Grant Support Research Articles

The AACR Journals: Advancing Progress Toward the AACR's 115-Year Mission.

The AACR Journals: Advancing Progress Toward the AACR's 115-Year Mission.

The AACR Journals: Advancing Progress Toward the AACR's 115-Year Mission.

The AACR Journals: Advancing Progress Toward the AACR's 115-Year Mission.

Longitudinal association between informal unpaid caregiving and mental health amongst working age adults in high-income OECD countries: A systematic review.

Informal unpaid caregivers provide most of the world's care needs, experiencing numerous health and wealth penalties as a result. As the COVID-19 pandemic has highlighted, informal care is highly gendered. Longitudinal evidence is needed to assess the causal effect of caregiving on mental health. This review addresses a gap by summarising and appraising the longitudinal evidence examining the association between unpaid caregiving and mental health among working age adults in high-income Organisation for Economic Co-operation and Development (OECD) countries and examining gender differences. Six databases were searched (Medline, PsycInfo, EMBASE, Scopus, Web of Science, Econlit) from Jan 1, 2000 to April 1, 2022. Population-based, peer-reviewed quantitative studies using any observational design were included. Population of interest was working age adults. Exposure was any unpaid caregiving, and studies must have had a non-caregiving comparator for inclusion. Mental health outcomes (depression, anxiety, psychological distress/wellbeing) were measurable by validated self-report tools or professional diagnosis. Screening, data extraction and quality assessment (ROBINS-E) were conducted by two reviewers. The study was prospectively registered with PROSPERO (CRD42022312401). Of the 4536 records screened; 13 eligible studies (133,426 participants) were included. Overall quality of evidence was moderate. Significant between-study heterogeneity precluded meta-analysis, so albatross and effect-direction plots complement the narrative synthesis. Results indicate a negative association between informal unpaid care and mental health in adults of working age. Importantly, all included studies were longitudinal in design. Where studies were stratified by gender, caregiving had a consistently negative impact on the mental health of women. Few studies examined men but revealed a negative effect where an association was found. Our review highlights the need to mitigate the mental health risks of caregiving in working age adults. Whilst men need to be included in further scholarship, reducing the disproportionate caregiving load on women is a crucial requirement for policy development. Melbourne School of Population and Global Health, Targeted Research Support Grant.

Network evaluation of an innovation platform in continuous quality improvement in Australian Indigenous primary healthcare

BackgroundFrom 2014 to 2019, the Centre for Research Excellence in Integrated Quality Improvement (CRE-IQI) was evaluated as an innovation platform focusing on continuous quality improvement in Indigenous Australian primary healthcare. Although social network analysis (SNA) is a recognized method for evaluating the functioning, collaboration and effectiveness of innovation platforms, applied research is limited. This study applies SNA to evaluate the CRE-IQI’s functioning as an innovation platform.MethodsTwo surveys (2017, 2019) were conducted using social survey and network methods. Survey items covered respondent characteristics, their perceptions of the CRE-IQI’s performance, and its impact and sociometric relationships. Members’ relationship information was captured for the CRE-IQI at three time points, namely start (retrospectively), midpoint and final year, on three network types (knew, shared information, collaborated). SNA software was used to compute standard network metrics including diameter, density and centrality, and to develop visualizations. Survey and network results were addressed in a workshop held by members to develop improvement strategies.ResultsThe response rate was 80% in 2017 and 65% in 2019 (n = 49 and 47, respectively). Between 2017 and 2019, respondents’ mean ratings of the CRE-IQI’s functioning and achievements in meeting its goals were sustained. They perceived the CRE-IQI as multidisciplinary, having effective management and governance, and incorporating Indigenous research leadership, representation and ways of working. Respondents recognized high levels of trust amongst members, rated “good communication and coordination with participants” highly, and “facilitating collaboration” as the CRE’s most strongly recognized achievement. In collaboration and information-sharing networks, average path length remained low in 2017 and 2019, indicating good small-world network properties for relaying information. On average, respondents shared information and collaborated with more CRE members in 2017 than 2019. However, in both 2017 and 2019 there were new collaborations and information-sharing outside of direct collaborations. CRE-IQI outcomes included: evidence generation; knowledge transfer and skills development in quality improvement; research capacity-building, career development; mentoring; grant support; development of new projects; health service support; and policy impact.ConclusionsThis study shows the utility of network analysis in evaluating the functioning, and collaboration, at the individual, organizational and health system levels, of an innovation platform, and adds to our understanding of factors enabling successful innovation platforms.

