The efficacy of manipulatives versus fingers in supporting young children's addition skills.

Recent empirical investigations have revealed that finger counting is a strategy associated with good arithmetic performance in young children. Fingers could have a special status during development because they operate as external support that provide sensory-motor and kinesthetic affordances in addition to visual input. However, it was unknown whether fingers are more helpful than manipulatives such as tokens during arithmetic problem solving. To address this question, we conducted a study with 93 Vietnamese children (48 girls) aged 4 and 5 years (mean = 58 months, range = 47-63) with high arithmetic and counting skills from families with relatively high socioeconomic status. Their behaviors were observed as they solved addition problems with manipulatives at their disposal. We found that children spontaneously used both manipulatives and fingers to solve the problems. Crucially, their performance was not higher when fingers rather than manipulatives were used (i.e., 70% vs. 81% correct answers, respectively). Therefore, at the beginning of learning, it is possible that, at least for children with high numerical skills, fingers are not the only gateway to efficient arithmetic development and manipulatives might also lead to proficient arithmetic.

Health-Related quality of life and DNA Methylation-Based aging biomarkers among survivors of childhood cancer.

BACKGROUND: Childhood cancer survivors are at high risk for morbidity and mortality and poor patient-reported outcomes, typically health-related-quality-of-life (HRQOL). However, associations between DNA methylation (DNAm)-based aging biomarkers and HRQOL have not been evaluated. METHODS: DNAm was generated with Infinium EPIC BeadChip on blood-derived DNA (median[range] for age at blood draw = 34.5[18.5-66.6] years) and HRQOL was assessed with age at survey (32.3[18.4-64.5] years) from 2,206 survivors in the St Jude Lifetime Cohort. DNAm-based aging biomarkers, including epigenetic age using multiple clocks (eg, GrimAge) and others (eg, DNAmB2M beta-2-microglobulin; DNAmADM: adrenomedullin), were derived from the DNAm Age Calculator (https://dnamage.genetics.ucla.edu). HRQOL was assessed using the Medical Outcomes Study 36-Item Short-Form Health Survey to capture eight domains, and physical and mental component summaries (PCS and MCS). General linear models evaluated associations between HRQOL and epigenetic age acceleration (EAA, eg, EAA_GrimAge) or other age-adjusted DNAm-based biomarkers (eg, ageadj_DNAmB2M) after adjusting for age at blood draw, sex, cancer treatments, and DNAm-based surrogate for smoking pack-years. All P values were 2-sided. RESULTS: Worse HRQOL was associated with greater EAA_GrimAge (PCS ß[95%CI]=-0.18[-0.251,-0.11] years, P = 1.85 × 10-5; and four individual HRQOL domains), followed by ageadj_DNAmB2M (PCS: -0.08[-0.124,-0.037], P = .003; and three individual HRQOL domains), and ageadj_DNAmADM (PCS: -0.082[-0.125,-0.039], P = .002; and two HRQOL domains). EAA_Hannum (Hannum clock) was not associated with any HRQOL. CONCLUSIONS: Overall and domain-specific measures of HRQOL are associated with DNAm measures of biological aging. Future longitudinal studies should test biological aging as a potential mechanism underlying the association between poor HRQOL and increased risk of clinically assessed adverse health outcomes.

Cancer germline predisposing variants and late mortality from subsequent malignant neoplasms among long-term childhood cancer survivors: a report from the St Jude Lifetime Cohort and the Childhood Cancer Survivor Study.

