Abstract Background Malaria contributes to excess child mortality in The Gambia. Children under five are at risk of severe malaria and death if not treated promptly and appropriately. It is crucial that a child with fever receive appropriate care from a trained provider. The aim was to identify influences on child fever care-seeking in The Gambia to inform malaria control strategies. Methods This cross-sectional analysis of The Gambia 2019–20 Demographic and Health Survey used logistic regression analysis to identify associations between source of care for a child with fever (public or private healthcare provider, other, or no treatment) and mother, child, and household characteristics. Results Only 52.0% of mothers sought care from a trained healthcare provider for a child with fever—45.1% from a public facility and 7.0% from the private sector. 35.2% of mothers did not seek treatment. Mothers in urban households were 2.67 times as likely (aOR, 95% CI 1.504–4.736) as mothers in rural households to seek care from an informal source (e.g., pharmacy) versus not seeking treatment, and 0.29 times as likely (aOR, 95% CI 0.165–0.515) as mothers in rural households to seek care from a public provider versus informal source. Mothers in wealthier households were 2.30 times as likely (aOR, 95% CI 1.274–4.164) as mothers in poorer households to seek care from an informal source versus no treatment and half as likely as mothers in poorer households to seek care from a public provider versus informal source (aOR 0.53, 95% CI 0.291–0.959). Conclusions Maintaining The Gambia’s malaria control achievements will require the active engagement and oversight of private pharmacies along with continued integrated community case management to reach mothers who do not seek care for a child with fever, and remove challenges to seeking appropriate care from trained providers. Whether influenced by convenience, costs, perceived urgency, or other factors, given the likelihood of urban mothers and mothers in wealthier households to seek care from private pharmacies, it will be necessary to incorporate private pharmacies into malaria control strategies while building public sector capacity and workforce, and initiating more effective attitude and behavioural change among mothers and households.

IntroductionFederal food safety net programs, like the Supplemental Nutrition Assistance Program (SNAP), may not reach vulnerable populations like rural residents, immigrants, and Latinx individuals. Because these groups are overrepresented among the farm workforce, exploring SNAP utilization among farm communities may clarify the role it plays in alleviating food insecurity. MethodsIn-depth interviews were conducted with 31 farmworkers and farm owners. Patterns and predictors of SNAP utilization were organized using an adapted Andersen Behavioral Model of Health Service Utilization.ResultsPsychosocial factors played the central role in participants’ use of SNAP. Discussion: Opportunities to improve the design and delivery of SNAP include expanded eligibility cut-offs and targeted engagement mechanisms.

Objectives:Muscle power is a critical measure of physical capacity in older adults, however the association between muscle power and frailty is not well explored. The purpose of this study is to estimate the association between muscle power and frailty in community-dwelling older adults in the National Health and Aging Trends Study from 2011-2015.Methods:Cross-sectional and prospective analyses were performed on 4,803 community-dwelling older adults. Mean muscle power was calculated using the five-time sit-to-stand test, height, weight, and chair height and dichotomized into high-watt and low-watt groups. Frailty was defined using the five Fried criteria.Results:The low watt-group had higher odds of pre-frailty and frailty at baseline year 2011. In prospective analyses, the low-watt group that was pre-frail at baseline had increased hazards of frailty (AHR 1.62, 95% CI 1.31, 1.99) and decreased hazards of non-frailty (AHR 0.71, 95% CI 0.59, 0.86). The low-watt group that was non-frail at baseline had increased hazards of pre-frailty (1.24, 95% CI 1.04, 1.47) and frailty (1.70, 1.07, 2.70).Conclusions:Lower muscle power is associated with higher odds of pre-frailty and frailty and increased hazards of becoming frail or pre-frail over four years in those who are pre-frail or non-frail at baseline.

