Assessing Accuracy and Precision of Hemoglobin Determination in Venous, Capillary Pool, and Single-Drop Capillary Blood Specimens Using three Different HemoCue® Hb Models: The Multicountry Hemoglobin Measurement (HEME) Study.

BACKGROUND: Anemia prevalence estimates reported in population surveys can vary based on the blood specimen source (capillary or venous) and analytic device (hematology autoanalyzers or portable hemoglobinometers) used for hemoglobin (Hb) determination. OBJECTIVES: This study aimed to compare accuracy and precision of Hb measurement in three blood specimen types on three models of hemoglobinometers against the results from venous blood from the same individuals measured on automated analyzers (AAs). METHODS: This multisite (Cambodia, Ethiopia, Guatemala, Lebanon, Nigeria, and Tanzania) study assessed Hb measurements in paired venous and capillary blood specimens from apparently healthy women (aged 15-49 y) and children (aged 12-59 mo) using three HemoCue® Hb models (201+, 301, and 801). Measurements were compared against reference values: venous blood in hematology AA and adjusted via regression calibration or mean difference in HemoCue® Hb. Venous, capillary pool, and single-drop capillary blood specimens were assessed for accuracy and precision. RESULTS: Venous blood measured using HemoCue® Hb 301 exhibited a positive mean error, whereas responses in HemoCue® Hb 201+ and 801 were nondirectional compared with the reference. Adjustment with the reference harmonized mean errors for all devices across study sites to <1.0 g/L using venous blood. Precision was highest for venous blood (±5-16 g/L) in all sites, lowest for single-drop capillary (±9-37 g/L), and intermediate (±9-28 g/L) for capillary pool blood specimen. Imprecision differed across sites, especially with both capillary blood specimens, suggesting different levels of personnel skills. CONCLUSIONS: Findings suggest that venous blood is needed for accurate and precise Hb determination. Single-drop capillary blood use should be discouraged owing to high measurement variability. Further research should evaluate the viability and reliability of capillary pool blood for this purpose. Accuracy of HemoCue® Hb devices can be improved via standardization against results from venous blood assessed using AA.

Risk factors for anaemia among women and their young children hospitalised with suspected thiamine deficiency in northern Lao PDR.

Anaemia among women and young children remains a major public health concern. This secondary study describes the anaemia prevalence among young hospitalised children and their mothers in northern Lao People's Democratic Republic and explores possible nutritional causes and risk factors for anaemia. Hospitalised children (ages 21 days to <18 months) with clinical symptoms suggestive of thiamine deficiency disorders were eligible along with their mothers. Venous blood was collected for determination of haemoglobin, ferritin, soluble transferrin receptor (sTfR), retinol-binding protein (RBP), erythrocyte glutathione reductase activation coefficient (EGRac), thiamine diphosphate (ThDP) and acute phase proteins. Risk factors for anaemia were modelled using minimally adjusted logistic regression controlling for age. Haemoglobin results were available for 436 women (mean ± SD age 24.7 ± 6.4 years; 1.6% pregnant) and 427 children (4.3 ± 3.5 months; 60.3% male). Anaemia prevalence (Hb < 120 g/L for nonpregnant women and <110 g/L for pregnant women and children) was 30.7% among women and 55.2% among children. In bivariate analyses, biomarkers significantly associated with anaemia in women were ferritin, sTfR, RBP, EGRac and ThDP. Other risk factors for women were lower BMI, mid-upper arm circumference < 23.5 cm, lower education, lower socioeconomic index, food insecurity, Hmong ethnicity, not/rarely having attended antenatal care, not having taken antenatal iron-containing supplements and not meeting minimum dietary diversity. Risk factors for anaemia among children were older age, male sex, stunting, sTfR, ThDP and alpha-1-acid-glycoprotein. Anaemia was common among women and their hospitalised children and was associated with micronutrient deficiencies and socioeconomic, dietary and health care-seeking risk factors, suggesting that multiple strategies are required to prevent anaemia among women and children.

Assessing the performance of national sentinel food lists at subnational levels in six countries.

