Effects of engaging fathers and bundling parenting and nutrition interventions on early child development and maternal and paternal parenting in Mara, Tanzania: a factorial cluster-randomized controlled trial

BACKGROUND

Multicomponent interventions are needed to address the various co-occurring risks that compromise early child nutrition and development. We compared the independent and combined effects of engaging fathers and bundling parenting components into a nutrition intervention on early child development (ECD) and parenting outcomes.

METHODS

We conducted a 2×2 factorial cluster-randomized controlled trial across 80 villages in Mara Region, Tanzania, also known as EFFECTS (Engaging Fathers for Effective Child Nutrition and Development in Tanzania; ClinicalTrials.gov, NCT03759821). Households with children under 18 months of age residing with their mother and father were enrolled. Villages were randomly assigned to one of five groups: a nutrition intervention for mothers, a nutrition intervention for couples, a bundled nutrition and parenting intervention for mothers, a bundled intervention for couples, and a standard-of-care control. Interventions were delivered by trained community health workers through peer groups and home visits over 12 months. Mothers, fathers, and children were assessed at baseline, midline, and endline or postintervention. We used a difference-in-difference approach with intention-to-treat analysis to estimate intervention effects on ECD (Bayley Scales of Infant and Toddler Development, third edition) and maternal and paternal parenting and psychosocial well-being.

RESULTS

Between October 29, 2018, and May 24, 2019, 960 households were enrolled (n = 192 per arm). Compared to nutrition interventions, bundled interventions improved children's cognitive (β = .18 [95% CI: 0.01, 0.36]) and receptive language development (β = .23 [0.04, 0.41]). There were no differences between interventions for other ECD domains. Compared to nutrition interventions, bundled interventions achieved additional benefits on maternal stimulation (β = .21 [0.04, 0.38]) and availability of home learning materials (β = .25 [0.07-0.43]) and reduced paternal parenting distress (β = -.34 [-0.55, -0.12]). Compared to interventions with mothers only, interventions that engaged fathers improved paternal stimulation (β = .45 [0.27, 0.63]).

CONCLUSIONS

Jointly bundling parenting components into nutrition interventions while also engaging both mothers and fathers is most effective for improving maternal and paternal parenting and ECD outcomes.

Fibrin promotes oxidative stress and neuronal loss in traumatic brain injury via innate immune activation

BACKGROUND

Traumatic brain injury (TBI) causes significant blood-brain barrier (BBB) breakdown, resulting in the extravasation of blood proteins into the brain. The impact of blood proteins, especially fibrinogen, on inflammation and neurodegeneration post-TBI is not fully understood, highlighting a critical gap in our comprehension of TBI pathology and its connection to innate immune activation.

METHODS

We combined vascular casting with 3D imaging of solvent-cleared organs (uDISCO) to study the spatial distribution of the blood coagulation protein fibrinogen in large, intact brain volumes and assessed the temporal regulation of the fibrin(ogen) deposition by immunohistochemistry in a murine model of TBI. Fibrin(ogen) deposition and innate immune cell markers were co-localized by immunohistochemistry in mouse and human brains after TBI. We assessed the role of fibrinogen in TBI using unbiased transcriptomics, flow cytometry and immunohistochemistry for innate immune and neuronal markers in Fggγ390-396A knock-in mice, which express a mutant fibrinogen that retains normal clotting function, but lacks the γ390-396 binding motif to CD11b/CD18 integrin receptor.

RESULTS

We show that cerebral fibrinogen deposits were associated with activated innate immune cells in both human and murine TBI. Genetic elimination of fibrin-CD11b interaction reduced peripheral monocyte recruitment and the activation of inflammatory and reactive oxygen species (ROS) gene pathways in microglia and macrophages after TBI. Blockade of the fibrin-CD11b interaction was also protective from oxidative stress damage and cortical loss after TBI.

CONCLUSIONS

These data suggest that fibrinogen is a regulator of innate immune activation and neurodegeneration in TBI. Abrogating post-injury neuroinflammation by selective blockade of fibrin's inflammatory functions may have implications for long-term neurologic recovery following brain trauma.

Do tuition-free lower secondary education policies matter for antenatal care among women in sub-saharan African countries?

BACKGROUND

Antenatal care (ANC) is critical to reducing maternal and infant mortality. However, sub-Saharan Africa (SSA) continues to have among the lowest levels of ANC receipt globally, with half of mothers not meeting the WHO minimum recommendation of at least four visits. Increasing ANC coverage will require not only directly reducing geographic and financial barriers to care but also addressing the social determinants of health that shape access. Among those with the greatest potential for impact is maternal education: past research has documented a relationship between higher educational attainment and antenatal healthcare access, as well as related outcomes like health literacy and autonomy in health decision-making. Yet little causal evidence exists about whether changing educational policies can improve ANC coverage. This study fills this research gap by investigating the impact of national-level policies that eliminate tuition fees for lower secondary education in SSA on the number of ANC visits.

METHODS

To estimate the effect of women's exposure to tuition-free education policies at the primary and lower secondary levels on their ANC visits, a difference-in-difference methodology was employed. This analysis leverages the variation in the timing of education policies across nine SSA countries.

RESULTS

Exposure to tuition-free primary and lower secondary education is associated with improvements in the number of ANC visits, increasing the share of women meeting the WHO recommendation of at least four ANC visits by 6-14%. Moreover, the impact of both education policies combined is greater than that of tuition-free primary education alone. However, the effects vary across individual treatment countries, suggesting the need for further investigation into country-specific dynamics.

CONCLUSIONS

The findings of this study have significant implications for policymakers and stakeholders seeking to improve ANC coverage. Removing the tuition barrier at the secondary level has shown to be a powerful strategy for advancing health outcomes and educational attainment. As governments across Africa consider eliminating tuition fees at the secondary level, this study provides valuable evidence about the impacts on reproductive health outcomes. While investing in free education requires initial investment, the long-term benefits for both human development and economic growth far outweigh the costs.