The health of farm owners and farmworkers has significant impacts on farm businesses, farming families, and local rural communities where agriculture is an important driver of social and economic activity. Rural residents and farmworkers have higher rates of food insecurity, but little is known about food insecurity among farm owners and the collective experiences of farm owners and farmworkers. Researchers and public health practitioners have stressed the need for policies that target the health and well-being of farm owners and farmworkers while remaining sensitive to the nature of life on the farm, yet farm owner and farmworker lived experiences have been understudied, especially in relation to one another. In-depth qualitative interviews were conducted with 13 farm owners and 18 farmworkers in Oregon. Modified grounded theory was used to analyze interview data. Data were coded using a three-stage process to identify salient core characteristics of food insecurity. Farm owner and farmworker meanings and interpretations of their food insecurity were often contradicted by evaluated food security scores using validated quantitative measures. According to such measures, 17 experienced high food security, 3 had marginal food security, and 11 had low food security, but narrative experiences suggested higher rates. Narrative experiences were categorized by core characteristics of food insecurity, including seasonal food shortages, resource stretching, working extended hours most days of the week, limited use of food assistance, and the tendency to downplay hardship. These unique factors have important implications for developing responsive policies and programs to support the health and well-being of farm livelihoods whose work enables health and well-being among consumers. Future studies to test the relationships between the core characteristics of food insecurity identified in this study and farm owner and farmworker meanings and interpretations of food insecurity, hunger, and nourishment are warranted.

This cohort study examines data from Health and Retirement Study participants to determine associations between blood pressure control and sociodemographic, economic, and housing factors at the census tract level.

PURPOSE: Physical activity and obesity contribute to premature mortality among persons with diabetes. The independent effects of physical activity on all-cause mortality among persons with diabetes requires further examination in well-characterized cohort studies. We test the hypothesis that regular habitual physical activity of 5 or more times a week among persons with diabetes, regardless of duration, intensity or mode, will be associated with lower all-cause mortality when compared to sedentary adults with diabetes. METHODS: We used data from the Third National Health and Nutrition Examination Survey (NHANES III) conducted from 1988-1994. Participant records were linked to mortality data from the National Death Index to establish all-cause mortality. Detailed health information was obtained via a home interview and a medical examination. Self-reported participation in leisure time physical activity was used to classify participants as inactive (0 times/wk), infrequently active (1-4 times/wk) and habitually active (5 + times/wk). Measured weight and height were used to calculate body mass index (kg/m2) categories as follow: Underweight BMI < 18.5, Normal weight BMI = 18.5-24.9, Overweight BMI = 25-29.9, and Obesity BMI > =30. We used data from persons ages 40-74 years of age with a complete Oral Glucose Tolerance Test. Adults with A1C > =6.5%, fasting blood glucose > = 126 mg/dl or 2 hr. plasma glucose> = 200 mg/dl were classified as with diabetes. We used SAS version 9.4 for our statistical analysis. The outcome variable was all-cause mortality. RESULTS: Our analytic sample consisted of 240 adults, 183 were assumed alive, 56 were assumed deceased, and 1 had missing value. Among persons with diabetes, those who exercised during leisure time habitually (5+ times/wk) had significantly lower odds ratios (OR = 0.42, 95% CI: 0.18,0.96) of all-cause mortality than persons with diabetes that were physically inactive, independent of obesity status. Further adjustment for education or smoking did not change the association. CONCLUSIONS: For persons with diabetes, exposure to habitual physical activity 5+ times/wk is associated with lower all-cause mortality. The effect of physical activity was independent of obesity status.

Background Associations between multiple forms of discrimination and blood pressure control in older populations remain unestablished. Methods Participants were 14 582 noninstitutionalized individuals (59% women) in the Health and Retirement Study aged at least 51 years (76% non-Hispanic White, 15% non-Hispanic Black, 9% Hispanic/Latino). Primary exposures included the mean frequency of discrimination in everyday life, intersectional discrimination (defined as marginalization ascribed to more than one reason), and the sum of discrimination over the life span. We assessed whether discrimination was associated with a change in measured hypertension status (N = 14 582) and concurrent medication use among reported hypertensives (N = 9 086) over 4 years (2008-2014). Results There was no association between the frequency of everyday discrimination and change in measured hypertension. Lifetime discrimination was associated with higher odds of hypertension 4 years later among men (odds ratio [OR]: 1.21, 95% confidence interval [CI]: 1.08-1.36) but not women (OR: 0.98, 95% CI: 0.86-1.13). Only among men, everyday discrimination due to at least 2 reasons was associated with a 1.44-fold (95% CI: 1.03-2.01) odds of hypertension than reporting no everyday discrimination, reporting intersectional discrimination was not associated with developing hypertension among women (OR: 0.91, 95% CI: 0.70-1.20). All 3 discriminatory measures were inversely related to time-averaged antihypertensive medication use, without apparent gender differences (eg, OR for everyday discrimination-antihypertensive use associations: 0.85, 95% CI: 0.77-0.94). Conclusions Gender differences in marginalization may more acutely elevate hypertensive risk among older men than similarly aged women. Experiences of discrimination appear to decrease the likelihood of antihypertensive medication use among older adults overall.

