Corey L. Nagel

The Relation between Neighborhood Built Environment and Walking Activity among Older Adults

The association of neighborhood built environment with walking activity has received growing attention, although most studies have relied upon subjective measures of the built environment and few have examined the relation between built environment and walking among older adults. This 2001 study examined the relation between objectively measured characteristics of the local neighborhood and walking activity among a sample of 546 community-dwelling older adults in Portland, Oregon. A geographic information system was used to derive measures of the built environment within a quarter-mile (0.4 km) and half-mile (0.8 km) radius around each participants residence. Multilevel regression analysis was used to examine the association of built environment with walking behavior. No association between built environment and the likelihood of walking or not walking was observed in this cohort of older adults. However, among those participants who reported some degree of walking activity, average time spent walking per week was significantly associated with amount of automobile traffic and number of commercial establishments in their local neighborhood. These findings suggest that built environment may not play a significant role in whether older adults walk, but, among those who do walk, it is associated with increased levels of activity.

Use of complementary and alternative therapies to promote sleep in critically ill patients

The efficacy of complementary and alternative therapies for sleep promotion in critically ill patients is largely unexamined. We found only seven studies (three on environmental interventions and one each on massage, music therapy, therapeutic touch, and, melatonin) that examined the effect of complementary and alternative therapies. A number of studies, however, have shown that massage, music therapy. and therapeutic touch promote relaxation and comfort in critically ill patients, which likely leads to improved sleep. Massage, music therapy, and therapeutic touch are safe for critically ill patients and should be routinely applied by ICU nurses who have received training on how to administer these specialized interventions. Environmental interventions, such as reducing noise, playing white noise such as ocean sounds, and decreasing interruptions to sleep for care, also are safe and logical interventions that ICU nurses should use to help patients sleep. Progressive muscle relaxation has been extensively studied and shown to be efficacious for improving sleep in persons with insomnia; however, progressive muscle relaxation requires that patients consciously attend to relaxing specific muscle groups and practice these techniques, which may be difficult for critically 11 patients. We do not currently recommend aromatherapy and alternative sedatives, such as valerian and melatonin, for sleep promotion in critically ill patients because the safety of these substances is unclear. In summary, we recommend that ICU nurses implement music therapy, environmental interventions, therapeutic touch, and relaxing massage to promote sleep in critically ill patients. These interventions are safe and may improve patient sleep, although randomized controlled trials are needed to test their efficacy. Aromatherapy and alternative sedatives require further investigation to determine their safety and efficacy.

Does change in the neighborhood environment prevent obesity in older women

Neighborhood environment is consistently associated with obesity; changes to modifiable aspects of the neighborhood environment may curb the growth of obesity in the US and other developed nations. However, currently the majority of studies are cross-sectional and thus not appropriate for evaluating causality. The goal of this study was to evaluate the effect of a neighborhood-changing intervention on changes in obesity among older women. Over the past 30 years the Portland, Oregon metropolitan region has made significant investments in plans, regulatory structures, and public facilities to reduce sprawl and increase compact growth centers, transit-oriented development approaches, and green space. We used geocoded residential addresses to link data on land-use mix, public transit access, street connectivity, and access to green space from four time points between 1986 and 2004, with longitudinal data on body mass index (BMI) from a cohort of 2003 community-dwelling women aged 66 years and older. Height and weight were measured at clinic visits. Women self-reported demographics, health habits, and chronic conditions, and self-rated their health. Neighborhood socioeconomic status was assessed from census data. Neighborhood walkability and access to green space improved over the 18-year study period. On average there was a non-significant mean weight loss in the cohort between baseline (mean age 72.6 years) and the studys end (mean age 85.0 years). We observed no association between neighborhood built environment or change in built environment and BMI. Greater neighborhood socioeconomic status at baseline was independently associated with a healthier BMI at baseline, and protected against an age-related decline in BMI over time. BMI decreases with age reflect increased frailty, especially among older adults with complex morbidities. Future research should consider the influence of the neighborhood environment on additional relevant health outcomes and should include measures of the social environment in conjunction with built environment measures.

