Maternal and child health intervention to promote behaviour change: a population-level cluster-randomised controlled trial in Honduras.

OBJECTIVES: To assess the efficacy of a sustained educational intervention to affect diverse outcomes across the pregnancy and infancy timeline. SETTING: A multi-arm cluster-randomised controlled trial in 99 villages in Honduras' Copán region, involving 16 301 people in 5633 households from October 2015 to December 2019. PARTICIPANTS: Residents aged 12 and older were eligible. A photographic census involved 93% of the population, with 13 881 and 10 263 individuals completing baseline and endline surveys, respectively. INTERVENTION: 22-month household-based counselling intervention aiming to improve practices, knowledge and attitudes related to maternal, neonatal and child health. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcomes were prenatal/postnatal care behaviours, facility births, exclusive breast feeding, parental involvement, treatment of diarrhoea and respiratory illness, reproductive health, and gender/reproductive norms. Secondary outcomes were knowledge and attitudes related to the primary outcomes. RESULTS: Parents targeted for the intervention were 16.4% (95% CI 3.1%-29.8%, p=0.016) more likely to have their newborn's health checked in a health facility within 3 days of birth; 19.6% (95% CI 4.2%-35.1%, p=0.013) more likely to not wrap a fajero around the umbilical cord in the first week after birth; and 8.9% (95% CI 0.3%-17.5%, p=0.043) more likely to report that the mother breast fed immediately after birth. Changes in knowledge and attitudes related to these primary outcomes were also observed. We found no significant effect on various other practices. CONCLUSION: A sustained counselling intervention delivered in the home setting by community health workers can meaningfully change practices, knowledge and attitudes related to proper newborn care following birth, including professional care-seeking, umbilical cord care and breast feeding. TRIAL REGISTRATION NUMBER: NCT02694679.

Designing intervention prototypes to improve infant and young child nutrition in Peru: a participatory design study protocol.

INTRODUCTION: Nutrition during the complementary feeding period (6-23 months) is critical to ensure optimal growth and reduce the risk of diet-related disease across the life course. Strategies to reduce multiple forms of malnutrition (stunting, overweight/obesity and anaemia) in infants and young children (IYC) are a key priority in low-income and middle-income countries, including Peru. This study aims to co-design and develop prototypes for interventions to address the multiple forms of malnutrition in IYC in urban Peru, using a participatory design approach. METHODS AND ANALYSIS: The study will be based within peri-urban communities in two areas of Peru (Lima and Huánuco city). Following the identification of key nutritional challenges for IYC aged 6-23 months through formative research (phase I), we will conduct a series of workshops bringing together healthcare professionals from government health centres and caregivers of IYC aged 6-23 months. Workshops (on idea generation; creating future scenarios; storyboarding and early implementation and feedback) will take place in parallel in the two study areas. Through these workshops, we will engage with community participants to explore, experiment, co-design and iteratively validate new design ideas to address the challenges around IYC complementary feeding from phase I. Workshop outputs and transcripts will be analysed qualitatively using affinity diagramming and thematic analyses. The intervention prototypes will be evaluated qualitatively and piloted with the participating communities. ETHICS AND DISSEMINATION: Ethical approval for this study was obtained from the Ethical Review Committee of the Instituto de Investigación Nutricional (IIN) Peru (388-2019/CIEI-IIN), Loughborough University (C19-87) and confirmed by Cardiff University. Findings of the participatory design process will be disseminated through a deliberative workshop in Lima, Peru with national and regional government stakeholders, as well as participants and researchers involved in the design process. Further dissemination will take place through policy briefs, conferences and academic publications.

Maternal and child nutrition programme of investigation within the 100 Million Brazilian Cohort: study protocol.

