Feeding Homemade Sugar Sweetened Beverages in Addition to Breastfeeding: Survey Results from Caregivers of Infants and Young Children in Peri-Urban Lima, Peru.

OBJECTIVES: Consumption of sugar sweetened beverages (SSB) is associated with childhood obesity and other negative health conditions. Feeding SSB to infants and young children (IYC) under 2 years may displace consumption of breastmilk and nutrient rich foods critical for optimal growth and development. The World Health Organization (WHO) recommends avoiding added sugar (e.g. SSB) for IYC under 2 years. We sought to describe the variety of homemade and commercial SSB as well as breastmilk and beverages without added sugar fed to IYC aged 4-23 months living in a low-income, populous peri-urban area of Lima, Peru. METHODS: A cross-sectional survey was conducted with 181 households with IYC aged 4-23 months. A list of common local homemade and commercial beverages was used to investigate what caregivers had fed to the child in the past 24 h. RESULTS: A total of 93.9% of caregivers reported feeding at least one beverage to their child other than breastmilk in the past 24 h. This included a variety of homemade SSB (73.5%), commercial SSB (18.2%) and homemade beverages without added sugar (70.2%). A high percentage (83.4%) of children were also breastfed. CONCLUSIONS FOR PRACTICE: Our findings suggest that interventions to address feeding homemade SSB to IYC within households are needed to support WHO recommendations and complement current commercial SSB policy regulations in Peru.

School environments and obesity: a systematic review of interventions and policies among school-age students in Latin America and the Caribbean.

BACKGROUND: The rapid rise in obesity rates among school children in Latin America and the Caribbean (LAC) could have a direct impact on the region's physical and mental health, disability, and mortality. This review presents the available interventions likely to reduce, mitigate and/or prevent obesity among school children in LAC by modifying the food and built environments within and around schools. METHODS: Two independent reviewers searched five databases: MEDLINE, Web of Science, Cochrane Library, Scopus and Latin American and Caribbean Health Sciences Literature for peer-reviewed literature published from 1 January 2000 to September 2021; searching and screening prospective studies published in English, Spanish and Portuguese. This was followed by data extraction and quality assessment using the Cochrane risk-of-bias tool (RoB 2) and the Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I), adopting also the PRISMA 2020 guidelines. Due to the heterogeneity of the intervention's characteristics and obesity-related measurements across studies, a narrative synthesis was conducted. RESULTS: A total of 1342 research papers were screened, and 9 studies were included; 4 in Mexico, and 1 each in Argentina, Brazil, Chile, Colombia, and Ecuador. Four studies reported strategies for modifying food provision; four other targeted the built environment, (modifying school premises and providing materials for physical activity); a final study included both food and built environment intervention components. Overall, two studies reported that the intervention was significantly associated with a lower increase over time in BMI/obesity in the intervention against the control group. The remaining studies were non-significant. CONCLUSIONS: Data suggest that school environmental interventions, complementing nutritional and physical education can contribute to reduce incremental childhood obesity trends. However, evidence of the extent to which food and built environment components factor into obesogenic environments, within and around school grounds is inconclusive. Insufficient data hindered any urban/rural comparisons. Further school environmental intervention studies to inform policies for preventing/reducing childhood obesity in LAC are needed.

Efficacy, immunogenicity, and safety of a quadrivalent HPV vaccine in men: results of an open-label, long-term extension of a randomised, placebo-controlled, phase 3 trial.