Behavioral Reactivity Associated With Electronic Monitoring of Environmental Health Interventions-A Cluster Randomized Trial with Water Filters and Cookstoves

Subject reactivity--when research participants change their behavior in response to being observed--has been documented showing the effect of human observers. Electronics sensors are increasingly used to monitor environmental health interventions, but the effect of sensors on behavior has not been assessed. We conducted a cluster randomized controlled trial in Rwanda among 170 households (70 blinded to the presence of the sensor, 100 open) testing whether awareness of an electronic monitor would result in a difference in weekly use of household water filters and improved cookstoves over a four-week surveillance period. A 63% increase in number of uses of the water filter per week between the groups was observed in week 1, an average of 4.4 times in the open group and 2.83 times in the blind group, declining in week 4 to an insignificant 55% difference of 2.82 uses in the open, and 1.93 in the blind. There were no significant differences in the number of stove uses per week between the two groups. For both filters and stoves, use decreased in both groups over four-week installation periods. This study suggests behavioral monitoring should attempt to account for reactivity to awareness of electronic monitors that persists for weeks or more.

Faecal contamination of household drinking water in Rwanda: A national cross-sectional study.

Unsafe drinking water is a leading cause of morbidity and mortality, especially among young children in low-income settings. We conducted a national survey in Rwanda to determine the level of faecal contamination of household drinking water and risk factors associated therewith. Drinking water samples were collected from a nationally representative sample of 870 households and assessed for thermotolerant coliforms (TTC), a World Health Organization (WHO)-approved indicator of faecal contamination. Potential household and community-level determinants of household drinking water quality derived from household surveys, the 2012 Rwanda Population and Housing Census, and a precipitation dataset were assessed using multivariate logistic regression. Widespread faecal contamination was present, and only 24.9% (95% CI 20.9-29.4%, n=217) of household samples met WHO Guidelines of having no detectable TTC contamination, while 42.5% (95% CI 38.0-47.1%, n=361) of samples had >100TTC/100mL and considered high risk. Sub-national differences were observed, with poorer water quality in rural areas and Eastern province. In multivariate analyses, there was evidence for an association between detectable contamination and increased open waste disposal in a sector, lower elevation, and water sources other than piped to household or rainwater/bottled. Risk factors for intermediate/high risk contamination (>10TTC/100mL) included low population density, increased open waste disposal, lower elevation, water sources other than piped to household or rainwater/bottled, and occurrence of an extreme rain event the previous day. Modelling suggests non-household-based risk factors are determinants of water quality in this setting, and these results suggest a substantial proportion of Rwandas population are exposed to faecal contamination through drinking water.

Assessing Latrine Use in Rural India: A Cross-Sectional Study Comparing Reported Use and Passive Latrine Use Monitors

Although large-scale programs, like Indias Total Sanitation Campaign (TSC), have improved latrine coverage in rural settings, evidence suggests that actual use is suboptimal. However, the reliability of methods to assess latrine use is uncertain. We assessed the reliability of reported use, the standard method, by comparing survey-based responses against passive latrine use monitors (PLUMs) through a cross-sectional study among 292 households in 25 villages in rural Odisha, India, which recently received individual household latrines under the TSC. PLUMs were installed for 2 weeks and householders responded to surveys about their latrine use behavior. Reported use was compared with PLUM results using Bland–Altman (BA) plots and concordance statistics. Reported use was higher than corresponding PLUM-recorded events across the range of comparisons. The mean reported “usual” daily events per household (7.09, 95% confidence interval [CI] = 6.51, 7.68) was nearly twice that of the PLUM-recorded daily average (3.62, 95% CI = 3.29, 3.94). There was poor agreement between “usual” daily latrine use and the average daily PLUM-recorded events (ρc = 0.331, 95% CI = 0.242, 0.427). Moderate agreement (ρc = 0.598, 95% CI = 0.497, 0.683) was obtained when comparing daily reported use during the previous 48 hours with the average daily PLUM count. Reported latrine use, though already suggesting suboptimal adoption, likely exaggerates the actual level of uptake of latrines constructed under the program. Where reliance on self-reports is used, survey questions should focus on the 48 hours prior to the date of the survey rather than asking about “usual” latrine use behavior.