INTRODUCTION: There is a limited understanding of the early nutrition and pregnancy determinants of short-term and long-term maternal and child health in ethnically diverse and socioeconomically vulnerable populations within low-income and middle-income countries. This investigation programme aims to: (1) describe maternal weight trajectories throughout the life course; (2) describe child weight, height and body mass index (BMI) trajectories; (3) create and validate models to predict childhood obesity at 5 years of age; (4) estimate the effects of prepregnancy BMI, gestational weight gain (GWG) and maternal weight trajectories on adverse maternal and neonatal outcomes and child growth trajectories; (5) estimate the effects of prepregnancy BMI, GWG, maternal weight and interpregnancy BMI changes on maternal and child outcomes in the subsequent pregnancy; and (6) estimate the effects of maternal food consumption and infant feeding practices on child nutritional status and growth trajectories. METHODS AND ANALYSIS: Linked data from four different Brazilian databases will be used: the 100 Million Brazilian Cohort, the Live Births Information System, the Mortality Information System and the Food and Nutrition Surveillance System. To analyse trajectories, latent-growth, superimposition by translation and rotation and broken stick models will be used. To create prediction models for childhood obesity, machine learning techniques will be applied. For the association between the selected exposure and outcomes variables, generalised linear models will be considered. Directed acyclic graphs will be constructed to identify potential confounders for each analysis investigating potential causal relationships. ETHICS AND DISSEMINATION: This protocol was approved by the Research Ethics Committees of the authors' institutions. The linkage will be carried out in a secure environment. After the linkage, the data will be de-identified, and pre-authorised researchers will access the data set via a virtual private network connection. Results will be reported in open-access journals and disseminated to policymakers and the broader public.

Psychosocial dysfunction of children and adolescents during the COVID-19 lockdown in Ecuador: a cross-sectional study.

OBJECTIVE: Although the risk of morbidity and mortality of children and adolescents was lower during the COVID-19 pandemic, it appears that their mental health was strongly impacted. The goal of this study is to document psychological dysfunction among children and adolescents who underwent confinement due to COVID-19 in Ecuador. DESIGN: A cross-sectional, internet-based questionnaire. SETTING: Ecuador. PARTICIPANTS: A total of 1077 caregivers of children and adolescents (4-16 years old). OUTCOME MEASURES: Caregivers responded to Pediatric Symptom Checklist-35 to assess psychosocial dysfunction. RESULTS: The prevalence of psychosocial dysfunction was 20.8%, with internalising symptoms being the most common (30.7%). The prevalence of psychosocial dysfunction was higher in children who had a poor family relationship during confinement (prevalence ratio (PR) 2.23; 95% CI 1.22 to 4.07), children who never helped with housework (PR 2.63; 95% CI 1.13 to 6.14) and those whose caregivers were worried about children's need for emotional therapy (PR 2.86; 95% CI 1.97 to 4.15). Never playing video games (PR 0.34; 95% CI 0.17 to 0.69) or playing video games infrequently (PR 0.39; 95% CI 0.20 to 0.79) was a protective factor for the psychosocial problems of children and adolescents. CONCLUSION: Our study demonstrates that children and adolescents have experienced a deterioration of mental health due to the pandemic. Family factors played an important role in the mental health of children during the lockdown. When a public crisis occurs, supportive mental health policies should be developed and implemented to promote children's psychological welfare.

Diagnostic accuracy of ASQ for screening of neurodevelopmental delays in low resource countries.

OBJECTIVE: The Bayley Scales of Infant Development (BSID) is the most used diagnostic tool to identify neurodevelopmental disorders in children under age 3 but is challenging to use in low-resource countries. The Ages and Stages Questionnaire (ASQ) is an easy-to-use, low-cost clinical tool completed by parents/caregivers that screens children for developmental delay. The objective was to determine the performance of ASQ as a screening tool for neurodevelopmental impairment when compared with BSID second edition (BSID-II) for the diagnosis of moderate-to-severe neurodevelopmental impairment among infants at 12 and 18 months of age in low-resource countries. METHODS: Study participants were recruited as part of the First Bites Complementary Feeding trial from the Democratic Republic of Congo, Zambia, Guatemala and Pakistan between October 2008 and January 2011. Study participants underwent neurodevelopmental assessment by trained personnel using the ASQ and BSID-II at 12 and 18 months of age. RESULTS: Data on both ASQ and BSID-II assessments of 1034 infants were analysed. Four of five ASQ domains had specificities greater than 90% for severe neurodevelopmental delay at 18 months of age. Sensitivities ranged from 23% to 62%. The correlations between ASQ communications subscale and BSID-II Mental Development Index (MDI) (r=0.38) and between ASQ gross motor subscale and BSID-II Psychomotor Development Index (PDI) (r=0.33) were the strongest correlations found. CONCLUSION: At 18 months, ASQ had high specificity but moderate-to-low sensitivity for BSID-II MDI and/or PDI <70. ASQ, when administered by trained healthcare workers, may be a useful screening tool to detect severe disability in infants from rural low-income to middle-income settings. TRIAL REGISTRATION NUMBER: NCT01084109.