OBJECTIVE: To assess how well national sentinel lists of the most frequently consumed foods in each food group capture data at subnational levels to measure minimum diet diversity (MDD). DESIGN: We analysed data from seven surveys with 24-h open dietary recalls to evaluate: (1) the percentage of reported foods that were included in each sentinel food list; (2) whether these lists captured consumption of some food groups better than others and (3) differences between estimates of dietary diversity calculated from all food items mentioned in the open 24-h recall v. only food items included in the sentinel lists. SETTING: Seven subnational areas: Bangladesh (2), Benin, Colombia, Kenya, Malawi and Nepal. PARTICIPANTS: 8094 women 15-49 years; 4588 children 6-23 months. RESULTS: National sentinel food lists captured most foods reportedly consumed by women (84 %) and children (86 %). Food groups with the highest variability were 'other fruits' and 'other vegetables.' MDD calculated from the sentinel list was, on average, 6·5 (women) and 4·1 (children) percentage points lower than when calculated from open 24-h recalls, with a statistically significant difference in most subnational areas. CONCLUSION: National sentinel food lists can provide reliable data at subnational levels for most food groups, with some variability by country and sub-region. Assessing the accuracy of national sentinel food lists, especially for fruits and vegetables, before using them at the subnational level could avoid potentially underestimating dietary diversity and provide more accurate local information for programmes, policy and research.

Attitudes, beliefs and social norms regarding infant and young child feeding among Nigerian mothers, fathers and grandmothers across time.

Infant and young child feeding (IYCF) interventions in low-resource countries mainly target pregnant women and mothers of young children; however, fathers and grandmothers also influence IYCF practices. We conducted focus group discussions with mothers, fathers and grandmothers of young children across three time points in areas where an IYCF social and behaviour change intervention was implemented in Nigeria to explore differences by participant type and shifts over time in attitudes, beliefs and social norms related to breastfeeding and dietary diversity (DD). Overall, across time points, we found more discrepancies in attitudes, beliefs and social norms for early initiation of breastfeeding (EIBF) and exclusive breastfeeding (EBF) among different participant types than for DD. Although most participants agreed EIBF and EBF are good practices, mothers believed this more strongly than fathers and grandmothers; however, at endline, a shift towards acceptance of EIBF and EBF appeared among fathers and grandmothers. Across time points, all participant types acknowledged the nutritional and health benefits of green leafy vegetables and animal-source foods but described various barriers to feeding them to children. Across time points, all participant types also highlighted the importance of health workers and antenatal visits as important sources of IYCF knowledge and facilitators to following recommended practices. Insights from this study highlight the importance of including key influencers of IYCF practices in qualitative research.

In-Depth Evaluation of Saliency Maps for Interpreting Convolutional Neural Network Decisions in the Diagnosis of Glaucoma Based on Fundus Imaging.

Glaucoma, a leading cause of blindness, damages the optic nerve, making early diagnosis challenging due to no initial symptoms. Fundus eye images taken with a non-mydriatic retinograph help diagnose glaucoma by revealing structural changes, including the optic disc and cup. This research aims to thoroughly analyze saliency maps in interpreting convolutional neural network decisions for diagnosing glaucoma from fundus images. These maps highlight the most influential image regions guiding the network's decisions. Various network architectures were trained and tested on 739 optic nerve head images, with nine saliency methods used. Some other popular datasets were also used for further validation. The results reveal disparities among saliency maps, with some consensus between the folds corresponding to the same architecture. Concerning the significance of optic disc sectors, there is generally a lack of agreement with standard medical criteria. The background, nasal, and temporal sectors emerge as particularly influential for neural network decisions, showing a likelihood of being the most relevant ranging from 14.55% to 28.16% on average across all evaluated datasets. We can conclude that saliency maps are usually difficult to interpret and even the areas indicated as the most relevant can be very unintuitive. Therefore, its usefulness as an explanatory tool may be compromised, at least in problems such as the one addressed in this study, where the features defining the model prediction are generally not consistently reflected in relevant regions of the saliency maps, and they even cannot always be related to those used as medical standards.

Exclusive breastfeeding: Measurement to match the global recommendation.