Assessing patterns and determinants of latrine use in rural settings: A longitudinal study in Odisha, India

Introduction Monitoring of sanitation programs is often limited to sanitation access and coverage, with little emphasis on use of the facilities despite increasing evidence of widespread non-use. Objectives We assessed patterns and determinants of individual latrine use over 12 months in a low- income rural study population that had recently received latrines as part of the Government of India’s Total Sanitation Campaign (TSC) in coastal Puri district in Odisha, India. Materials and methods We surveyed 1938 individuals (>3 years) in 310 rural households with latrines from 25 villages over 12 months. Data collection rounds were timed to correspond with the seasons. The primary outcome was reported use by each member of the household over the prior 48 h. We classified use into three categories—“never”, “sometimes” and “always/usually”. We also assessed consistency of use over six days across the three seasons (dry cold, dry hot, rainy). We explored the association between individual and household-level variables and latrine use in any given season and longitudinally using multinomial logistic regression. We also inquired about reasons for non-use. Results Overall, latrine use was poor and inconsistent. The average response probability at any given round of never use was 43.5% (95% CI = 37.9, 49.1), sometimes use was 4.6% (95% CI = 3.8, 5.5), and always/usual use was 51.9% (95% CI = 46.2, 57.5). Only two-thirds of those who reported always/usually using a latrine in round one reported the same for all three rounds. Across all three rounds, the study population was about equally divided among those who reported never using the latrine (30.1%, 95% CI = 23.0, 37.2), sometimes using the latrine (33.2%, 95% CI = 28.3, 38.1) and always/usually using the latrine (36.8%, 95% CI = 31.8, 41.8). The reported likelihood of always/usually versus never using the latrine was significantly greater in the dry cold season (OR = 1.50, 95% CI = 1.18, 1.89, p = 0.001) and in the rainy season (OR = 1.34, 95% CI = 1.07, 1.69, p = 0.012), than in the dry hot season. Across all three seasons, there was increased likelihood of always/usually and sometimes using the latrine versus never using it among females and where latrines had a door and roof. Older age groups, including those aged 41–59 years and 60+ years, and increase in household size were associated with a decreased likelihood of always/usually using the latrine versus never using it. The leading reason for non-use was a preference for open defecation. Conclusion Results highlight the low and inconsistent use of subsidized latrines built under the TSC in rural Odisha. This study identifies individual and household levels factors that may be used to target behavior change campaigns to drive consistent use of sanitation facilities by all.

Study design of a cluster-randomized controlled trial to evaluate a large-scale distribution of cook stoves and water filters in Western Province, Rwanda

