Determinants of food preparation and hygiene practices among caregivers of children under two in Western Kenya: a formative research study.

INTRODUCTION: Diarrhea is a leading cause of child morbidity and mortality worldwide and is linked to early childhood stunting. Food contamination from improper preparation and hygiene practices is an important transmission pathway for exposure to enteric pathogens. Understanding the barriers and facilitators to hygienic food preparation can inform interventions to improve food hygiene. We explored food preparation and hygiene determinants including food-related handwashing habits, meal preparation, cooking practices, and food storage among caregivers of children under age two in Western Kenya. METHODS: We used the Capabilities, Opportunities, and Motivations model for Behavior Change (COM-B) framework in tool development and analysis. We conducted 24 focus group discussions with mothers (N = 12), fathers (N = 6), and grandmothers (N = 6); 29 key informant interviews with community stakeholders including implementing partners and religious and community leaders; and 24 household observations. We mapped the qualitative and observational data onto the COM-B framework to understand caregivers' facilitators and barriers to food preparation and hygiene practices. RESULTS: Facilitators and barriers to food hygiene and preparation practices were found across the COM-B domains. Caregivers had the capability to wash their hands at critical times; wash, cook, and cover food; and clean and dry utensils. Barriers to food hygiene and preparation practices included lack of psychological capability, for instance, caregivers' lack of knowledge of critical times for handwashing, lack of perceived importance of washing some foods before eating, and not knowing the risks of storing food for more than four hours without refrigerating and reheating. Other barriers were opportunity-related, including lack of resources (soap, water, firewood) and an enabling environment (monetary decision-making power, social support). Competing priorities, socio-cultural norms, religion, and time constraints due to work hindered the practice of optimal food hygiene and preparation behaviors. CONCLUSION: Food hygiene is an underexplored, but potentially critical, behavior to mitigate fecal pathogen exposure for young children. Our study revealed several knowledge and opportunity barriers that could be integrated into interventions to enhance food hygiene.

A Pilot Study of Integration of Medical and Dental Care in 6 States.

INTRODUCTION: Poor oral health affects overall health. Chronic diseases and related risk factors such as tobacco use or consuming sugar-sweetened beverages can also increase a person's risk of periodontitis. Given the linkages between oral health and certain chronic diseases, we conducted a pilot study to facilitate intradepartmental collaborations between state chronic disease and oral health programs. METHODS: State health departments in 6 states (Alaska, Colorado, Georgia, Maryland, Minnesota, and New York) collaborated to develop and implement projects that addressed oral health and the following chronic diseases or risk factors: obesity, diabetes, heart disease, stroke, and tobacco use. States developed various projects, including media campaigns, clinical education, and screening and referrals. We used a mixed-methods approach to understand barriers to and facilitators of states' increasing collaboration and implementation of pilot projects. In-depth interviews were conducted with 12 staff (1 from oral health and 1 from chronic disease for each state). We also reviewed state-submitted documents and performance measures. RESULTS: All 6 states increased collaboration between their oral health and chronic disease programs and successfully implemented pilot projects. Collaboration was facilitated by investing in relationships, championing medical-dental integration, and meeting and communicating frequently. Barriers to collaboration included the perception of oral health in chronic disease programs as separate and distinct from other chronic diseases and the structure of funding. The pilot projects were facilitated by partner support, providing technical assistance to clinics, and working early on referral networks. Barriers to implementing the pilot projects included gaining clinician buy-in and establishing referral networks. CONCLUSION: This pilot study demonstrated that by fostering collaboration, state health departments are able to train dental and medical clinicians, deliver clinical preventive education to patients, implement referral systems, and deliver impressions via media campaigns.

Utility of State-Based Basic Screening Survey Reports for National Oral Health Surveillance in Older Adults.