The World Health Organization (WHO) and United Nations Children's Fund (UNICEF) recommend exclusive breastfeeding (EBF) for the first 6 months of life. To estimate the proportion of infants that are exclusively breastfed, many agencies use the point prevalence of EBF among infants currently 0-5.9 months of age, as recommended by WHO and UNICEF. This measure tends to overestimate the percentage of infants that are exclusively breastfed for the entire recommended period. We compared five methods of measuring EBF, using data from three large-scale cross-sectional surveys. The five methods were: the WHO/UNICEF recommended method (EBF-24H); an estimate of EBF for 6 months, using the 24-h recall among infants 4-5.9 and 6-7.9 months (EBF-24H-Pul); a since birth recall (EBF-SB); an estimate of EBF for 6 months, using the since-birth recall among infants 4-5.9 and 6-7.9 months (EBF-SB-Pul); a retrospective measure of EBF collected from infants 6-11.9 months, based on the age of introduction of liquids and foods (EBF-AI). EBF-24H-Pul and EBF-SB-Pul produced lower estimates of EBF than other measures, while also aligning better with the WHO recommendation, but may be difficult to estimate from multipurpose surveys due to sample size limitations. The EBF-AI method produced estimates between these, aligns well with the WHO recommendation and can be easily collected in large-scale household surveys. Additional validation of the EBF-24-Pul, EBF-SB-Pul, and EBF-AI methods is recommended to understand how accurately they measure EBF for the recommended 6-month period.

Determinants of Maternal Diet Quality in Winter in the Kyrgyz Republic.

Diet quality influences maternal health and nutrition from preconception through pregnancy and lactation, as well as infant health and nutrition. Women are vulnerable to poor nutrition given their increased nutrient requirements during the prenatal period through the first 2 years postpartum. Minimum diet diversity among women, a good predictor of adequate micronutrient intake, is often used as a proxy for diet quality. The Kyrgyz Republic is experiencing a triple burden of malnutrition-stunting in children, overweight and obesity in women, and micronutrient deficiencies and anemia in both women and children. In this study, we assessed factors associated with the quality of maternal diets in winter when micronutrient-rich foods may be more difficult to access due to scarcity and price. We conducted secondary data analysis from a survey conducted in the winter of 1,359 mothers of children aged younger than 2 years. Women were asked about the types of foods they stored and preserved in the fall and whether any remained in winter. After controlling for maternal characteristics, household size, main source of income, and region (including urban and rural), women with preserved food remaining at the time of the survey, who stored more than 4 different types of food in the fall, and who lived in Jalal-Abad oblast were more likely to have consumed a minimally diverse diet. Where seasonality affects food availability, promoting culturally appropriate home processing of a variety of foods in the fall and increased market access may improve diet diversity in winter.

Increasing the availability and utilization of reliable data on population micronutrient (MN) status globally: the MN Data Generation Initiative.

Micronutrient (MN) deficiencies can produce a broad array of adverse health and functional outcomes. Young, preschool children and women of reproductive age in low- and middle-income countries are most affected by these deficiencies, but the true magnitude of the problems and their related disease burdens remain uncertain because of the dearth of reliable biomarker information on population MN status. The reasons for this lack of information include a limited understanding by policy makers of the importance of MNs for human health and the usefulness of information on MN status for program planning and management; insufficient professional capacity to advocate for this information and design and implement related MN status surveys; high costs and logistical constraints involved in specimen collection, transport, storage, and laboratory analyses; poor access to adequately equipped and staffed laboratories to complete the analyses reliably; and inadequate capacity to interpret and apply this information for public health program design and evaluation. This report describes the current situation with regard to data availability, the reasons for the lack of relevant information, and the steps needed to correct this situation, including implementation of a multi-component MN Data Generation Initiative to advocate for critical data collection and provide related technical assistance, laboratory services, professional training, and financial support.

Measuring coverage of infant and young child feeding counselling interventions: A framework and empirical considerations for survey question design.

