St. Louis Enhancing Engagement and Retention in HIV/AIDS Care (STEER): a participatory intersectional needs assessment for intervention and implementation planning.

Background Missouri is one of seven priority states identified by the Ending the HIV Epidemic Initiative, and St. Louis contains almost half of the people living with HIV (PLWH) in Missouri. As St. Louis has a marked history of structural racism and economic inequities, we utilized the Intersectionality Based Policy Analysis (IBPA) framework to guide a participatory needs assessment for planning and program development. Methods The planning team included researchers, the lead implementer from our community partner, and two community representatives, and had biweekly 60-90 minute meetings for 18 months. The planning team discussed and approved all research materials, reviewed and interpreted results, and made decisions about outreach, recruitment, conduct of the needs assessment and development of the planned intervention. The needs assessment integrated information from existing data, (1) interviews with (a) PLWH (n=12), (b) community leaders (n=5), (c) clinical leaders (n=4), and (d) community health workers (CHWs) (n=3) and (e) CHW supervisors (n=3) who participated in a Boston University-led demonstration project on CHWs in the context of HIV and (2) focus groups (2 FG, 12 participants) with front line health workers such as peer specialists, health coaches and outreach workers. A rapid qualitative analysis approach was used for all interviews and focus groups. Results The IBPA was used to guide team discussions of team values, definition and framing of the problem, questions and topics in the key informant interviews, and implementation strategies. Applying the IBPA framework contributed to a focus on intersectional drivers of inequities in HIV services. The effective management of HIV faces significant challenges from high provider turnover, insufficient integration of CHWs into care teams, and organizational limitations in tailoring treatment plans. Increasing use of CHWs for HIV treatment and prevention also faces challenges. People living with HIV (PLWH) encounter multiple barriers such as stigma, lack of social support, co-morbidities, medication side effects and difficulties in meeting basic needs. Conclusions Addressing intersectional drivers of health inequities may require multi-level, structural approaches. We see the IBPA as a valuable tool for participatory planning while integrating community engagement principles in program and implementation design for improving HIV outcomes.

United States Long-Term Trends in Adult BMI (1959-2018): Unraveling the Roots of the Obesity Epidemic.

The escalating rates of obesity since the 1950s poses a critical public health challenge across all age groups in the United States. While numerous studies have examined cross-sectional disparities across racial, ethnic, and socioeconomic groups, there has been limited research on long-term trends. To address this gap, we analyzed average adult body mass index (BMI) trends from 1959 to 2018, using data from the National Health and Nutrition Examination Survey (NHANES) and the National Health Examination Survey (NHES). Employing time series analysis, we evaluated BMI trends across income, education, and race/ethnicity. The results revealed a consistent upward trajectory in average BMI across all groups over the six-decade period, with no significant differences by income or education levels among high school graduates. However, individuals with less than a high school education displayed a more gradual increase in BMI. Racial disparities were also evident, with Black adults showing higher BMI growth rates compared to White adults, while Hispanic and other racial groups experienced slower increases. These findings underscore the need for systemic interventions to address the ongoing obesity epidemic, emphasizing the importance of research to identify trends over time and a system-thinking approach to inform effective population-level interventions and policy decisions.

The intersectionality-based policy analysis framework: demonstrating utility through application to the pre-vaccine U.S. COVID-19 policy response.

Few guidelines exist for the development of socially responsible health policy, and frameworks that balance considerations of data, strategy, and equity are limited. The Intersectionality-Based Policy Analysis (IBPA) framework utilizes a structured questioning process to consider problems and policies, while applying guiding principles of equity, social justice, power, intersectionality, and diversity of knowledge and input. We apply the IBPA framework's guiding principles and questions to the pre-vaccine U.S. COVID-19 policy response. Results suggest the IBPA approach is a promising tool for integrating equity considerations in the development of policy solutions to urgent US public health challenges, including the COVID-19 pandemic. We found the IBPA framework particularly useful in differentiating between problems or policies and representations of problems or policies, and in considering the impacts of representations on different groups. The explicit inclusion of short-, medium- and long-term solutions is a reminder of the importance of holding a long-term vision of the equitable public health system we want while working towards immediate change.