Untested psychosocial or economic factors mediate associations between perceived discrimination and suboptimal antihypertensive therapy. This study included 2 waves of data from Health and Retirement Study participants with self-reported hypertension (n = 8,557, 75% non-Hispanic White, 15% non-Hispanic Black, and 10% Hispanic/Latino) over 4 years (baselines of 2008 and 2010, United States). Our primary exposures were frequency of experiencing discrimination, in everyday life or across 7 lifetime circumstances. Candidate mediators were self-reported depressive symptoms, subjective social standing, and household wealth. We evaluated with causal mediation methods the interactive and mediating associations between each discrimination measure and reported antihypertensive use at the subsequent wave. In unmediated analyses, everyday (odds ratio (OR) = 0.86, 95% confidence interval (CI): 0.78, 0.95) and lifetime (OR = 0.91, 95% CI: 0.85, 0.98) discrimination were associated with a lower likelihood of antihypertensive use. Discrimination was associated with lower wealth, greater depressive symptoms, and decreased subjective social standing. Estimates for associations due to neither interaction nor mediation resembled unmediated associations for most discrimination-mediator combinations. Lifetime discrimination was indirectly associated with reduced antihypertensive use via depressive symptomatology (OR = 0.99, 95% CI: 0.98, 1.00). In conclusion, the impact of lifetime discrimination on the underuse of antihypertensive therapy appears partially mediated by depressive symptoms.

Low-income households may acquire foods from purchases, federal food assistance, and alternative food sources (AFS) to meet their food needs. The objectives of this study were to quantify and compare the contribution of AFS to total kilocalories and dietary quality of food acquisitions between AFS users and non-users among low-income households. Users obtained 22.3% of kilocalories from AFS and purchased fewer kilocalories compared to non-users [14,886 +/- 1464.10 versus 19,915.00 +/- 1036.41 kilocalories]. AFS users had lower 2015-Healthy Eating Index scores from purchased acquisitions than non-users, but there was no difference in dietary quality between AFS users and non-users after accounting for alternative acquisitions.

Background: Pregnancy is a sensitive time for maternal cardiovascular functioning and exposures to arsenic or manganese may adversely affect blood pressure (BP).Objectives: This study examined the associations between arsenic and manganese exposures and maternal BP measured during pregnancy. Effect modification by pre-pregnancy body mass index (BMI) was evaluated.Methods: Pregnant women (N = 1522) were recruited for a prospective cohort study in Bangladesh (2008-2011). Exposure to arsenic and manganese was measured in drinking water at <16 weeks gestation and toenails at onemonth postpartum. Systolic and diastolic BP were measured monthly. Linear mixed models estimated mean BP and differences in mean BP over gestation for arsenic or manganese exposures and adjusted for covariates. Results: Arsenic levels had an increasing dose-response association with maternal BP after 25 weeks gestation. Effect modification was observed for BMI. Participants with lower BMI (<23 kg/m2) exposed to 50 mu g/L arsenic had 2.83 mmHg (95% CI:1.74-3.92) greater mean systolic and 1.96 mmHg (95% CI: 1.02-2.91 mmHg) diastolic BP compared to those exposed to < 1 mu g/L arsenic at 40 weeks gestation. Participants with higher BMI (>= 23 kg/ m2) showed a greater mean systolic BP of 5.72 mmHg (95% CI: 3.18-8.27 mmHg) and diastolic BP change of 6.09 mmHg (95% CI: 4.02-8.16 mmHg) at 40 weeks gestation when exposed to 50 mu g/L compared to < 1 mu g/L arsenic. Participants with lower BMI exposed to drinking water manganese in the 2nd quartile (181-573 mu g/L) had 1.04 mmHg higher mean diastolic BP (95% CI: 0.01-2.07 mmHg) at 40 weeks gestation compared to those in the 1st quartile (0.5-180 mu g/L).Conclusion: Arsenic exposures during pregnancy were consistently associated with increased average maternal systolic and diastolic BP. The effect of manganese on BP was less consistent.

