Reducing childhood illness - fostering growth : an integrated home-based intervention package (IHIP) to improve indoor-air pollution, drinking water quality and child nutrition

Child mortality attributable to pneumonia, diarrhoea and malnutrition accounts globally for the majority of 8.8 million annual deaths. More than half of these deaths are preventable. Available and effective interventions include safe water supply, household water treatment, improved chimney stoves and personal- and home-hygiene and -health messages. In Peru, the current health services reform is focused on shifting responsibilities to peripheral levels; thus, empowering community organisations to manage primary health care services, including health promotion and preventive measures at household level. The current political situation and policy framework to integrate effective preventive interventions that can be delivered at family level, prompted us to test the efficacy of a package of health interventions to reduce childhood illness burden at rural household level. The goal of this PhD thesis was to assess the efficacy of an Integrated Environmental Home-based-Intervention Package (IHIP), comprised of an improved chimney stoves, access to safe drinking water from solar radiation household water treatment (SODIS), and hygiene education interventions, to reduce morbidity of acute respiratory infections, diarrhoea and poor growth of rural Peruvian children under three years of age. We implemented a community-randomised control field trial (cRCT) in 51 community’s clusters of the San Marcos Province, Cajamarca Region, Peru. The cRCT was divided as follows: * Set-up, community selection and participatory intervention development: A pilot study was carried out for the selection of the interventions. These were adapted to local customs. The participatory phase is described in detail in Chapters 4 & 5. * Randomization, enrolment and baseline data collection: Chapter 6 describes the randomisation, enrolment and baseline in detail. * Carbon monoxide (CO) and Particulate Matter (PM2.5) household air quality assessment: Chapter 7 & 8 describe the efficacy of the OPTIMA-improved stove in improving household air quality in comparison to traditional open fire stoves. * Morbidity surveillance and field data acquisition: Morbidity data on the daily occurrence of signs and symptoms diarrhoea and respiratory illnesses of children was collected weekly. Anthropometric every two months and microbial data every 6 months. Chapter 9 describes the IHIP impact on morbidity reduction. * Workshops for a community-driven sustainable dessimination: Chapter 10 describes the community workshops and dissemination processes and dynamics within a socio-ecological framework. Our community-randomised control trial demonstrated that IHIP reduced 22% per year of child diarrhoea (RR 0.78, 95% CI: 0.49-1.05) and found an odds ratio of 0.71 for diarrhoea prevalence (OR 0.71, 95%, CI: 0.47, 1.06). No effects on the frequency of acute lower respiratory infections (RR 0.99, 95% CI: 0.59, 1.65) or child’s growth rates were found when comparing study arms. We identified three reasons for this moderate diarrhoea reduction: i) hand-washing promotion was universally found in our setting, since it is being promoted by the health care centre; ii) SODIS compliance was moderate: only one third of the beneficiaries were using the method regularly; and iii) the increased awareness for the child’s needs linked to the control intervention, could induce improved child care behaviour. The lack of effect on ALRI, could be linked to insufficient reduction in exposure to household air pollutants and high health service utilisation due to cultural beliefs and health seeking behavoiur. The household air pollution assessment study revealed only moderate reductions of 45% and 27% reduction of PM2.5 and CO, respectively for mothers’ personal exposure. This result was achieved in the best working stoves only. This may most likely not be sufficient to reduce impact on physician-diagnosed pneumonia. Community participatory meetings and surveys revealed that people’s decisions on adopting household-level environmental and hygiene interventions, was not only based on individual perceptions of their potential gains, but also depended on peer pressure and social network relations. Individual perceptions regarding pollution levels of water and household air (transparent, odourless water vs dirty air environments) influenced perceived gains and the adoption of certain interventions. Access to information and encouragement from health-care providers and programme implementers also increased adoption. The IHIP had several additional benefits beyond health outcomes. Mother’s expressed that the stoves could reduce cooking time and wood consumption, which translated into cost saving. They also could perform other task while cooking. Regarding the kitchen sink, the mothers expressed it facilitated handwashing, and washing of utensils with detergent, generating a cleaner kitchen environment that fostered home and food hygiene. We believe that the IHIP package motivated families to improve the kitchen living area in general. The high acceptance and sustained use was not only observed in the IHIP families but also in non-participating families that had copied the OPTIMA-improved stove after the community engagement in the desimination activities. We can also conclude that the IHIP package added to the family status, improved quality of life and impacted on their livelihoods, by empowering the beneficiary families. In conclusion, through this project we envisaged to demonstrate how an integrated package could be implemented at the household level in rural areas of Peru and its effect on health, quality of life and livelihoods. However, behaviour change for keeping maintanence of the interventions and use is necessary to achieve compliance, replication and sustainability

