Identifying bottlenecks in the iron and folic acid supply chain in Bihar, India: a mixed-methods study

Background: Maternal anaemia prevalence in Bihar, India remains high despite government mandated iron supplementation targeting pregnant women. Inadequate supply has been identified as a potential barrier to iron and folic acid (IFA) receipt. Our study objective was to examine the government health system’s IFA supply and distribution system and identify bottlenecks contributing to insufficient IFA supply. Methods: Primary data collection was conducted in November 2011 and July 2012 across 8 districts in Bihar, India. A cross-sectional, observational, mixed methods approach was utilized. Auxiliary Nurse Midwives were surveyed on current IFA supply and practices. In-depth interviews (n = 59) were conducted with health workers at state, district, block, health sub-centre, and village levels. Results: Overall, 44% of Auxiliary Nurse Midwives were out of IFA stock. Stock levels and supply chain practices varied greatly across districts. Qualitative data revealed specific bottlenecks impacting IFA forecasting, procurement, storage, disposal, lack of personnel, and few training opportunities for key players in the supply chain. Conclusions: Inadequate IFA supply is a major constraint to the IFA supplementation program, the extent of which varies widely across districts. Improvements at all levels of infrastructure, practices, and effective monitoring will be critical to strengthen the IFA supply chain in Bihar

Increased climate variability and sedentarization in Tanzania: Health and nutrition implications on pastoral communities of Mvomero and Handeni districts, Tanzania

African pastoralists are undergoing significant changes in livelihood strategies, from predominantly mobile pastoralism to agro-pastoralism in which both livestock raising and cultivation of crops are practiced, to agro- pastoralism combined with wage labor and petty trade. These changes often result in fixed settlements or a process known as sedentarization. Previous research indicates that sedentarization and increased climate vari-ability are prominent forces shaping livelihood opportunities and constraints in East Africa, but the effects of these co-occurring processes have yet to be investigated. This paper develops theory, using qualitative data collected in Morogoro and Tanga Regions of Tanzania, explaining the relationships between climate variability, pastoral sedentarization, livelihood outcomes, and resulting nutritional status. We observed that the co-occurring processes of increased climate variability and sedentarization among pastoralists in these regions have dramatic impacts on communities’ economic prosperity, health status, and nutritional outcomes. Due to risks associated with climate and sedentarization, land tenure policies that allow continued practice of highly mobile livelihood strategies, namely, legal recognition of collective land rights, should be adopted

Participation in the Georgia Food for Health program and cardiovascular disease risk factors: A longitudinal observational study

Abstract Objective To assess the relationship between program attendance in a produce prescription program and changes in cardiovascular risk factors. Design The Georgia Food for Health (GF4H) program provided 6 monthly nutrition education sessions, 6 weekly cooking classes, and weekly produce vouchers. Participants became program graduates attending at least 4 of the 6 of both the weekly cooking classes and monthly education sessions. We used a longitudinal, single-arm approach to estimate the association between the number of monthly program visits attended and changes in health indicators. Setting GF4H was implemented in partnership with a large safety-net health system in Atlanta, GA. Participants 331 participants living with or at-risk of chronic disease and food insecurity were recruited from primary care clinics. Over three years, 282 participants graduated from the program. Results After adjusting for program site, year, participant sex, age, race & ethnicity, SNAP participation, and household size, we estimated that each additional program visit attended beyond 4 visits was associated with a 0.06 kg/m2 reduction in BMI (95% CI: -0.12, -0.01; p=0.02), a 0.37 inch reduction in waist circumference (95% CI: -0.48, -0.27; p<0.001), a 1.01 mmHg reduction in systolic blood pressure (95% CI: -1.45, -0.57; p<0.001), and a 0.43 mmHg reduction in diastolic blood pressure (95% CI: -0.69, -0.17; p=0.001). Conclusions Each additional cooking and nutrition education visit attended beyond the graduation threshold was associated with modest but significant improvements in cardiovascular disease risk factors, suggesting that increased engagement in educational components of a produce prescription program improves health outcomes

Women’s empowerment, food security and nutrition of pastoral communities in Tanzania

This paper presents a mixed-methods study that examines the relationship between women’s empowerment, household food security, and maternal and child diet diversity (as one indicator of nutrition security) in two regions of Tanzania. Indicators across three domains of women’s empowerment were scored and matched to a household food insecurity access scale. Qualitative research helped appreciate the gender dynamics affecting the women’s empowerment-food security and women’s empowerment-nutrition security nexus. In cluster adjusted regression analyses, scores from each domain were significantly associated with women’s dietary diversity, but not with household food security. All three empowerment domains were positively associated with food security and nutrition in the qualitative analysis. This article discusses these findings and shows the pathways by which respondents saw their empowerment to affect their household food security

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial.

Importance: Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. Objective: To determine whether hydrocortisone improves outcome for patients with severe COVID-19. Design, Setting, and Participants: An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. Interventions: The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). Main Outcomes and Measures: The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). Results: After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. Conclusions and Relevance: Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. Trial Registration: ClinicalTrials.gov Identifier: NCT02735707

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Individual and facility-level determinants of iron and folic acid receipt and adequate consumption among pregnant women in rural Bihar, India.