BACKGROUND: The quadrivalent human papillomavirus (HPV) vaccine was shown to prevent infections and lesions related to HPV6, 11, 16, and 18 in a randomised, placebo-controlled study in men aged 16-26 years. We assessed the incidences of external genital warts related to HPV6 or 11, and external genital lesions and anal dysplasia related to HPV6, 11, 16, or 18, over 10 years of follow-up. METHODS: The 3-year base study was an international, multicentre, double-blind, randomised, placebo-controlled trial done at 71 sites in 18 countries. Eligible participants were heterosexual men (aged 16-23 years) or men who have sex with men (MSM; aged 16-26 years). Men who had clinically detectable anogenital warts or genital lesions at screening that were suggestive of infection with non-HPV sexually transmitted diseases, or who had a history of such findings, were excluded. Eligible participants were randomly assigned (1:1) to receive three doses of either quadrivalent HPV vaccine or placebo on day 1, month 2, and month 6, administered as a 0·5-mL injection into the deltoid muscle. The 7-year, open-label, long-term follow-up extension study was done at 46 centres in 16 countries. Participants who received one or more doses of the quadrivalent HPV vaccine in the base study were eligible for enrolment into the long-term follow-up study (early vaccination group). Placebo recipients were offered the three-dose quadrivalent HPV vaccine at the end of the base study; those who received one or more quadrivalent HPV vaccine doses were eligible for enrolment into the long-term follow-up study (catch-up vaccination group). The primary efficacy endpoints were the incidence of external genital warts related to HPV6 or 11 and the incidence of external genital lesions related to HPV6, 11, 16, or 18 in all participants and the incidence of anal intraepithelial neoplasia (including anal warts and flat lesions) or anal cancer related to HPV6, 11, 16, or 18 in MSM only. The primary efficacy analysis was done in the per-protocol population for the early vaccination group, which included participants who received all three vaccine doses, were seronegative at day 1 and PCR-negative from day 1 through month 7 of the base study for the HPV type being analysed, had no protocol violations that could affect evaluation of vaccine efficacy, and had attended at least one visit during the long-term follow-up study. For the catch-up vaccination group, efficacy was assessed in the modified intention-to-treat population, which included participants who had received at least one vaccine dose, were seronegative and PCR-negative for HPV types analysed from day 1 of the base study to the final follow-up visit before receiving the quadrivalent HPV vaccine, and had at least one long-term follow-up visit. Safety was assessed in all randomised participants who received at least one vaccine dose. This study is registered with ClinicalTrials.gov, NCT00090285. FINDINGS: Between Aug 10, 2010, and April 3, 2017, 1803 participants were enrolled in the long-term follow-up study, of whom 936 (827 heterosexual men and 109 MSM) were included in the early vaccination group and 867 (739 heterosexual men and 128 MSM) were included in the catch-up vaccination group. Participants in the early vaccination group were followed up for a median of 9·5 years (range 0·1-11·5) after receiving the third dose of the quadrivalent HPV vaccine, and participants in the catch-up vaccination group were followed up for a median of 4·7 years (0·0-6·6) after receiving the third dose. In early vaccine group participants during long-term follow-up compared with the placebo group in the base study, the incidence per 10 000 person-years of external genital warts related to HPV6 or 11 was 0·0 (95% CI 0·0-8·7) versus 137·3 (83·9-212·1), of external genital lesions related to HPV6, 11, 16, or 18 was 0·0 (0·0-7·7) versus 140·4 (89·0-210·7), and of anal intraepithelial neoplasia or anal cancer related to HPV6, 11, 16, or 18 in MSM only was 20·5 (0·5-114·4) versus 906·2 (553·5-1399·5). Compared with during the base study (ie, before quadrivalent HPV vaccine administration), during the long-term follow-up period, participants in the catch-up vaccination group had no new reported cases of external genital warts related to HPV6 or 11 (149·6 cases per 10 000 person-years [95% CI 101·6-212·3] vs 0 cases per 10 000 person-years [0·0-13·5]) or external genital lesions related to HPV6, 11, 16, or 18 (155·1 cases per 10 000 person-years [108·0-215·7] vs 0 cases per 10 000 person-years [0·0-10·2]), and a lower incidence of anal intraepithelial neoplasia or anal cancer related to HPV6, 11, 16, or 18 (886·0 cases per 10 000 person-years [583·9-1289·1] vs 101·3 cases per 10 000 person-years [32·9-236·3]). No vaccine-related serious adverse events were reported. INTERPRETATION: The quadrivalent HPV vaccine provides durable protection against anogenital disease related to HPV6, 11, 16, and 18. The results support quadrivalent HPV vaccination in men, including catch-up vaccination. FUNDING: Merck Sharp & Dohme.