Investigating Environmental Determinants of Soil-Transmitted Helminths Transmission using GPS Tracking and Metagenomics Technologies.

Background: The Global Health community aims to eliminate soil-transmitted helminth (STH) infections by 2030. Current preventive methods such as Mass Drug Administration, WASH practices, and health education needs to be complimented to halt transmission. We tracked the movement of hookworm-infected and non-infected persons and investigated soil factors in the places they frequented within an endemic community to further understand the role of human movement and sources of infections. Methods: 59 positive and negative participants wore GPS tracking devices for 10 consecutive days and their movement data captured in real time. The data was overlaid on the community map to determine where each group differentially spent most of their time. Soil samples were collected from these identified sites and other communal places. Physical and chemical properties were determined for each sample using standard methods and helminth eggs cultured into larvae using the Baermann technique. Bivariate and multivariate analyses were used to determine associations between larvae counts and soil factors. Helminth species were identified with metagenomic sequencing and their distributions mapped to sampling sites in the community. Results: The study found that there was no significant difference in the average larvae counts in soil between sites assessed by infected and non-infected participants (P=0.59). However, soil factors, such as pH, carbon and sandy-loamy texture were associated with high larvae counts (P<0.001) while nitrogen and clay content were associated with low counts(P<0.001). The dominant helminth species identified were Panagrolaimus superbus (an anhydrobiotic helminth), Parastrongyloides trichosuri (a parasite of small mammals), Trichuris trichuria (whipworm), and Ancylostoma caninum (dog hookworm). Notably, no Necator americanus was identified in any soil sample. Conclusion: This study provides important insights into the association between soil factors and soil-transmitted helminths. These findings contribute to our understanding of STH epidemiology and support evidence-based decision-making for elimination strategies.

Action learning and public health pedagogy: Student reflections from an experiential public health course.

Introduction: Applied practice experiences are essential components of the Masters of Public Health (MPH) curriculum. The objective of this study was to examine students' perspectives on the skills and expertise they developed in an MPH course offering applied practice opportunities. Methods: Of 236 students who took the course from 2008 to 2018, email addresses were obtained for 212 and 104 completed the consent form. Following consent, reflection essays were de-identified and analyzed using a rapid qualitative analysis approach. The essays addressed students' learning experiences and application of the competencies for MPH programs set by the Council for Education in Public Health (CEPH). Deductive and inductive analytical lenses were used to identify the key lessons learned by each cohort of students. Semi-structured guides and matrixes for essay analysis were created using assignment instructions and CEPH competencies. Results: Although the reflection paper assignment varied across the years, commonalities were observed in the student reflections. Key themes included turning theory into practice, navigating the complex environment of public health practice, skill building, critical self-reflection, challenges encountered, and elements that facilitated project success. Students reported developing practical skills, such as planning for independent research (e.g., preparing for institutional review board (IRB) submission, consulting with faculty and other experts), identifying realistic approaches for data extraction during chart reviews and analyses of electronic medical records, and disseminating findings for diverse stakeholders and audiences. Students also reported strengthening cross-cutting skills such as communication, teamwork, and problem-solving that were useful for navigating power dynamics and balancing competing interests and expectations. Students explored their identity as public health professionals as they navigated the dynamics of public health practice. Conclusion: The applied practice experience served as a valuable tool for knowledge and skills acquisition. Moreover, it served as an opportunity for students to engage with the unique organizational cultures of their respective community partners and to deepen their understanding the complexities of conducting meaningful community-engaged research. Implications: This study demonstrates the utility of analyzing students' critical self-reflections as a tool for exploring learning experiences when training future public health professionals. The findings can help educators design future applied practice experiences.

Using Health Care Professionals' Perspectives to Refine a Clinical Decision Support Implementation Strategy for Increasing the Prescribing of HIV Preexposure Prophylaxis (PrEP) in Alabama.

