Human biomonitoring without in-person interaction: public health engagements during the COVID-19 pandemic and future implications.

BACKGROUND: Public health initiatives, including human biomonitoring, have been impacted by unique challenges since the onset of the COVID-19 pandemic, compounding a decades-long trend of declining public participation. To combat low public participation rates, public health professionals often employ extensive engagement approaches including in-person interactions related to enrollment and sampling, success of which is an essential component of a statistically defensible study. The onset of the COVID-19 pandemic challenged public health programs to diversify engagement and sampling approaches, limiting direct interactions for the health and safety of the population. This study explores biomonitoring recruitment strategies through non-contact mechanisms and evaluate the application feasibility for population-based studies. METHODS: The Iowa Biomonitoring Program at the State Hygienic Laboratory developed a human biomonitoring study that utilized a multifaceted, distance-based approach. Traditional techniques, such as mailed recruitment invitations and phone-based discussions, were coupled with internet-based surveys and self-collected, shipped urine and water samples. Participation rates were evaluated by employing different mailing methods, and the demographics of enrolled participants were examined. RESULTS: This non-human contact approach achieved a nearly 14% participation rate among a rural population, well above our target rates. Our improved mailing strategy for targeting initially unresponsive participants yielded a significantly increase in the participation rates. The respondents were predominantly individuals with educational attainment of at least high school level. Among all the eligible participants, 83% submitted self-collected samples, a rate comparable to the National Health and Nutrition Examination Survey which involved in-person interviews. CONCLUSIONS: The practice of engaging a rural population during the COVID-19 pandemic by transitioning from face-to-face interactions to a combination of mailing and internet-based approaches resulted in higher-than-expected participant recruitment and sample collection rates. Given the declining trend in the response rates for population-based survey studies, our results suggest conducting human biomonitoring without direct human interaction is feasible, which provides further opportunity to improve response rates and the relevance and reach of public health initiatives.

Revisiting geophagy: An evolved sickness behavior to microbiome-mediated gastrointestinal inflammation.

Geophagy, the consumption of clay or similar substances, is known as an evolved behavior that protects vulnerable populations, such as pregnant women and children, against gastrointestinal injury. However, perplexing questions remain, like the presence of geophagy in the absence of overt gastrointestinal infection and the potential causal relationship between geophagy and iron deficiency anemia. In this review, we hypothesize that geophagy is an inflammation-mediated sickness behavior regulated via the vagus nerve. We further hypothesize that the gut microbiome plays a critical role in mediating the relationship between inflammation and geophagy. By including inflammation and the microbiome within the existing protection hypothesis, we can explain how subclinical gastrointestinal states induce geophagy. Furthermore, we can explain how gastrointestinal inflammation is responsible for both geophagy and iron-deficiency anemia, explaining why the two phenomena frequently co-occur. Ultimately, defining geophagy as a sickness behavior allows us to integrate the gut-brain axis into geophagy research.

Patient and family members' experiences with language and environment when receiving bad news: A qualitative exploratory study.

OBJECTIVES: Receiving bad news about one's health can be devastating, yet little is known about how the therapeutic nature of the environment where bad news is delivered affects the experience. The current study aimed to explore how patients and their families were affected by the language and the built, natural, social, and symbolic environments when receiving bad news, through the Therapeutic Landscapes theoretical framework. METHODS: Patients diagnosed with a life-limiting illness living in regional Victoria who had a hospital admission within 24 months and a diagnostic/prognostic conversation were invited to participate, as well as a family member who witnessed the conversation. Participants were recruited through social media and snowballing, resulting in 14 online semi-structured interviews being conducted between November 2021 and March 2022, audio-recorded, and transcribed verbatim. Reflexive thematic analysis was used to develop the themes. RESULTS: Fourteen semi-structured interviews were conducted with women aged between 30 and 77 years. Interviews lasted between 45 and 120 minutes, with an average of 69 minutes, and were conducted online or via mobile phone. Four central themes were developed: "Hearing bad news for the first time," "Preferences for having hard conversations," "Creating a sense of safety for ongoing care," and "The therapeutic nature of the ward." SIGNIFICANCE OF RESULTS: This body of work will help inform practice and future policy regarding bad news delivery and the design and aesthetics of environments where bad news is delivered. It is essential that bad news is delivered within a quiet, calm, and emotionally safe environment within a supportive therapeutic relationship.