Practitioner-led, peer-group sports intervention combined with a context-focused intervention for children with cerebral palsy: a protocol of a feasibility randomised clinical trial.

BACKGROUND: There is a need to investigate relevant, acceptable and feasible approaches that promote participation in leisure-time physical activity for children with cerebral palsy (CP). The aim of this study is to assess the feasibility of a randomised controlled trial comparing a peer-group intervention focused on improving physical literacy (Sports Stars) with the combination of Sports Stars and a context-focused intervention (Pathways and Resources for Engagement and Participation, PREP) for ambulant children with CP in Brazil. METHODS: In this feasibility trial, 18 ambulant children (aged 6-12 years) with CP will be randomised into two groups (nine per group): (1) Sports Stars and (2) Sports Stars plus PREP. The Sports Stars group will receive 8 weekly group sessions, focusing on developing the physical, social, cognitive and psychological skills required to participate in popular Brazilian sports. The combined Sports Stars and PREP group will receive Sports Stars in addition to eight individual PREP sessions focused on overcoming environmental barriers to participation. The primary outcome will include feasibility measures: willingness to participate in an RCT, eligibility and recruitment rates, maintenance of evaluator blinding, acceptability of screening procedures and random allocation, feasibility of evaluating outcomes, contamination between the groups, intervention adherence, treatment satisfaction, understanding of the intervention and implementation resources. Additional instruments will be applied to obtain data related to leisure-time physical activity participation goals, overall participation (home, school and community), physical literacy, level of physical activity and family empowerment. Outcomes will be assessed before, after and 12 weeks after intervention. ETHICS AND DISSEMINATION: This feasibility trial has been approved by ethical Federal University of Minas Gerais' Ethics Review Committee (CAAE: 33238520.5.0000.5149). All potential subjects will provide written informed consent. The results of this study will be published in peer-reviewed journals and be presented at academic conferences. TRIAL REGISTRATION NUMBERS: RBR-4m3b4b6, U1111-1256-4998.

Spatial distribution, determinants and trends of full vaccination coverage in children aged 12-59 months in Peru: A subanalysis of the Peruvian Demographic and Health Survey.

OBJECTIVE: To assess the spatial distribution, trends and determinants of crude full vaccination coverage (FVC) in children aged 12-59 months between 2010 and 2019 in Peru. DESIGN, SETTING AND ANALYSIS: A cross-sectional study based on the secondary data analysis of the 2010 and 2019 Peruvian Demographic and Health Surveys (DHSs) was conducted. Logit based multivariate decomposition analysis was employed to identify factors contributing to differences in FVC between 2010 and 2019. The spatial distribution of FVC in 2019 was evaluated through spatial autocorrelation (Global Moran's I), ordinary kriging interpolation (Gaussian process regression) and Bernoulli-based purely spatial scan statistic. OUTCOME MEASURE: FVC, as crude coverage, was defined as having completely received BCG; three doses of diphtheria, pertussis, and tetanus, and polio vaccines; and measles vaccine by 12 months of age. PARTICIPANTS: A total of 5 751 and 14 144 children aged 12-59 months from 2010 and 2019 DHSs, respectively, were included. RESULTS: FVC increased from 53.62% (95% CI 51.75% to 55.49%) in 2010 to 75.86% (95% CI 74.84% to 76.85%) in 2019. Most of the increase (70.39%) was attributable to differences in coefficients effects. Family size, visit of health workers in the last 12 months, age of the mother at first delivery, place of delivery and antenatal care follow-up were all significantly associated with the increase. The trend of FVC was non-linear and increased by 2.22% annually between 2010 and 2019. FVC distribution was heterogeneous at intradepartmental and interdepartmental level. Seven high-risk clusters of incomplete coverage were identified. CONCLUSIONS: Although FVC has increased in Peru, it still remains below the recommended threshold. The increase of FVC was mainly attributed to the change in the effects of the characteristics of the population. There was high heterogeneity across Peruvian regions with the presence of high-risk clusters. Interventions must be redirected to reduce these geographical disparities.

Quality of newborn healthcare in the first week of life in Brazil's primary care network: a cross-sectional multilevel analysis of the National Programme for Improving Primary Care Access and Quality - PMAQ.