Most countries implement nutrition counselling interventions as part of programmes to support breastfeeding and complementary feeding. However, data to track coverage of counselling interventions are rarely available. As a result, little is known about the coverage of counselling on infant and young child feeding (IYCF). Survey-based data collection systems generally collect data on IYCF practices but do not collect data on coverage of interventions to support IYCF, and those surveys that do collect this information do not do so consistently. We present a framework to guide the design of survey questions to measure IYCF counselling coverage. We provide examples of how large-scale surveys for programme evaluation and national monitoring have included survey questions to address these data gaps. Our review suggests that elements relevant to designing survey questions to capture coverage of counselling interventions include timing of contact, target behaviour and message content, place of contact, type of service provider, frequency of contact and mode of intervention. Application of this framework may help strengthen harmonized measurement of IYCF counselling coverage to enable better tracking of programme investments, document progress in scaling up nutrition services and allow for cross-country comparisons. Thus, improving measurement of counselling coverage may lead to improved reach of programmes to support optimal IYCF practices.

Different Combinations of Behavior Change Interventions and Frequencies of Interpersonal Contacts Are Associated with Infant and Young Child Feeding Practices in Bangladesh, Ethiopia, and Vietnam.

BACKGROUND: Social and behavior change communication interventions are integral to improving dietary and care practices, but evidence on the impact of the combination and intensity of these interventions in different contexts is scarce. OBJECTIVES: We examined the extent of and factors associated with intervention exposure: interpersonal communication (IPC) alone or with other interventions (i.e., mass media, community mobilization, or nutrition-sensitive agricultural activities), number of and factors associated with IPC contacts, and combinations of intervention components and number of contacts associated with infant and young child feeding (IYCF) practices. METHODS: We used endline survey data from impact evaluations in Bangladesh, Ethiopia, and Vietnam (n = 1001, 1720, and 1001 mothers with children aged <2 y, respectively). Multivariable regression models were used for analyses. RESULTS: Exposure to the interventions varied in all 3 countries. On average, mothers received 8 visits in the last 6 mo in Bangladesh, 2 visits in the last 3 mo in Ethiopia, and 1 visit in the last 6 mo in Vietnam. Across countries, the factors associated with intervention exposure and number of IPC contacts differed. In Ethiopia, exposure to IPC with other interventions was associated with higher odds of achieving minimum meal frequency (OR: 1.6), minimum dietary diversity (OR: 1.8), and consumption of iron-rich foods (OR: 4.7). In Vietnam, exposure to IPC alone or with mass media was associated with higher odds of exclusive breastfeeding (EBF; OR: 2.8-3.7). Near-monthly visits were associated with 2-3 times higher odds of IYCF practices in Bangladesh and Ethiopia. In Vietnam, even 1 IPC visit was associated with 2 times higher odds of EBF. CONCLUSIONS: Exposure matters for impact, but the combination of behavior change interventions and number of IPC contacts required to support IYCF behavior change are context specific. This trial was registered at www.clinicaltrials.gov as NCT01678716 (Bangladesh), NCT02775552 (Ethiopia), and NCT01676623 (Vietnam).

Nutrition Interventions Integrated into an Existing Maternal, Neonatal, and Child Health Program Reduce Food Insecurity Among Recently Delivered and Pregnant Women in Bangladesh.

Background: Antenatal care may be a means to reduce food insecurity in pregnancy and postpartum periods. Objective: With the use of a cluster-randomized design, we tested whether participation in nutrition-focused antenatal care intending to improve household knowledge about the importance of nutrition for pregnant and lactating women and encourage allocation of household resources to ensure sufficient quality and quantity of foods, without providing food assistance, would reduce household food insecurity. Methods: Alive & Thrive integrated nutrition interventions into an existing Maternal, Neonatal, and Child Health (MNCH) program in Bangladesh. The nutrition-focused MNCH package was delivered in 10 subdistricts through antenatal care visits with the use of interpersonal communication, community mobilization, and monitoring of weight gain, aiming to improve maternal diet quality, quantity, and micronutrient intake during pregnancy and breastfeeding. The package included components that could reduce food insecurity, measured using the Household Food Insecurity Access Scale. To examine the impact of the nutrition-focused MNCH package compared with the standard MNCH package, we used linear and multinomial logit regression models, adjusted for subdistrict clustering, to test differences at endline in items, domains, and categories of food insecurity, after first confirming no differences at baseline. Results: At baseline, nearly half of households were food insecure. At endline, the groups differed in food insecurity, whether expressed as items, domains, or categories, with food insecurity in the nutrition-focused MNCH group 22 percentage points lower than in the standard MNCH group and 20 percentage points lower than at baseline. Conclusions: Participation in nutrition-focused antenatal care reduced household food insecurity among recently delivered and pregnant women. Integration of social and behavioral nutrition interventions into antenatal care with components that promote food security provides a potentially effective means to reduce food insecurity, without incurring high costs of providing supplemental food, in populations where limited resources can be directed towards accessing adequate and appropriate foods. Registered at clinicaltrials.gov as NCT02745249.