Peru - Progress in health and sciences in 200 years of independence.

Peru celebrates 200 years of independence in 2021. Over this period of independent life, and despite the turbulent socio-political scenarios, from internal armed conflict to economic crisis to political instability over the last 40 years, Peru has experienced major changes on its epidemiological and population health profile. Major advancements in maternal and child health as well as in communicable diseases have been achieved in recent decades, and today Peru faces an increasing burden of non-communicable diseases including mental health conditions. In terms of the configuration of the public health system, Peru has also strived to secure country-wide optimal health care, struggling in particular to improve primary health care and intercultural services. The science and technology infrastructure has also evolved, although the need for substantial investments remains if advancing science is to be a national priority. Climate change will also bring significant challenges to population health given Peru's geographical and microclimates diversity. Looking back over the 200-years of independence, we present a summary of key advances in selected health-related fields, thus serving as the basis for reflections on pending agendas and future challenges, in order to look forward to ensuring the future health and wellbeing of the Peruvian population. Resumen translated abstract: El Perú cumple 200 años de independencia en 2021. Durante estos dos siglos de vida independiente, junto con periodos sociales y políticos turbulentos, incluyendo un conflicto armado interno, hiperinflación y la inestabilidad política de los últimos 40 años, el Perú ha experimentado importantes cambios en su perfil epidemiológico con repercusiones directas en la salud de la población. En las últimas décadas, los indicadores de salud materno-infantil y de las enfermedades transmisibles muestran mejoría importante, pero el país se enfrenta de manera simultánea a una carga cada vez mayor de enfermedades no transmisibles y de salud mental. En cuanto a los sistemas de salud pública, se han realizado esfuerzos por aumentar la cobertura y calidad de la atención de salud en todo el país, apostándose en particular por mejorar la atención primaria. La ciencia y tecnología relacionadas con la salud también han mejorado, aunque si se quiere que la ciencia sea una prioridad nacional, son necesarias inversiones sustanciales. El cambio climático traerá importantes desafíos para la salud de la población, dada la diversidad geográfica y de microclimas del país. Para conmemorar los 200 años de vida independiente del Perú, presentamos un resumen de avances clave en diversas áreas y temas relacionados con la salud. Este repaso sirve como base para reflexionar sobre agendas y desafíos pendientes y futuros, con el fin de asegurar la salud y el bienestar de la población peruana en las próximas décadas.

Role of Government Financial Support and Vulnerability Characteristics Associated with Food Insecurity during the COVID-19 Pandemic among Young Peruvians.

Peruvian households have experienced one of the most prevalent economic shocks due to COVID-19, significantly increasing their vulnerability to food insecurity (FI). To understand the vulnerability characteristics of these households among the Peruvian young population, including the role of the government's response through emergency cash transfer, we analysed longitudinal data from the Young Lives study (n = 2026), a study that follows the livelihoods of two birth cohorts currently aged 18 to 27 years old. FI was assessed using the Food Insecurity Experience Scale. Household characteristics were collected before and during the COVID-19 outbreak in Peru to characterise participants' vulnerability to FI. Multivariate logistic regression was used to evaluate the association between government support and participants' vulnerability characteristics to FI. During the period under study (March to December 2020), 24% (95% CI: 22.1-25.9%) of the participants experienced FI. Families in the top wealth tercile were 49% less likely to experience FI. Larger families (>5 members) and those with increased household expenses and decreased income due to COVID-19 were more likely to experience FI (by 35%, 39% and 42%, respectively). There was no significant association between government support and FI (p = 0.768). We conclude that pre-pandemic socioeconomic status, family size, and the economic disruption during COVID-19 contribute to the risk of FI among the Peruvian young population, while government support insufficiently curtailed the risk to these households.

Adiposity and pathogen exposure: An investigation of response to iron supplementation and hypothesized predictors in anemic pre-school-aged children living in a dual burden environment.