Adoption of clean cookstoves after improved solid fuel stove programme exposure: a cross-sectional study in three Peruvian Andean regions

This study examined measures of clean cookstove adoption after improved solid fuel stove programmes in three geographically and culturally diverse rural Andean settings and explored factors associated with these measures. A questionnaire was administered to 1200 households on stove use and cooking behaviours including previously defined factors associated with clean cookstove adoption. Logistic multivariable regressions with 16 pre-specified explanatory variables were performed for three outcomes; (1) daily improved solid fuel stove use, (2) use of liquefied petroleum gas stove and (3) traditional stove displacement. Eighty-seven percent of households reported daily improved solid fuel stove use, 51% liquefied petroleum gas stove use and 66% no longer used the traditional cookstove. Variables associated with one or more of the three outcomes are: education, age and civil status of the reporting female, household wealth and size, region, encounters of problems with the improved solid fuel stove, knowledge of somebody able to build an improved solid fuel stove, whether stove parts are obtainable in the community, and subsidy schemes. We conclude that to be successful, improved solid fuel stove programmes need to consider (1) existing household characteristics, (2) the household's need for ready access to maintenance and repair, and (3) improved knowledge at the community level

Cohort Profile: The Study of Respiratory Pathogens in Andean Children

We investigated respiratory pathogens in a prospective cohort study of young children living in the Peruvian Andes. In the study we assessed viral respiratory infections among young children, and explored interactions of viruses with common respiratory bacteria, especially Streptococcus pneumoniae. Through weekly household visits, data were collected on the signs and symptoms of acute respiratory illness (ARI), nasal samples were collected to test for viruses during episodes of ARI, and nasopharyngeal samples were collected on a monthly basis to monitor bacterial colonisation. We also collected data on vaccination coverage, patterns of social mixing, geographic information, and environmental and socio-demographic variables. Understanding the interaction of respiratory viruses with bacteria and its impact on the burden and severity of ARIs in rural areas of developing countries is critical to designing strategies for preventing such infections. Investigators interested in more details about this study or in accessing these resources should contact Dr. Carlos G. Grijalva at Vanderbilt University ([email protected]

Critical linkages between land use change and human health in the Amazon region : a scoping review

Land use change (LUC) is a main cause of global environmental change, and is an important activity to be studied. Our research aims to examine the current state of evidence on the link between LUC and human health in the Amazon region. We conducted a scoping review of literature in two research databases, resulting in 14 papers for analysis. Our analysis demonstrated a lack of clear definitions for LUC, a wide variety of negative health effects from LUC, the lack of qualitative articles, a lack of studies exploring the potential positive health effects of LUC, and the predominance of studies coming from the Brazilian Amazon. Our study validated the prevailing idea that LUC can lead to negative health consequences, if not managed properly

Data integrity based methodology and checklist for identifying implementation risks of physiological sensing in mHealth projects