Impact of laws prohibiting domestic violence on wasting in early childhood

Intimate partner violence (IPV) affects an estimated 641 million women and girls globally with far-reaching consequences for the health of women and children. Yet, laws that prohibit domestic violence (DV) are not universal. Countries actively debate the effectiveness of DV laws in improving conditions given the inconclusive evidence on deterrent effects within households particularly in low- and middle-income countries that have limited infrastructure, and fewer resources to implement and enforce policy changes. This is the first study to rigorously examine the impact of DV laws on women's health decision-making and the intergenerational impact on children's wasting, a key predictor of mortality. We used the Demographic and Health Surveys (DHS) data collected between 2000-2020 across 23 African countries. Exploiting the staggered adoption of laws, we used a difference-in-differences study design to estimate the impact of DV laws in the treated countries compared to countries without such laws. We find that DV laws increased women's decision-making autonomy in healthcare by 16.7% as well as other measures of women's autonomy that matter for health such as financial autonomy by 6.3% and social mobility by 11.0%. The improvements in women's autonomy translated into reductions in the probability of wasting among children aged 0-23 months by 5.4% points, a 30.9% reduction from the mean. DV laws also reduced wasting among older children aged 24-59 months by 3.6% points, a 38.7% reduction from the mean. The laws were effective in all 6 countries analyzed individually that criminalized DV. A civil prohibition in the seventh country was not found to be effective. The effect was positive and significant for all wealth and geographical categories. Our findings demonstrate the value of enacting criminal laws that prohibit domestic violence as one important tool to reducing the profound health impacts of IPV, a critical health and human rights issue.

Engaging Fathers for Effective Child Nutrition and Development in Tanzania (EFFECTS): study protocol for a five-arm, cluster-randomized trial

BACKGROUND

Globally, 144 million children under 5 years are undernourished and 250 million do not meet their developmental potential. Multi-input interventions, such as bundled nutrition and parenting interventions, are designed to mitigate risks for multiple child outcomes. There is limited evidence that bundled interventions have additive benefits to nutrition, growth, or development outcomes. These outcomes share common risks; therefore, designing interventions to tackle these risks using a common theory of change may optimize effectiveness. Emerging evidence suggests explicit engagement of fathers may benefit child outcomes, but few trials have tested this or included data collected from fathers.

METHODS

Engaging Fathers for Effective Child Nutrition and Development in Tanzania (EFFECTS) is a community-based cluster-randomized controlled trial that will be implemented in the rural Mara Region, Tanzania. The trial aims (1) to test a bundled nutrition and parenting program delivered to mothers' groups, with or without fathers' groups, over 12 months on child and caregiving outcomes compared to a nutrition program alone, and (2) to test nutrition or bundled nutrition and parenting programs delivered to mothers' and fathers' groups over 12 months on child and caregiving outcomes compared to programs delivered to mothers alone. The trial comprises five arms: (1) mothers' groups receiving a nutrition program, (2) mothers' groups receiving a bundled nutrition and parenting program, (3) mothers' and fathers' groups receiving a nutrition program, (4) mothers' and fathers' groups receiving a bundled nutrition and parenting program, and (5) control receiving standard of care health services. The primary outcomes are child dietary diversity and early child development (mental and motor development). Parents with a child under 18 months will be enrolled in peer groups and receive twice monthly intervention by trained community health workers. Data will be collected from mothers, fathers, and children at baseline (pre-intervention), midline, and endline (post-intervention).

DISCUSSION

EFFECTS will generate evidence on the effects of bundled nutrition and parenting interventions on child nutrition, growth, and development outcomes; determine the benefits of engaging fathers on child, caregiving, and caregiver outcomes; and investigate common and unique pathways between treatments and child outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03759821. Registered on November 30, 2018.

Is the impact of paid maternity leave policy on the prevalence of childhood diarrhoea mediated by breastfeeding duration? A causal mediation analysis using quasi-experimental evidence from 38 low-income and middle-income countries

OBJECTIVES

Quasi-experimental evidence suggests that extending the duration of legislated paid maternity leave is associated with lower prevalence of childhood diarrhoea in low-income and middle-income countries (LMICs). This could be due to a variety of mechanisms. This study examines whether this effect is mediated by changes in breastfeeding duration.

DESIGN AND SETTING

Difference-in-difference approach and causal mediation analysis were used to perform secondary statistical analysis of cross-sectional data from Demographic and Health Surveys (DHSs) in 38 LMICs.

PARTICIPANTS

We merged longitudinal data on national maternity leave policies with information on childhood diarrhoea related to 639 153 live births between 1996 and 2014 in 38 LMICs that participated in the DHS at least twice between 1995 and 2015.

PRIMARY OUTCOME MEASURE

Our outcome was whether the child had bloody stools in the 2 weeks prior to the interview. This measure was used as an indicator of severe diarrhoea because the frequency of loose stools in breastfed infants can be difficult to distinguish from pathological diarrhoea based on survey data.

RESULTS

A 1-month increase in the legislated duration of paid maternity leave was associated with a 34% (risk ratio 0.66, 95% CI 0.47 to 0.91) reduction in the prevalence of bloody diarrhoea. Breast feeding for at least 6 months and 12 months mediated 10.6% and 7.4% of this effect, respectively.

CONCLUSION

Extending the duration of paid maternity leave appears to lower diarrhoea prevalence in children under 5 years of age in LMICs. This effect is slightly mediated by changes in breastfeeding duration.

Maternal stimulation and early child development in sub-saharan Africa: evidence from Kenya and Zambia

BACKGROUND

Despite major improvements in child survival over the past decade, many children in low and middle-income countries (LMICs) remain at risk of not reaching their developmental potential due to malnutrition, poor health, and a lack of stimulation. Maternal engagement and stimulation have been identified as some of the most critical inputs for healthy development of children. However, relatively little evidence exists on the links between maternal stimulation and child development exists in sub-Saharan Africa (SSA). This current paper aims to identify the associations between maternal stimulation and child development in Kenya and Zambia, as well as the activities that are most predictive of developmental outcomes in these settings.