OBJECTIVES: Peruvians are experiencing rapid dietary and lifestyle changes, resulting in a phenomenon known as the "dual burden of disease." A common manifestation of the dual burden in individuals is the co-occurrence of overweight and anemia. Despite recent initiatives introduced to address these concerns, rates continue to be public health concerns. This study investigates the relationship between immune activation and lack of response to iron supplementation after 1 month of treatment and explores variation in body fat stores as a potential moderator between immune function and response to treatment. METHODS: Data come from children, aged 2-5 years (n = 50) from a peri-urban community in Lima, Peru. Multivariate logistic regression models were used to explore the associations between response to treatment (Hb > =11.0 g/dl) after 1 month of treatment), markers of immune activation (C-reactive protein [CRP] and reported morbidity symptoms), and measures of body fat (waist-to-height ratio, triceps skinfold thickness, and body mass index [BMI]). RESULTS: We found that high CRP is associated with a lack of response to iron supplementation after 1 month of treatment and that BMI z-score may moderate this association. Generally, larger body size is associated with response to iron supplementation whether or not the children in this sample have high immune activation. However, the probability of anemic children responding to iron supplementation treatment differed across adiposity measures. CONCLUSIONS: Our finding suggesting that adiposity and CRP influence response to iron supplementation, furthers our understanding of the relationship between inflammation and anemia treatment in children and has both theoretical and public health implications.

Social predictors of food insecurity during the stay-at-home order due to the COVID-19 pandemic in Peru. Results from a cross-sectional web-based survey.

BACKGROUND: Stay-at-home orders and social distancing have been implemented as the primary tools to reduce the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, this approach has indirectly lead to the unemployment of 2·3 million Peruvians, in Lima, Perú alone. As a result, the risk of food insecurity may have increased, especially in low-income families who rely on a daily wage. This study estimates the prevalence of moderate or severe food insecurity (MSFI) and identifies the associated factors that explain this outcome during the stay-at-home order. METHODS: A cross-sectional web-based survey, with non-probabilistic sampling, was conducted between May 18 and June 30, 2020, during the stay-at-home order in Peru. We used social media advertisements on Facebook to reach 18-59-year-olds living in Peru. MSFI was assessed using the Food Insecurity Experience Scale (FIES). Rasch model methodology requirements were considered, and factors associated with MSFI were selected using stepwise forward selection. A Poisson generalized linear model (Poisson GLM), with log link function, was employed to estimate adjusted prevalence ratios (aPR). FINDINGS: This analysis is based on 1846 replies. The prevalence of MSFI was 23·2%, and FIES proved to be an acceptable instrument with reliability 0·72 and infit 0·8-1·3. People more likely to experience MSFI were those with low income (less than 255 US$/month) in the pre-pandemic period (aPR 3·77; 95%CI, 1·98-7·16), those whose income was significantly reduced during the pandemic period (aPR 2·27; 95%CI, 1·55-3·31), and those whose savings ran out in less than 21 days (aPR 1·86; 95%CI, 1·43-2·42). Likewise, heads of households (aPR 1·20; 95%CI, 1·00-1·44) and those with probable SARS-CoV2 cases as relatives (aPR 1·29; 95%CI, 1·05-1·58) were at an increased risk of MSFI. Additionally, those who perceived losing weight during the pandemic (aPR 1·21; 95%CI, 1·01-1·45), and increases in processed foods prices (aPR 1·31; 95%CI, 1·08-1·59), and eating less minimally processed food (aPR 1·82; 95%CI, 1·48-2·24) were more likely to experience MSFI. INTERPRETATION: People most at risk of MSFI were those in a critical economic situation before and during the pandemic. Social protection policies should be reinforced to prevent or mitigate these adverse effects.

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.

Time use and sexual maturity-related indicators differentially predict youth body mass indices, Peruvian girls versus boys.