Mobile health (mHealth) technologies have the potential to bring health care closer to people with otherwise limited access to adequate health care. However, physiological monitoring using mobile medical sensors is not yet widely used as adding biomedical sensors to mHealth projects inherently introduces new challenges. Thus far, no methodology exists to systematically evaluate these implementation challenges and identify the related risks.; This study aimed to facilitate the implementation of mHealth initiatives with mobile physiological sensing in constrained health systems by developing a methodology to systematically evaluate potential challenges and implementation risks.; We performed a quantitative analysis of physiological data obtained from a randomized household intervention trial that implemented sensor-based mHealth tools (pulse oximetry combined with a respiratory rate assessment app) to monitor health outcomes of 317 children (aged 6-36 months) that were visited weekly by 1 of 9 field workers in a rural Peruvian setting. The analysis focused on data integrity such as data completeness and signal quality. In addition, we performed a qualitative analysis of pretrial usability and semistructured posttrial interviews with a subset of app users (7 field workers and 7 health care center staff members) focusing on data integrity and reasons for loss thereof. Common themes were identified using a content analysis approach. Risk factors of each theme were detailed and then generalized and expanded into a checklist by reviewing 8 mHealth projects from the literature. An expert panel evaluated the checklist during 2 iterations until agreement between the 5 experts was achieved.; Pulse oximetry signals were recorded in 78.36% (12,098/15,439) of subject visits where tablets were used. Signal quality decreased for 1 and increased for 7 field workers over time (1 excluded). Usability issues were addressed and the workflow was improved. Users considered the app easy and logical to use. In the qualitative analysis, we constructed a thematic map with the causes of low data integrity. We sorted them into 5 main challenge categories: environment, technology, user skills, user motivation, and subject engagement. The obtained categories were translated into detailed risk factors and presented in the form of an actionable checklist to evaluate possible implementation risks. By visually inspecting the checklist, open issues and sources for potential risks can be easily identified.; We developed a data integrity-based methodology to assess the potential challenges and risks of sensor-based mHealth projects. Aiming at improving data integrity, implementers can focus on the evaluation of environment, technology, user skills, user motivation, and subject engagement challenges. We provide a checklist to assist mHealth implementers with a structured evaluation protocol when planning and preparing projects

Nasopharyngeal pneumococcal density is associated with viral activity but not with use of improved stoves among young Andean children

Indoor smoke exposure is common in developing countries and may influence nasopharyngeal (NP) pneumococcal colonization density and risk of acute respiratory illness. We compared colonization density among Andean children living in households previously enrolled in a randomized controlled trial of a home intervention package including improved stoves to reduce smoke, kitchen sinks, and water disinfection.; We enrolled 260 children aged <3 years and made weekly household visits to assess for acute respiratory illness (ARI) and collect nasal swabs for respiratory virus polymerase chain reaction (PCR) testing during ARI. At monthly intervals, NP swabs were collected to determine pneumococcal colonization density through quantitative lytA PCR. We used linear quantile mixed-effects models to compare median log-transformed colonization densities among children in households randomized to the control (n = 129) versus intervention (n = 131) in sequential time points, accounting for random effects of multiple="multiple" samples from individual children. Other covariates included age, sex, month, antibiotic exposure, and timing of sample collection relative to ARI with and without viral detection.; Age and sociodemographic characteristics were similar between groups. Although no differences were observed in densities between groups, colonization density varied significantly over time in both groups, with highest densities coinciding with spring months. Time during and after virus-associated ARI was also associated with higher pneumococcal colonization density than time remote from ARIs.; A home intervention package, including improved stoves, was not associated with changes in pneumococcal densities in young Andean children. However, increasing pneumococcal density was observed with spring season and viral-associated ARIs

Community perceptions of health and rodent-borne diseases along the Inter-Oceanic Highway in Madre de Dios, Peru.

BACKGROUND: Madre de Dios is located in the southeastern Amazonian region of Peru. Rodents have been estimated to be the reservoirs for up to 50 % of emerging zoonotic pathogens, including a host of viruses, bacteria, and parasites. As part of a larger study involving both human and animal research, this study serves to obtain a broader understanding of the key challenges and concerns related to health and rodent-borne illnesses from the perspective of the people living in these communities. METHODS: We used a mixed methods approach, which comprised of 12 focus group discussions, 34 key informant interviews and the application of a survey (n = 522) in four communities along the Inter-Oceanic Highway (IOH) in Madre de Dios, Peru over a two-year period. RESULTS: Although 90 % of survey respondents answered that rodents can transmit diseases and had seen rodents in their homes and immediate surroundings, most could not name specific rodent-borne diseases and, when probed, described rodents as pests or nuisance animals, but were not concerned about acquiring illnesses from them. Key informant interview data suggests that there has been a perceived increase in the amount of rodents in the communities since the construction of the IOH, however this potential increase was not coupled with increased knowledge about diseases or perceived risks among these key informants. Health providers also mentioned a lack of diagnostic tools specific for rodent-borne illnesses. This may be related to the fact that although a common rodent-borne disease like leptospirosis is frequently detected in the region, it is not routinely and readily diagnosed, therefore the real burden of the disease and exposure risk can be underestimated. If rodent-borne diseases are not on the radar of health professionals, they may not consider presumptive treatment, which could result in unnecessary morbidity and mortality. CONCLUSION: Awareness of rodent-borne diseases is still lacking in the area, even among health care professionals within the communities, despite the known burden of diseases like leptospirosis. We expect to report further findings as we obtain more information from all the study components

