Gender and neglected tropical disease front-line workers: Data from 16 countries.

BACKGROUND: Delivery of preventive chemotherapy (PC) through mass drug administration (MDA) is used to control or eliminate five of the most common neglected tropical diseases (NTDs). The success of an MDA campaign relies on the ability of drug distributors and their supervisors-the NTD front-line workers-to reach populations at risk of NTDs. In the past, our understanding of the demographics of these workers has been limited, but with increased access to sex-disaggregated data, we begin to explore the implications of gender and sex for the success of NTD front-line workers. METHODOLOGY/PRINCIPAL FINDINGS: We reviewed data collected by USAID-supported NTD projects from national NTD programs from fiscal years (FY) 2012-2017 to assess availability of sex-disaggregated data on the workforce. What we found was sex-disaggregated data on 2,984,908 trainees trained with financial support from the project. We then analyzed the percentage of males and females trained by job category, country, and fiscal year. During FY12, 59% of these data were disaggregated by sex, which increased to nearly 100% by FY15 and was sustained through FY17. In FY17, 43% of trainees were female, with just four countries reporting more females than males trained as drug distributors and three countries reporting more females than males trained as trainers/supervisors. Except for two countries, there were no clear trends over time in changes to the percent of females trained. CONCLUSIONS/SIGNIFICANCE: There has been a rapid increase in availability of sex-disaggregated data, but little increase in recruitment of female workers in countries included in this study. Women continue to be under-represented in the NTD workforce, and while there are often valid reasons for this distribution, we need to test this norm and better understand gender dynamics within NTD programs to increase equity.

How are the domains of women's inclusion, justice, and security associated with maternal and infant mortality across countries? Insights from the Women, Peace, and Security Index.

Women's autonomy and empowerment in their homes, communities, and societies at large have been shown, through many direct and indirect pathways, to be associated with maternal and infant health. A novel global measure-the Women, Peace, and Security (WPS) Index-that bridges insights from gender and development indices with those from peace and security has recently been developed to capture the constructs of women's inclusion, justice, and security, using indicators and targets in the Sustainable Development Goals. This paper adds to the growing literature about the importance of gender inequality to key mortality outcomes for women and children by investigating the associations between nations' WPS Index scores and maternal mortality ratios and infant mortality rates. We use a range of international databases to obtain country-level data from 144 nations on health, demographic, income, and gender equality indicators. The aim is to highlight the role of women's inclusion, justice, and security in explaining national rates of maternal and infant mortality. Fully adjusted Poisson regression models indicate that a one point (0.01) increase on the WPS Index score is associated with a 2.0% reduction in the number of maternal deaths and a 2.3% reduction in the number of infant deaths. For a country such as Sierra Leone, with a maternal mortality ratio of 1360 maternal deaths per 100,000 live births, a one point improvement in the WPS Index would correspond to a maternal mortality ratio of 1,332, or 28 fewer deaths per 100,000 births. These associations are ecological and apply to the average level of mortality at the country level rather than the likelihood or risk faced at the individual level. Although we cannot claim causality for the observed relations in the cross-country regressions, the findings and recurring patterns are both suggestive and encouraging about the potential contributions of women's inclusion, justice, and security to maternal and infant mortality.

Targeting Sleep, Food, and Activity in Infants for Obesity Prevention: An RCT.

OBJECTIVE: The few existing early-life obesity prevention initiatives have concentrated on nutrition and physical activity, with little examination of sleep. METHODS: This community-based, randomized controlled trial allocated 802 pregnant women (≥16 years, <34 weeks' gestation) to: control, FAB (food, activity, and breastfeeding), sleep, or combination (both interventions) groups. All groups received standard well-child care. FAB participants received additional support (8 contacts) promoting breastfeeding, healthy eating, and physical activity (antenatal-18 months). Sleep participants received 2 sessions (antenatal, 3 weeks) targeting prevention of sleep problems, as well as a sleep treatment program if requested (6-24 months). Combination participants received both interventions (9 contacts). BMI was measured at 24 months by researchers blinded to group allocation, and secondary outcomes (diet, physical activity, sleep) were assessed by using a questionnaire or accelerometry at multiple time points. RESULTS: At 2 years, 686 women remained in the study (86%). No significant intervention effect was observed for BMI at 24 months (P = .086), but there was an overall group effect for the prevalence of obesity (P = .027). Exploratory analyses found a protective effect for obesity among those receiving the "sleep intervention" (sleep and combination compared with FAB and control: odds ratio, 0.54 [95% confidence interval, 0.35-0.82]). No effect was observed for the "FAB intervention" (FAB and combination compared with sleep and control: odds ratio, 1.20 [95% confidence interval, 0.80-1.81]). CONCLUSIONS: A well-developed food and activity intervention did not seem to affect children's weight status. However, further research on more intensive or longer running sleep interventions is warranted.