BACKGROUND: Carriers of cancer predisposing variants are at an increased risk of developing subsequent malignant neoplasms among those who have survived childhood cancer. We aimed to investigate whether cancer predisposing variants contribute to the risk of subsequent malignant neoplasm-related late mortality (5 years or more after diagnosis). METHODS: In this analysis, data were included from two retrospective cohort studies, St Jude Lifetime Cohort (SJLIFE) and the Childhood Cancer Survivor Study (CCSS), with prospective follow-up of patients who were alive for at least 5 years after diagnosis with childhood cancer (ie, long-term childhood cancer survivors) with corresponding germline whole genome or whole exome sequencing data. Cancer predisposing variants affecting 60 genes associated with well-established autosomal-dominant cancer-predisposition syndromes were characterised. Subsequent malignant neoplasms were graded using the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) version 4.03 with modifications. Cause-specific late mortality was based on linkage with the US National Death Index and systematic cohort follow up. Fine-Gray subdistribution hazard models were used to estimate subsequent malignant neoplasm-related late mortality starting from the first biospecimen collection, treating non-subsequent malignant neoplasm-related deaths as a competing risk, adjusting for genetic ancestry, sex, age at diagnosis, and cancer treatment exposures. SJLIFE (NCT00760656) and CCSS (NCT01120353) are registered with ClinicalTrials.gov. FINDINGS: 12 469 (6172 male and 6297 female) participants were included, 4402 from the SJLIFE cohort (median follow-up time since collection of the first biospecimen 7·4 years [IQR 3·1-9·4]) and 8067 from the CCSS cohort (median follow-up time since collection of the first biospecimen 12·6 years [2·2-16·6]). 641 (5·1%) of 12 469 participants carried cancer predisposing variants (294 [6·7%] in the SJLIFE cohort and 347 [4·3%] in the CCSS cohort), which were significantly associated with an increased severity of subsequent malignant neoplasms (CTCAE grade ≥4 vs grade <4: odds ratio 2·15, 95% CI 1·18-4·19, p=0·0085). 263 (2·1%) subsequent malignant neoplasm-related deaths (44 [1·0%] in the SJLIFE cohort; and 219 [2·7%] in the CCSS cohort) and 426 (3·4%) other-cause deaths (103 [2·3%] in SJLIFE; and 323 [4·0%] in CCSS) occurred. Cumulative subsequent malignant neoplasm-related mortality at 10 years after the first biospecimen collection in carriers of cancer predisposing variants was 3·7% (95% CI 1·2-8·5) in SJLIFE and 6·9% (4·1-10·7) in CCSS versus 1·5% (1·0-2·1) in SJLIFE and 2·1% (1·7-2·5) in CCSS in non-carriers. Carrying a cancer predisposing variant was associated with an increased risk of subsequent malignant neoplasm-related mortality (SJLIFE: subdistribution hazard ratio 3·40 [95% CI 1·37-8·43]; p=0·0082; CCSS: 3·58 [2·27-5·63]; p<0·0001). INTERPRETATION: Identifying participants at increased risk of subsequent malignant neoplasms via genetic counselling and clinical genetic testing for cancer predisposing variants and implementing early personalised cancer surveillance and prevention strategies might reduce the substantial subsequent malignant neoplasm-related mortality burden. FUNDING: American Lebanese Syrian Associated Charities and US National Institutes of Health.

Changing environmental conditions have altered the feeding ecology of two keystone Arctic marine predators.

Environmental change in the Arctic has impacted the composition and structure of marine food webs. Tracking feeding ecology changes of culturally-valued Arctic char (Salvelinus alpinus) and ringed seals (Pusa hispida) can provide an indication of the ecological significance of climate change in a vulnerable region. We characterized how changes in sea ice conditions, sea surface temperature (SST), and primary productivity affected the feeding ecology of these two keystone species over a 13- and 18-year period, respectively, in northern Labrador, Canada. Arctic char fed consistently on pelagic resources (δ13C) but shifted over time to feeding at a higher trophic level (δ15N) and on more marine/offshore resources (δ34S), which correlated with decreases in chlorophyll a concentration. A reduction in Arctic char condition factor and lipid content was associated with higher trophic position. Ringed seals also shifted to feeding at a higher trophic level, but on more pelagic resources, which was associated with lower SST and higher chlorophyll a concentrations. Years with abnormally high SSTs and reduced sea ice concentrations resulted in large isotopic niche sizes for both species, suggesting abrupt change can result in more variable feeding. Changes in abundance and distribution of species long valued by the Inuit of Labrador could diminish food security.

Sediment Spatial Distribution and Quality Assessment of Metals in Chinook Salmon and Resident Killer Whale Marine Habitat in British Columbia, Canada.

At-risk resident killer whale (Orcinus orca) populations of the northeastern Pacific, Canada, and their main prey, Chinook Salmon (Oncorhynchus tshawytscha), are exposed to a variety of contaminants including chemical elements from both natural and anthropogenic sources, which may be constraining their recovery. Concentrations of 36 chemical elements in subtidal surface sediments (1-435 m depth) collected from 98 sites along the British Columbia coast were used to characterize coast-wide patterns, and a subset of metals (mercury (Hg), cadmium (Cd), arsenic (As), nickel (Ni), copper (Cu), and lead (Pb)) were selected to assess Chinook Salmon and resident killer whale marine habitat quality. Principal component analysis (PCA) showed a dominance of Hg, antimony (Sb), Pb, Cu, and zinc (Zn) for Prince Rupert Harbour, Victoria Harbour, and Burrard Inlet, suggesting local sources. Based on the PCA, geochemical properties such as total organic carbon (TOC), acid volatile sulfide (AVS), and pH explained the spatial distribution of all elements in sediment (p < 0.001). Mercury, Cd, As, Ni, Cu, and Pb hotspots were identified along the coast of Vancouver Island, the central and north coast, in the Strait of Georgia, and Haida Gwaii. Bischof Island of Haida Gwaii and Ardmillan Bay on the central coast were most contaminated and enriched by Cd, determined by geoaccumulation index (Igeo) and enrichment factor (EF), respectively. Marine habitat quality was assessed by comparing metal concentrations to Canadian Sediment Quality Guidelines (SQGs). Chinook Salmon populations may be indirectly affected by metal toxicity (As > Cd and Cu > Ni > Hg > Pb) to lower trophic level prey species. Toxicity related impacts to benthic organisms as a result of exposure to elevated Cd and As concentrations in Northern Resident Killer Whale critical habitat and to Hg, Cd, As, Ni, Cu, and Pb concentrations in Southern Resident Killer Whale critical habitat may indirectly pose a threat to resident killer whale populations, highlighting a need for management actions to reduce risks associated with these metals.