Engagement of Husbands in a Maternal Nutrition Program Substantially Contributed to Greater Intake of Micronutrient Supplements and Dietary Diversity during Pregnancy: Results of a Cluster-Randomized Program Evaluation in Bangladesh.

Background: Although husbands may provide support during pregnancy, limited evidence exists on how to promote husbands' engagement and what impact it has. Alive & Thrive integrated nutrition-focused interventions, targeting both wives and husbands, through an existing Maternal, Neonatal, and Child Health (MNCH) platform in Bangladesh. Objectives: We evaluated 1) the impact of a nutrition-focused MNCH program, compared with the standard MNCH program, on husbands' behavioral determinants (i.e., awareness, knowledge, self-efficacy) and support to wives to adopt optimal nutrition practices and 2) how much of the previously documented impact on women's supplement intake and dietary diversity was explained by husbands' behavioral determinants and support. Methods: We used a cluster-randomized design with cross-sectional surveys at baseline (2015) and endline (2016) (n = ∼1000 women and ∼700 husbands/survey). We used mixed linear regression accounting for clustering to estimate difference-in-differences (DIDs) for impact on husbands' behavioral determinants and path analysis to examine how much these determinants explained the impact on women's nutrition behaviors. Results: Of husbands in the nutrition-focused MNCH group, 62% were counseled by health workers, 66% attended a husbands' forum, and 34% saw video shows. The nutrition-focused MNCH, compared with the standard MNCH group, resulted in greater husbands' awareness (DID: 2.74 of 10 points), knowledge (DID: 1.31), self-efficacy and social norms with regard to optimal nutrition practices (difference: 1.08), and support to their wives (DID: 1.86). Husbands' behavioral determinants and support explained nearly half of the program impact for maternal supplement intake and one-quarter for dietary diversity. Conclusions: A nutrition-focused MNCH program that promoted and facilitated husbands' engagement during their wives' pregnancies significantly improved husbands' awareness, knowledge, self-efficacy, and support. These improvements substantially explained the program's impact on women's intake of micronutrient supplements and dietary diversity. Targeting wives and husbands and designing activities to engage men in maternal nutrition programs are important to maximize impact. This trial was registered at www.clinicaltrials.gov as NCT02745249.

Importance of coverage and quality for impact of nutrition interventions delivered through an existing health programme in Bangladesh.

Understanding implementation of interventions is critical to illuminate if, how, and why the interventions achieve impact. Alive & Thrive integrated a nutrition intervention into an existing maternal, neonatal, and child health (MNCH) programme in Bangladesh, documenting improvements in women's micronutrient supplement intake and dietary diversity. Here, we examined how well the nutrition intervention was implemented and which elements of implementation explained intervention impact. Survey data were collected in 2015 and 2016 from frontline health workers (FLW) and households in areas randomized to nutrition-focused MNCH (intensified interpersonal counselling, community mobilization, distribution of free micronutrient supplements, and weight-gain monitoring) or standard MNCH (antenatal care with standard nutrition counselling). Seven intervention elements were measured: time commitment, training quality, knowledge, coverage, counselling quality, supervision, and incentives. Multiple regression was used to derive difference-in-differences (DID) estimates. Using village-level endline data, path analysis was used to determine which elements most explained intervention impacts. FLWs in both areas were highly committed and well supervised. Coverage was high (>90%) for counselling, supplement provision, and weight-gain monitoring. Improvements were significantly greater for nutrition-focused MNCH, versus standard MNCH, for training quality (DID: 2.42 points of 10), knowledge (DID: 1.20 points), delivery coverage (DID: 4.16 points), and counselling quality (DID: 1.60 points). Impact was substantially explained by coverage and delivery quality. In conclusion, integration nutrition intervention into the MNCH programme was feasible and well-implemented. Although differences in coverage and counselling quality most explained impacts, all intervention elements-particularly FLW training and performance-were likely important to achieving impact.