The objective of this research was to investigate associations among self-reported health status, chronic conditions, and use of dietary supplements containing botanicals and describe reasons for use among U.S. adult supplement users. This was a cross-sectional analysis using data from the 2009-2014 National Health and Nutrition Examination Survey (NHANES). Supplement information was collected with a 30-day recall interview. Self-reported general health status and doctor-informed diagnoses of chronic conditions were assessed using a health status questionnaire. We used weighted multivariate logistic regressions to assess associations between supplement use and perceived health and number of chronic conditions. Participants were 16,958 non-institutionalized U.S. adults aged 20 years and older. Adults with excellent or very good self-perceived health were more likely to use botanical supplements than adults with good perceived health (adjusted odds ratio [aOR], 1.48; 95% confidence interval [CI], 1.28-1.74). Adults with three or more chronic conditions were more likely to report using botanical supplements than adults with no chronic conditions (aOR, 1.49; 95% CI, 1.13-1.69). The most frequently reported reasons for both non-botanical and botanical supplements use were "personal choice or influenced by advertisements or word of mouth," "improve health," and "specific health conditions" (93.3%, 84.2%, and 64.7%, respectively). While perceptions of health are more positive among adults using botanical supplements, chronic conditions and reasons for botanical supplements use related to personal choice, improving health, or addressing specific conditions were more likely. Differentiating botanical supplements from other complementary and integrative therapies may be useful for facilitating a deeper understanding of the reasons.

BACKGROUND:Policies that restrict access to and use of the Supplemental Nutrition Assistance Program (SNAP) and Special Supplemental Nutrition Assistance Program for Women, Infants, and Children (WIC) by legal status may disproportionately disadvantage particular racial and ethnic groups. While immigrant legal status, race, and ethnicity are recognized as independent social determinants of health, studies examining the extent to which legal status structures racial and ethnic health disparities are limited. Research is needed to identify factors that mitigate disparate health outcomes, such as SNAP and WIC.METHODS:Cross-sectional data from the 2009/2010 National Agricultural Workers Survey (N = 3,961) were analyzed. Chi-square tests and logistic regressions examined associations among self-reported health, race, ethnicity, legal status, and SNAP/WIC participation.RESULTS:Farmworkers reporting excellent or good health were more likely to be non-Hispanic White, U.S. citizen, aged 18-25, single, male, educated beyond primary school, living above the poverty level, without chronic health conditions, and located in the Midwest. Hispanic farmworkers had lower odds of reporting excellent or good health (OR 0.27, 95% CI 0.12-0.62). Among SNAP/WIC participants, Hispanic farmworkers had higher odds of reporting excellent or good health (OR 6.74, 95% CI 1.54-29.57) compared to non-Hispanic White farmworkers. There was no significant association between self-reported health and legal status.DISCUSSION:This study complements the extant literature showing racial and ethnic health disparities among the U.S. farmworker population. Results provide valuable insight on the health-protective potential of programs like SNAP and WIC, particularly among Hispanic farmworkers, who may be both less likely to be eligible and more hesitant to participate. These findings underscore the need to expand U.S. farmworkers' eligibility and participation in SNAP and WIC.