BackgroundIn Bihar, India, high maternal anemia prevalence and low iron and folic acid supplement (IFA) receipt and consumption have continued over time despite universal IFA distribution and counseling during pregnancy.PurposeTo examine individual and facility-level determinants of IFA receipt and consumption among pregnant women in rural Bihar, India.MethodsUsing District Level Household Survey (2007-08) data, multilevel modeling was conducted to examine the determinants of two outcomes: IFA receipt (any IFA receipt vs. none) and IFA consumption (≥90 days vs. ResultsOverall, 37% of women received any IFA during their last pregnancy. Of those, 24% consumed IFA for 90 or more days. Women were more likely to receive any IFA when they received additional ANC services and counseling, and attended ANC earlier and more frequently. Significant interactions were found between ANC quality factors (odds ratio (OR): 0.37, 95% confidence interval (CI): 0.25, 0.56) and between ANC services and ANC timing and frequency (OR: 0.68, 95% CI: 0.56, 0.82). No HSC factors were significantly associated with IFA receipt. Women were more likely to consume IFA for ≥90 days if they attended at least 4 ANC check-ups and received more ANC services. IFA supply at the HSC (OR: 1.37, 95% CI: 1.04, 1.82) was also significantly associated with IFA consumption.ConclusionsOur findings indicate that individual and ANC factors (timing, frequency, and quality) play a key role in facilitating IFA receipt and consumption. Although HSC capacity factors were not found to influence our outcomes, significant variation at the facility level indicates unmeasured factors that could be important to address in future interventions

GT Roundtable 2: Food-Energy-Water Nexus and Social Sustainability

Baabak Ashuri is Associate Professor in the School of Civil and Environmental Engineering and the School of Building Construction at Georgia Tech as well as the Director of the Construction Research Center. His work focuses on Economic Decision Analysis of Resilient and Sustainable Infrastructure Systems. He co-moderates this roundtable discussion.Bill Bolling is the founder of the Atlanta Community Food Bank (ACFB) and has served as its executive director since 1979. In this capacity he oversees the distribution of millions of pounds of good but unmarketable food and grocery products each year through a network of more than 600 nonprofit partner organizations that feed the hungry, as well as other food banks throughout the southeast.Amy Webb Girard is an Assistant Professor in the School of Public Health at Emory University.Carey W. King performs interdisciplinary research on how energy systems interact within the economy and environment, and how competing factors affect societal decisions and tradeoffs and policy development. Dr. King’s research goals center on rigorous interpretations of the past performance of energy systems to determine the most probable future energy pathways.Matthew Realff is a Professor of the School of Chemical and Biomolecular Engineering at Georgia Tech. His research interests include process design, simulation, scheduling, and control. He co-moderates this roundtable discussion.Dr. Joseph D. Smith currently holds the Laufer Endowed Energy Chair and also serves as Director of the Energy Research and Development Center at Missouri University of Science and Technology. He has been developing hybrid energy systems that integrate nuclear energy with chemical and petrochemical processes to produce liquid fuels and chemicals. Clean carbon free nuclear heat is used with high temperature steam electrolysis to replaces traditional steam methane reforming. Hybrid Energy Systems represent transformational energy technology that supports national energy security.This roundtable discussion took place on June 9, 2016 from 3:30 - 4:45 p.m. in the Engineered Biosystems Building (EBB), room 1005 as part of the Paths to Social Sustainability: Building a Research, Teaching, & Action Agenda for the Southeast conference.Runtime: 67:39 minute

Development and Application of Novel Caregiver Hygiene Behavior Measures Relating to Food Preparation, Handwashing, and Play Environments in Rural Kenya

Exposure to fecal pathogens results in both acute and chronic sequalae in young children. Diarrhea causes nearly 20% of all under-five mortality, while even sub-clinical enteric infections may lead to growth shortfalls. Stunting affects nearly 165 million children globally and results in lifelong and intergenerational effects for the world&rsquo;s poorest populations. Caregiver hygiene behaviors, such as those surrounding handwashing and food preparation, play a critical role in exposure to fecal pathogens; standard metrics to assess these behaviors are warranted to provide a means of quantifying the impact these behaviors have on enteric infections and to evaluate the success or failure of interventions and programs. This paper documents the development of three novel caregiver hygiene behavior measures: hygienic food preparation and storage, handwashing at key times, and provision of a safe play environment for children under two years. We developed these measures using formative qualitative work, survey creation and deployment theoretically underpinned by the COM-B model of behavior change, and exploratory and confirmatory factor analysis. The final measure for hygienic food preparation and storage includes 10 items across two factors; the final measure for handwashing at key times includes 15 items across three factors; and the final measure for safe play environment contains 13 items across three factors. Future researchers may employ these measures to assess caregiver behaviors in other populations, identify specific behavioral dimensions that should be the focus of interventions, and evaluate interventions and programs