A Rare Case of Traumatic Pericardio-Diaphragmatic Injury Following a Road Traffic Accident.

Traumatic pericardi0-diaphragmatic rupture is very rare. It occurs due to high-velocity blunt trauma or penetrating injury to the abdomen or chest, which requires emergency intervention. The severity of injury varies, and it is very difficult to diagnose. Diaphragmatic ruptures are more common on the left side. Pericardial tears and diaphragmatic rupture are rare and often unrecognized in the acute phase. Computed Tomography is essential to diagnose and requires emergency surgery to avoid dreaded complications. A twenty-eight-year-old female reported to the emergency department with blunt injury to the abdomen following a road traffic accident. She was found to have diaphragmatic and a pericardial rupture with herniation of the bowel into the thoracic cavity. Emergency surgical repair was done. We report this case, as it is very rare to have a pericardial involvement along with diaphragmatic rupture, and to elaborate on the technical aspect of the surgical repair.

Epigenetic Age in Peripheral Blood Among Children, Adolescent, and Adult Survivors of Childhood Cancer.

Importance: Certain cancer therapies are risk factors for epigenetic age acceleration (EAA) among survivors of childhood cancer, and EAA is associated with chronic health conditions (CHCs). However, small numbers of younger survivors (aged <20 years) previously evaluated have limited the ability to calculate EAA among this age group. Objective: To evaluate the change rate of epigenetic age (EA) and EAA in younger compared with older survivors and the possible association of EAA with early-onset obesity (aged <20 years), severity/burden of CHCs, and late mortality (>5 years from cancer diagnosis). Design, Setting, and Participants: Study participants were from the St Jude Lifetime Cohort, initiated in 2007 with ongoing follow-up. The present study was conducted from April 17, 2022, to March 23, 2023. Survivors in this cohort of European ancestry with DNA methylation data were included. Cross-sectional annual changes in EA and EAA were compared across 5 different chronologic age groups: age 0 to 9 (children), 10 to 19 (adolescents), 20 to 34 (younger adults), 35 to 49 (middle-aged adults), and greater than or equal to 50 (older adults) years. Logistic regression evaluated the association between EAA and early-onset obesity or severity/burden of CHCs. Cox proportional hazards regression assessed the association between EAA and late mortality. Main Outcomes and Measures: Early-onset obesity, severity/burden of CHCs (graded using the Common Terminology Criteria for Adverse Events (grade 1, mild; 2, moderate; 3, severe/disabling; 4, life-threatening) and were combined into high vs low severity/burden based on frequency and grade), and late mortality were the outcomes based on follow-up until April 2020. Expanded DNA methylation profiling increased the number of survivors younger than 20 years (n = 690). Epigenetic age was calculated primarily using the Levine clock, and EAA was derived from least squares regression of EA against chronologic age and was standardized to a z score (Levine EEA). Results: Among 2846 participants (median age, 30.3 [IQR, 9.3-41.5] years; 53% males), the cross-sectional annual change in EA_Levine was higher in children (1.63 years) and adolescents (1.14 years), and the adjusted least-squares mean of Levine EEA was lower in children (-0.22 years) and older adults (-1.70 years). Each 1-SD increase in Levine EEA was associated with increased risk of developing early-onset obesity (odds ratio [OR], 1.46; 95% CI, 1.19-1.78), high severity/burden of CHCs (OR, 1.13; 95% CI, 1.03-1.24), and late mortality (hazard ratio, 1.75; 95% CI, 1.35-2.26). Conclusions and Relevance: The findings of this study suggest that EAA measured in children and adolescent survivors of childhood cancer is associated with early-onset obesity, severity/burden of all CHCs, and late mortality. Evaluating EAA may help identify survivors of childhood cancer at increased risk for early-onset obesity, morbidity in general, and mortality.