INTRODUCTION: Untreated dental disease and resulting tooth loss can diminish quality of life for older adults by limiting food choices and discouraging social interaction. Before the Basic Screening Survey (BSS) for older adults, no clinical data were available to monitor the oral health of older adults in long-term care (LTC) facilities at the national level or older adults overall at the state level. Although BSS is widely used, no guidelines exist to ensure the validity, reliability, and comparability of survey information across states. We examined BSS content to help establish reporting guidelines and synthesized findings across states for older adults living in LTC. METHODS: We systematically reviewed BSS reports published from 2011-2019, assessing how oral health outcomes were measured and reported. For reports that included statewide estimates for LTC residents, we calculated the mean, median, and ranges of 3 preventable oral health conditions and 4 indicators of tooth loss. RESULTS: We found wide variation in reporting of sampling, screening, and statistical methods, as well as in indicators of tooth loss. Median prevalence of untreated tooth decay and edentulism (total tooth loss) among LTC adults in 11 states was almost twice that for community-dwelling adults in a national survey. CONCLUSIONS: The substantial variation in BSS reporting highlights the potential benefits of adopting standardized guidance, which could improve the utility of BSS. Poor oral health outcomes among LTC residents underscore the importance of systematic monitoring of the oral health of this vulnerable population.

Novel E815K knock-in mouse model of alternating hemiplegia of childhood.

De novo mutations causing dysfunction of the ATP1A3 gene, which encodes the α3 subunit of Na+/K+-ATPase pump expressed in neurons, result in alternating hemiplegia of childhood (AHC). AHC manifests as paroxysmal episodes of hemiplegia, dystonia, behavioral abnormalities, and seizures. The first aim of this study was to characterize a novel knock-in mouse model (Atp1a3E815K+/-, Matoub, Matb+/-) containing the E815K mutation of the Atp1a3 gene recognized as causing the most severe and second most common phenotype of AHC with increased morbidity and mortality as compared to other mutations. The second aim was to investigate the effects of flunarizine, currently the most effective drug used in AHC, to further validate our model and to help address a question with significant clinical implications that has not been addressed in prior studies. Specifically, many E815K patients have clinical decompensation and catastrophic regression after discontinuing flunarizine therapy; however, it is not known whether this is congruent with the natural course of the disease and is a result of withdrawal from an acute beneficial effect, withdrawal from a long-term protective effect or from a detrimental effect of prior flunarizine exposure. Our behavioral and neurophysiological testing demonstrated that Matb+/- mice express a phenotype that bears a strong resemblance to the E815K phenotype in AHC. In addition, these mice developed spontaneous seizures with high incidence of mortality and required fewer electrical stimulations to reach the kindled state as compared to wild-type littermates. Matb+/- mice treated acutely with flunarizine had reduction in hemiplegic attacks as compared with vehicle-treated mice. After withdrawal of flunarizine, Matb+/- mice that had received flunarizine did neither better nor worse, on behavioral tests, than those who had received vehicle. We conclude that: 1) Our mouse model containing the E815K mutation manifests clinical and neurophysiological features of the most severe form of AHC, 2) Flunarizine demonstrated acute anti-hemiplegic effects but not long-term beneficial or detrimental behavioral effects after it was stopped, and 3) The Matb+/- mouse model can be used to investigate the underlying pathophysiology of ATP1A3 dysfunction and the efficacy of potential treatments for AHC.

Knock-in mouse model of alternating hemiplegia of childhood: behavioral and electrophysiologic characterization.

