of each MND using established WHO cutoffs, after adjusting ferritin and retinol for inflammation. Primary predictors of MND were dietary intake and access to school services. Multivariable logistic regression models were used to examine associations between these factors and each MND, controlling for socio-demography (sex, residence, wealth quintile, ethnicity, parental education, siblings) and hygiene-sanitation services.

Results

The top three micronutrient deficiencies were folate (29%), vitamin A (22%), vitamin D (19%) among CH and folate (38%), zinc and B12 (31% each) in AD. One or more MND affected 69% of CH and 83% of AD. In CH, deworming was associated with reduced odds of folate deficiency (AOR and 95% CI: 0.80, 0.68–0.94) and health camps were associated with vitamin A deficiency (0.68, 0.51–0.91). In AD 10–14y, receipt of free school meals had lower odds of B12 deficiency (0.66, 0.49–0.88). In AD 15–19y, health camps were inversely associated with vitamin D deficiency (0.69, 0.51–0.95). CH and AD who consumed green leafy vegetables, pulses and fruits daily had reduced odds of iron, folate or vitamin D deficiencies (AORs: 0.58–0.81). Consumption of fish, chicken or meat (≥2 times/week) was associated with lower odds of almost all MND in CH (AORs: 0.39–0.75), and of iron and B12 deficiencies in AD (AORs: 0.42–0.66).

Conclusions

Most CH and AD in India suffer from multiple MND. Improving diet quality through school meals and strengthening school-based health services may contribute to MND reductions in this population.

Funding Sources

UNICEF, POSHAN.

Are Data Available to Measure Progress in the Coverage of Essential Nutrition Actions in South Asia? A Review of Demographic and Health Surveys in Seven Countries, 2005–2018

Objectives

South Asian countries carry the largest burden of undernutrition globally. The World Health Organization has recommended a set of Essential Nutrition Actions (ENA) to tackle all forms of malnutrition. Limited evidence exists on the availability of data in nationally representative surveys to analyse coverage patterns and to track progress on these actions.

Methods

We reviewed household and woman questionnaires from DHS surveys conducted in South Asia—Afghanistan (2014), Bangladesh (2011 and 2014), India (2006 and 2016), Maldives (2009 and 2017), Nepal (2011 and 2016), Pakistan (2013 and 2018), and Sri Lanka (2006 and 2016)—to assess the availability of data to track coverage of the ENAs in South Asia region. For each ENA, we examined questionnaires to identify the availability of questions that could be used to construct coverage indicators.

Results

For adolescents and women of reproductive age, DHS questionnaires ask about prenatal iron folic acid (IFA) supplementation in zero countries and use of iodized salt in five countries. For pregnant women, out of six recommended ENAs, five are measured in at least one country: health and nutrition education, energy and protein supplementation, IFA supplementation, calcium supplementation, and multiple micronutrients that contain IFA. For postpartum women, data on iron supplementation and breastfeeding counselling are collected in only four countries. For early childhood, DHS surveys only measure 6 of 25 ENAs; only vitamin A supplementation is being tracked in DHS across all seven countries, while children who were breastfed early, had immediate skin to skin contact and zinc supplementation are measured in most countries.

Conclusions

Data for more than half of the ENAs across the continuum of care are not collected in the South Asian DHS questionnaires; gaps exist both for interventions and among countries. Coverage data from household surveys are critical to enable countries to track progress towards national coverage goals and to examine equity in the reach of interventions. To support national efforts to scale-up the coverage of ENAs, national survey instruments should be reviewed to include indicators on the coverage of a broader set of ENA indicators.

Funding Sources

Data for Decisions to Expand Nutrition Transformation (DataDENT) project, supported by the Bill and Melinda Gates Foundation.

An Analysis of Nutrition-Relevant National Policies in South Asia Reveals a Gap in Addressing the Essential Nutrition Actions Recommended by World Health Organization (WHO)

Objectives

The WHO recommends Essential Nutrition Actions (ENAs) throughout the life course to tackle malnutrition in all its forms. However, limited evidence exists on the availability of policies to support the implementation of ENAs in South Asia, a region with the highest burden of malnutrition globally. We conducted a policy analysis to assess the extent to which current policies address ENAs for adolescent girls, women, and children in South Asia.

Methods

We first identified the WHO ENAs targeting non-pregnant menstruating adolescent girls (1 ENA), non-pregnant women of reproductive age (2 ENAs), pregnant women (6 ENAs), postpartum women (2 ENAs), and children aged 0–5 years (25 ENAs). We then reviewed 40 health- and nutrition-relevant national policy and program documents, strategic plans, and guidelines for health workers from Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka. Using these documents, we identified policies that address the ENAs. We report the number of recommended ENAs addressed by the policies for each population group.

Results

National nutrition policies exist in all eight countries. Six countries have multi-sector nutrition plans or strategy. These documents primarily guide provisions for nutrition actions in the region. Six countries have policies that address the ENA for non-pregnant menstruating adolescent girls. Only two countries have policies that address both ENAs for non-pregnant women of reproductive age. For pregnant women, three countries address four of six ENAs, but no countries address all six ENAs. Seven countries have policies that address both ENAs for postpartum women. Five countries have policies that address more than 20 of 25 ENAs for children aged 0–5 years.

Conclusions

Our policy analysis identifies substantial gaps in national policies related to the ENAs among South Asian countries and gaps are more pronounced for non-pregnant women of reproductive age and for pregnant women. Policy revisions, including updating policies, implementation and financing plans, will be needed to deliver the ENAs at scale and with quality to enable the South Asian region to tackle malnutrition in all its forms.

Funding Sources

Bill and Melinda Gates Foundation through DataDENT.