Distinct DNA methylation signatures associated with blood lipids as exposures or outcomes among survivors of childhood cancer: a report from the St. Jude lifetime cohort.

BACKGROUND: DNA methylation (DNAm) plays an important role in lipid metabolism, however, no epigenome-wide association study (EWAS) of lipid levels has been conducted among childhood cancer survivors. Here, we performed EWAS analysis with longitudinally collected blood lipid data from survivors in the St. Jude lifetime cohort study. METHODS: Among 2052 childhood cancer survivors of European ancestry (EA) and 370 survivors of African ancestry (AA), four types of blood lipids, including high-density lipoprotein (HDL), low-density lipoprotein (LDL), total cholesterol (TC), and triglycerides (TG), were measured during follow-up beyond 5-years from childhood cancer diagnosis. For the exposure EWAS (i.e., lipids measured before blood draw for DNAm), the DNAm level was an outcome variable and each of the blood lipid level was an exposure variable; vice versa for the outcome EWAS (i.e., lipids measured after blood draw for DNAm). RESULTS: Among EA survivors, we identified 43 lipid-associated CpGs in the HDL (n = 7), TC (n = 3), and TG (n = 33) exposure EWAS, and 106 lipid-associated CpGs in the HDL (n = 5), LDL (n = 3), TC (n = 4), and TG (n = 94) outcome EWAS. Among AA survivors, we identified 15 lipid-associated CpGs in TG exposure (n = 6), HDL (n = 1), LDL (n = 1), TG (n = 5) and TC (n = 2) outcome EWAS with epigenome-wide significance (P < 9 × 10-8). There were no overlapping lipids-associated CpGs between exposure and outcome EWAS among EA and AA survivors, suggesting that the DNAm changes of different CpGs could be the cause or consequence of blood lipid levels. In the meta-EWAS, 12 additional CpGs reached epigenome-wide significance. Notably, 32 out of 74 lipid-associated CpGs showed substantial heterogeneity (Phet < 0.1 or I2 > 70%) between EA and AA survivors, highlighting differences in DNAm markers of blood lipids between populations with diverse genetic ancestry. Ten lipid-associated CpGs were cis-expression quantitative trait methylation with their DNAm levels associated with the expression of corresponding genes, out of which seven were negatively associated. CONCLUSIONS: We identified distinct signatures of DNAm for blood lipids as exposures or outcomes and between EA and AA survivors, revealing additional genes involved in lipid metabolism and potential novel targets for controlling blood lipids in childhood cancer survivors.

Microplastics distribution in sediment and mussels along the British Columbia Coast, Canada.

Microplastics (MPs) were characterized in surficial marine sediment (n = 36) and mussel (n = 29) samples collected along the British Columbia (BC) coast, Canada, using visual identification and Fourier Transform Infrared Spectrometry. MPs counts averaged 32.6 ± 5.3 particles per kg in sediment and 0.38 ± 0.04 particles per individual mussel (0.24 ± 0.04 /g of tissue). Victoria Harbour and the North Coast (Prince Rupert area) were MP hotspots, likely resulting from a combination of local sources and oceanographic conditions. Microfibers <1000 µm dominated the pattern in both matrices (61.1 % in sediment; 65.4 % mussels) highlighting the suspected role of textiles in the widespread distribution of MPs in the marine environment. Overall, polyester was dominant in sediment and mussels (54.1 % and 63.5 %, respectively), followed by polyethylene (16.2 % and 11.5 %, respectively). This is the first report of MPs in sediment and mussels along the coast of BC using standardized methods.

A Multi-Matrix Metabolomic Approach in Ringed Seals and Beluga Whales to Evaluate Contaminant and Climate-Related Stressors.

As a high trophic-level species, ringed seals (Pusa hispida) and beluga whales (Delphinapterus leucas) are particularly vulnerable to elevated concentrations of biomagnifying contaminants, such as polychlorinated biphenyls (PCBs), polybrominated diphenyl ethers (PBDEs) and mercury (Hg). These species also face climate-change-related impacts which are leading to alterations in their diet and associated contaminant exposure. The metabolomic profile of marine mammal tissues and how it changes to environmental stressors is poorly understood. This study characterizes the profiles of 235 metabolites across plasma, liver, and inner and outer blubber in adult ringed seals and beluga whales and assesses how these profiles change as a consequence of contaminants and dietary changes. In both species, inner and outer blubber were characterized by a greater proportion of lipid classes, whereas the dominant metabolites in liver and plasma were amino acids, carbohydrates, biogenic amines and lysophosphatidylcholines. Several metabolite profiles in ringed seal plasma correlated with δ13C, while metabolite profiles in blubber were affected by hexabromobenzene in ringed seals and PBDEs and Hg in belugas. This study provides insight into inter-matrix similarities and differences across tissues and suggests that plasma and liver are more suitable for studying changes in diet, whereas liver and blubber are more suitable for studying the impacts of contaminants.

