A Community Health Worker Intervention to Increase Childhood Disease Treatment Coverage in Rural Liberia: A Controlled Before-and-After Evaluation.

OBJECTIVES: To assess a community health worker (CHW) program's impact on childhood illness treatment in rural Liberia. METHODS: We deployed CHWs in half of Rivercess County in August 2015 with the other half constituting a comparison group until July 2016. All CHWs were provided cash incentives, supply chain support, and monthly clinical supervision. We conducted stratified cluster-sample population-based surveys at baseline (March-April 2015) and follow-up (April-June 2016) and performed a difference-in-differences analysis, adjusted by inverse probability of treatment weighting, to assess changes in treatment of fever, diarrhea, and acute respiratory infection by a qualified provider. RESULTS: We estimated a childhood treatment difference-in-differences of 56.4 percentage points (95% confidence interval [CI] = 36.4, 76.3). At follow-up, CHWs provided 57.6% (95% CI = 42.8, 71.2) of treatment in the intervention group. The difference-in-differences diarrhea oral rehydration therapy was 22.4 percentage points (95% CI = -0.7, 45.5). CONCLUSIONS: Implementation of a CHW program in Rivercess County, Liberia, was associated with large, statistically significant improvements treatment by a qualified provider; however, improvements in correct diarrhea treatment were lower than improvements in coverage. Findings from this study offer support for expansion of Liberia's new National Community Health Assistant Program.

"Do You Wanna Breathe or Eat?": Parent Perspectives on Child Health Consequences of Food Insecurity, Trade-Offs, and Toxic Stress.

OBJECTIVES: This study among 51 parents of young children under age four investigated how parents that report marginal, low and very low food security characterize how trade-offs associated with food insecurity affect parents' mental health and child well-being. METHODS: We carried out 51 semi-structured audio-recorded interviews after participants responded to a survey regarding food security status and maternal depressive symptoms. Each interview was transcribed. Through a content analysis, we coded "meaning units" in each manuscript and organized them by themes in ATLAS.ti. Among participants reporting both food insecurity and depressive symptoms, we identified three primary areas of concern: trade-offs, mental health, and child well-being. RESULTS: Parents described how trade-offs associated with food insecurity have a profound relationship with their mental health and home environment that strongly affects young children. Descriptions of hardships include anxiety and depression related to overdue bills and shut-off notices, strains with housing costs, and safety. Parents described how their own frustration, anxiety, and depression related to economic hardship have a negative impact on their children's physical health, and their social and emotional development. CONCLUSIONS: Parents in food insecure households recognize that trade-offs between food and other basic necessities are associated with their personal stress and poor mental health that, in turn, affects their children's health and development. Partnerships between healthcare providers, policymakers, and parents are essential to successfully address and prevent the poor child health outcomes of toxic stress associated with food insecurity and poverty.

The relationship between childhood adversity and food insecurity: 'It's like a bird nesting in your head'.

OBJECTIVE: Adverse childhood experiences, including abuse, neglect and household instability, affect lifelong health and economic potential. The present study investigates how adverse childhood experiences are associated with food insecurity by exploring caregivers' perceptions of the impact of their childhood adversity on educational attainment, employment and mental health. DESIGN: Semi-structured audio-recorded in-person interviews that included (i) quantitative measures of maternal and child health, adverse childhood experiences (range: 0-10) and food security using the US Household Food Security Survey Module; and (ii) qualitative audio-recorded investigations of experiences with abuse, neglect, violence and hunger over participants' lifetimes. SETTING: Households in Philadelphia, PA, USA. SUBJECTS: Thirty-one mothers of children <4 years old who reported low or very low household food security. RESULTS: Twenty-one caregivers (68 %) reported four or more adverse childhood experiences, and this severity was significantly associated with reports of very low food security (Fisher's exact P=0·021). Mothers reporting emotional and physical abuse were more likely to report very low food security (Fisher's exact P=0·032). Qualitatively, participants described the impact of childhood adverse experiences with emotional and physical abuse/neglect, and household substance abuse, on their emotional health, school performance and ability to maintain employment. In turn, these experiences negatively affected their ability to protect their children from food insecurity. CONCLUSIONS: The associations between mothers' adverse experiences in childhood and reports of current household food security should inspire researchers, advocates and policy makers to comprehensively address family hardship through greater attention to the emotional health of caregivers. Programmes meant to address nutritional deprivation and financial hardship should include trauma-informed approaches that integrate behavioural interventions.

Very low food security in the USA is linked with exposure to violence.

OBJECTIVE: To investigate characteristics of exposure to violence in relation to food security status among female-headed households. DESIGN: Ongoing mixed-method participatory action study. Questions addressed food insecurity, public assistance, and maternal and child health. Grounded theory analysis of qualitative themes related to violence was performed. These themes were then categorized by food security status. SETTING: Homes of low-income families in Philadelphia, PA, USA. SUBJECTS: Forty-four mothers of children under 3 years of age participating in public assistance programmes. RESULTS: Forty women described exposure to violence ranging from fear of violence to personal experiences with rape. Exposure to violence affected mental health, ability to continue school and obtain work with living wages, and subsequently the ability to afford food. Exposure to violence during childhood and being a perpetrator of violence were both linked to very low food security status and depressive symptoms. Ten of seventeen (59%) participants reporting very low food security described life-changing violence, compared with three of fifteen (20%) participants reporting low food security and four of twelve (33%) reporting food security. Examples of violent experiences among the very low food secure group included exposure to child abuse, neglect and rape that suggest exposure to violence is an important factor in the experience of very low food security. CONCLUSIONS: Descriptions of childhood trauma and life-changing violence are linked with severe food security. Policy makers and clinicians should incorporate violence prevention efforts when addressing hunger.

Witnesses to hunger: participation through photovoice to ensure the right to food.

Currently 30.2% of female-headed households with children in the United States experience food insecurity, defined as the lack of access to enough food for an active and healthy life. In 2007, approximately 12.4 million children were at risk for hunger. When female-headed households and households with children have the highest prevalence of food insecurity and hunger in the US, the participation of low-income mothers in the development and administration of policies and programs related to nutrition and poverty are fundamental to the process of ending hunger and improving child well-being. In this article, we describe the Witnesses to Hunger program, a participatory advocacy project that uses the "photovoice" technique to engage mothers to take photos and record their stories about poverty and hunger with the intent to inform social welfare policy in the US. Witnesses to Hunger is grounded in the human rights framework that is supported by international conventions on the rights of women, the rights of the child, and economic, social, and cultural rights. The Witnesses to Hunger program works to increase civic participation of low-income women and to maintain a strategic public awareness campaign. After introducing the Witnesses to Hunger program, this article describes the past decade of unchanging food insecurity disparities, demonstrates the lack of participatory dialogue in health and welfare programs, and provides examples of how Witnesses to Hunger counters the conventional dialogue about welfare. Throughout, this paper demonstrates how the participatory approach of the Witnesses to Hunger program improves our understanding of basic human needs and the social determinants of health, and informs legislators on how to improve health and welfare policy.