OBJECTIVE: To estimate the prevalence of good quality child care in the first week of life in primary care services in Brazil and identify associated factors related to maternal, primary healthcare (PHC) facility and municipality characteristics. SETTING: Brazilian PHC. PARTICIPANTS: 6715 users of PHC facilities aged over 18 years with children under 2 years of age. PRIMARY OUTCOME: The good quality child care was defined when the following health interventions were performed during postnatal check-up in the first week of life: the child was weighed and measured; the healthcare professional observed breastfeeding techniques and offered counselling on the safest sleeping position; the umbilical cord was examined and the heel prick test was performed. RESULTS: The prevalence of good quality care was 52.6% (95% CI 51.4% to 53.8%). Observation of breastfeeding techniques (75.9%) and counselling on the safest sleeping position (72.3%) were the activities least performed. Babies born to mothers who received a home visit from a community health worker and made a postpartum visit were twice as likely to receive good quality care (OR 1.96; 95% CI 1.70 to 2.24 and OR 1.97; 95% CI 1.74 to 2.24, respectively). CONCLUSIONS: The information reported by the mothers related to Family Health team work processes was associated with good quality care in the first week of life. Supporting strategies that strengthen health team active search and timely screening actions could promote adequate early childhood development.

Impact of expansion of primary care in child health: a population-based panel study in municipalities in the Brazilian Amazon.

OBJECTIVES: Considering the expansion of primary care in areas of difficult access in the Brazilian territory in recent decades, the aim of this study to evaluate the effect of the Family Health Strategy (FHS) expansion on hospitalisations due to ambulatory care-sensitive conditions (ACSCs) and mortality in children under 5 years of age in the state of Pará, Brazilian Amazon. METHODS: A longitudinal analysis from 2008 to 2017 was conducted for data collected from the SUS's database (DATASUS) using panel regression methods to determine the association between the expansion FHS coverage, ACSC rate, under 5 mortality rate and child mortality rate in municipalities of the state of Pará. RESULTS: There was an expansion of 40% of the population coverage of the FHS, in the same period there were 347 468.55 hospitalisations due to ASCSs of children under 5 years of age in the public health network in the state of Pará, which represented a reduction of almost 28% (p value <0001), and significant reduction of almost 57.67% in government hospital expenditures with hospitalisations between 2008 and 2017. In this period, there was also a significant decrease in the mortality rate in children under 5 years of age. CONCLUSIONS: Our findings reinforce the importance of the public health protection for the child population and the positive impacts of FHS in the state of Pará, in the Brazilian Amazon. The government actions aimed at reducing regional health disparities and the effort to strengthen primary care can improve health indicators of children and be an important strategy to developing countries.

Cohort-profile: Household transmission of SARS-CoV-2 in a low-resource community in Rio de Janeiro, Brazil.

PURPOSE: To better understand the household transmission of SARS-COV-2 in a low-resource community in Rio de Janeiro during the COVID-19 pandemic (2020-2022). PARTICIPANTS: This is an open prospective cohort study of children ≤12 years old and their household contacts. During home visits over 24 months, we collected data on sociodemographic characteristics, behavioural data, clinical manifestations of SARS-CoV-2, vaccination status, SARS-CoV-2 (reverse transcription-polymerase chain reaction) RT-PCR and anti-S antibody tests. Among adults, the majority of participants were women (62%). FINDINGS TO DATE: We enrolled 845 families from May 2020 to May 2022. The median number of residents per household was four. The median household density, defined as the number of persons per room, was 0.95. The risk of SARS-CoV-2 occurrence was higher in households with a high number of persons per room. Children were not the principal source of SARS-CoV-2 infections in their households during the first wave of the pandemic. FUTURE PLANS: Future studies will investigate cellular and humoral immune responses to locally circulating SARS-CoV-2 variants, which is relevant for the design of vaccines, antivirals and monoclonal antibodies. We will also engage in outreach to encourage vaccination as a means of limiting the transmission of novel SARS-CoV-2 variants and other emerging pathogens.

Opportunities to catalyse improved healthcare access in pluralistic systems: a cross-sectional study in Haiti.