METHODS

We conducted a descriptive study using data from a prospective study in Kenya and Zambia. The study included three rounds of data collection. Children were on average 10 months old in round one, 25 months old in round two, and 36 months old in round three. The primary exposure variable of interest was maternal stimulation activities, which we grouped into cognitive, language, motor, and socio-emotional activities. The outcome of interest was child development measured through the Third Edition of the Ages and Stages Questionnaire (ASQ-3). Linear regression models were used to estimate the associations between overall maternal stimulation and domain-specific maternal stimulation and child development across the three rounds of the survey.

RESULTS

Higher maternal stimulation scores were associated with higher ASQ scores (effect size = 0.25; 95% CI: 0.19, 0.31) after adjusting for other confounders. For domain specific and child development (ASQ scores), the largest effect size (ES) was found for language stimulation (ES = 0.15) while weakest associations were found for socio-emotional domain activities (ES= -0.05). Overall maternal stimulation was most strongly associated with gross motor development (ES = 0.21) and the least associated with problem-solving (ES = 0.16).

CONCLUSION

Our study findings suggest a strong positive link between maternal stimulation activities and children's developmental outcomes among communities in poor rural settings.

TRIAL REGISTRATION

NA (not a clinical trial).

Three-Year Custody Outcomes Among Infants Investigated by Child Protection Systems for Prenatal Substance Exposure in California

OBJECTIVE

Infants affected by prenatal alcohol and drug use are more likely to be removed from parental custody than those in the general population, although it is unclear whether their custody outcomes differ from infants investigated by child protection systems (CPS) for other reasons. This analysis seeks to compare trajectories of involvement and custody outcomes among infants investigated by CPS with and without documentation of prenatal substance exposure (PSE).

METHOD

We used vital birth records linked to administrative CPS records to examine the timing of system involvement and 3-year custodial outcomes among investigated infants with and without identified PSE. We defined PSE according to documentation on the state's standardized hotline screening form, which CPS completes upon referral for alleged maltreatment. We estimated the likelihood a child was in nonparental custody at age 3 by specifying multivariable generalized linear models, adjusted for covariates available in the birth record.

RESULTS

In our sample of 22,855 infants investigated by CPS in 2017 in California, more than 26% had documentation of PSE. These infants experienced an accelerated timeline of system penetration and were 2.2 times as likely to be in nonparental placement at age 3.

DISCUSSION

PSE confers an independent risk of custody interruption among infants investigated by CPS. The younger age of these infants, complexity of parental substance use, and potential misalignment of administrative permanency timelines with parental recovery all suggest the need for increased research, policy, and programmatic interventions to serve this vulnerable population.

Association between levels of receptor binding domain antibodies of SARS-CoV-2, receipt of booster and risk of breakthrough infections: LA pandemic surveillance cohort study

Prevention of COVID-19 with vaccine requires multiple doses and updated boosters to maintain protection; however currently there are no tests that can measure immunity and guide clinical decisions about timing of booster doses. This study examined the association between the risk of COVID-19 breakthrough infections and receptor binding domain (RBD) antibody levels and receipt of booster of COVID-19 vaccines. A community sample of Los Angeles County adults were surveyed between 2021 and 2022 to determine if they had a self-reported breakthrough infection. Predictors included RBD antibody levels, measured by binding antibody responses to the ancestral strain at baseline and self-reported booster shot during the study period. Of the 859 participants, 182 (21%) reported a breakthrough infection. Irrespective of the level of antibodies, the risk of breakthrough infection was similar, ranging from 19 to 23% (P = 0.78). The risk of breakthrough infections was lower among participants who had a booster shot (P = 0.004). The protective effect of a booster shot did not vary by antibody levels prior to receiving the booster. This study found no association between RBD antibody levels and risk of breakthrough infections, while the receipt of booster was associated with lower risk of breakthrough infections, which was independent of pre-booster antibody levels. Therefore, antibody levels might not be a useful guide for clinical decisions about timing of booster doses.

Assessing national action through emergency paid leave to mitigate the impact of COVID-19-related school closures on working families in 182 countries

In April 2020, nearly 1.6 billion learners were out of school. While a growing body of literature has documented the detrimental impact of these closures on children, less attention has been devoted to the steps countries took to mitigate the impact of these closures on working families. Paid leave is recognized as an important policy tool to enable working parents the time they need to respond to family needs without risking job or income loss. This article uses a novel data set to assess whether countries had policies in place prior to the pandemic to respond to increased care needs and the extent to which policies were introduced or expanded during the pandemic to fill the gap. Only 48 countries had policies in place prior to the pandemic that could be used to respond to the care needs created by school and childcare center closures. In the vast majority of these countries, the duration of leave in these policies was too short to meet the care needs of the pandemic or relied on parents reserving extended parental leave options. Only 36 countries passed new legislation during the pandemic, but the majority of those that did covered the full duration of closures. As countries continue to face COVID-19 and consider how to better prepare for the next pandemic, emergency childcare paid leave policies should be part of pandemic preparedness frameworks to prevent further exacerbating inequalities. The policies introduced during the pandemic offer a wide range of approaches for countries to identify feasible solutions.

Therapeutic potential of blocking GAPDH nitrosylation with CGP3466b in experimental autoimmune encephalomyelitis

Multiple sclerosis (MS) is a neuroinflammatory disease of the central nervous system (CNS). Although classically considered a demyelinating disease, neuroaxonal injury occurs in both the acute and chronic phases and represents a pathologic substrate of disability not targeted by current therapies. Nitric oxide (NO) generated by CNS macrophages and microglia contributes to neuroaxonal injury in all phases of MS, but candidate therapies that prevent NO-mediated injury have not been identified. Here, we demonstrate that the multifunctional protein glyceraldehyde-3-phosphate dehydrogenase (GAPDH) is robustly nitrosylated in the CNS in the experimental autoimmune encephalomyelitis (EAE) mouse model of MS. GAPDH nitrosylation is blocked in vivo with daily administration of CGP3466b, a CNS-penetrant compound with an established safety profile in humans. Consistent with the known role of nitrosylated GAPDH (SNO-GAPDH) in neuronal cell death, blockade of SNO-GAPDH with CGP3466b attenuates neurologic disability and reduces axonal injury in EAE independent of effects on the immune system. Our findings suggest that SNO-GAPDH contributes to neuroaxonal injury during neuroinflammation and identify CGP3466b as a candidate neuroprotective therapy in MS.