Suaahara in Nepal: An at-scale, multi-sectoral nutrition program influences knowledge and practices while enhancing equity.

The burden of undernutrition in South Asia is greater than anywhere else. Policies and programmatic efforts increasingly address health and non-health determinants of undernutrition. In Nepal, one large-scale integrated nutrition program, Suaahara, aimed to reduce undernutrition among women and children in the 1,000-day period, while simultaneously addressing inequities. In this study, we use household-level process evaluation data (N = 480) to assess levels of exposure to program inputs and levels of knowledge and practices related to health, nutrition, and water, sanitation, and hygiene (WASH). We also assess Suaahara's effect on the differences between disadvantaged (DAG) and non-disadvantaged households in exposure, knowledge, and practice indicators. All regression models were adjusted for potential confounders at the child-, maternal-, and household levels, as well as clustering. We found a higher prevalence of almost all exposure and knowledge indicators and some practice indicators in Suaahara areas versus comparison areas. A higher proportion of DAG households in Suaahara areas reported exposure, were knowledgeable, and practiced optimal behaviors related to nearly all maternal and child health, nutrition, and WASH indicators than DAG households in non-Suaahara areas and sometimes even than non-DAG households in Suaahara areas. Moreover, differences in some of these indicators between DAG and non-DAG households were significantly smaller in Suaahara areas than in comparison areas. These results indicate that large-scale integrated interventions can influence nutrition-related knowledge and practices, while simultaneously reducing inequities.

The Association of a Large-Scale Television Campaign With Exclusive Breastfeeding Prevalence in Vietnam.

OBJECTIVES: To examine the association between exposure to breastfeeding television spots and exclusive breastfeeding (EBF). METHODS: We performed face-to-face interviews with 11 722 mothers of infants younger than 6 months using 5 cross-sectional surveys 6 or more months apart between 2011 and 2014 in Vietnam. Sample sizes were 2065 to 2593, and approximately 50% of participants lived in areas with (Alive & Thrive [A&T]-intensive [I]) and approximately 50% without (A&T-nonintensive [NI]) facilities offering counseling services. We analyzed data at individual and commune levels separately for A&T-I and A&T-NI areas. RESULTS: Exposure to television spots was associated with higher EBF in A&T-I (odds ratio [OR] = 3.33; 95% confidence interval [CI] = 2.70, 4.12) and A&T-NI (OR = 1.31; 95% CI = 1.03, 1.67) areas. In A&T-I areas, mothers who could recall at least 1 message were more likely to report EBF. In A&T-NI areas, only recall of at least 3 messages was associated with higher EBF. In communes, 1 message recalled (mean score range = 0.3-2.4) corresponded to 17 (P = .005) and 8 (P = .1) percentage points higher EBF prevalence in A&T-I and A&T-NI communes, respectively. CONCLUSIONS: Mass media should be part of comprehensive programs to promote EBF.

Impacts on Breastfeeding Practices of At-Scale Strategies That Combine Intensive Interpersonal Counseling, Mass Media, and Community Mobilization: Results of Cluster-Randomized Program Evaluations in Bangladesh and Viet Nam.