Pre-exposure prophylaxis (PrEP) is underused in the southern United States (US), a region with high HIV incidence. Clinical decision support (CDS) tools could increase PrEP prescriptions. We explored barriers to PrEP delivery and views of CDS tools to identify refinements for implementation strategies for PrEP prescribing and PrEP CDS tools. We conducted focus groups with health care providers from two federally qualified health centers in Alabama and analyzed the results using rapid qualitative methods. Barriers to PrEP included providers' lack of training in PrEP, competing priorities and time constraints during clinical visits, concerns about side effects, and intensive workload. We identified refinements to the planned implementation strategies to address the barriers, including training all clinic staff in PrEP and having CDS PrEP alerts in electronic health records sent to all staff. Development and deployment of CDS tools in collaboration with providers has potential to increase PrEP prescribing in high-priority jurisdictions.

Application of multiplex amplicon deep-sequencing (MAD-seq) to screen for putative drug resistance markers in the Necator americanus isotype-1 ß-tubulin gene.

Global control of hookworm infections relies on periodic Mass Drug Administration of benzimidazole drugs to high-risk groups, regardless of infection status. Mutations in the isotype-1 ß-tubulin gene have been identified in veterinary nematodes, resulting in structural changes and reduced drug-binding. In Ghana, previous studies have demonstrated significant variability in albendazole effectiveness among people infected with the hookworm Necator americanus, although the mechanisms underlying deworming response have not been defined. Using hookworm egg samples from a cross-sectional study in Ghana, we developed a multiplex amplicon deep sequencing (MAD-seq) method to screen genomic regions encapsulating putative drug-resistance markers in N. americanus isotype-1 ß-tubulin gene. Three single nucleotide polymorphisms (SNPs) corresponding to resistance-associated mutations (F167Y, E198A, F200Y) within the coding region of the isotype-1 ß-tubulin gene were characterized using MAD-seq in 30 matched pre- and post-treatment samples from individuals with persistent infection following therapy. Post-sequence analysis showed that the highest mean alternative nucleotide allele at each PCR amplicon was 0.034% (167amplicon) and 0.025% (198/200amplicon), suggesting minimal allelic variation. No samples contained the F167Y SNP, while one contained low-frequency reads associated with E198A (3.15%) and F200Y (3.13%). This MAD-seq method provides a highly sensitive tool to monitor the three putative benzimidazole resistance markers at individual and community levels. Further work is required to understand the association of these polymorphisms to treatment response.

The Importance of Sociocultural Context When Choosing to Eat Healthier.

OBJECTIVE: To explore how working women in metropolitan Malaysia make food decisions. DESIGN: A grounded theory approach and semistructured interviews. SETTING: A large university in metropolitan Malaysia. PARTICIPANTS: Twenty-four female employees purposively recruited to vary in ethnicity, body mass index, age, and marital status via convenience sampling. PHENOMENON OF INTEREST: Perceptions of sociocultural influences on healthy eating behavior among working women. ANALYSIS: Researchers audio-recorded interviews and analyzed verbatim transcripts. RESULTS: Working women shared a desire to eat a healthier, more balanced diet by reducing processed food consumption through home-cooked meals. Participants described aspects of their living situations and cultural values about food that made it seem impossible to change their diets. Living with other people limited their ability to cook the food they wanted to eat. In addition, unspoken rules about communal eating in Malaysia, such as not refusing food and not wasting food, prevented working women from practicing healthy eating. CONCLUSIONS AND IMPLICATIONS: In this population of working women in metropolitan Malaysia, experiences of time scarcity and limited sociocultural support for behavior change were major barriers to healthy eating. Interventions could prioritize leveraging these realities about food to facilitate environments in which women feel like they have control of their own food intake.

Assessing community health research capacity across stakeholders: adapting a tool.

Multi-sectoral collaborative approaches with strong community engagement are essential for addressing health disparities. A valid tool for assessing organizational research and capacity for community health research stakeholders could help strengthen organizational capacity for engagement in such collaborations. This study was conducted to validate an innovative tool for assessing research activity and capacity of a spectrum of stakeholder organizations to provide support for strengthening community health research capacity in Bhutan. In-person interviews with academics (n = 10), clinicians (n = 10), government staff (n = 10), consultants (n = 2) and management of health-related civil society organizations (CSOs; n = 12 interviews/organizations, 13 individuals) were recorded and transcribed. Questions covered individual and organizational research activity and capacity, research networks and an international version of the Community Research Assessment Tool (CREAT-I). Almost all participants (84%) had participated in community health research projects. Social network analysis showed a large, interconnected cluster with a few key individuals linking across sectors. CREAT-I responses identified the highest capacity in organizational support for research among academic participants, while clinical and CSO participants reported highest capacity in practical research experiences and government participants reported highest capacity in research specific experiences. The CREAT-I tool showed strong internal reliability (Cronbach's α = 0.91) and validity. Limited money, time and skilled staff were identified as barriers to research. The CREAT-I assesses community health research capacity of organizations, and such a tool could be useful in identifying research capacity needs, monitoring impact of research capacity-building activities and contributing to a greater capacity for multi-sectoral collaborative approaches to community health research in international settings.