The X factor in neurodegeneration

Given the aging population, it is important to better understand neurodegeneration in aging healthy people and to address the increasing incidence of neurodegenerative diseases. It is imperative to apply novel strategies to identify neuroprotective therapeutics. The study of sex differences in neurodegeneration can reveal new candidate treatment targets tailored for women and men. Sex chromosome effects on neurodegeneration remain understudied and represent a promising frontier for discovery. Here, we will review sex differences in neurodegeneration, focusing on the study of sex chromosome effects in the context of declining levels of sex hormones during aging.

Local Laws Regulating Cannabis in California Two Years Post Legalization: Assessing Incorporation of Lessons from Tobacco Control

Introduction

As cannabis legalization continues to spread, best regulatory practice remains ill-defined and elusive, exposing the population to potential harms.

Methods

We conducted an annual, statewide, cross- sectional survey to assess cannabis-related laws in effect by January 1, 2020, in local California jurisdictions and at the state level and measured adoption of potential best practices.

Results

The current laws of all 539 jurisdictions were located; 276 jurisdictions allowed any retail sales (storefront or delivery) covering 58% of the population, an increase of 20 jurisdictions (8%) from year 1 of legalization (2018). Half allowed sales of medical cannabis, whereas slightly fewer jurisdictions (n = 225) allowed adult-use sales. Only 9 jurisdictions imposed any restrictions on products stricter than state regulations. Cannabis temporary special events were allowed in 22 jurisdictions, up from 14 in the year prior. Thirty-three jurisdictions required additional health warnings for consumers. Just over half of legalizing jurisdictions taxed cannabis locally and little revenue was captured for prevention. No new jurisdictions established a potency-linked tax. Of jurisdictions allowing storefront retailers (n = 162), 114 capped outlet licenses, and 49 increased the state-specified buffers between storefronts and schools. Thirty-six allowed on-site consumption, up from 29. As of January 2020, the state had not updated its regulations of key provisions addressed in this paper.

Conclusions

In year 2 of legalized adult-use cannabis sales in California, the state remained split between retail bans and legal sale. Local policy continued to vary widely on protective measures, and State policy remained misaligned with protection of youth and public health.

Chronic experimental autoimmune encephalomyelitis is an excellent model to study neuroaxonal degeneration in multiple sclerosis

Animal models of multiple sclerosis (MS), specifically experimental autoimmune encephalomyelitis (EAE), have been used extensively to develop anti-inflammatory treatments. However, the similarity between MS and one particular EAE model does not end at inflammation. MS and chronic EAE induced in C57BL/6 mice using myelin oligodendrocyte glycoprotein (MOG) peptide 35-55 share many neuropathologies. Beyond both having white matter lesions in spinal cord, both also have widespread neuropathology in the cerebral cortex, hippocampus, thalamus, striatum, cerebellum, and retina/optic nerve. In this review, we compare neuropathologies in each of these structures in MS with chronic EAE in C57BL/6 mice, and find evidence that this EAE model is well suited to study neuroaxonal degeneration in MS.

Mitigating Risks of Incarceration Among Transition-Age Foster Youth: Considering Domains of Social Bonds

Transitioning to adulthood is difficult for young people aging out of foster care. Research shows that this population faces substantial challenges in trying to avoid legal system involvement during this difficult period of life. Seeking to improve our understanding of the protective factors that mitigate the risks of legal system involvement among transition-age foster youth, this study focuses on social bonds as predictors. Drawing from social control theory and using longitudinal foster youth survey data (n = 687), we explore two domains of social bonds (interpersonal bonds, institutional bonds) youth had at the onset of adulthood (age 17), and assess the association between domains of social bonds and later incarceration in early adulthood (between ages 17 and 21). While results provide no support for the significance of interpersonal bondedness, institutional bonds were significantly associated with decreased odds of later incarceration. This suggests that social bonds may be stronger for institutional domains than for interpersonal domains in helping youth to avoid later incarceration. These findings help explain why some youth navigate the transition to adulthood better than others with regard to legal system involvement, and inform efforts to develop policy and provide services more effectively. Implications and recommendations for the field and professionals are discussed.

Men care too: a qualitative study examining women's perceptions of fathers' engagement in early childhood development (ECD) during an ECD program for HIV-positive mothers in Malawi

OBJECTIVES

Integrated early childhood development (ECD) and prevention of mother-to-child transmission (PMTCT) interventions rarely target fathers, a missed opportunity given existing research demonstrating that father involvement improves maternal and child outcomes. We aimed to explore mother's perceptions of fathers' buy-in to an integrated PMTCT-ECD programme, any impact the programme had on couple dynamics, and perceived barriers to fathers' involvement in ECD activities.

DESIGN

Qualitative study using individual in-depth interviews with mothers participating in a PMTCT-ECD programme. Interviews assessed mothers' perceptions of father buy-in and engagement in the programme and ECD activities. Data were coded using inductive and deductive strategies and analysed using constant comparison methods in Atlas.ti V.1.6.

SETTING

Four health facilities in Malawi where PMTCT services were provided.

PARTICIPANTS

Study participants were mothers infected with HIV who were enrolled in the PMTCT-ECD programme for >6 months.

INTERVENTIONS

The PMTCT-ECD intervention provided ECD education and counselling sessions during routine PMTCT visits for mothers infected with HIV and their infants (infant age 1.5-24 months). The intervention did not target fathers, but mothers were encouraged to share information with them.