OBJECTIVE: To identify determinants of intended versus actual care-seeking behaviours in a pluralistic healthcare system that is reliant on both conventional and non-conventional providers and discover opportunities to catalyse improved healthcare access. DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: In Haiti 568 households (incorporating 2900 members) with children less than 5 years of age were randomly sampled geographically with stratifications for population density. These households identified the healthcare providers they frequented. Among 140 providers, 65 were located and enrolled. OUTCOME MEASURES: Household questionnaires with standardised cases (intentions) were compared with self-recall of health events (behaviours). The connectedness of households and their providers was determined by network analysis. RESULTS: Households reported 636 health events in the prior month. Households sought care for 35% (n=220) and treated with home remedies for 44% (n=277). The odds of seeking care increased 217% for severe events (adjusted OR (aOR)=3.17; 95% CI 1.99 to 5.05; p<0.001). The odds of seeking care from a conventional provider increased by 37% with increasing distance (aOR=1.37; 95% CI 1.06 to 1.79; p=0.016). Despite stating an intention to seek care from conventional providers, there was a lack of congruence in practice that favoured non-conventional providers (McNemar's χ2 test p<0.001). Care was sought from primary providers for 68% (n=150) of cases within a three-tiered network; 25% (n=38/150) were non-conventional. CONCLUSION: Addressing geographic barriers, possibly with technology solutions, should be prioritised to meet healthcare seeking intentions while developing approaches to connect non-conventional providers into healthcare networks when geographic barriers cannot be overcome.

Cross-sectional study on the awareness, susceptibility and use of heated tobacco products among adolescents in Guatemala City, Guatemala.

OBJECTIVES: Heated tobacco products (HTPs) are increasingly marketed worldwide, yet limited research on HTPs has been conducted in low and middle-income countries (LMICs) or among adolescents. Guatemala is one of the few LMICs where HTPs are available. This study examined prevalence and correlates of HTP awareness, susceptibility and use among adolescents in Guatemala. DESIGN, SETTING AND PARTICIPANTS: A cross-sectional survey on HTP awareness, susceptibility and use was conducted among 2870 students between the ages of 13 and 17 in private schools in Guatemala City, Guatemala. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was susceptibility to future use of HTP among school-aged current and never smokers in Guatemala. We also explored awareness and use of HTPs. Multivariate binomial regression models were used to explore associations between these outcomes and both sociodemographic factors and established smoking correlates. RESULTS: Of all students (n=2870), about half were aware of HTPs (52.4%) and susceptible to future or continued use (52.4%). Whereas 8.4% of students had tried HTPs in the lifetime (but not in the last month), only 2.9% used HTPs in the past month. Independent correlates of HTP susceptibility and ever-use included: use of other tobacco products (current smoking: adjusted OR (AOR)=10.53 and 6.63, respectively; current e-cigarette use: AOR=21.87 and 10.40, respectively), moderate alcohol consumption (AOR=1.49 and 1.19, respectively), marijuana use in the past 30 days (AOR=3.49 and 2.29, respectively) and having friends who use HTPs (AOR=1.83 and 7.28, respectively). CONCLUSIONS: Among this sample of adolescents in Guatemala City, where tobacco control is weak, the prevalence of HTP use was low but susceptibility to future use was high. Tobacco prevention and intervention strategies for cigarettes and e-cigarettes should now also include HTPs, which tend to be used by similar adolescent populations (ie, those who use other substances or are exposed to tobacco through family and friends).

Optimisation, validation and field applicability of a 13C-sucrose breath test to assess intestinal function in environmental enteropathy among children in resource poor settings: study protocol for a prospective study in Bangladesh, India, Kenya, Jamaica, Peru and Zambia.