BACKGROUND: Despite recommendations supporting optimal breastfeeding, the number of women practicing exclusive breastfeeding (EBF) remains low, and few interventions have demonstrated implementation and impact at scale. Alive & Thrive was implemented over a period of 6 y (2009-2014) and aimed to improve breastfeeding practices through intensified interpersonal counseling (IPC), mass media (MM), and community mobilization (CM) intervention components delivered at scale in the context of policy advocacy (PA) in Bangladesh and Viet Nam. In Bangladesh, IPC was delivered through a large non-governmental health program; in Viet Nam, it was integrated into government health facilities. This study evaluated the population-level impact of intensified IPC, MM, CM, and PA (intensive) compared to standard nutrition counseling and less intensive MM, CM, and PA (non-intensive) on breastfeeding practices in these two countries. METHODS AND FINDINGS: A cluster-randomized evaluation design was employed in each country. For the evaluation sample, 20 sub-districts in Bangladesh and 40 communes in Viet Nam were randomized to either the intensive or the non-intensive group. Cross-sectional surveys (n ~ 500 children 0-5.9 mo old per group per country) were implemented at baseline (June 7-August 29, 2010, in Viet Nam; April 28-June 26, 2010, in Bangladesh) and endline (June 16-August 30, 2014, in Viet Nam; April 20-June 23, 2014, in Bangladesh). Difference-in-differences estimates (DDEs) of impact were calculated, adjusting for clustering. In Bangladesh, improvements were significantly greater in the intensive compared to the non-intensive group for the proportion of women who reported practicing EBF in the previous 24 h (DDE 36.2 percentage points [pp], 95% CI 21.0-51.5, p < 0.001; prevalence in intensive group rose from 48.5% to 87.6%) and engaging in early initiation of breastfeeding (EIBF) (16.7 pp, 95% CI 2.8-30.6, p = 0.021; 63.7% to 94.2%). In Viet Nam, EBF increases were greater in the intensive group (27.9 pp, 95% CI 17.7-38.1, p < 0.001; 18.9% to 57.8%); EIBF declined (60.0% to 53.2%) in the intensive group, but less than in the non-intensive group (57.4% to 40.6%; DDE 10.0 pp, 95% CI -1.3 to 21.4, p = 0.072). Our impact estimates may underestimate the full potential of such a multipronged intervention because the evaluation lacked a "pure control" area with no MM or national/provincial PA. CONCLUSIONS: At-scale interventions combining intensive IPC with MM, CM, and PA had greater positive impacts on breastfeeding practices in Bangladesh and Viet Nam than standard counseling with less intensive MM, CM, and PA. To our knowledge, this study is the first to document implementation and impacts of breastfeeding promotion at scale using rigorous evaluation designs. Strategies to design and deliver similar programs could improve breastfeeding practices in other contexts. TRIAL REGISTRATION: ClinicalTrials.gov NCT01678716 (Bangladesh) and NCT01676623 (Viet Nam).

Exposure to mass media and interpersonal counseling has additive effects on exclusive breastfeeding and its psychosocial determinants among Vietnamese mothers.

The pathways through which behavior change interventions impact breastfeeding practices have not been well studied. This study aimed to examine: (1) the effects of exposure to mass media and interpersonal counseling on exclusive breastfeeding (EBF) and hypothesized psychosocial determinants (i.e. knowledge, intention, beliefs, social norms, and self-efficacy); and (2) the pathways through which exposure to mass media and interpersonal counseling are associated with EBF. We used survey data from mothers with children < 2 year (n = 2045) from the 2013 process evaluation of Alive & Thrive's program in Viet Nam. Multiple linear regression analyses and structural equation modeling were used to estimate effects. Exposure to mass media only, interpersonal counseling only, both or neither was 51%, 5%, 19% and 25%, respectively. Exposure to both mass media and interpersonal counseling had additive effects on EBF as well as on related psychosocial factors, compared with no exposure. For example, EBF prevalence was 26.1 percentage points (pp) higher in the group that received interpersonal counseling only, 3.9 pp higher in the mass media group and 31.8 pp higher in the group that received both interventions. As hypothesized, more than 90% of the total effect of the two interventions on EBF was explained by the psychosocial factors measured. Our findings suggest that combining different behavior change interventions leads to greater changes in psychosocial factors, which in turn positively affects breastfeeding behaviors.

Estimating the Amount of Hemoglobin in the Neuroretinal Rim Using Color Images and OCT.

PURPOSE: To calculate the amount of hemoglobin (Hb) in the optic nerve head (ONH), using superimposed color fundus images with disc, rim and cup boundaries obtained by OCT-Cirrus. MATERIAL AND METHODS: We examined 100 healthy and 121 glaucomatous eyes using Oculus-Spark perimetry, Cirrus-OCT and Visucam (Zeiss) ONH color images. The Laguna ONhE program was then used to calculate the amount of Hb in the cup and six sectors of the rim. Receiver operating characteristic (ROC) analysis was performed and correlations between parameters were calculated. RESULTS: In suspected and confirmed glaucoma, Hb was significantly lower than controls in all rim sectors, especially the inferior and superonasal (p < 0.0001). Mean deviation (MD) of visual field regions showed greater correlation with the amount of Hb in the superior and inferior sectors of the rim than with rim area (p = 0.02) or nerve fiber layer thickness (p < 0.0001). On ROC analysis, the best diagnostic indicators were OCT rim area, vertical cup/disc ratio (C/D) and Glaucoma Discriminant Function (GDF) of Laguna ONhE, without significant differences. CONCLUSIONS: The amount of Hb in the ONH seems to have an important relationship with glaucomatous visual field sensitivity. The remaining rim has insufficient perfusion in many cases of glaucoma.