A critical biocultural approach to early growth in the United States.

OBJECTIVES: A critical biocultural anthropology seeks to link perspectives from social theory and ethnography to human biology. In the United States (U.S.), multiple forms of structural inequalities affect early growth, including racism and poverty. The goal of this paper is to test the effects of social inequalities on birth weight and later height in the U.S. National Health and Nutrition Survey (NHANES), and to contextualize potential pathways of embodiment that link social structure and biology. METHODS: This study used data from 8392 children ages 0-5 years from the 2005 to 2016 NHANES. Reported birth weight and measured length/height (converted to height-for-age z-scores) were used as outcome variables, while various measures of socioeconomic status and the NHANES-defined race and ethnicity categories were operationalized as social variables. Structural equation modeling (SEM) was chosen to represent the data. RESULTS: The final model represented an excellent fit to the data. Higher birth weights were associated with higher height-for-age z-scores. The Black racial category was associated with lower birth weight and higher height-for-age z-score, while the "Other" racial category was also associated with lower birth weight. The socioeconomic status factor variable was significantly associated with birth weight and height-for-age z-scores. There were also multiple indirect effects of social variables on height-for-age z-scores mediated via their effects on birth weight. CONCLUSIONS: Inequalities in race and socioeconomic status persist in birth weight and early childhood stature in the U.S. These findings can be contextualized by a critical biocultural anthropology that integrates lived experiences and pathways of embodiment.

The experiences of health professionals, patients, and families with truth disclosure when breaking bad news in palliative care: A qualitative meta-synthesis.

OBJECTIVE: Disclosing the truth when breaking bad news continues to be difficult for health professionals, yet it is essential for patients when making informed decisions about their treatment and end-of-life care. This literature review aimed to explore and examine how health professionals, patients, and families experience truth disclosure during the delivery of bad news in the inpatient/outpatient palliative care setting. METHODS: A systemized search for peer-reviewed, published papers between 2013 and 2020 was undertaken in September 2020 using the CINAHL, Medline, and PsycInfo databases. The keywords and MeSH terms ("truth disclosure") AND ("palliative care or end-of-life care or terminal care or dying") were used. The search was repeated using ("bad news") AND ("palliative care or end-of-life care or terminal care or dying") terms. A meta-synthesis was undertaken to synthesize the findings from the eight papers. RESULTS: Eight papers were included in the meta-synthesis and were represented by five Western countries. Following the synthesis process, two concepts were identified: "Enablers in breaking bad news" and "Truth avoidance/disclosure." Several elements formed the concept of Enablers for breaking bad news, such as the therapeutic relationship, reading cues, acknowledgment, language/delivery, time/place, and qualities. A conceptual model was developed to illustrate the findings of the synthesis. SIGNIFICANCE OF RESULTS: The conceptual model demonstrates a unique way to look at communication dynamics around truth disclosure and avoidance when breaking bad news. Informed decision-making requires an understanding of the whole truth, and therefore truth disclosure is an essential part of breaking bad news.

Doula Perspectives on Lactation Education and Breastfeeding Support for Diverse, Low-income Women: A Field Report.

Women living below the federal poverty level have low breastfeeding rates and historically have lacked access to doula care. This disparity is particularly evident among African American women. The objective of this pilot study was to assess doulas' experiences delivering lactation education to racially/ethnically diverse, primarily Medicaid-eligible pregnant women and describe doulas' perceptions of client barriers to breastfeeding. We also wanted to understand doulas' views of infant feeding and lactation education during their participation in a quality improvement intervention that trained doulas to provide lactation education and breastfeeding support at 4 clinics serving low-income clients. Two focus groups were conducted with 7 doulas. Focus group data were transcribed, coded, and analyzed using qualitative thematic analysis. Doulas reported close relationships with their clients and provided consistent breastfeeding support and education to women in prenatal, birth, and postpartum phases of care. Doulas emphasized the need for more lactation education, especially to overcome clients' perceived milk insufficiency and early termination due to breastfeeding barriers. Doula-led breastfeeding education and support may improve breastfeeding outcomes for diverse women from underserved areas.