INTRODUCTION: Environmental enteropathy (EE) is suspected to be a cause of growth faltering in children with sustained exposure to enteric pathogens, typically in resource-limited settings. A major hindrance to EE research is the lack of sensitive, non-invasive biomarkers. Current biomarkers measure intestinal permeability and inflammation, but not the functional capacity of the gut. Australian researchers have demonstrated proof of concept for an EE breath test based on using naturally 13C-enriched sucrose, derived from maize, to assay intestinal sucrase activity, a digestive enzyme that is impaired in villus blunting. Here, we describe a coordinated research project to optimise, validate and evaluate the usability of a breath test protocol based on highly enriched 13C-sucrose to quantify physiological dysfunction in EE in relevant target populations. METHODS AND ANALYSIS: We use the 13C-sucrose breath test (13C-SBT) to evaluate intestinal sucrase activity in two phases. First, an optimisation and validation phase will (1) confirm that a 13C-SBT using highly enriched sucrose tracers reports similar information to the naturally enriched 13C-SBT; (2) examine the dose-response relationship of the test to an intestinal sucrase inhibitor; (3) validate the 13C-SBT in paediatric coeliac disease (4) validate the highly enriched 13C-SBT against EE defined by biopsy in adults and (5) validate the 13C-SBT against EE defined by the urinary lactulose:rhamnose ratio (LR) among children in Peru. Second, a cross-sectional study will be conducted in six resource-limited countries (Bangladesh, India, Jamaica, Kenya, Peru and Zambia) to test the usability of the optimised 13C-SBT to assess EE among 600 children aged 12-15 months old. ETHICS AND DISSEMINATION: Ethical approval will be obtained from each participating study site. By working as a consortium, the test, if shown to be informative of EE, will demonstrate strong evidence for utility across diverse, low-income and middle-income country paediatric populations. TRIAL REGISTRATION NUMBER: NCT04109352; Pre-results.

Evidence for Better Lives Study: a comparative birth-cohort study on child exposure to violence and other adversities in eight low- and middle-income countries - foundational research (study protocol).

INTRODUCTION: Violence against children is a health, human rights and social problem affecting approximately half of the world's children. Its effects begin at prenatal stages with long-lasting impacts on later health and well-being. The Evidence for Better Lives Study (EBLS) aims to produce high-quality longitudinal data from cities in eight low- and middle-income countries-Ghana, Jamaica, Pakistan, the Philippines, Romania, South Africa, Sri Lanka and Vietnam-to support effective intervention to reduce violence against children. EBLS-Foundational Research (EBLS-FR) tests critical aspects of the planned EBLS, including participant recruitment and retention, data collection and analysis. Alongside epidemiological estimates of levels and predictors of exposure to violence and adversity during pregnancy, we plan to explore mechanisms that may link exposure to violence to mothers' biological stress markers and subjective well-being. METHODS AND ANALYSES: EBLS-FR is a short longitudinal study with a sample of 1200 pregnant women. Data are collected during the last trimester of pregnancy and 2 to 6 months after birth. The questionnaire for participating women has been translated into nine languages. Measures obtained from mothers will include, among others, mental and physical health, attitudes to corporal punishment, adverse childhood experiences, prenatal intimate partner violence, substance use and social/community support. Hair and dry blood spot samples are collected from the pregnant women to measure stress markers. To explore research participation among fathers, EBLS-FR is recruiting 300 fathers in the Philippines and Sri Lanka. ETHICS AND DISSEMINATION: The study received ethical approvals at all recruiting sites and universities in the project. Results will be disseminated through journal publications, conferences and seminar presentations involving local communities, health services and other stakeholders. Findings from this work will help to adjust the subsequent stages of the EBLS project.

Caribbean Consortium for Research in Environmental and Occupational Health (CCREOH) Cohort Study: influences of complex environmental exposures on maternal and child health in Suriname.

PURPOSE: The Caribbean Consortium for Research in Environmental and Occupational Health prospective environmental epidemiologic cohort study addresses the impact of chemical and non-chemical environmental exposures on mother/child dyads in Suriname. The study determines associations between levels of environmental elements and toxicants in pregnant women, and birth outcomes and neurodevelopment in their children. PARTICIPANTS: Pregnant women (N=1143) were enrolled from December 2016 to July 2019 from three regions of Suriname: Paramaribo (N=738), Nickerie (N=204) and the tropical rainforest interior (N=201). Infants (N=992) were enrolled at birth. Follow-up will take place until children are 48 months old. FINDINGS TO DATE: Biospecimens and questionnaire data on physiological and psychosocial health in pregnant women have been analysed. 39.1% had hair mercury (Hg) levels exceeding values considered safe by international standards. Median hair Hg concentrations in women from Paramaribo (N=522) were 0.64 µg/g hair (IQRs 0.36-1.09; range 0.00-7.12), from Nickerie (N=176) 0.73 µg/g (IQR 0.45-1.05; range 0.00-5.79) and the interior (N=178) 3.48 µg/g (IQR 1.92-7.39; range 0.38-18.20). 96.1% of women ate fish, respective consumption of the three most consumed carnivorous species, Hoplias aimara, Serrasalmus rhombeus and Cichla ocellaris, known to have high Hg levels, was 44.4%, 19.3% and 26.3%, respectively, and was greater among the interior subcohort. 89% frequently consumed the vegetable tannia, samples of which showed presence of worldwide banned pesticides. 24.9% of pregnant women had Edinburgh Depression Scale scores indicative of probable depression. FUTURE PLANS: Fish consumption advisories are in development, especially relevant to interior women for whom fish consumption is likely to be the primary source of Hg exposure. Effects of potentially beneficial neuroprotective factors in fish that may counter neurotoxic effects of Hg are being examined. A pesticide literacy assessment in pregnant women is in progress. Neurodevelopmental assessments and telomere length measurements of the children to evaluate long-term effects of prenatal exposures to toxicant mixtures are ongoing.