A theory-based behavioural change communication intervention to decrease the provision of water to infants under 6 months of age in the Republic of Guinea.

OBJECTIVE: In many countries, the provision of water in the early months of a baby's life jeopardises exclusive breast-feeding (EBF). Using a behavioural theory, this study assessed the impact of a behaviour change intervention on mothers' intention to act and, in turn, on the water provision in addition to breast milk to their infants under 6 months of age (IU6M) in two regions of Guinea. DESIGN: A quasi-experimental design. Data on individual and environmental factors of the theoretical framework, sociodemographic and outcomes were collected using validated questionnaires before and after the intervention. The outcomes examined were the intention to provide water to IU6M, the provision of water and EBF. Path analyses were performed to investigate pathways by which psychosocial and environmental factors influenced the water provision in addition to breast milk. SETTING: Four health centres were assigned randomly to each study's arm (one control/CG and one intervention group/IG per region). PARTICIPANTS: The sample included 300 mothers of IU6M: 150 per group. RESULTS: In IG, the proportion of mothers providing water decreased from 61 % to 29 % before and after the intervention (P < 0·001), while no difference was observed in CG (P = 0·097). The EBF rate increased in IG (from 24·0 % to 53·8 %, P < 0·001) as opposed to CG (36·7 % to 45·9 %, P = 0·107). An association (P < 0·001) between the intention and the behaviour was observed in both groups. CONCLUSIONS: An intervention developed using a sound framework reduces the provision of water among IU6M and improves EBF.

Hepatic retinoic acid receptor alpha mediates all-trans retinoic acid's effect on diet-induced hepatosteatosis.

All-trans retinoic acid (AtRA) is an active metabolite of vitamin A that influences many biological processes in development, differentiation, and metabolism. AtRA functions through activation of retinoid acid receptors (RARs). AtRA is shown to ameliorate hepatic steatosis, but the underlying mechanism is not well understood. In this study, we investigated the role of hepatocyte RAR alpha (RARα) in mediating the effect of AtRA on hepatosteatosis in mice. Hepatocyte-specific Rarα-/- (L-Rarα-/- ) mice and their control mice were fed a chow diet, high-fat diet (HFD), or a high-fat/cholesterol/fructose (HFCF) diet. Some of the mice were also treated with AtRA. Loss of hepatocyte RARα-induced hepatosteatosis in chow-fed aged mice and HFD-fed mice. AtRA prevented and reversed HFCF diet-induced obesity and hepatosteatosis in the control mice but not in L-Rarα-/- mice. Furthermore, AtRA reduced hepatocyte fatty acid uptake and lipid droplet formation, dependent on hepatocyte RARα. Our data suggest that hepatocyte RARα plays an important role in preventing hepatosteatosis and mediates AtRA's effects on diet-induced hepatosteatosis.

Characterization and Interpolation of Sediment Polychlorinated Biphenyls and Polybrominated Diphenyl Ethers in Resident Killer Whale Habitat along the Coast of British Columbia, Canada.

The northeastern Pacific northern and southern resident killer whale (Orcinus orca) populations are listed as threatened and endangered in Canada, respectively, with persistent, bioaccumulative contaminants, such as polychlorinated biphenyls (PCBs) and polybrominated diphenyl ethers (PBDEs), posing threats to their recovery. Concentrations of PCBs and PBDEs in subtidal surface sediments collected from 97 sites along the British Columbia (BC) coast were used to identify their distribution and profiles, and to assess killer whale habitat quality. Victoria Harbour (VH3(site ID: 1) ) sediments exhibited the highest PCB and PBDE concentrations. For PCBs, PCB-138 was found at the highest concentration, followed by PCB-153, PCB-110, PCB-149, PCB-101, and PCB-118. For PBDEs, individual congeners were ranked as follows: BDE-209 > BDE-207 > BDE-206 > BDE-208 > BDE-47 > BDE-99. Principal component analyses (PCA) illustrated the variations in contaminant profiles, with PC1 for PCBs and PBDEs correlated with the octanol-water partition coefficient (log KOW , p < 0.003). Based on the PCA, sediment particle size, total organic carbon (TOC), and water depth at collection were other factors associated with the distribution of PBDEs, while PCB profiles were associated with TOC. Total PCB and PBDE concentrations at 100% and 34% of the sites, respectively, exceeded the recently adopted British Columbia's Ministry of Environment and Climate Change Strategy Working Sediment Quality Guidelines (PCBs 3.7 pg/g dry wt and PBDEs 1000 pg/g dry wt), considered protective of killer whales. Our findings suggest that the legacy of banned PCBs and PBDEs has the potential to constrain the recovery of killer whales as a result of their mobilization from sediments and consequent uptake by marine food webs. Environ Toxicol Chem 2022;41:2139-2151. © 2022 SETAC.