OBJECTIVES: Mutations in the ATP1α3 subunit of the neuronal Na+/K+-ATPase are thought to be responsible for seizures, hemiplegias, and other symptoms of alternating hemiplegia of childhood (AHC). However, the mechanisms through which ATP1A3 mutations mediate their pathophysiologic consequences are not yet understood. The following hypotheses were investigated: (1) Our novel knock-in mouse carrying the most common heterozygous mutation causing AHC (D801N) will exhibit the manifestations of the human condition and display predisposition to seizures; and (2) the underlying pathophysiology in this mouse model involves increased excitability in response to electrical stimulation of Schaffer collaterals and abnormal predisposition to spreading depression (SD). METHODS: We generated the D801N mutant mouse (Mashlool, Mashl+/-) and compared mutant and wild-type (WT) littermates. Behavioral tests, amygdala kindling, flurothyl-induced seizure threshold, spontaneous recurrent seizures (SRS), and other paroxysmal activities were compared between groups. In vitro electrophysiologic slice experiments on hippocampus were performed to assess predisposition to hyperexcitability and SD. RESULTS: Mutant mice manifested a distinctive phenotype similar to that of humans with AHC. They had abnormal impulsivity, memory, gait, motor coordination, tremor, motor control, endogenous nociceptive response, paroxysmal hemiplegias, diplegias, dystonias, and SRS, as well as predisposition to kindling, to flurothyl-induced seizures, and to sudden unexpected death. Hippocampal slices of mutants, in contrast to WT animals, showed hyperexcitable responses to 1 Hz pulse-trains of electrical stimuli delivered to the Schaffer collaterals and had significantly longer duration of K+-induced SD responses. SIGNIFICANCE: Our model reproduces the major characteristics of human AHC, and indicates that ATP1α3 dysfunction results in abnormal short-term plasticity with increased excitability (potential mechanism for seizures) and a predisposition to more severe SD responses (potential mechanism for hemiplegias). This model of the human condition should help in understanding the molecular pathways underlying these phenotypes and may lead to identification of novel therapeutic strategies of ATP1α3 related disorders and seizures.

Impact of school sealant programs on oral health among youth and identification of potential barriers to implementation.

BACKGROUND: School sealant programs (SSPs) increase sealant prevalence among children lacking access to oral health care. SSPs, however, are substantially underused. From 2013 through 2018, the Centers for Disease Control and Prevention funded 18 states for SSP activities in high-need schools (≥ 50% free and reduced-price meal program participation). From 2019 through 2020, the authors assessed SSPs' impact in reducing caries and how states expanded SSPs. The authors also discuss potential barriers to expansion. METHODS: For Aim 1, the authors used a published methodology and SSP baseline screening and 1-year retention data to estimate averted caries over 9 years attributable to SSPs. For Aim 2, the authors used state responses to an online survey, phone interviews, and annual administrative reports. RESULTS: Using data for 62,750 children attending 18.6% of high-need schools in 16 states, the authors estimated that 7.5% of sound, unsealed molars would develop caries annually without sealants and placing 4 sealants would prevent caries in 1 molar. Fourteen states reported SSP expansion in high-need schools. The 2 most frequently reported barriers to SSP expansion were levels of funding and policies requiring dentists to be present at assessment or sealant placement. CONCLUSIONS: The authors found that SSPs typically served children at elevated caries risk and reduced caries. In addition, the authors identified funding levels and policies governing supervision of dental hygienists as possible barriers to SSP expansion. PRACTICAL IMPLICATIONS: Increasing SSP prevalence could reduce caries. Further research on potential barriers to SSP implementation identified in this study could provide critical information for long-term SSP sustainability.

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

Background: Interventions aimed at improving dietary intake and feeding practices have alone proven insufficient for combatting stunting resulting from poor nutrition and repeated infections. Objectives: To support the development of an integrated water, sanitation, and hygiene (WASH) and nutrition, social, and behavior change strategy aimed at reducing stunting, formative research was conducted in 2 program sites in western Kenya. Methods: Twenty-nine key informant interviews were conducted with community leaders, health workers, and project staff, and 24 focus group discussions with caregivers of children under 2 y on topics related to feeding, sanitation, and hygiene behaviors. Three frameworks informed the study design and analysis of our formative research: the Capabilities, Opportunities, and Motivations model for behavior change, which identifies what needs to change in order for behavior change interventions to be effective; the Grandmother Project's Change Through Culture Approach, which values the important role of influential household and community members in producing household health; and Starr and Fornoff's approach to Theory of Change development. Results: Caregivers exhibited sufficient psychological capabilities (knowledge and skills) for many of the key maternal and infant nutrition behaviors. However, reflective motivation to perform optimal behaviors was undermined by limitations in physical and social opportunities, including limited time and competing priorities for mothers, limited accessibility and availability of diverse foods, low self-efficacy for exclusive breastfeeding, and fears of negative consequences related to specific foods and recommended practices. Conclusions: Interventions that aim to improve maternal and child diets should address the underlying social, cultural, and environmental determinants that contribute to motivations and opportunities to perform recommended practices.