Predictors of interleukin-1ß and interleukin-1 receptor antagonist in infant saliva.

OBJECTIVES: This study assesses the feasibility of measuring interleukin-1ß (IL-1ß) and interleukin-1 receptor antagonist (IL-1ra) in infant salivary samples as representative of pro- and anti-inflammatory processes, and explores predictors of these biomarkers in a US population. METHODS: Data were collected from 73 US mother-infant pairs. Salivary samples were collected with an infant swab and analyzed for IL-1ß, IL-1ra, and immunoglobulin A (IgA) using ELISA. Household, maternal, infant, and anthropometric predictors were selected using stepwise regression to build final multivariate models. RESULTS: Both IL-1ß and IL-1ra can be feasibly measured in infant saliva. The predictors in the final IL-1ß model were IL-1ra and reported infant illness. IL-1ß, IgA, infant age, household income, maternal BMI, and infant weight-for-age z-score were significant in the final model for IL-1ra. CONCLUSIONS: IL-1ß and IL-ra are useful biomarkers of immune function for infants. In particular, IL-1ra has the potential to address the relationship between immune function and body composition in the mother-infant dyad.

Perceptions and Practices of Infant Feeding among African American Women.

A large urban hospital in Florida implemented changes to achieve the Baby-Friendly Hospital Initiative (BFHI) designation in 2015 resulting in an increase of exclusive breastfeeding rates at hospital discharge; however, African American women continue to have the lowest rates overall. Qualitative interviews were conducted with 20 African American women who received prenatal care at a low-income women's clinic and gave birth at an affiliated BFHI hospital. Using a medical anthropology analytical framework to examine predisposing, enabling, and service-related factors that affect breastfeeding, this study investigated interpersonal, sociocultural, and institutional barriers to breastfeeding. Common challenges experienced by participants included lack of maternity leave from work, lack of access to electric pumps, social pressures to initiate formula supplementation, fears that breastfeeding renders infants overly dependent on their mother's care, and a lack of breastfeeding role models and/or support networks to normalize longer-term breastfeeding. We conclude that efforts to increase breastfeeding rates for African American women and promote culturally sensitive interventions must address underlying socioeconomic and structural barriers, women's perceptions of breastfeeding benefits and difficulties, and the need for improvements in postnatal lactation and doula support to foster a more inclusive culture of breastfeeding.

The first Seriatum study of growth by R. E. Scammon.

Richard E. Scammon's article, "The First Seriatim Study of Human Growth," provided one of the best-known visuals in the field of human biology. Scammon resurrected longitudinal height data of one child from Buffon's Histoire Naturelle, converted them to metric, and plotted these measurements as a function of age. The result was the first graph of one individual's growth curve from birth to 18 years of age. This image was subsequently reproduced in numerous texts on human growth and biology. Published in 1927, Scammon's article provides a snapshot of the state of growth research at the time and gives a (literal) picture of the future of human biology. The graph of the growth of one child symbolizes the importance of process and variation in biological anthropology.

Ecological immunity of human milk: Life history perspectives from the United States and Kenya.

OBJECTIVES: Previous research has established population variation in anti-inflammatory immunological biomarkers in human milk. This immunity is potentially ecology-dependent and may alter the life history trade-off between growth and maintenance in infants. The current study has two aims: (1) to assess the ecological differences in milk immunity in two populations, one from the urban U.S. and one from rural Kenya; and (2) to test the hypothesis that milk immunity can affect infant growth indicators. MATERIALS AND METHODS: Kenyan Ariaal (n = 233) and U.S. (n = 75) breastfeeding mother-infant pairs participated in a cross-sectional study at two separate field sites. Laboratory analysis was performed on milk for the anti-inflammatory biomarkers TGF-ß2, sTNF-αRI, sTNF-αRII, and IL-1ra using ELISA. Multiple imputation was used to extrapolate data below the limit of detection before multivariate analysis. RESULTS: There were significant differences between U.S. and Kenyan mothers on all four milk biomarkers, with Kenyan mothers having significantly higher sTNF-αRI and sTNF-αRII and lower TGF-ß2 and IL-1ra than U.S. mothers. U.S. mothers with higher milk TGF-ß2 and IL-1ra have infants that are significantly longer and heavier for their age, while Kenyan mothers with higher sTNF-αRI have significantly longer and heavier infants for their age, and those with higher TGF-ß2 have marginally significantly longer infants. DISCUSSION: There were significant differences in ecological milk immunity between U.S. and Kenyan mothers. These differences potentially play a role in the growth of their infants. Further research in milk immunity should consider the possibility of shared maternal-infant life histories.