Early Intervention to Encourage Physical Activity in Infants and Toddlers: A Randomized Controlled Trial.

INTRODUCTION: Few physical activity interventions have been undertaken in infants and toddlers, despite concerns that they are insufficiently active. The Prevention of Overweight in Infancy trial encouraged parents to be physically active with their child from birth, including prone-based play ("tummy time"), while reducing time spent restrained in car seats and "strollers." METHODS: A total of 802 women, recruited in late pregnancy, were randomized to a physical activity intervention, which provided information antenatally, and active group sessions with their infant at 3, 9, and 18 months of age. Questionnaires were completed at multiple time points, and toddlers wore Actical accelerometers for 5 d at 24 months of age. RESULTS: Attendance at intervention sessions was high in infancy but declined by 18 months to 66%. Almost all parents placed their infant prone to play at least once a day (90%-95%, overall median 25 min·d), with no intervention differences observed (P = 0.445 and P = 0.350 at 4 and 6 months, respectively). Few differences were observed in other measures of restraint or parental activity at any time point. At 2 yr, children spent approximately 8 h·d in sedentary time while awake and 3.6 h in light-to-vigorous activity. However, no group differences were apparent in counts per minute (P = 0.759) or time in light-to-vigorous activity (P = 0.960). CONCLUSION: An early life intervention targeting improvements in child and parent physical activity as part of a wider obesity prevention initiative had little effect on physical activity at 2 yr of age.

Prevention of Overweight in Infancy (POI.nz) study: a randomised controlled trial of sleep, food and activity interventions for preventing overweight from birth.

BACKGROUND: Rapid weight gain during the first three years of life predicts child and adult obesity, and also later cardiovascular and other morbidities. Cross-sectional studies suggest that infant diet, activity and sleep are linked to excessive weight gain. As intervention for overweight children is difficult, the aim of the Prevention of Overweight in Infancy (POI.nz) study is to evaluate two primary prevention strategies during late pregnancy and early childhood that could be delivered separately or together as part of normal health care. METHODS/DESIGN: This four-arm randomised controlled trial is being conducted with 800 families recruited at booking in the only maternity unit in the city of Dunedin, New Zealand. Mothers are randomised during pregnancy to either a usual care group (7 core contacts with a provider of government funded "Well Child" care over 2 years) or to one of three intervention groups given education and support in addition to "Well Child" care: the Food, Activity and Breastfeeding group which receives 8 extra parent contacts over the first 2 years of life; the Sleep group which receives at least 3 extra parent contacts over the first 6 months of life with a focus on prevention of sleep problems and then active intervention if there is a sleep problem from 6 months to 2 years; or the Combination group which receives all extra contacts. The main outcome measures are conditional weight velocity (0-6, 6-12, 12-24 months) and body mass index z-score at 24 months, with secondary outcomes including sleep and physical activity (parent report, accelerometry), duration of breastfeeding, timing of introduction of solids, diet quality, and measures of family function and wellbeing (parental depression, child mindedness, discipline practices, family quality of life and health care use). This study will contribute to a prospective meta-analysis of early life obesity prevention studies in Australasia. DISCUSSION: Infancy is likely to be the most effective time to establish patterns of behaviour around food, activity and sleep that promote healthy child and adult weight. The POI.nz study will determine the extent to which sleep, food and activity interventions in infancy prevent the development of overweight. TRIAL REGISTRATION: Clinical Trials NCT00892983. Prospective meta-analysis registered on PROSPERO CRD420111188. Available from http://www.crd.york.ac.uk/PROSPERO.

Body mass index and waist circumference cutoffs to define obesity in indigenous New Zealanders.