Rapid development in Latin America has been accompanied by lifestyle shifts, including changes in time use and social environments. Overweight/obesity has also emerged as a public health challenge. We examined whether lifestyle changes and sexual maturity-related indicators (early pubertal development and having a child) predict increases in adiposity among Peruvian youth. Using longitudinal data from Young Lives, we examined changes in adiposity between ages 8 and 15 years old for the younger cohort and ages 15 and 22 years old for the older cohort. Boys and girls in both cohorts demonstrated substantial increases in age-adjusted adiposity measures, but predictors were different for boys versus girls. For boys, increases in time spent in work and domestic chores predicted increases in adiposity body mass index and BMI-for-age Z-score and increases in time spent sleeping were associated with decreases in adiposity (waist circumference and waist-to-height ratio). For girls, sexual maturity-related indicators (early menarche and childbearing) predicted increases in adiposity, regardless of time use. Potential mechanisms for these results may include diet, physical activity, wealth, and urban-rural residence. Time use among youth was associated with diet quality and physical activity, but in different ways for boys versus girls. Strategies for dealing with rising overweight and obesity should incorporate sex-based specificities.

The double burden of malnutrition among youth: Trajectories and inequalities in four emerging economies.

As part of the nutritional transition, undernutrition is globally declining while changes brought by economic development have ushered in increases in overweight and its related economic costs and health consequences around the world. We examine trajectories in stunting and overweight from age one year to mid-adolescence and from mid-childhood to early adulthood among two cohorts from Ethiopia, India, Peru and Vietnam using data from the Young Lives study. We examine descriptive data and then model trajectories in stunting and overweight status over age. Group-based trajectory analysis with five ages of overweight and stunting for each country-cohort reveals (1) trajectories of catch-up growth for a subset of study children between the ages of 12 and 19 in the older cohort in Ethiopia (20.1% of the cohort), India (20.5%), Peru (16.9%), and Vietnam (14.0%); (2) trajectories of increasing probabilities of stunting as children age from 12 to 22 in the older cohort in India (22.2%) and Peru (30.7%); (3) trajectories of early (childhood) increases in overweight probabilities (younger cohort: India, 3.4%, Peru, 19.4%, and Vietnam, 8.1%), and of later (adolescence) increases in overweight probabilities (older cohort: Ethiopia, 0.5%, India, 6.3%, Peru, 40.9%, and Vietnam, 9.4%). Multinomial logit prediction of membership in trajectory categories reveals that higher wealth quartiles and maternal schooling are protective against high stunting probability trajectory group membership, but higher wealth and urban residence predict high overweight probability trajectory group membership. This evidence suggests a window of opportunity for interventions to reduce stunting and to avert overweight development in adolescence, in addition to the often-emphasized first 1000 days after conception. A life-course approach to policies and programs to target both undernutrition and overweight should be considered.

Birth seasons and heights among girls and boys below 12 years of age: lasting effects and catch-up growth among native Amazonians in Bolivia.

BACKGROUND: Seasons affect many social, economic, and biological outcomes, particularly in low-resource settings, and some studies suggest that birth season affects child growth. AIM: To study a predictor of stunting that has received limited attention: birth season. SUBJECTS AND METHODS: This study uses cross-sectional data collected during 2008 in a low-resource society of horticulturists-foragers in the Bolivian Amazon, Tsimane'. It estimates the associations between birth months and height-for-age Z-scores (HAZ) for 562 girls and 546 boys separately, from birth until age 11 years or pre-puberty, which in this society occurs ∼13-14 years. RESULTS: Children born during the rainy season (February-May) were shorter, while children born during the end of the dry season and the start of the rainy season (August-November) were taller, both compared with their age-sex peers born during the rest of the year. The correlations of birth season with HAZ were stronger for boys than for girls. Controlling for birth season, there is some evidence of eventual partial catch-up growth, with the HAZ of girls or boys worsening until ∼ age 4-5 years, but improving thereafter. By age 6 years, many girls and boys had ceased to be stunted, irrespective of birth season. CONCLUSION: The results suggest that redressing stunting will require attention to conditions in utero, infancy and late childhood.

Iron and infection: An investigation of the optimal iron hypothesis in Lima, Peru.