What is significant about a single nursing session? An exploratory study.

OBJECTIVES: Researchers and clinicians specializing in breastfeeding often rely on measuring one nursing session to characterize the breastfeeding relationship. However, less is known about the descriptive or statistically predictive characteristics of one nursing session. The purposes of this study are twofold: (1) to explore the relationships between variables in a single nursing session; and (2) to study the association between variables in a single nursing session and infant length-for-age (LAZ) and weight-for-age (WAZ). METHODS: In 63 nursing mother-infant pairs in the United States, anthropometric measurement and observation of a single nursing session revealed six nursing session variables: fore milk fat percent, hind milk fat percent, infant milk intake, duration of session, time since last session, and time of day of session. RESULTS: A principle factor analysis, undertaken to explore latent variables underlying the six session variables, revealed two factors: (1) loaded highly on fore and hind milk fat percentage, reflecting the overall fat percent in a feed; and (2) loaded highly on milk intake and hind milk fat percentage, indicating the process of breast emptying. In multivariate analyses of all session variables on infant LAZ and WAZ, only hind milk fat percentage was significantly negatively associated with LAZ (ß = -0.14, P = .01 (two-tailed), R2 = 0.070), confirmed by a significant negative association between LAZ and factor one (ß = -0.32, P = .05 (two-tailed), R2 = 0.090). CONCLUSIONS: This research describes the dynamics of a single nursing session, and has the potential to help explain variation in infant growth and nutrition.

Pregnancy and immune stimulation: re-imagining the fetus as parasite to understand age-related immune system changes in US women.

OBJECTIVES: Pregnancy can increase production of Immunoglobulin E (IgE), an immune response more often directed towards parasite infections. An absence of parasitism makes the US population ideal to test the hypothesis that the maternal immune system recognizes a fetus as a parasite. We predict that total IgE levels are positively associated with a history of pregnancy across all ages of adult women, mirroring patterns of IgE in parasitized populations. METHODS: Reproductive-aged women (n = 2201) from the National Health and Nutrition Examination Survey 2005-2006 were analyzed in a cross-sectional design using complex survey regression and multiple imputation to evaluate associations between total IgE levels, pregnancy history, and interactions between age and pregnancy. RESULTS: Women with a history of pregnancy have significantly higher IgE levels and a significantly shallower slope of IgE levels across ages (P = .031). CONCLUSIONS: This research supports the hypothesis that maternal immune systems respond to prior pregnancies as they do to macro-parasitic exposures, and may modify the expected linear declines of IgE levels in women that accompanies aging. These finding have implications for understanding the evolution of internal gestation in mammals.

The reproductive ecology of iron in women.

Reproductive ecology focuses on the sensitivity of human reproduction to environmental variation. While reproductive ecology has historically focused on the relationship between energy status and reproductive outcomes, iron status is equally critical to women's reproductive health, given the wide-ranging detrimental effects of iron-deficiency anemia on maternal and infant well-being. This review interprets the vast literature on iron status and women's reproduction through an evolutionary framework. First, it will critique the evidence for iron deficiency caused by blood loss during menstruation, reinterpreting the available data as ecological variation in menses within and between populations of women. Second, it will highlight the scant but growing evidence that iron status is implicated in fertility, a relationship that has deep evolutionary roots. Third, this review proposes a new hypothesis for the transfer of iron from mother to infant via pregnancy and breastfeeding: reproductive iron withholding. In this hypothesis, mothers transfer iron to infants in a manner that helps infants avoid iron-mediated infection and oxidative stress, but trades off with potential risk of maternal and infant iron deficiency. Finally, this review explores two main factors that can modify the relationship between iron status and the gestation-lactation cycle: (1) the relationship between long-term reproductive effort (parity) and iron status and (2) supplementation schemes before and during pregnancy. The review concludes by suggesting continued research into iron homeostasis in women using evolutionary, ecological, and biocultural frameworks.