Physical activity patterns in a representative sample of adolescents from the largest city in Latin America: a cross-sectional study in Sao Paulo.

OBJECTIVES: We examined the patterns of total and domain-specific physical activity (PA) by sex, socioeconomic status and maternal education level in adolescents from Sao Paulo city, Brazil. DESIGN: Cross-sectional study. PARTICIPANTS: We included a representative sample of 2682 (52.2% boys) adolescents aged 14-15 years from public and private schools in Sao Paulo, 2017. Socioeconomic status was assessed using a wealth index derived from principal component analysis. Descriptive analyses evaluated differences in total and domain-specific PA by sex, socioeconomic status and maternal education level. OUTCOME MEASURES: We collected data on the frequency and duration that adolescents spent in each PA domain (active transportation, leisure PA and physical education classes) through a self-report questionnaire. RESULTS: On average, adolescents spent 197.7 min/week (95% CI 190.6-204.8) in total PA. The proportion of adolescents achieving at least 60 min/day (≥420 min/week) was 12.7% (95% CI 11.4-14.1), with a higher prevalence in boys (18.3%) and in those with higher socioeconomic status (17.4%). Similar patterns were observed for leisure PA and physical education classes. Active transportation was higher in girls (46.0 min/week; 95% CI 42.6-49.6) than in boys (43.4 min/week, 95% CI 39.9-46.6). Boys and adolescents with higher socioeconomic status and higher maternal education level had higher levels of total PA. CONCLUSIONS: We found a variation in patterns of total and domain-specific PA by sex, socioeconomic status and maternal education level in adolescents from Sao Paulo. Initiatives for promoting PA in adolescents should take these findings into account.

Designing a comprehensive behaviour change intervention to promote and monitor exclusive use of liquefied petroleum gas stoves for the Household Air Pollution Intervention Network (HAPIN) trial.

INTRODUCTION: Increasing use of cleaner fuels, such as liquefied petroleum gas (LPG), and abandonment of solid fuels is key to reducing household air pollution and realising potential health improvements in low-income countries. However, achieving exclusive LPG use in households unaccustomed to this type of fuel, used in combination with a new stove technology, requires substantial behaviour change. We conducted theory-grounded formative research to identify contextual factors influencing cooking fuel choice to guide the development of behavioural strategies for the Household Air Pollution Intervention Network (HAPIN) trial. The HAPIN trial will assess the impact of exclusive LPG use on air pollution exposure and health of pregnant women, older adult women, and infants under 1 year of age in Guatemala, India, Peru, and Rwanda. METHODS: Using the Capability, Opportunity, Motivation-Behaviour (COM-B) framework and Behaviour Change Wheel (BCW) to guide formative research, we conducted in-depth interviews, focus group discussions, observations, key informant interviews and pilot studies to identify key influencers of cooking behaviours in the four countries. We used these findings to develop behavioural strategies likely to achieve exclusive LPG use in the HAPIN trial. RESULTS: We identified nine potential influencers of exclusive LPG use, including perceived disadvantages of solid fuels, family preferences, cookware, traditional foods, non-food-related cooking, heating needs, LPG awareness, safety and cost and availability of fuel. Mapping formative findings onto the theoretical frameworks, behavioural strategies for achieving exclusive LPG use in each research site included free fuel deliveries, locally acceptable stoves and equipment, hands-on training and printed materials and videos emphasising relevant messages. In the HAPIN trial, we will monitor and reinforce exclusive LPG use through temperature data loggers, LPG fuel delivery tracking, in-home observations and behavioural reinforcement visits. CONCLUSION: Our formative research and behavioural strategies can inform the development, implementation, monitoring and evaluation of theory-informed strategies to promote exclusive LPG use in future stove programmes and research studies. TRIAL REGISTRATION NUMBER: NCT02944682, Pre-results.