Investigating the Relationship between Food Insecurity and Fertility Preferences in Tanzania.

OBJECTIVE: We analyze fertility preferences among women at risk of pregnancy with children ages five or younger as a function of two food security metrics: perceptions of household hunger and child stunting (height for age z scores ≤ -2.0) in order to convey a robust picture of food insecurity. METHODS: We use data from the 2016 Tanzania Demographic and Health Surveys to analyze this research question. Multinomial generalized logit models with cluster-adjusted standard errors are used to determine the association between different dimensions of food insecurity and individual-level fertility preferences. RESULTS: On average, women who experience household hunger are 19% less likely to want more children compared to women who do not experience household hunger (AOR: 0.81, p = 0.02) when controlling for education, residence, maternal age, number of living children, and survey month. Adjusting for the same covariates, having at least one child ≤ 5 years old who is stunted is associated with 13% reduced odds of wanting more children compared to having no children stunted (AOR: 0.87, p = 0.06). CONCLUSIONS FOR PRACTICE: In the context of a divided literature base, this research aligns with the previous work identifying a preference among women to delay or avoid pregnancy during times of food insecurity. The similarity in magnitude and direction of the association between food insecurity and fertility preferences across the two measures of food insecurity suggest a potential association between lived or perceived resource insecurity and fertility aspirations. Further research is needed in order to establish a mechanism through which food insecurity affects fertility preferences. SIGNIFICANCE STATEMENT: Individual fertility preferences are sensitive to dynamic multi-level factors in a woman's life. While qualitative research has explored the effect that food insecurity and associated resource constraints have on fertility preferences, results are conflicting. Here, we quantitatively examine how individual woman's fertility preferences associate with two measures of food insecurity and qualitatively compare the associations across food insecurity measures. We establish that two food insecurity measures- household hunger and child stunting- capture similar populations and have similar associations with fertility preferences. This is a critical step forward in understanding the dynamic relationship between resource availability, child well-being, and fertility preferences.

Are Household Expenditures on Food Groups Associated with Children's Future Heights in Ethiopia, India, Peru, and Vietnam?

Household expenditure surveys, routinely conducted in low-and middle-income countries (LMICs), usually include questions pertaining to recent household expenditures on key food groups. When child anthropometrics are also available, such expenditure data can provide insights into household food purchasing patterns that are associated with subsequent child growth measures. We used data from 6993 children, born around 2001, from Ethiopia, India, Peru, and Vietnam, from the Young Lives younger cohort. We compared associations between two weeks of household food expenditures (in PPP-Purchasing Power Parity adjusted dollars) on food groups and child height-for-age-Z score (HAZ) at subsequent time points to assess longitudinal associations. Total food expenditures, rural/urban residence, maternal and paternal schooling, and child sex were included in our adjusted models because they may affect the relations between household food group expenditures and future child HAZ. In Ethiopia, India, and Peru every extra PPP$ spent on fats was associated with 0.02-0.07 higher future HAZ. In Vietnam every extra PPP$ spent on starches, was significantly associated with a 0.01 lower future HAZ. Across countries, different patterns of food expenditure and procurement may be differentially critical for predicting child HAZ. Our results demonstrate how expenditures on specific food groups can be associated with children's linear growth. This study provides additional evidence of the utility of longitudinal household food expenditure data in understanding child nutritional status.

Dogs and pigs are transport hosts of Necator americanus: Molecular evidence for a zoonotic mechanism of human hookworm transmission in Ghana.