RESULTS

Interviews were conducted with 29 mothers. Almost all mothers discussed the PMTCT-ECD intervention with male partners. Most mothers reported that fathers viewed ECD as valuable and practised ECD activities at home. Several reported improved partner relationships and increased communication due to the intervention. However, most mothers believed fathers would not attend the PMTCT-ECD intervention due to concerns regarding HIV-related stigma at PMTCT clinics, time required to attend and perceptions that the intervention was intended for women.

CONCLUSIONS

Fathers were interested in an integrated PMTCT-ECD programme and actively practised ECD activities at home, but felt uncomfortable visiting PMTCT clinics. Interventions should consider direct community outreach or implementing ECD programmes at facility entry points where men frequent, such as outpatient departments.

Application of the Capabilities, Opportunities, Motivations, and Behavior (COM-B) Change Model to Formative Research for Child Nutrition in Western Kenya

Background

Interventions aimed at improving dietary intake and feeding practices have alone proven insufficient for combatting stunting resulting from poor nutrition and repeated infections.

Objectives

To support the development of an integrated water, sanitation, and hygiene (WASH) and nutrition, social, and behavior change strategy aimed at reducing stunting, formative research was conducted in 2 program sites in western Kenya.

Methods

Twenty-nine key informant interviews were conducted with community leaders, health workers, and project staff, and 24 focus group discussions with caregivers of children under 2 y on topics related to feeding, sanitation, and hygiene behaviors. Three frameworks informed the study design and analysis of our formative research: the Capabilities, Opportunities, and Motivations model for behavior change, which identifies what needs to change in order for behavior change interventions to be effective; the Grandmother Project's Change Through Culture Approach, which values the important role of influential household and community members in producing household health; and Starr and Fornoff's approach to Theory of Change development.

Results

Caregivers exhibited sufficient psychological capabilities (knowledge and skills) for many of the key maternal and infant nutrition behaviors. However, reflective motivation to perform optimal behaviors was undermined by limitations in physical and social opportunities, including limited time and competing priorities for mothers, limited accessibility and availability of diverse foods, low self-efficacy for exclusive breastfeeding, and fears of negative consequences related to specific foods and recommended practices.

Conclusions

Interventions that aim to improve maternal and child diets should address the underlying social, cultural, and environmental determinants that contribute to motivations and opportunities to perform recommended practices.

Associations between exclusive breastfeeding duration and children's developmental outcomes: Evidence from Siaya county, Kenya

BACKGROUND

Exclusive breastfeeding (EBF) during the first 6 months of life is widely promoted as a key strategy to enhance child health, growth, and development. Even though a high proportion of children in Kenya are currently breastfed exclusively, there is little evidence regarding the developmental benefits during the first year of life. This paper aims to fill this gap by establishing an association between EBF and early childhood developmental outcomes among children below the age of 6 months in Kenya.

METHODS

We used data collected as part of a cluster-randomized controlled trial conducted in Bondo sub-county in the western part of Kenya to assess the associations between EBF and development in the first year of life. The primary exposure variable was EBF, and the outcome variable was child development as measured by the Ages and Stages Questionnaire-Third Edition (ASQ-3).

RESULTS

We analyzed data from 570 children aged below 6 months at the time of the interview. Breastfeeding children exclusively between 3 and 6 months was associated with 0.61 standard deviation (SD) higher ASQ-3 scores in the adjusted model. When specific domains were considered, in the adjusted models, EBF in the 3-6 months period was associated with 0.44 SD, 0.34 SD and 0.36 SD higher ASQ-3 scores in communication, gross motor, and problem solving domains, respectively. There were weak associations in the fine motor and social-emotional domains.

CONCLUSION

EBF in the 3- to 6-month age range has significant positive associations with child development, especially for communication, gross motor, and problem-solving. Programs encouraging mothers to continue EBF in this period may have substantial benefits for children.

Relaxation-Compensated Chemical Exchange Saturation Transfer MRI in the Brain at 7T: Application in Relapsing-Remitting Multiple Sclerosis

Chemical exchange saturation transfer (CEST) magnetic resonance imaging (MRI) can probe tissue biochemistry in vivo with high resolution and sensitivity without requiring exogenous contrast agents. Applying CEST MRI at ultrahigh field provides advantages of increasing spectral resolution and improving sensitivity to metabolites with faster proton exchange rates such as glutamate, a critical neurotransmitter in the brain. Prior magnetic resonance spectroscopy and CEST MRI studies have revealed altered regulation of glutamate in patients with multiple sclerosis (MS). While CEST imaging facilitates new strategies for investigating the pathology underlying this complex and heterogeneous neurological disease, CEST signals are contaminated or diluted by concurrent effects (e.g., semi-solid magnetization transfer (MT) and direct water saturation) and are scaled by the T1 relaxation time of the free water pool which may also be altered in the context of disease. In this study of 20 relapsing-remitting MS patients and age- and sex-matched healthy volunteers, glutamate-weighted CEST data were acquired at 7.0 T. A Lorentzian fitting procedure was used to remove the asymmetric MT contribution from CEST z-spectra, and the apparent exchange-dependent relaxation (AREX) correction was applied using an R1 map derived from an inversion recovery sequence to further isolate glutamate-weighted CEST signals from concurrent effects. Associations between AREX and cognitive function were examined using the Minimal Assessment of Cognitive Function in MS battery. After isolating CEST effects from MT, direct water saturation, and T1 effects, glutamate-weighted AREX contrast remained higher in gray matter than in white matter, though the difference between these tissues decreased. Glutamate-weighted AREX in normal-appearing gray and white matter in MS patients did not differ from healthy gray and white matter but was significantly elevated in white matter lesions. AREX in some cortical regions and in white matter lesions correlated with disability and measures of cognitive function in MS patients. However, further studies with larger sample sizes are needed to confirm these relationships due to potential confounding effects. The application of MT and AREX corrections in this study demonstrates the importance of isolating CEST signals for more specific characterization of the contribution of metabolic changes to tissue pathology and symptoms in MS.