Acceptance and challenges of the introduction of the routine community-based vitamin A supplementation strategy: the case of Burkina Faso.

OBJECTIVES: With the phase-out of the polio campaigns, Burkina Faso has developed a new strategy for routine community-based vitamin A supplementation (VAS) by institutionalising community-based health workers (CBHW) to sustain the gain of two decades of successful programming. Formative research was conducted soon after the strategy was introduced to solicit feedback on the acceptability of the new approach by the implementing actors while identifying the main implementation challenges for improving its effectiveness and sustainability. DESIGN: This qualitative study was conducted in 2018 through (i) document review, (ii) individual interviews with key informants at the central, regional and district levels, and (iii) focus groups with CBHW and caregivers. SETTING: Data collection was carried out at six levels of sites covering the entire country and selected based on VAS coverage rates with the community routine. A total of six health districts were selected. PARTICIPANTS: We conducted 46 individual interviews with health workers and 20 focus groups with 59 CBHW and 108 caregivers. RESULTS: The study showed good acceptability of the strategy by all stakeholders. In the first 2 years of implementation, the national coverage of VAS was maintained at a high level (above 90 %) and there was a reduction in operational costs. The main challenges included delayed CBHW remuneration and weak communication and supervision. CONCLUSIONS: The acceptability of the community-based routine VAS was good and was perceived to have a high potential for sustainability. Addressing identified challenges will allow us to better manage the expectations of community stakeholders and maintain the initial results.

A tool to assess underlying factors to water provision among Guinean children.

In many countries, water is provided to children under 6 months of age (CU6M) in addition to breast milk (BM), hence increasing the risk of child mortality and morbidity. Factors related to this practice have not been thoroughly investigated either a tool to assess them. Based on the extended theory of planned behaviour (eTPB), we aim to develop and validate a questionnaire to assess psychosocial and environmental factors that may contribute/limit the water provision in addition to BM by mothers of CU6M in the Republic of Guinea. A three-step process was used. Ten focus group discussions (FGDs) were held to identify salient beliefs related to each of the four constructs of the eTPB. Data from FGDs were used to develop a questionnaire composed of 88 items administered to 428 mothers. Exploratory factor analyses were conducted to identify latent factors for each construct. A shorter version of the questionnaire was administered to another sample of 300 mothers. Confirmatory factor analyses (CFAs) were performed. Hancock and Mueller's H reliability indices were computed on final models to assess the tool's validity and reliability. The final questionnaire included 57 items. For all four final models, most criteria for fit indices of CFA were generally met. Reliability coefficients were all equal to or above 0.90 for each construct. This research offers a tool that could be used to investigate determinants of water provision besides BM among mothers of CU6M. Further validation in other contexts is warranted.

Levels and trends of adolescent marriage and maternity in West and Central Africa, 1986-2017.

BACKGROUND: The world has made considerable progress in the reduction of adolescent maternity and early marriage. However, this progress has been uneven, with many countries finding themselves far from achieving the Sustainable Development Goals in this dimension. We assessed levels and trends over time in adolescent marriage and maternity prevalence within the West and Central African region as well as their correlation with select macro-level indicators for income and social institutions. METHODS: We estimated country-specific prevalence rates using survey data (pooled cross-sectional) conducted between 1986 and 2017. The pooled sample provides information on 262 721 adolescent girls between the ages of 15 and 19. We assessed the relative country-level trends by comparing prevalence rates from the first and latest available survey in each country. We further analyzed regional trends by country income group (low- and middle-income) and examined the association of prevalence rates with measurements of gender discrimination and social institutions at the country-level. Estimations were conducted using survey weights and country-specific weights for population shares in the pooled sample. RESULTS: Prevalence of adolescent maternity declined from 30.1 percent (95% confidence interval (CI) = 29.6%-32.2%) in the 1990s, to 28.7 percent (95% CI = 27.9%-29.6%) in the 2000s and 26.2 percent (95% CI = 25.4%-27.1%) in the 2010s. Adolescent marriage rates decreased from 37.3 percent (95% CI = 35.5%-39.1%) in the 1990s to 27.5 percent (95% CI = 26.5%-28.6%) in the 2000s, and to 24.9 percent (95% CI = 24.1%-25.7%) in the 2010s. Between 1986 and 2017, adolescent marriage decreased in all countries except for the Central African Republic (with a rise from 39% to 55%) and Niger (56% to 61%). The prevalence of adolescent maternity decreased in all but three countries: Congo, Dem. Rep. (25% to 37%), Niger (36% to 40%), and the Central African Republic (36% to 49%). When grouped by income level, the prevalence was 8 percentage points higher in low-income countries than in middle-income countries in both outcomes. We did not establish any statisticly significant association between adolescent marriage and maternity with country-level measures of discrimination against women. However, we found evidence of an association between specific legal measures of protection against early marriage and lower prevalence rates for both early marriage and maternity. CONCLUSIONS: Despite considerable progress in the reduction of adolescent maternity and marriage over the last 30 years, current levels of both indicators remain overall high in the WCA region, with high heterogeneity across individual countries. Countries with higher income level and higher standard in legal protection of young girls perform consistently better on both indicators. The prevalence rates of adolescent marriage and maternity reversed over the course of three decades, so that nowadays adolescent maternity rates exceed adolescent marriage rates in most countries. Further research is needed to understand the weak or non-existent association between adolescent marriage and maternity with gender discrimination and social institutions.