Milk immunity and reproductive status among Ariaal women of northern Kenya.

UNLABELLED: Abstract Background: The immune factors in human milk protect infants from infection and promote immune development. Evidence suggests that the production of milk-specific immunoproteins is energetically costly, making them a form of maternal investment in offspring health that is subject to life history trade-offs. AIM: This research tests the relationship between measures of reproductive effort and the production of milk immunoglobulin A (IgA) among Ariaal women, a settled northern Kenyan pastoralist population that experiences nutritional and disease stress. SUBJECTS AND METHODS: Two hundred and forty-three lactating Ariaal women participated in a questionnaire, anthropometric measurement and milk collection. Milk IgA was analysed using ELISA. RESULTS: There was a significant U-shaped relationship between post-partum months and milk IgA, reflecting decreasing investment in the current offspring over the early post-partum period and subsequent recovery of maternal energy status near the end. There was also a significant inverse U-shaped relationship between milk IgA and parity, with high parity women showing a drop in milk IgA. In contrast, anthropometric measures of energy status were not associated with the production of milk IgA. CONCLUSION: This research shows that patterns of reproductive investment can be demonstrated in milk IgA in the absence of measured energy changes.

A comparison of three infant skinfold reference standards: Tanner-Whitehouse, Cambridge Infant Growth Study, and WHO Child Growth Standards.

As researchers increasingly focus on early infancy as a critical period of development, there is a greater need for methodological tools that can address all aspects of infant growth. Infant skinfold measures, in particular, are measurements in need of reliable reference standards that encompass all ages of infants and provide an accurate assessment of the relative fatness of a population. This report evaluates three published reference standards for infant skinfold measurements: Tanner-Whitehouse, Cambridge Infant Growth Study, and the World Health Organization (WHO) Child Growth Standards. To assess these standards, triceps skinfolds from a population of rural Kenyan infants (n = 250) and triceps skinfolds and subscapular skinfolds from infants in the National Health and Nutrition Examination Survey 1999-2002 (NHANES; n = 1197) were calculated as z-scores from the lambda-mu-sigma curves provided by each reference population. The Tanner-Whitehouse standards represented both the Kenyan and US populations as lean, while the Cambridge standards represented both populations as overfat. The distribution of z-scores based on the WHO standards fell in the middle, but excluded infants from both populations who were below the age of 3 months. Based on these results, the WHO reference standard is the best skinfold reference standard for infants over the age of 3 months. For populations with infants of all ages, the Tanner-Whitehouse standards are recommended, despite representing both study populations as underfat. Ideally, the WHO will extend their reference standard to include infants between the ages of 0 and 3 months.

Chronic undernutrition and traditional weaning foods are associated with fat stores in Ariaal infants of Northern Kenya.

The high proportion of human infant fat is hypothesized to protect infant brains by mobilizing against growth disturbances caused by acute nutritional and pathogen stress during weaning. However, individuals who experience chronic nutritional stress have been shown to store fat rather than mobilize fat stores, although this has not been demonstrated during infancy. This study investigated the relationship between fat development, diet, and nutritional status among 239 breastfeeding Ariaal infants, a group of settled pastoralists who experience both acute and chronic nutritional stress residing in Marsabit District, Kenya. This study had three goals: 1) To investigate the pattern of fat accumulation among Ariaal infants compared with a reference population; 2) to explore the relationship between chronic nutritional stress and fat deposits; and 3) to determine the relationship between traditional weaning foods, particularly cow's milk, and infant's fat. Infants, particularly infants experiencing chronic nutritional stress, were found to accumulate fat deposits in a manner that suggests reduced oxidation of fat stores. Infant upper arm fat area significantly increases with age over the weaning period compared with reference populations, who show a decline in body fat. Chronically undernourished infants were particularly likely to have increased levels of upper arm fat compared with normal infants or acutely undernourished infants. In addition, infants who consume cow's milk are significantly fatter than those that do not. These results suggest that Ariaal infants have both physiological and cultural mechanisms for fat storage in the face of their nutritionally stressed environment.