BACKGROUND: The suggestion that body mass index (BMI) cutoffs to define obesity should differ in persons of Polynesian descent compared with Europeans is based principally on the observation that persons of Polynesian descent have a relatively higher proportion of lean body mass for a given BMI. OBJECTIVES: The objectives were to determine whether the relation between BMI, waist circumference, and metabolic comorbidity differs in the 2 major ethnic groups in New Zealand and to ascertain whether ethnicity-specific BMI and waist circumference cutoffs for obesity are justified for Maori (indigenous New Zealanders). DESIGN: Subjects included a convenience sample of 1539 men and women aged 17-82 y (47% Maori, 53% white) with measures of BMI, waist circumference, blood pressure, fasting insulin, glucose, and lipids. The sensitivity and specificity of BMI (in kg/m(2); 30 and 32), waist circumference (80 and 88 cm in women, 94 and 102 cm in men), and waist-to-height ratio (WHtR; > or =0.6) in relation to insulin sensitivity, insulin resistance, and the metabolic syndrome were determined. Receiver operating characteristic curves and areas under the curve (AUCs) were also calculated. RESULTS: No ethnic or sex differences between AUCs were observed for BMI, waist circumference, or WHtR, which showed that these anthropometric measures perform similarly in Maori and European men and women and correctly discriminate between those with and without insulin resistance or the metabolic syndrome 79-87% of the time. Any increase in specificity from a higher BMI cutoff of 32 in Maori was offset by appreciable reductions in sensitivity. CONCLUSION: These findings argue against having different BMI or waist circumference cutoffs for people of Polynesian descent.

Determining optimal approaches for weight maintenance: a randomized controlled trial.

BACKGROUND: Weight regain often occurs after weight loss in overweight individuals. We aimed to compare the effectiveness of 2 support programs and 2 diets of different macronutrient compositions intended to facilitate long-term weight maintenance. METHODS: Using a 2 x 2 factorial design, we randomly assigned 200 women who had lost 5% or more of their initial body weight to an intensive support program (implemented by nutrition and activity specialists) or to an inexpensive nurse-led program (involving "weigh-ins" and encouragement) that included advice about high-carbohydrate diets or relatively high-monounsaturated-fat diets. RESULTS: In total, 174 (87%) participants were followed-up for 2 years. The average weight loss (about 2 kg) did not differ between those in the support programs (0.1 kg, 95% confidence interval [CI] -1.8 to 1.9, p = 0.95) or diets (0.7 kg, 95% CI -1.1 to 2.4, p = 0.46). Total and low-density lipoprotein (LDL) cholesterol levels were significantly higher among those on the high-monounsaturated-fat diet (total cholesterol: 0.17 mmol/L, 95% CI 0.01 to 0.33; p = 0.040; LDL cholesterol: 0.16 mmol/L, 95% CI 0.01 to 0.31; p = 0.039) than among those on the high-carbohydrate diet. Those on the high-monounsaturated-fat diet also had significantly higher intakes of total fat (5% total energy, 95% CI 3% to 6%, p < 0.001) and saturated fat (2% total energy, 95% CI 1% to 2%, p < 0.001). All of the other clinical and laboratory measures were similar among those in the support programs and diets. INTERPRETATION: A relatively inexpensive program involving nurse support is as effective as a more resource-intensive program for weight maintenance over a 2-year period. Diets of different macronutrient composition produced comparable beneficial effects in terms of weight loss maintenance.

Sustainability of lifestyle changes following an intensive lifestyle intervention in insulin resistant adults: Follow-up at 2-years.

The objective of this study was to determine whether overweight insulin resistant individuals who lost weight and improved cardiovascular risk factors during a 4-month lifestyle intervention could sustain these lifestyle changes in the long-term. Seventy-nine insulin resistant adults were randomised to a control group or either a modest or intensive lifestyle intervention group for 4-months. Thereafter the two intervention groups were combined and all participants were followed-up at 8, 12 and 24 months. Anthropometry, blood pressure, fasting glucose, lipids, insulin and aerobic fitness were measured and dietary intake was assessed. An interview was conducted to determine factors which participants perceived facilitated or hindered maintenance of healthy lifestyle habits. Seventy-two (91.1%), sixty-nine (87.3%) and sixty-two (78.5%) participants were retained at 8, 12 and 24-month respectively. At 4-months the adjusted difference in weight between the modest and control groups was -3.4 kg (95% CI -5.4, -1.3) p=0.002 and intensive and control groups was -4.7 kg (-6.9, -2.4) p=0.0001 respectively. At 2-years there were no significant differences for weight when the initial 3 groups were compared or when the combined intervention group was compared with the control group. At 2-years, 64% of participants reported that more frequent follow-up would have helped them to maintain healthy lifestyle habits. Even intensive counselling for 4-months with 4-monthly and then yearly monitoring were not enough for maintaining lifestyle changes sufficient to sustain weight loss. More frequent monitoring for an indefinite period was perceived by two-thirds of participants as necessary for them to maintain their initial lifestyle changes.