Socio-economic predictors of adolescent marriage and maternity in West and Central Africa between 1986 and 2017.

BACKGROUND: Early marriage and maternity prevalence rates among adolescent girls remain alarmingly high in West and Central Africa (WCA). This study aims to explore the associations between socio-economic factors and the prevalence of early marriage and maternity, thus contributing to the identification of girls at risk of early pregnancy or marriage. METHODS: We pooled data from national representative surveys (1986 - 2017) for 23 countries in WCA to examine associations between wealth, educational attainment, religious affiliation, and place of residence with adolescent marriage and maternity. We decomposed the wealth and education gradients for individual countries, while controlling for common characteristics of the local environment via the use of primary sampling unit fixed-effects. The pooled sample provides information on 262 721 girls (age 15-19 years). Survey weights and population share weights were used in the estimations. RESULTS: The prevalence of adolescent maternity and marriage exhibited a wealth and education gradient. Prevalence of marriage in the poorest wealth quintile was 41.1% (95% confidence interval (CI) = 38.8%-43.5%) and 10.5% (95% CI = 9.5%-11.6%) in the richest. For maternity it was 38.3% (95% CI = 36.4%-40.3%) in the poorest quintile and 12.7% (95% CI = 11.5%-13.9%) in the richest. Marriage/maternity is three/two times more likely to occur among girls with incomplete primary or no formal education than in those with at least primary. Maternity and marriage among adolescents exhibit a geographical pattern and differences between religious groups. Adolescent marriage prevalence was 34.4% (95% CI = 32.9%-35.8%) in rural areas compared to 13.3% (95% CI = 12.3%-14.2%) in urban areas. Adolescent maternity prevalence was 32.8% (95% CI = 31.7%-33.9%) in rural compared to 16.3% (95% CI = 15.3%-17.3%) in urban areas. Finally, the prevalence of adolescent marriage was substantially higher among Muslims compared to all other religious groups. CONCLUSIONS: Our results highlight the disparities in the prevalence of adolescent marriage and maternity and confirm the existence of wealth and education gradients. These findings can help to improve targeting of vulnerable adolescents and to identify areas for policy implementation.

Does early childbearing affect utilization of antenatal care services and infant birth weight: Evidence from West and Central African Region.

BACKGROUND: Adequate antenatal care (ANC) utilization is recognized as one of the important drivers of safe childbirth and positive birth outcomes. The usage of ANC services fluctuates with various personal, socio-economic, and cultural characteristics and in resource-poor settings, adolescent mothers are at a particularly high risk of insufficient ANC utilization. OBJECTIVES: This paper investigates whether the usage of ANC services and institutional delivery as well as newborn birth weight differ systematically between adolescent and adult mothers in West and Central Africa. Moreover, we explore to what extent differences in birth weight are explained by ANC usage, adolescence, and select socio-economic characteristics of the mother. METHODS: We pooled cross-sectional data from all Demographic and Health Surveys (DHS) and Multi Indicator Cluster Surveys (MICS) conducted in countries in West and Central Africa region between 1986 and 2017 to estimate measures of ANC usage and qualified delivery assistance (along with a combined measure of "adequate maternal healthcare" aggregating these two factors) and newborn birth weight by maternal age group. We estimated various regression models to analyze a) the association between adolescence and adequate prenatal and maternal health care controlling for select socio-economic maternal characteristics as well as the local environment and b) between adolescence, adequate maternal health care, and newborn birth weight outcomes, also controlling for maternal characteristics and the local environment. All regressions were linear probability models for binary outcomes and simple linear models for continuous outcomes. RESULTS: Adequate maternal health care provision was lowest among adolescent mothers: 23.0% among adolescents vs an average of 29.2% across all other age groups. Moreover, we found maternal education and wealth to be positively and significantly associated with receiving adequate maternal health care. Adolescent mothers had the highest risk of low infantile birth weight with 14.5% (95% confidence interval (CI) = 13.6%-15.5%), which is roughly 1.5-2 times higher than in older mothers. We found that adolescence is still strongly associated with low birth weight even when adequate maternal health care and various socio-economic factors as well as the local environment are controlled for. CONCLUSIONS: Our findings suggest that ANC supply in resource-poor settings should be particularly tailored to adolescent mothers' needs and that further research is necessary to explore what individual maternal characteristics beyond socio-economic and physical (eg, BMI) factors drive the prevalence of low birth weight. Moreover, the currently used measures of maternal care quality are heavily dependent on pure quantitative measures (number of ANC visits). New indicators incorporating measures of factual quality and scope ought to be developed and incorporated into large routine household surveys such as DHS and MICS.