Effect of an innovative behavioural change strategy and small-quantity lipid-based nutrient supplements on stunting and obesity in children in Baja Verapaz, Guatemala: protocol for a randomised control trial.

INTRODUCTION: In Latin America, a rapid increase in obesity alongside persistent malnutrition has resulted in a double burden of disease that affects the most vulnerable segments of the population. Infant and young child feeding practices are important factors that affect both sides of the growth curve. Interventions such as behavioural change strategies and home fortification using products like small-quantity lipid-based nutrient supplements (SQ-LNS) have the potential to reduce the presence of both these conditions, especially if they are implemented during the first 1000 days of life. This paper details the protocol for Sustained Programme for Improving Nutrition (SPOON), an innovative strategy to prevent stunting and reduce risk for obesity in children under 24 months old in high-poverty areas in Baja Verapaz, Guatemala. METHODS AND ANALYSIS: SPOON Guatemala is a three-arm randomised control trial: treatment group 1 will receive the SPOON behavioural change strategy and SQ-LNS, treatment group 2 will receive the SPOON behavioural change strategy and micronutrient powders; the control group will receive the standard of care provided by the Ministry of Health, which includes micronutrient powders. A modified formula of SQ-LNS has been especially developed for this trial. A total of 76 communities are included in the study and 1628 households with a pregnant woman in the third trimester or a child under 4.5 months were recruited at baseline. Baseline data were collected between September and November 2018. Follow-up data will be collected 2 years after the start of the intervention. The primary outcomes of interest are related to mothers' infant feeding knowledge and practice, and indicators of children's nutritional status and growth including height, weight, weight gain rate and prevalence of stunting, overweight, obesity and anaemia. After follow-up data have been collected, differences of simple means and regression models including covariates such as child's age and sex, characteristics of the primary caregiver and household socioeconomic indicators will be estimated. Heterogeneous effects will also be estimated within subgroups of age at exposure, sex, caregiver characteristics and household socioeconomic status. ETHICS AND DISSEMINATION: This study was approved by the National Health Ethics Committee of the Ministry of Health of Guatemala (resolution 10-2018). Informed consent was obtained from all mothers and caregivers prior to enrolment in the programme. Results will be submitted to a peer-reviewed medical or public health journal, and disseminated internally at the Inter-American Development Bank, with the Government and Stakeholders in Guatemala and through international conferences and seminars. TRIAL REGISTRATION NUMBER: NCT03399617.

Cohort profile: Center for Research on Early Childhood Exposure and Development in Puerto Rico.

PURPOSE: Puerto Rican children experience high rates of asthma and obesity. Further, infants born in Puerto Rico are more at risk for being born prematurely compared with infants on the mainland USA. Environmental exposures from multiple sources during critical periods of child development, potentially modified by psychosocial factors, may contribute to these adverse health outcomes. To date, most studies investigating the health effects of environmental factors on infant and child health have focused on single or individual exposures. PARTICIPANTS: Infants currently in gestation whose mother is enrolled in Puerto Rico Testsite for Exploring Contamination Threats (PROTECT) cohort, and infants and children already born to mothers who participated in the PROTECT study. FINDINGS TO DATE: Data collection and processing remains ongoing. Demographic data have been collected on 437 mother-child pairs. Birth outcomes are available for 420 infants, neurodevelopmental outcomes have been collected on 319 children. Concentrations of parabens and phenols in maternal spot urine samples have been measured from 386 mothers. Center for Research on Early Childhood Exposure and Development mothers have significantly higher urinary concentrations of dichlorophenols, triclosan and triclocarban, but lower levels of several parabens compared with reference values from a similar population drawn from the National Health and Nutrition Examination Survey. FUTURE PLANS: Data will continue to be collected through recruitment of new births with a target of 600 children. Seven scheduled follow-up visits with existing and new participants are planned. Further, our research team continues to work with healthcare providers, paediatricians and early intervention providers to support parent's ability to access early intervention services for participants.