Impact of a demand-side integrated WASH and nutrition community-based care group intervention on behavioural change: a randomised controlled trial in western Kenya.

INTRODUCTION: Growth shortfalls and diarrhoeal diseases remain a major cause of morbidity and mortality in low-income settings. Due to the multifaceted causes of undernutrition and the identified limitations of siloed nutrition programmes, improving the delivery of integrated water, sanitation, hygiene (WASH) and nutrition programming could improve child health. METHODS: We conducted a cluster randomised trial in western Kenya to assess the impact on household behaviours of a novel, theory-informed and integrated WASH and nutrition intervention delivered through care groups as compared with the standard care group approach. We developed an intervention targeting practices relating to food hygiene, mealtime and feeding, and compound cleanliness, each using various behavioural change techniques to influence the uptake of targeted behaviours. Prespecified behavioural outcomes were verified through direct observation, 24 hours recall, and self-reported picture-based methods. RESULTS: Compared with control households, a greater proportion of intervention households had a hygienic food preparation area (Risk double difference (RDD) 0.81, 95% CI 0.68 to 0.96), had stored food hygienically (RDD 0.76, 95% CI 0.58 to 1.00), had a functional handwashing station (RDD 0.64, 95% CI 0.56 to 0.74), provided a safe space for their child to play (RDD 0.73, 95% CI 0.56 to 0.96), and who fed their children thickened porridge (RDD 0.56, 95% CI 0.51 to 0.63) at endline. The proportion of children 6-24 months in intervention households consuming a sufficient diversity of foods (RDD 0.81, 95% CI 0.64 to 1.04) was higher than in control households; however, there was a non-significant increase in the percentage of pregnant and lactating women receiving an adequate diversity of foods in their diets (RDD 0.86, 95% CI 0.70 to 1.05) among intervention compared with control households at endline. CONCLUSION: Our integrated WASH and nutrition intervention resulted in important changes in behaviours. This theory-informed intervention could be added to existing care group programmes to considerable advantage.

Practices and Perspectives on Latrine Use, Child Feces Disposal, and Clean Play Environments in Western Kenya.

Exposure to fecal pathogens contributes to childhood diarrhea and stunting, causing harmful short- and long-term impacts to health. Understanding pathways of child fecal exposure and nutritional deficiencies is critical to informing interventions to reduce stunting. Our aim was to explore determinants of latrine use, disposal of child feces, and perceptions and provisions of a safe and clean child play environment among families with children under two (CU2) years to inform the design of a behavior change intervention to address water, sanitation, and hygiene (WASH), and nutrition behaviors. In 2016, we conducted a mixed-methods formative research in western Kenya. We conducted 29 key informant interviews with community leaders, health workers, and project staff; 18 focus group discussions with caregivers of CU2 years; and 24 semi-structured household observations of feeding, hygiene, and sanitation behaviors. We used the capability, opportunity, motivation, and behavior model as our theoretical framework to map caregiver behavioral determinants. Latrine use barriers were lack of latrines, affordability of lasting materials, and social acceptability of unobserved open defecation. Barriers to safe disposal of child feces were lack of latrines, time associated with safe disposal practices, beliefs that infant feces were not harmful, and not knowing where children had defecated. Primary barriers of clean play environments were associated with creating and maintaining play spaces, and shared human and animal compounds. The immediate cost to practicing behaviors was perceived as greater than the long-term potential benefits. Intervention design must address these barriers and emphasize facilitators to enable optimal WASH behaviors in this context.