OBJECTIVES: This article explores the optimal iron hypothesis through secondary data analysis of the association between hemoglobin levels and morbidity among children living in Canto Grande, a peri-urban community located on the outskirts of Lima, Peru. METHODS: Risk ratios were used to test whether lower iron status, assessed using the HemoCue B-Hemoglobin System, was associated with an increased relative risk of morbidity symptoms compared to iron replete status, controlling for infant age, sex, weight for height z-score, maternal education, and repeated measures in 515 infants aged 6-12 months. RESULTS: Infants with fewer current respiratory and diarrheal morbidity symptoms had a lower risk of low iron deficiency compared to participants who were iron replete (P < .10). Infants with fewer current respiratory infection symptoms had a statistically significant (P < .05) reduction in risk of moderate iron deficiency compared to infants who were iron replete. CONCLUSION: In this study, morbidity status was not predictive of iron deficient status over a six-month interval period, but nonreplete iron status was shown to be associated with current morbidity symptoms. These results support investigating iron status as an allostatic system that responds to infection adaptively, rather than expecting an optimal preinfection value.

Adolescent mothers' anthropometrics and grandmothers' schooling predict infant anthropometrics in Ethiopia, India, Peru, and Vietnam.

We investigated intergenerational associations of adolescent mothers' and grandmothers' anthropometrics and schooling with adolescent mothers' offspring's anthropometrics in Ethiopia, India, Peru, and Vietnam. We examined birthweight (n = 283), birthweight Z-score (BWZ), conditional growth in weight-for-age Z-score (cWAZ, residuals from a regression of WAZ at last survey round on BWZ, sex, and age), and height-for-age Z-score (HAZ) of children born to older cohort adolescent girls in the Young Lives study. Our key independent variables were adolescent mothers' body size: HAZ and body-mass-index-for-age Z-score (BMIZ) at age 8, conditional HAZ (cHAZ, residuals from a regression of HAZ at the end of a growth period on prior HAZ, age, and sex), conditional BMIZ growth (cBMIZ, calculated analogously), and grandmaternal BMIZ, HAZ, and schooling. We adjusted for child, maternal, and household characteristics. Adolescent mothers' cHAZ (ages 8-15) predicted birthweight (ß = 130 g, 95% confidence interval (CI) 31-228), BWZ (ß = 0.31, CI 0.09-0.53), and cWAZ (ß = 0.28, CI 0.04-0.51). Adolescent mothers' BMIZ at age 8 predicted birthweight (ß = 79 g, CI 16-43) and BWZ (ß = 0.22, CI 0.08-0.36). Adolescent mothers' cBMIZ (ages 12-15) predicted child cWAZ and HAZ. Grandmothers' schooling predicted grandchild birthweight (ß = 22 g, CI 1-44) and BWZ (ß = 0.05, CI 0.01-0.10).

Birth weight and prepubertal body size predict menarcheal age in India, Peru, and Vietnam.

Evidence on the associations of birth weight and prepubertal nutritional status with menarcheal age for low- and middle-income countries is limited. We investigated these relationships using the Young Lives younger cohort for 2001 Indian, Peruvian, and Vietnamese girls born in 2001-2002. Girls were followed at approximately ages 1, 5, 8, and 12 years. Weibull survival models estimated hazards of earlier menarche on the basis of birth weight Z-scores (BWZ), and age-8 BMI-for-age Z-scores (BMIZ) and height-for-age Z-scores (HAZ). Estimates controlled for potential individual-, mother-, and household-level confounders and for changes in anthropometry between 1 and 8 years. In adjusted models, BWZ predicted later age at menarche (hazard ratio (HR) = 0.90, 95% CI: 0.83-0.97). Conversely, HAZ (HR = 1.66, 95% CI 1.5-1.83) and BMIZ at 8 years (HR = 1.28, 95% CI: 1.18-1.38) predicted earlier menarche. Changes in HAZ and BMIZ between 1 and 8 years were not associated with earlier menarche. Associations were consistent across countries, though with variation in estimated magnitudes. Maternal height and age were associated with later menarche. This evidence points to consistently robust and opposite associations of birth weight versus prepubertal attained height and body mass index with menarcheal age in three diverse settings with regard to nutrition, ethnicity, and socioeconomic status.

Health workers' attitudes, perceptions and knowledge of influenza immunization in Lima, Peru: A mixed methods study.