Background: Systematic evaluation of neighborhood factors which capture an array of characteristics -analogous to genome-wide-association studies- may identify important patterns in spatial determinants of blood pressure control. Methods: Our sample included Health and Retirement Study participants (N=13180; 58% women, 13% non-Hispanic Black, 4% Hispanic/Latino) with at least one sphygmomanometer reading taken between 2006 and 2016. Our main study outcome was at least one hypertensive blood pressure measurement over the study period. Participants were randomly assigned to either a training or test dataset. Using generalized estimating equations, we summarized multivariable associations between each of 51 standardized American Community Survey sociodemographic, housing, and income-related census tract variables (2005-09) and the period prevalence of measured hypertension. We adjusted for individual factors and accounted for multiple comparisons in the training set using the Simes significance test. Neighborhood-based factors that revealed statistically significant associations (Simes-adjusted p-value<=0.05) with hypertension in the training dataset were rerun in the test dataset to replicate findings. Lastly, in the full cohort, we evaluated main and race/ethnicity-stratified independent effects of each significant neighborhood factor on the likelihood of at least one hypertensive sphygmomanometer reading between 2006 and 2016. We hypothesized that residence in neighborhoods with worse housing or socioeconomic characteristics would be associated with a higher odds of hypertension, and that associations in the full sample would differ by racial/ethnic designation. Results: Thirty-two percent (4218 out of 13180) of participants had at least one hypertensive sphygmomanometer reading between 2006 and 2016. In the training set, two of the 51 census-tract level variables were independently associated with period prevalence of hypertension. In the full sample, we observed a lower likelihood of prevalent hypertension (OR: 0.95; 95% CI: 0.92, 0.99) among participants residing in a census tract with recent (since 2000) in-migration. A higher proportion of relatively recent (since 2000) renters in the census tract was associated with a lower hypertension prevalence (OR: 0.95; 95% CI: 0.91, 0.98). When stratified by racial/ethnic designation, these patterns were apparent among Non-Hispanic White and to some extent Hispanic/Latino but not Non-Hispanic Black participants. However, differences were not statistically significant by race or ethnicity. Conclusion: In conclusion, relatively more recent relocation to an area appears to be modestly associated with reduced prevalence of hypertension. These findings support possible differential cardiovascular health impacts of gentrification. Further investigation is needed to confirm these findings.

(1) Background: Arsenic (As) is a common drinking water contaminant that is regulated as a carcinogen. Yet, As is a systemic toxicant and there is considerable epidemiological data showing As adversely impacts reproductive health. This study used data from a birth cohort in Bangladesh (2008–2011) to examine associations between drinking water As levels and reproductive outcomes. (2) Methods: Pregnant individuals (n = 1597) were enrolled at <16 weeks gestation and drinking water As was measured. Participants with live births (n = 1130) were propensity score matched to participants who experienced miscarriage (n = 132), stillbirth (n = 72), preterm birth (n = 243), and neonatal mortality (n = 20). Logistic regression was used to examine drinking water As recommendations of 50, 10, 5, 2.5, and 1 µg/L on the odds of adverse birth outcomes. (3) Results: The odds of miscarriage were higher for pregnant women exposed to drinking water ≥2.5 versus <2.5 µg As/L [adjusted odds ratio (OR) 1.90, 95% Confidence Interval (CI): 1.07–3.38)]. (4) Conclusions: These preliminary findings suggest a potential threshold where the odds of miscarriage increases when drinking water As is above 2.5 µg/L. This concentration is below the World Health Organizations and Bangladesh’s drinking water recommendations and supports the re-evaluation of drinking water regulations.

A secondary data analysis of 33,093 children and adolescents age 6-17 years (12% with disabilities) from a 2016-2017 National Survey of Children's Health nonrepresentative sample aimed to identify (a) unique clusters of sociodemographic characteristics and (b) the relative importance of disability status in predicting participation in daily physical activity (PA) and sports. Exploratory classification tree analyses identified hierarchical predictors of daily PA and sport participation separately. Disability status was not a primary predictor of daily PA. Instead, it emerged in the fifth level after age, sex, body mass index, and income, highlighting the dynamic intersection of disability with sociodemographic factors influencing PA levels. In comparison, disability status was a second-level predictor for sport participation, suggesting that unique factors influencing PA level are likely experienced by disabled children and adolescents. The authors employ an intersectionality lens to critically discuss implications for research in adapted PA.