Hookworm infection (Necator americanus and Ancylostoma spp) causes significant morbidity in resource-limited countries. Dog and pig ownership is associated with human infection, although the mechanism through which animals increase risk remains unknown. We first confirmed this association in Kintampo North, Ghana, using a retrospective analysis and serology, followed by a prospective molecular study of animal faeces. As a proxy of exposure to dog faeces, we analysed immunoreactivity of human serum to the zoonotic nematode Toxocara canis. Anti-Toxocara antibodies were present in 62% of samples (n = 89), and reactivity was associated with dog ownership. A subsequent prospective study revealed that 43% of dog and 56% of pig faecal samples contained hookworm eggs by microscopy. PCR analysis confirmed the presence of N. americanus DNA in 47% of samples from dogs and 56% pig samples. Nematode larvae were successfully cultured from samples collected from 36 dogs and seven pigs. These results demonstrate that dogs and pigs have a likely role in the transmission of N. americanus in endemic communities.

Assessing Research Activity and Capacity of Community-Based Organizations: Refinement of the CREAT Instrument Using the Delphi Method.

Community-based organizations (CBOs) are essential partners in community-engaged research, yet little is known about their research capacity. Community experts and organizations bring unique knowledge of the community to research partnerships, but standard validated measures of CBO research capacity do not yet exist. We report here on the refinement through a structured Delphi panel of a previously developed and piloted framework of CBO research capacity and an accompanying instrument, the Community REsearch Activity Assessment Tool (CREAT). A Delphi panel composed of twenty-three experts recruited from community (52%) and academic researchers (48%) from around the USA participated in five rounds of review to establish consensus regarding framework domains, operational definitions, and tool items. Panelists rated the importance of items on a 5-point Likert scale and assessed for the inclusion and language of items. Initial rounds of review began with reviewing the framework and definitions, with subsequent rounds including review of the full instrument. Concluding rounds brought back items that had not yet reached consensus for additional review. Median response values (MRV) and intra-quartile ranges (IQR) were calculated for each Likert item. Items with an MRV > 3.5 were deemed as having reached consensus and were retained. Language changes were made for items with MRV > 2.0 and < 3.5 and an IQR > 1.5. Items with MRV < 2.0 were excluded from the final tool. Panelist response rate was high (> 75%). Consensus was achieved for the inclusion of all domains, subdomains and operational definitions except "evidence-based practices." Extensive changes to the CREAT instrument were made for clarification, to provide additional detail and to ensure applicability for CBOs. The CREAT framework and tool was refined through input from community and academic researchers. Availability of a validated tool to assess research capacity of CBOs will support targeted research capacity building for community organizations and partners, thus strengthening collaborations.

Genetic Markers of Benzimidazole Resistance among Human Hookworms (Necator americanus) in Kintampo North Municipality, Ghana.

Hookworm infection causes anemia, malnutrition, and growth delay, especially in children living in sub-Saharan Africa. The World Health Organization recommends periodic mass drug administration (MDA) of anthelminthics to school-age children (SAC) as a means of reducing morbidity. Recently, questions have been raised about the effectiveness of MDA as a global control strategy for hookworms and other soil-transmitted helminths (STHs). Genomic DNA was extracted from Necator americanus hookworm eggs isolated from SAC enrolled in a cross-sectional study of STH epidemiology and deworming response in Kintampo North Municipality, Ghana. A polymerase chain reaction (PCR) assay was then used to identify single-nucleotide polymorphisms (SNPs) associated with benzimidazole resistance within the N. americanus ß-tubulin gene. Both F167Y and F200Y resistance-associated SNPs were detected in hookworm samples from infected study subjects. Furthermore, the ratios of resistant to wild-type SNP at these two loci were increased in posttreatment samples from subjects who were not cured by albendazole, suggesting that deworming drug exposure may enrich resistance-associated mutations. A previously unreported association between F200Y and a third resistance-associated SNP, E198A, was identified by sequencing of F200Y amplicons. These data confirm that markers of benzimidazole resistance are circulating among hookworms in central Ghana, with unknown potential to impact the effectiveness and sustainability of chemotherapeutic approaches to disease transmission and control.

Cross-Jurisdictional Resource Sharing in Local Health Departments: Implications for Services, Quality, and Cost.