Long-term consequences of early marriage and maternity in West and Central Africa: Wealth, education, and fertility.

OBJECTIVE: Early marriage and childbearing have substantial detrimental effects on both, the affected girls and women at the micro level, as well as entire economies on the macro level. West and Central African countries have some of the highest prevalence rates of early marriage and maternity worldwide. This work attempts to quantify the long-term economic, societal, and fertility effects of marriage and pregnancy in early and late adolescence in West and Central Africa. METHODS: We used pooled cross-sectional data collected between 1986 and 2017 in 21 West and Central African countries within the DHS and MICS programs to estimate the associations of marriage and maternity during early (10-14) and late (15-19) adolescence retrospectively on wealth accumulation, educational attainment, as well as the woman's lifetime fertility. RESULTS: Descriptively, women who married or gave birth as young or very young adolescents are overrepresented among the poorest and least educated quintiles of the adult population and underrepresented among the richest and most educated. These gradients were confirmed within a regression analysis which additionally controlled for current age of the woman and PSU fixed effects. Marrying in early/late adolescence was associated with a 12%/6% higher likelihood of being in the poorest wealth quintile in later life and 29%/20% increased likelihood of not completing primary education, as compared to women who married as adults. Maternity in early/late adolescence was associated with a 7%/4% higher likelihood of belonging to the poorest quintile and 17%/10% higher likelihood of being uneducated. Moreover, women who married/gave birth during early or late adolescence, on average, have 2.2/2.3 or 1.4/1.5 more children than those who have married/become mothers as adults. CONCLUSIONS: Our findings suggest that the dire consequences of early marriage and maternity hit youngest girls the hardest - both immediately and long-term. Hence, it is not only worthwhile to prevent adolescent marriage and pregnancy in general, but also specifically target very young girls below age 15 to attempt to at least delay such far-reaching demographic life events.

Correlates of HIV seropositivity in young West and Central African women: A pooled analysis of 17 Demographic and Health Surveys.

BACKGROUND: Young women in West and Central Africa have been described by the United Nations as being especially vulnerable to HIV/AIDS. Despite a consensus that increased efforts are necessary to address the needs of this particular demographic, correlates of HIV seropositivity in young West and Central African women have not been systematically described. This study fills this gap using a rich set of publicly available survey data. METHODS: For this cross-sectional study, we combined HIV test results for young women (age 15-24 years) with information on demographic, cultural and socioeconomic correlates from 17 recent Demographic and Health Surveys (DHS) to estimate odds ratios (OR) from fixed effects logistic regression models accounting for potential individual, household-level and contextual risk factors of HIV seropositivity. RESULTS: The prevalence of HIV seropositivity among young women is higher than for men of the same age in all included surveys, except for the Burkina Faso DHS. An important correlate of HIV seropositivity in young women is early sexual activity (OR = 1.510; 95% confidence interval (CI) = 1.100, 2.072), while higher education is associated with reduced odds of being HIV positive (OR = 0.215; 95% CI = 0.057, 0.820). No significant correlation has been found for individual HIV awareness, but HIV stigma is negatively associated with HIV seropositivity (OR = 0.495; 95% CI = 0.247, 0.990, in the fully adjusted model). CONCLUSIONS: The results demonstrate the need to design effective policies addressing behavioral risks in young women. In particular, increasing HIV awareness alone is likely to be insufficient. Instead, information campaigns need to focus on transforming awareness into behavioral change. Moreover, fostering formal education may be an effective tool in the fight against HIV/AIDS.