BACKGROUND:Previous studies have demonstrated an association between gait speed and cognitive function. However, the relationship between balance and cognition remains less well explored. This study examined the cross-sectional and longitudinal relationship of balance and cognitive decline in older adults.METHODS:A cohort of 4,811 adults, aged ≥65 years, participating in the Cardiovascular Health Study was followed for 6 years. Modified Mini-Mental State Examination (3MSE) and Digit Symbol Substitution Test (DSST) were used to measure cognition. Tandem balance measures were used to evaluate balance. Regression models were adjusted for demographics, behavioural and disease factors.RESULTS:Worse balance was independently associated with worse cognition in cross-sectional analysis. Longitudinally, participants aged ≥76 years with poorer balance had a faster rate of decline after adjustment for co-variates: -0.97 points faster decline in 3MSE per year (95% confidence interval (CI): -1.32, -0.63) compared to the participants with good balance. There was no association of balance and change in 3MSE among adults aged <76 years (P value for balance and age interaction < 0.0001). DSST scores reflected -0.21 (95% CI: -0.37, -0.05) points greater decline when adjusted for co-variates. In Cox proportional hazard models, participants with worse balance had a higher risk of being cognitively impaired over the 6 years of follow-up visits (adjusted HR:1.72, 95% CI: 1.30, 2.29).CONCLUSIONS:Future studies should evaluate standing balance as a potential screening technique to identify individuals at risk of cognitive decline. Furthermore, a better understanding of the pathophysiological link between balance and cognition may inform strategies to prevent cognitive decline.

Background: Recent studies indicate airborne PAH levels have decreased in the U.S., but it is unclear if this has resulted in PAH exposure changes in the U.S. population. Objective: Examine temporal trends in urinary metabolites of Naphthalene, Fluorene, Phenanthrene, and Pyrene in U.S. non-smokers, 6+ years old. Methods: We used biomonitoring data from the National Health and Nutrition Examination Survey (NHANES) program, 2001-2014, (N = 11,053) using survey weighted linear regression. Models were adjusted for age, sex, race/ethnicity, creatinine, BMI, income, diet, and seasonality. Stratified models evaluated the effect of age, sex, and race/ethnicity on trends. Results: Between 2001 and 2014, Naphthalene exposure increased 36% (p < 0.01); Pyrene exposure increased 106% (p < 0.01); Fluorene and Phenanthrene exposure decreased 55% (p < 0.01), and 37% (p < 0.01), respectively. Naphthalene was the most abundant urinary PAH, 20-fold higher than Fluorene and Phenanthrene, and over 50-fold higher than Pyrene compared to reference groups, effect modification was observed by age (Naphthalene, Pyrene), sex (Fluorene, Pyrene), and race/ethnicity (Naphthalene, Fluorene, Phenanthrene, Pyrene). Significance: This study shows exposure to Naphthalene and Pyrene increased, while exposure to Fluorene and Phenanthrene decreased among the non-smoking U.S. general population between 2001 and 2014, suggesting environmental sources of PAHs have changed over the time period. (C) 2021 Elsevier Ltd. All rights reserved.

BACKGROUND:For decades, Americans have increasingly relied on food away from home (FAFH) despite its association with negative health outcomes. Little is known about FAFH frequency and expenditures of adults with lower food security (FS) and their association with health outcomes, such as BMI.OBJECTIVES:We evaluated patterns of adults' FAFH purchases by FS status and other demographic characteristics, and examined the association between FAFH frequency and BMI in adults of varying levels of FS.METHODS:This cross-sectional study used data from the Consumer Behavior Survey, Food Security Survey, and anthropometric measurements to assess FAFH frequency and expenditures, FS, and calculated BMI of adults (≥18 y) who participated in the NHANES 2007-2014 (n = 20,733). We used multinomial logistic regression to examine the association between FAFH frequency quartiles (quartile 1: 0 n/wk; quartile 2: 1-2 n/wk; quartile 3: 3-4 n/wk; quartile 4: ≥5 n/wk) and BMI by FS category.RESULTS:Although FAFH frequency was similar across FS levels, adults with high FS spent more dollars (${\$}$213.60) and a greater proportion (29.4%) of their food budget on FAFH compared with adults with marginal, low, and very low FS (${\$}$133.00, ${\$}$116.20, ${\$}$103.30 and 21.4%, 19.7%, 20.0%, respectively). Obesity prevalence was highest in adults with low FS (42.9%) and very low FS (41.5%), and lowest in adults with high FS (33.7%). FAFH frequency and BMI were positively associated in adults with high (P < 0.001), marginal (P = 0.025), and low (P = 0.024) FS, but not in adults with very low FS (P = 0.589).CONCLUSIONS:FAFH is frequent in adults regardless of FS status. The positive association between FAFH and BMI is the strongest in adults with high FS, the group with the lowest prevalence of obesity. Conversely, BMI was not associated with FAFH in adults with very low FS, despite their higher prevalence of obesity.