Effects of COVID-19 on Child Health Services Utilisation and Delivery in Rural Mozambique: A Qualitative Study

Little is known about the COVID-19 pandemic-related disruptions in health services and the resilience of the health system response in rural low-resource settings. We conducted a phenomenological qualitative study (October-November 2020) to understand COVID-19-related influences on the utilisation and delivery of child health services in Monapo district, rural Mozambique. We interviewed 36 caregivers with children <2.5 years, 21 health providers, and 4 district health services staff using in-person in-depth interviews. Data were analysed using inductive thematic content analysis. Our findings showed that caregivers, providers, and district health services staff unanimously reported a decrease in child consultations at the start of the pandemic. Administrative data from health facilities confirmed persisting declines in monthly consultations. Respondents explained reductions due to miscommunication about health facility operations, fear of COVID-19, reduced consultation schedules, and reduced household incomes. Providers reported several challenges in delivering services including lack of caregiver compliance with risk mitigation measures, caregivers’ fear of risk mitigation measures, perceived lack of caregiver knowledge about COVID-19, and lack of supplies and protective equipment. All respondents described how COVID-19 had increased food insecurity and food prices, and reduced incomes and livelihoods. These negative economic consequences were perceived as the main reason for reported increases in cases of child malnutrition. Despite reductions, child health service utilisation and delivery has largely continued throughout the COVID-19 pandemic, indicating an adaptive and resilient primary health system response in Monapo district. Our findings highlighted the persistent difficulties providers and caregivers face adhering to COVID-19 prevention and risk mitigation measures. A coordinated multi-sectoral response is needed to address the persistent negative economic impacts of the pandemic for young children and their families in rural areas.

Does Enhancing Paid Maternity Leave Policy Help Promote Gender Equality? Evidence from 31 Low- and Middle-Income Countries

Globally, women continue to have less economic decision-making power and face gender-unequal norms at work. Little is known about the impact of national public policies on norms surrounding equality. We examined the impact of extending paid maternity leave policy on decision making in the household and gender norms in the workplace, specifically whether women have sole or joint decision-making power with respect to large household purchases and whether women are perceived as having an equal right to jobs when jobs are scarce. We used difference-in-differences models to analyze the impact of increasing paid maternity leave on outcomes measured in the Demographic Health Surveys and World Values Surveys collected in 31 low- and middle-income countries. A one-month increase in the legislated duration of paid maternity leave increased the odds that women and their partners/spouses reported that women had more decision-making power by 40% (95% CI 1.14, 1.70) and 66% (95% CI 1.36, 2.03), respectively. A one-month increase in the legislated duration of paid maternity leave was associated with 41.5 percentage-point increase in the prevalence of individuals disagreeing with the statement that "when jobs are scarce, men should have more right to a job than women." More generous maternity leave increases gender equality in economic decision making in the household and improves gender norms related to work. Future studies should examine the impact of paternity leave and non-discrimination policy, as well as other large-scale policies aiming to improve gender equality at work and at home.

Evaluation of photography using head-mounted display technology (ICAPS) for district Trachoma surveys

Background

As the prevalence of trachoma declines worldwide, it is becoming increasingly expensive and challenging to standardize graders in the field for surveys to document elimination. Photography of the tarsal conjunctiva and remote interpretation may help alleviate these challenges. The purpose of this study was to develop, and field test an Image Capture and Processing System (ICAPS) to acquire hands-free images of the tarsal conjunctiva for upload to a virtual reading center for remote grading.

Methodology/Principal findings

This observational study was conducted during a district-level prevalence survey for trachomatous inflammation—follicular (TF) in Chamwino, Tanzania. The ICAPS was developed using a Samsung Galaxy S8 smartphone, a Samsung Gear VR headset, a foot pedal trigger and customized software allowing for hands-free photography. After a one-day training course, three trachoma graders used the ICAPS to collect images from 1305 children ages 1–9 years, which were expert-graded remotely for comparison with field grades. In our experience, the ICAPS was successful at scanning and assigning barcodes to images, focusing on the everted eyelid with adequate examiner hand visualization, and capturing images with sufficient detail to grade TF. The percentage of children with TF by photos and by field grade was 5%. Agreement between grading of the images compared to the field grades at the child level was kappa = 0.53 (95%CI = 0.40–0.66). There were ungradable images for at least one eye in 199 children (9.1%), with more occurring in children ages 1–3 (18.5%) than older children ages 4–9 (4.2%) (χ² = 145.3, p<0.001).

Conclusions/Significance

The prototype ICAPS device was robust, able to image 1305 children in a district level survey and transmit images from rural Tanzania to an online grading platform. More work is needed to improve the percentage of ungradable images and to better understand the causes of disagreement between field and photo grading.

Trachoma is the leading infectious cause of blindness worldwide, caused by the bacterium Chlamydia trachomatis. Programs targeting trachoma elimination in endemic regions largely rely on periodic prevalence surveys to monitor progress, but training field graders requires active cases, which is becoming challenging as prevalence declines. Photography of the tarsal conjunctiva with remote interpretation via telemedicine may serve as a more auditable, effective, and cost-efficient method for surveys. We developed and evaluated the Image Capture and Processing System (ICAPS), a smartphone-based, hands-free, head-mounted camera system (Samsung Galaxy S8 with custom app, Samsung Gear VR headset, and a Bluetooth-linked foot pedal trigger). The ICAPS was easy to use in challenging field conditions, was able to upload images from Tanzania and link images to field data. The percentage of TF was 5% by both field grade and photo grade, with agreement kappa = 0.53. Additional field training and enhanced certification of photographers may help reduce the proportion of ungradable images; further research on reasons for mismatch of grades between field and photo is needed.