Identifying gaps on health impacts, exposures, and vulnerabilities to climate change on human health and wellbeing in South America: a scoping review

There is an important gap in regional information on climate change and health, limiting the development of science-based climate policies in South American countries. This study aims to identify the main gaps in the existing scientific literature on the impacts, exposure, and vulnerabilities of climate change on population health. A scoping review was performed guided by four sub-questions focused on the impacts of climate change on physical and mental health, exposure and vulnerability factors of population to climate hazards. The main findings showed that physical impacts mainly included infectious diseases, while mental health impacts included trauma, depression, and anxiety. Evidence on population exposure to climate hazards is limited, and social determinants of health and individual factors were identified as vulnerability factors. Overall, evidence on the intersection between climate change and health is limited in South America and has been generated in silos, with limited transdisciplinary research. More formal and systematic information should be generated to inform public policy

Small scale migration along the interoceanic highway in Madre de Dios, Peru: an exploration of community perceptions and dynamics due to migration.

BACKGROUND: Madre de Dios, a southern state in the Peruvian Amazon basin, has experienced rapid development as well as an influx of migrants since the construction of the Interoceanic Highway (IOH) connecting Brazil, Bolivia, and the Peruvian coast. We explored perceptions of migration and development in up to eight communities along the IOH in Madre de Dios following construction of the highway. METHODS: We conducted a multiple methods study involving focus group (FG) discussions and interviews with key informants (KIs) in eight communities in Madre de Dios. The data was used to develop and apply a survey on demographics, financial, personal, social, human, and physical capital in four communities between February 2014 and March 2015. RESULTS: We conducted 12 FGs and 34 KI interviews. A total of 522 people participated in the survey. Comparing migrants (those who had moved to the area after construction of the IOH) and non-migrants, we found no difference in food security or access to health services. The majority (67.6%) of respondents from both groups reported that illness was their primary threat to well-being. Non-migrants owned more land than migrants (p < 0.001), were more likely to have piped water directly in their home (p = 0.046), and were more likely to participate in community groups (p = 0.012). Looking at perceptions about migrants, KIs and FGs discussed both positive perceptions of migrants (increased cultural exchange and new technology) and negative perceptions (increased drugs and alcohol in their communities and a lack of investment in the community). Both migrants and non-migrants reported trusting the local government more than the national government. CONCLUSIONS: Although we hypothesized that migrants would have decreased access to food, water, health services, and land relative to non-migrants, our results show that the only significant differences were in land ownership and water access. Efforts to improve community infrastructure should be carried out at the local level and focus on improving issues reported by both groups, such as potable water, sewage, and increased access to health services. Furthermore, an emphasis on community cohesion, ensuring land rights, and increasing long-term job opportunities should help ease tensions between migrants and non-migrants

The Impact of Road Construction on Subjective Well-Being in Communities in Madre de Dios, Peru.

The interoceanic highway (IOH) in Madre de Dios, Peru has driven dramatic change in the Peruvian Amazon basin. We conducted a mixed methods study to examine the impact of these changes on the subjective well-being (SWB) of four communities on the IOH. Themes that emerged qualitatively included changing health threats, environmental degradation, and the impact of increased migration. To achieve a higher level of SWB, respondents emphasized the need for higher incomes, opportunities to learn new skills, and a better education for their children. Potential threats to SWB included marital problems and poorer health. Quantitative analyses suggested that social support and a sense of security impacted reported SWB scores based on life satisfaction, and the impact of income on life satisfaction was mediated by food security. Although long-term residents felt that specific determinants of SWB had both increased (food variety, transport and access to work) and decreased (access to natural resources and hunting), the majority reported that their lives had improved overall. Health had been affected by the IOH in both negative ways (increased dengue and road accidents) and positive ways (improved access to health services). Our results suggest that the rapidly-changing communities near the IOH link well-being to health, income, community, and the environment