Glaucoma morphologic damage estimated from functional tests.

PURPOSE: To compare direct morphologic measurements with the ones deduced from functional tests. METHODS: A total of 111 normal eyes (examined twice) and 112 consecutive eyes with suspected or confirmed glaucoma were analyzed using Spark strategy (Oculus Easyfield Perimeter) and Cirrus optical coherence tomography (OCT). The threshold values were used to deduce the thickness of the retinal nerve fiber layer (RNFL) in 25 sectors. They were also used to derive a normalized value of the neuroretinal rim area, correcting the influence of the optic disc area size, and expressing the result as a percentage of their normal average relation. RESULTS: The correlation between the deduced and the measured RNFL thicknesses were r = 0.77 (p<0.001, standard error [SE] = 15.4 µm in normal and 15.1 µm in glaucomatous eyes) in the sector to sector comparison, and r = 0.80 (p<0.000001, SE = 10.0 µm in normal and 10.4 µm in glaucomatous eyes) for the average thickness. In normal subjects, the SE of deducing a second OCT result from the previous one was 13.2 µm in the sector by sector analysis and 4.6 µm for average thickness. The correlation between the deduced and measured rim area was r = 0.87 (p<0.000001, SE = 6.7% in normal and 15.9% in glaucomatous eyes). Receiver operating characteristic analysis yielded the following areas, sensitivities, and specificities: measured thickness: 0.89, 75.5%, 91.5%; deduced thickness: 0.91, 86.5%, 93.4%; measured rim area: 0.96, 89.2%, 95.3%; deduced rim area: 0.94, 82.9%, 96.2%. Additionally, the results in a new series of 71 normal and 68 glaucomatous eyes are verified. CONCLUSIONS: Spark perimetry allowed deducing glaucomatous morphologic alterations with significant accuracy.

Estimation of the relative amount of hemoglobin in the cup and neuroretinal rim using stereoscopic color fundus images.

PURPOSE: To calculate the relative amount of hemoglobin (Hb) in sectors of the optic nerve head (ONH) from stereoscopic color fundus images using the Laguna ONhE method and compare the results with the visual field evaluation and optical coherence tomography (OCT). METHODS: Healthy eyes (n = 87) and glaucoma eyes (n = 71) underwent reliable Oculus Spark perimetry and Cirrus OCT. Optical nerve head color images were acquired with a nonmydriatic stereoscopic Wx Kowa fundus camera. Laguna ONhE program was applied to these images to calculate the relative Hb amount in the cup and six sectors of the rim. Receiver operating characteristic (ROC) analysis and correlations between parameters were calculated. RESULTS: We did not observe any variations in the relative amount of Hb in relation to age in healthy subjects (R(2) = 0.033, P > 0.05). Maximum ROC area confidence intervals were observed for a combination between perimetric indices and the Laguna ONhE Glaucoma discriminant function (0.970-0.899) followed by rim area (0.960-0.883), and mean deviation (MD; 0.944-0.857). In glaucoma cases, relative Hb amount presented significant reduction in all rim sectors, especially 231° to 270° and 81° to 120° (P < 0.001), except in the temporal 311° to 40° (P = 0.11). Perimetry mean sensitivity by sectors was better correlated with respective Hb levels than with rim areas or the corresponding nerve fiber thickness, especially the superior and inferior sectors (P < 0.05). CONCLUSIONS: Visual field sensitivity was better correlated with Hb levels than with rim sector areas or the corresponding nerve fiber thickness. In many cases the remaining rim show low perfusion, especially in the superior and inferior sectors.