COVID-19 vaccine access and attitudes among people experiencing homelessness from pilot mobile phone survey in Los Angeles, CA

People experiencing homelessness (PEH) are at high risk for COVID-19 complications and fatality, and have been prioritized for vaccination in many areas. Yet little is known about vaccine acceptance in this population. The objective of this study was to determine the level of vaccine hesitancy among PEH in Los Angeles, CA and to understand the covariates of hesitancy in relation to COVID-19 risk, threat perception, self-protection and information sources. A novel mobile survey platform was deployed to recruit PEH from a federally qualified health center (FQHC) in Los Angeles to participate in a monthly rapid response study of COVID-19 attitudes, behaviors, and risks. Of 90 PEH surveyed, 43 (48%) expressed some level of vaccine hesitancy based either on actual vaccine offers (17/90 = 19%) or a hypothetical offer (73/90 = 81%). In bivariate analysis, those with high COVID-19 threat perception were less likely to be vaccine hesitant (OR = 0.34, P = 0.03), while those who frequently practiced COVID-19 protective behaviors were more likely to be vaccine hesitant (OR = 2.21, P = 0.08). In a multivariate model, those with high threat perception (AOR = 0.25, P = 0.02) were less likely to be hesitant, while those engaging in COVID-19 protective behaviors were more hesitant (AOR = 3.63, P = 0.02). Those who trusted official sources were less hesitant (AOR = 0.37, P = 0.08) while those who trusted friends and family for COVID-19 information (AOR = 2.70, P = 0.07) were more likely to be hesitant. Findings suggest that targeted educational and social influence interventions are needed to address high levels of vaccine hesitancy among PEH.

Inhibition of neutral sphingomyelinase 2 promotes remyelination

Myelination requires a highly organized synthesis of multiple lipid species that regulate myelin curvature and compaction. For reasons that are not understood, central nervous system remyelinated axons often have thin myelin sheaths with a disorganized structure susceptible to secondary demyelination. We found that expression of the sphingomyelin hydrolase neutral sphingomyelinase 2 (nSMase2) during the differentiation of oligodendrocyte progenitor cells (OPCs) to myelinating oligodendrocytes changes their response to inflammatory cytokines. OPCs do not express nSMase2 and exhibit a protective/regenerative response to tumor necrosis factor-α and interleukin-1β. Oligodendrocytes express nSMase2 and exhibit a stress response to cytokine challenge that includes an overproduction of ceramide, a sphingolipid that forms negative curvatures in membranes. Pharmacological inhibition or genetic deletion of nSMase2 in myelinating oligodendrocytes normalized the ceramide content of remyelinated fibers and increased thickness and compaction. These results suggest that inhibition of nSMase2 could improve the quality of myelin and stabilize structure.

WaSH CQI: Applying continuous quality improvement methods to water service delivery in four districts of rural northern Ghana

Continuous, safely managed water is critical to health and development, but rural service delivery faces complex challenges in low- and middle-income countries (LMICs). We report the first application of continuous quality improvement (CQI) methods to improve the microbial quality of household water for consumption (HWC) and the functionality of water sources in four rural districts of northern Ghana. We further report on the impacts of interventions developed through these methods. A local CQI team was formed and trained in CQI methods. Baseline data were collected and analyzed to identify determinants of service delivery problems and microbial safety. The CQI team randomized communities, developed an improvement package, iteratively piloted it in intervention communities, and used uptake survey data to refine the package. The final improvement package comprised safe water storage containers, refresher training for community WaSH committees and replacement of missing maintenance tools. This package significantly reduced contamination of HWC (p<0.01), and significant reduction in contamination persisted two years after implementation. Repair times in both intervention and control arms decreased relative to baseline (p<0.05), but differences between intervention and control arms were not significant at endline. Further work is needed to build on the gains in household water quality observed in this work, sustain and scale these improvements, and explore applications of CQI to other aspects of water supply and sanitation.

Remyelination alters the pattern of myelin in the cerebral cortex

Destruction of oligodendrocytes and myelin sheaths in cortical gray matter profoundly alters neural activity and is associated with cognitive disability in multiple sclerosis (MS). Myelin can be restored by regenerating oligodendrocytes from resident progenitors; however, it is not known whether regeneration restores the complex myelination patterns in cortical circuits. Here, we performed time lapse in vivo two photon imaging in somatosensory cortex of adult mice to define the kinetics and specificity of myelin regeneration after acute oligodendrocyte ablation. These longitudinal studies revealed that the pattern of myelination in cortex changed dramatically after regeneration, as new oligodendrocytes were formed in different locations and new sheaths were often established along axon segments previously lacking myelin. Despite the dramatic increase in axonal territory available, oligodendrogenesis was persistently impaired in deeper cortical layers that experienced higher gliosis. Repeated reorganization of myelin patterns in MS may alter circuit function and contribute to cognitive decline.

5-Carboxylcytosine is resistant towards phosphodiesterase I digestion: implications for epigenetic modification quantification by mass spectrometry

DNA cytosine modifications are important epigenetic modifications in gene regulation and pathogenesis. DNA hydrolysis followed by HPLC-MS/MS is the gold standard in DNA modification quantification. In particular, it is the only sensitive and accurate method for low abundance modifications, such as 5-carboxylcytosine (5caC). Here, we report the discovery of the nuclease resistance property of 5caC to snake venom phosphodiesterase I (PDE1), a 3' to 5' exonuclease commonly used in several DNA hydrolysis protocols. We conducted a systematic evaluation of six commonly used hydrolysis protocols and found that all protocols that use PDE1 underestimate the level of 5caC. Finally, we identified the best method for cytosine modification quantification of biological samples, which leads to an over 10-fold higher amount of 5caC being detected compared with other methods. Our results highlight that caution should be taken when choosing a DNA hydrolysis protocol to quantify certain DNA modifications.

Prevalence of trachoma in the Kayes region of Mali eight years after stopping mass drug administration

BACKGROUND

In 2009, three years after stopping mass treatment with azithromycin, a trachoma impact survey in four health districts in the Kayes region of Mali found a prevalence of trachomatous inflammation-follicular (TF) among children aged 1 to 9 years of >5% and a trachomatous trichiasis (TT) prevalence within the general population (≥1-year-old) of <1%. As a result, the government's national trachoma program expanded trichiasis surgery and related activities required to achieve trachoma elimination.