Foundations for literacy: An early literacy intervention for deaf and hard-of-hearing children.

The present study evaluated the efficacy of a new preschool early literacy intervention created specifically for deaf and hard-of-hearing (DHH) children with functional hearing. Teachers implemented Foundations for Literacy with 25 DHH children in 2 schools (intervention group). One school used only spoken language, and the other used sign with and without spoken language. A "business as usual" comparison group included 33 DHH children who were matched on key characteristics with the intervention children but attended schools that did not implement Foundations for Literacy. Children's hearing losses ranged from moderate to profound. Approximately half of the children had cochlear implants. All children had sufficient speech perception skills to identify referents of spoken words from closed sets of items. Teachers taught small groups of intervention children an hour a day, 4 days a week for the school year. From fall to spring, intervention children made significantly greater gains on tests of phonological awareness, letter-sound knowledge, and expressive vocabulary than did comparison children. In addition, intervention children showed significant increases in standard scores (based on hearing norms) on phonological awareness and vocabulary tests. This quasi-experimental study suggests that the intervention shows promise for improving early literacy skills of DHH children with functional hearing.

Providing a localised cervical cancer screening course for general practice nurses.

Cervical cancer screening programs in Australia have been developed to detect early precancerous changes in women with a cervix aged between 25 and 74. Yet, many barriers remain to the uptake of cervical screening. Barriers include a lack of culturally appropriate service provision, physical access, poor health literacy, emotional difficulties, socio-economic disadvantage and not having access to a female service provider. In remote and very remote areas of Australia, additional barriers experienced by Aboriginal or Torres Strait Islander peoples include a distrust of healthcare providers and a lack of services, resulting in a much higher rate of diagnosis and death from cervical cancer. General practice nurses (GPNs) are well placed to conduct cervical screening tests (CSTs) after they have undertaken additional education and practical training. GPNs' increase in scope of practice is beneficial to general practice as it helps to remove some barriers to cervical screening. In addition, GPNs conducting CSTs reduce GP workload and burnout and increase teamwork. GPNs working in metropolitan clinics have greater access to training facilities, whereas those working in rural and remote clinics are required to travel potentially long distances to complete practical assessments. This highlights the need for training to be made available in rural and remote areas. The aim of this forum paper is therefore to generate further discussion on the need for training programs to be made available in rural and remote areas to aid the upskilling of GPNs.

Field and laboratory methods in human milk research.

Human milk is a complex and variable fluid of increasing interest to human biologists who study nutrition and health. The collection and analysis of human milk poses many practical and ethical challenges to field workers, who must balance both appropriate methodology with the needs of participating mothers and infants and logistical challenges to collection and analysis. In this review, we address various collection methods, volume measurements, and ethical considerations and make recommendations for field researchers. We also review frequently used methods for the analysis of fat, protein, sugars/lactose, and specific biomarkers in human milk. Finally, we address new technologies in human milk research, the MIRIS Human Milk Analyzer and dried milk spots, which will improve the ability of human biologists and anthropologists to study human milk in field settings.

Phonological awareness: explicit instruction for young deaf and hard-of-hearing children.

The goal of this study was to explore the development of spoken phonological awareness for deaf and hard-of-hearing children (DHH) with functional hearing (i.e., the ability to access spoken language through hearing). Teachers explicitly taught five preschoolers the phonological awareness skills of syllable segmentation, initial phoneme isolation, and rhyme discrimination in the context of a multifaceted emergent literacy intervention. Instruction occurred in settings where teachers used simultaneous communication or spoken language only. A multiple-baseline across skills design documented a functional relation between instruction and skill acquisition for those children who did not have the skills at baseline with one exception; one child did not meet criteria for syllable segmentation. These results were confirmed by changes on phonological awareness tests that were administered at the beginning and end of the school year. We found that DHH children who varied in primary communication mode, chronological age, and language ability all benefited from explicit instruction in phonological awareness.