Background In Rwanda, pneumonia and diarrhea are the first and second leading causes of death, respectively, among children under five. Household air pollution (HAP) resultant from cooking indoors with biomass fuels on traditional stoves is a significant risk factor for pneumonia, while consumption of contaminated drinking water is a primary cause of diarrheal disease. To date, there have been no large-scale effectiveness trials of programmatic efforts to provide either improved cookstoves or household water filters at scale in a low-income country. In this paper we describe the design of a cluster-randomized trial to evaluate the impact of a national-level program to distribute and promote the use of improved cookstoves and advanced water filters to the poorest quarter of households in Rwanda. Methods/Design We randomly allocated 72 sectors (administratively defined units) in Western Province to the intervention, with the remaining 24 sectors in the province serving as controls. In the intervention sectors, roughly 100,000 households received improved cookstoves and household water filters through a government-sponsored program targeting the poorest quarter of households nationally. The primary outcome measures are the incidence of acute respiratory infection (ARI) and diarrhea among children under five years of age. Over a one-year surveillance period, all cases of acute respiratory infection (ARI) and diarrhea identified by health workers in the study area will be extracted from records maintained at health facilities and by community health workers (CHW). In addition, we are conducting intensive, longitudinal data collection among a random sample of households in the study area for in-depth assessment of coverage, use, environmental exposures, and additional health measures. Discussion Although previous research has examined the impact of providing household water treatment and improved cookstoves on child health, there have been no studies of national-level programs to deliver these interventions at scale in a developing country. The results of this study, the first RCT of a large-scale programmatic cookstove or household water filter intervention, will inform global efforts to reduce childhood morbidity and mortality from diarrheal disease and pneumonia. Trial registration This trial is registered at Clinicaltrials.gov (NCT02239250).

Use of Serologic Responses against Enteropathogens to Assess the Impact of a Point-of-Use Water Filter: A Randomized Controlled Trial in Western Province, Rwanda

Diarrhea is a leading contributor to childhood morbidity and mortality in sub-Saharan Africa. Given the challenge of blinding most water, sanitation, and hygiene (WASH) interventions, diarrheal disease outcome measures in WASH intervention trials are subject to potential bias and misclassification. Using the platform of a cluster-randomized controlled trial of a household-based drinking water filter in western province, Rwanda, we assessed the impact of the drinking water filter on enteric seroconversion in young children as a health outcome and examined the association between serologic responses and caregiver-reported diarrhea. Among the 2,179 children enrolled in the trial, 189 children 6-12 months of age were enrolled in a nested serology study. These children had their blood drawn at baseline and 6-12 months after the intervention was distributed. Multiplex serologic assays for Giardia, Cryptosporidium, Entamoeba histolytica, norovirus, Campylobacter, enterotoxigenic Escherichia coli and Vibrio cholerae were performed. Despite imperfect uptake, receipt of the water filter was associated with a significant decrease in seroprevalence of IgG directed against Cryptosporidium parvum Cp17 and Cp23 (relative risk [RR]: 0.62, 95% confidence interval [CI]: 0.44-0.89). Serologic responses were positively associated with reported diarrhea in the previous 7 days for both Giardia intestinalis (RR: 1.94, 95% CI: 1.04-3.63) and C. parvum (RR: 2.21, 95% CI: 1.09-4.50). Serologic responses for all antigens generally increased in the follow-up round, rising sharply after 12 months of age. The water filter is associated with reduced serologic responses against C. parvum, a proxy for exposure and infection; therefore, serologic responses against protozoa may be a suitable health outcome measure for WASH trials among children with diarrhea.

Active living environment assessments in four rural Latino communities.

Objective Latinos and rural residents are less active and have a greater prevalence of overweight/obesity compared with their non-Latino white and urban counterparts. The objective of this study was to assess the active living environment in four rural, predominantly Latino communities. Methods Assessments were taken using the Rural Active Living Assessment (RALA) in four rural predominantly Latino communities in Central Washington from September–November 2013. Street Segment Assessments of town center, thoroughfare, neighborhood and school zones were assessed for features related to walkability. Physical activity amenities, programs and policies in each town were assessed. Scores were generated for amenities, programs and policies. Data were analyzed with descriptive statistics and logistic regression. Results A total of 103 segments were assessed. Sidewalks in good condition were present in 32% of segments and shoulders in 44% of segments. Half of street segments were rated as walkable. Parks and playgrounds were available; however, half of these were rated in poor condition. All four districts offered after school physical activity programming but only two had a late bus option. Conclusions These four rural towns have some policies, programming and infrastructure in place that support active living. The information from the RALA can be used to inform program and policy development to enhance physical activity in these rural communities.