METHODOLOGY/PRINCIPAL FINDINGS

In 2015, to assess progress towards elimination, a follow-up impact survey was conducted in the Kayes, Kéniéba, Nioro and Yélimané health districts. The survey used district level two-stage cluster random sampling methodology with 20 clusters of 30 households in each evaluation unit. Subjects were eligible for examination if they were ≥1 year. TF and TT cases were identified and confirmed by experienced ophthalmologists. In total 14,159 people were enumerated and 11,620 (82%) were examined. TF prevalence (95% confidence interval (CI)) was 0.5% (0.3-1%) in Kayes, 0.8% (0.4-1.7%) in Kéniéba, 0.2% (0-0.9%) in Nioro and 0.3% (0.1-1%) in Yélimané. TT prevalence (95% CI) was 0.04% (0-0.25%) in Kayes, 0.29% (0.11-0.6%) in Kéniéba, 0.04% (0-0.25%) in Nioro and 0.07% (0-0.27%) in Yélimané.

CONCLUSIONS/SIGNIFICANCE

Eight years after stopping MDA and intensifying trichiasis surgery outreach campaigns, all four districts reached the TF elimination threshold of <5% and three of four districts reached the TT elimination threshold of <0.1%.

Limbic system damage in MS: MRI assessment and correlations with clinical testing

Volume loss in some limbic region structures has been observed in multiple sclerosis (MS) patients. However, in vivo evaluation of existing tissue cellular microstructure integrity has received less attention. The goal of studies reported here was to quantitatively assess loss of limbic system volumes and tissue integrity, and to evaluate associations of these measures with cognitive and physical dysfunction in MS patients. Thirty-one healthy controls (HC) and 80 MS patients, including 32 relapsing remitting (RRMS), 32 secondary progressive (SPMS) and 16 primary progressive (PPMS), participated in this study. Tissue cellular integrity was evaluated by means of recently introduced tissue-specific parameter R2t* that was calculated from multi-gradient-echo MRI signals using a recently developed method that separates R2t* from BOLD (blood oxygen level dependent) contributions to GRE signal decay rate constant (R2*), and accounting for physiological fluctuations and artifacts from background gradients. Volumes in limbic system regions, normalized to skull size (NV), were measured from standard MPRAGE images. MS patients had lower R2t* and smaller normalized volumes in the hippocampus, amygdala, and several other limbic system regions, compared to HC. Alterations in R2t* of several limbic system regions correlated with clinical and neurocognitive test scores in MS patients. In contrast, smaller normalized volumes in MS were only correlated with neurocognitive test scores in the hippocampus and amygdala. This study reports the novel finding that R2t*, a measure that estimates tissue integrity, is more sensitive to tissue damage in limbic system structures than is atrophy. R2t* measurements can serve as a biomarker that is distinct from and complementary to volume measurements.

Human and nonhuman primate meninges harbor lymphatic vessels that can be visualized noninvasively by MRI

Here, we report the existence of meningeal lymphatic vessels in human and nonhuman primates (common marmoset monkeys) and the feasibility of noninvasively imaging and mapping them in vivo with high-resolution, clinical MRI. On T2-FLAIR and T1-weighted black-blood imaging, lymphatic vessels enhance with gadobutrol, a gadolinium-based contrast agent with high propensity to extravasate across a permeable capillary endothelial barrier, but not with gadofosveset, a blood-pool contrast agent. The topography of these vessels, running alongside dural venous sinuses, recapitulates the meningeal lymphatic system of rodents. In primates, meningeal lymphatics display a typical panel of lymphatic endothelial markers by immunohistochemistry. This discovery holds promise for better understanding the normal physiology of lymphatic drainage from the central nervous system and potential aberrations in neurological diseases.

Pregnancy: Effect on Multiple Sclerosis, Treatment Considerations, and Breastfeeding

Multiple sclerosis (MS) commonly affects women in childbearing years making pregnancy issues important for patients with MS and their families. Pregnancy is a naturally occurring disease modifier of MS associated with a 70% reduction in relapse rates in the third trimester. This relapse rate reduction during the last trimester is roughly equal to the most effective disease-modifying treatments for MS. Given this efficacy, various pregnancy factors have been tested to determine which play a part in pregnancy's protection, and some have been translated to completed and ongoing phase II clinical trials. In contrast to protective effects during pregnancy, the postpartum period entails increased relapse risk, which may be due to either abrupt removal of protective pregnancy factors after delivery or to unique deleterious factors inherent to the postpartum period. The effect of breastfeeding on MS remains unclear. The best predictor for whether a patient will have a postpartum relapse is the incidence of her having active relapsing MS prior to pregnancy. The medical management of MS during pregnancy and the postpartum period is challenging given the risks of medication exposure to the fetus in utero and to the infant through breast milk. This review will focus on clinical aspects of pregnancy, including the effects of pregnancy on MS disease activity, as well as the medical management of MS during pregnancy and postpartum.

Support for the feasibility of the ages and stages questionnaire as a developmental screening tool: a cross-sectional study of South African and Zambian children aged 2-60 months

BACKGROUND

There is a growing global acknowledgement that improving child survival rates is no longer sufficient. Emphasis is shifting to the improvement of health and developmental trajectories in early childhood. Screening and measurement of these trajectories in low and middle income countries is difficult, however, as they currently rely on developmental tests standardised among populations of children growing up in resource rich environments.

METHODS

This paper presents a comparison of one such tool adapted for use with children living in Southern Africa to children from the United States, Norway, Korea and Spain. The Ages and Stages Questionnaire version 3 (ASQ-3) was adapted and administered to 853 children living in South Africa and Zambia.

RESULTS

Children in southern Africa were found to perform significantly better than children from other countries early in life, especially in the domains of communication, gross motor and fine motor skills. By the age of five, children in southern Africa were performing significantly worse than their peers in the domains of fine motor and problem-solving.

CONCLUSION

The results indicate the applicability of the ASQ-3 in southern Africa and point to the importance of early interventions to protect the early good development of African children in order to promote positive life trajectories.