BACKGROUND: Forty one percent of local health departments in the U.S. serve jurisdictions with populations of 25,000 or less. Researchers, policymakers, and advocates have long questioned how to strengthen public health systems in smaller municipalities. Cross-jurisdictional sharing may increase quality of service, access to resources, and efficiency of resource use. OBJECTIVE: To characterize perceived strengths and challenges of independent and comprehensive sharing approaches, and to assess cost, quality, and breadth of services provided by independent and sharing health departments in Connecticut (CT) and Massachusetts (MA). METHODS: We interviewed local health directors or their designees from 15 comprehensive resource-sharing jurisdictions and 54 single-municipality jurisdictions in CT and MA using a semi-structured interview. Quantitative data were drawn from closed-ended questions in the semi-structured interviews; municipal demographic data were drawn from the American Community Survey and other public sources. Qualitative data were drawn from open-ended questions in the semi-structured interviews. RESULTS: The findings from this multistate study highlight advantages and disadvantages of two common public health service delivery models - independent and shared. Shared service jurisdictions provided more community health programs and services, and invested significantly more ($120 per thousand (1K) population vs. $69.5/1K population) on healthy food access activities. Sharing departments had more indicators of higher quality food safety inspections (FSIs), and there was a non-linear relationship between cost per FSI and number of FSI. Minimum cost per FSI was reached above the total number of FSI conducted by all but four of the jurisdictions sampled. Independent jurisdictions perceived their governing bodies to have greater understanding of the roles and responsibilities of local public health, while shared service jurisdictions had fewer staff per 1,000 population. IMPLICATIONS: There are trade-offs with sharing and remaining independent. Independent health departments serving small jurisdictions have limited resources but strong local knowledge. Multi-municipality departments have more resources but require more time and investment in governance and decision-making. When making decisions about the right service delivery model for a given municipality, careful consideration should be given to local culture and values. Some economies of scale may be achieved through resource sharing for municipalities <25,000 population.

Albendazole Treatment Improves Work Capacity in Women Smallholder Farmers Infected with Hookworm: A Double-Blind Randomized Control Trial.

An estimated 4.7 billion people live in regions exposed to soil-transmitted helminths, intestinal parasites that have significant impacts on the health of women smallholder farmers. The goal of this trial was to determine whether treatment with albendazole impacts the work capacity of these farmers. This is a prospective double-blind, randomized effectiveness trial. Participants (N = 250) were randomly selected from safe motherhood groups in the Democratic Republic of Congo. Prevalence/intensity of hookworm infection, hemoglobin, and demographics was obtained. At study (Time = 0), participants were randomized into treatment (albendazole 400 mg) and placebo (similar placebo tablet) groups. A step test was administered as a proxy metric for work capacity. Work capacity was defined as ∆heart rate before and after 3 minutes of step testing, in beats per minute. At study (time = 7 months), the step test was repeated and work capacity remeasured. The ∆work capacity (time = 0 minus time = 7 months) was the primary outcome. Investigators/field assistants were blinded to who was enrolled in groups, hookworm status, and step test results. Regression showed highly significant interactive effects of hookworm status and treatment group relative to ∆work capacity after controlling for resting pulse rate and age (P < 0.002). Estimated marginal means for work capacity (WC) for each of four groups (hookworm positive plus placebo, hookworm positive plus treatment, hookworm negative plus placebo, and hookworm negative plus treatment) showed women who were hookworm positive and received treatment decreased heart rate by 9.744 (95% confidence interval [CI]: 6.42, 13.07) beats per minute (increased WC), whereas women who were hookworm positive and received placebo saw a nonsignificant decrease of 0.034 (95% CI: -3.16, 3.84) beats per minute. Treatment with albendazole was associated with improved aerobic work capacity posttreatment. Given modest costs of drug distributions, risk benefits of periodic deworming warrants further study in larger controlled trials.

Detection of elder abuse: Exploring the potential use of the Elder Abuse Suspicion Index© by law enforcement in the field.