BACKGROUND: Vaccination against seasonal influenza in health workers is recommended but coverage is variable. This study aimed to determine coverage of influenza vaccination among health workers in Lima, Peru in 2010; explore barriers and enabling elements for vaccination; and suggest strategies to improve coverage. METHODS: Qualitative interviews informed the development of a survey instrument that consisted of open and close-ended questions. Sub-analyses were done by occupational group and results were calculated as percentages for each possible response with confidence intervals of 95%. RESULTS: Coverage of the influenza vaccination was 77.2%. Vaccinated staff were less likely to have permanent contracts (p=0.0150) and vaccination coverage was lower in physicians (p=0.0001). Over 90% cited protection of themselves, families and patients as reasons for vaccination and 48% mentioned peer encouragement. Fear of adverse events (47%) and organizational barriers (>30%) were reasons for non-vaccination. To improve coverage, highest priority was given to strategies providing more information. CONCLUSIONS: Key factors in driving health worker vaccination include desire for protection and peer encouragement. Perceptual barriers based on a misunderstanding of the epidemiology of influenza and vaccination could be overcome by targeted education and information. Organizational barriers require attention to how vaccination is implemented within health facilities.

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.

Children with access to improved sanitation but not improved water are at lower risk of stunting compared to children without access: a cohort study in Ethiopia, India, Peru, and Vietnam.

BACKGROUND: This study's purpose was to understand associations between water, sanitation, and child growth. METHODS: We estimated stunting (height-for-age Z score <-2 SD) and thinness (BMI-Z <-2 SD) risk ratios using data from 7,715 Ethiopian, Indian, Peruvian, and Vietnamese children from the Young Lives study. RESULTS: In unadjusted models, household access to improved water and toilets was often associated with reduced stunting risk. After adjusting for child, household, parent, and community variables, access to improved water was usually not associated with stunting nor thinness except in Ethiopia where access to improved water was associated with reduced stunting and thinness at 1y and 5y. In contrast, in both unadjusted and adjusted models, stunting at 1y was less common among children with good toilet access than among those without access and this difference persisted when children were 5y and 8y. For example, in adjusted estimates, Vietnamese 5y olds with access to improved toilets had relative stunting risk at 8y 0.62-0.68 that of 5y olds with no access to improved toilets. Water and toilets were rarely associated with thinness. CONCLUSIONS: Results from our study indicate that access to improved sanitation is more frequently associated with reduced stunting risk than access to improved water. However, additional studies are needed before drawing definitive conclusions about the impact of toilets relative to water. This study is the first to our knowledge to demonstrate the robust and persistent importance of access to improved toilets in infancy, not only during the first year but continuing into childhood. Additional longitudinal investigations are needed to determine concurrent and long-term associations of WASH with stunting and thinness.

Strengthening health services to deliver nutrition education to promote complementary feeding and healthy growth of infants and young children: formative research for a successful intervention in peri-urban Trujillo, Peru.

Formative research is critical for developing effective nutrition-specific interventions to improve infant and young child (IYC) feeding practices and promote healthy growth. Health workers interact with caregivers during health facility visits, yet there is limited research about how to optimize delivery of such interventions during these visits. The extensive reach of IYC health services globally calls for research to address this gap. In Trujillo, Peru, formative research was conducted to explore complementary feeding practices with caregivers as well as health worker routines and interactions with caregivers related to feeding and healthy growth; results informed the development and delivery of an educational intervention. Multiple qualitative methods were used to collect data on a purposive sample of health workers and caregivers from three health facilities and communities: household trials followed. Complementary feeding messages with doable behaviours were developed, and three were selected as key to promote based on their nutritional impact and cultural acceptability. In the health facilities, medical consultation, well-child visits and nutrition consultation all dealt with aspects of IYC nutrition/growth during their interactions with caregivers but were independent and inconsistent in approach. A nutrition education strategy was developed based on consistency, quality and coverage in the IYC health services. We conclude that formative research undertaken in the community and IYC health services was critical to developing a successful and culturally relevant intervention to promote optimal complementary feeding practices and healthy growth during interactions between health workers and caregivers at routine health facility visits. © 2016 John Wiley & Sons Ltd.