There are no known instruments to aid law enforcement officers in the assessment of elder abuse (EA), despite officers' contact with older adults. This study aimed to identify: 1) officers' perceptions and knowledge of EA, 2) barriers in detecting EA in the field, 3) characteristics officers value in a detection tool, and to explore 4) the potential for officers to use the Elder Abuse Suspicion Index (EASI)©. Data was collected from 69 Connecticut officers who confirmed that barriers to effectively detecting EA included a lack of EA detection instruments, as well as a lack of training on warning signs and risk factors. Officers indicated that the important elements of a desirable tool for helping to detect EA included ease of use, clear instructions, and information on follow-up resources. Approximately 80% of respondents could see themselves using the EASI

Does household access to improved water and sanitation in infancy and childhood predict better vocabulary test performance in Ethiopian, Indian, Peruvian and Vietnamese cohort studies?

OBJECTIVE: Test associations between household water and sanitation (W&S) and children's concurrent and subsequent Peabody Picture Vocabulary Test (PPVT) scores. DESIGN: Prospective cohort study. SETTING: Ethiopia, India, Peru, Vietnam. PARTICIPANTS: 7269 children. PRIMARY OUTCOME MEASURES: PPVT scores at 5 and 8 years. Key exposure variables were related to W&S, and collected at 1, 5 and 8 years, including 'improved' water (eg, piped, public tap or standpipe) and 'improved' toilets (eg, collection, storage, treatment and recycling of human excreta). RESULTS: Access to improved water at 1 year was associated with higher language scores at 5 years (3/4 unadjusted associations) and 8 years (4/4 unadjusted associations). Ethiopian children with access to improved water at 1 year had test scores that were 0.26 SD (95% CI 0.17 to 0.36) higher at 5 years than children without access. Access to improved water at 5 years was associated with higher concurrent PPVT scores (in 3/4 unadjusted associations), but not later scores (in 1/4 unadjusted associations). 5-year-old Peruvian children with access to improved water had better concurrent performance on the PPVT (0.44 SD, 95% CI 0.30 to 0.59) than children without access to improved water. Toilet access at 1 year was also associated with better PPVT scores at 5 years (3/4 unadjusted associations) and sometimes associated with test results at 8 years (2/4 unadjusted associations). Toilet access at 5 years was associated with concurrent PPVT scores (3/4 unadjusted associations). More than half of all associations in unadjusted models (water and toilets) persisted in adjusted models, particularly for toilets in India, Peru and Vietnam. CONCLUSIONS: Access to 'improved' water and toilets had independent associations with children's PPVT scores that often persisted with adjustment for covariates. Our findings suggest that effects of W&S may go beyond subacute and acute infections and physical growth to include children's language performance, a critical component of cognitive development.

Household food group expenditure patterns are associated with child anthropometry at ages 5, 8 and 12 years in Ethiopia, India, Peru and Vietnam.

Population-level analysis of dietary influences on nutritional status is challenging in part due to limitations in dietary intake data. Household expenditure surveys, covering recent household expenditures and including key food groups, are routinely conducted in low- and middle-income countries. These data may help identify patterns of food expenditure that relate to child growth. OBJECTIVES: We investigated the relationship between household food expenditures and child growth using factor analysis. METHODS: We used data on 6993 children from Ethiopia, India, Peru and Vietnam at ages 5, 8 and 12y from the Young Lives cohort. We compared associations between household food expenditures and child growth (height-for-age z scores, HAZ; body mass index-for-age z scores, BMI-Z) using total household food expenditures and the "household food group expenditure index" (HFGEI) extracted from household expenditures with factor analysis on the seven food groups in the child dietary diversity scale, controlling for total food expenditures, child dietary diversity, data collection round, rural/urban residence and child sex. We used the HFGEI to capture households' allocations of their finances across food groups in the context of local food pricing, availability and pReferences RESULTS: The HFGEI was associated with significant increases in child HAZ in Ethiopia (0.07), India (0.14), and Vietnam (0.07) after adjusting for all control variables. Total food expenditures remained significantly associated with increases in BMI-Z for India (0.15), Peru (0.11) and Vietnam (0.06) after adjusting for study round, HFGEI, dietary diversity, rural residence, and whether the child was female. Dietary diversity was inversely associated with BMI-Z in India and Peru. Mean dietary diversity increased from age 5y to 8y and decreased from age 8y to 12y in all countries. CONCLUSION: Household food expenditure data provide insights into household food purchasing patterns that significantly predict HAZ and BMI-Z. Including food expenditure patterns data in analyses may yield important information about child nutritional status and linear growth.