Longitudinal associations of insulin resistance with change in bone mineral density in midlife women.

BACKGROUNDThe effects of insulin resistance on bone mineral density (BMD) are unclear.METHODSIn Study of Women's Health Across the Nation (SWAN) participants, we used multivariable regression to test average insulin resistance (homeostatic model assessment of insulin resistance, HOMA-IR) and rate of change in insulin resistance as predictors of rate of change in lumbar spine (LS) and femoral neck (FN) BMD in 3 stages: premenopause (n = 861), menopause transition (MT) (n = 571), and postmenopause (n = 693). Models controlled for age, average BW, change in BW, cigarette use, race and ethnicity, and study site.RESULTSThe relation between HOMA-IR and BMD decline was biphasic. When average log2HOMA-IR was less than 1.5, greater HOMA-IR was associated with slower BMD decline; i.e., each doubling of average HOMA-IR in premenopause was associated with a 0.0032 (P = 0.01, LS) and 0.0041 (P = 0.004, FN) g/cm2 per year slower BMD loss. When greater than or equal to 1.5, average log2HOMA-IR was not associated with BMD change. In women in whom HOMA-IR decreased in premenopause, the association between the HOMA-IR change rate and BMD change rate was positive; i.e, slower HOMA-IR decline was associated with slower BMD loss. In women in whom insulin resistance increased in premenopause, the association was negative; i.e, faster HOMA-IR rise was associated with faster BMD decline. Associations of average HOMA-IR and HOMA-IR change rate with BMD change rate were similar in postmenopause, but weaker during the MT.CONCLUSIONWhen it decreases, insulin resistance is associated with BMD preservation; when it increases, insulin resistance is associated with BMD loss.FUNDINGThe SWAN has grant support from the NIH of the Department of Health and Human Services (DHHS) through the NIH National Institute on Aging (NIA), National Institute of Nursing Research (NINR), and Office of Research on Women's Health (ORWH) (grants U01NR004061, U01AG012505, U01AG012535, U01AG012531, U01AG012539, U01AG012546, U01AG012553, U01AG012554, U01AG012495, and U19AG063720).

Behavioral innovations in the management of obesity and overweight using the COM-B model

Abstract Background Increasing overweight and obesity rates represent one of the global health challenges in the 21st century. Obesity is a gateway to many non-communicable diseases and shorter life expectancy. Understanding individual capability, opportunity, and motivation for health behavior change (COM-B) may help to develop effective public health interventions. However, so far, only a very few studies examined interventions based on behavior change theories. Thus, we aimed to assess the potential facilitators and barriers to behavior change in weight management using the COM-B model. Methods We included 146 people with overweight and obesity (66.7% female; mean age 46.62±14.51 years; body mass index 32.46±6.51 kg/m2) from primary care settings. All participants completed the Brief Measure of Behavior Change (COM-B), the General Self-Efficacy Scale (GSE), the Rosenberg Self-esteem Scale (RSE), and the Self-Rated Heath scale (SRH). Multiple linear regression analyses were used to analyze the data. Results In univariate analyses COM-B domains were positively associated with female gender, living with a partner, lower body mass index, and higher SRH. However, the associations between sociodemographic and clinical variables and COM-B domains were no longer significant when self-esteem and general self-efficacy were added to the multivariate regression models. Self-efficacy was associated with reflective motivation (β: 0.53; p < 0.001), physical capability (β: 0.43; p < 0.001), and psychological capability (β: 0.44; p < 0.001) the most significantly. Self-esteem was strongly associated with physical capability (β: 0.41; p < 0.01). Total explained variances in the final models varied from 17.7% to 25.0%. Conclusions Personal resources may play a significant role in weight management and should be included in tailored public health interventions (Grant support: VEGA: 1/0748/22). Key messages • Interventions focused on the enhancement of personal resources may improve weight management. • Behavioral and cultural aspects should be considered when designing effective public health interventions.

Caregiver burden in professionals working in different settings for persons with dementia

Abstract Introduction Professionals caring for persons with dementia (PwD) have to meet demands from various sides. Considering today's high standards put on institutional care with respect to “person centred care” and the skills related to specific needs of PwD, caring for care staff is one of the major challenges. Objectives The aim of this study was to investigate the caregiver burden in professional dementia care and its work related differences. Methods The study was carried out from September 2021 to February 2022 among 105 professionals working in different settings for PwD in Slovakia including home care and day care centres. The Professional Care Team Burden scale (PCTB) and the Zarit Burden Interview (ZBI-12) were chosen to measure caregiver burden. Length of work in the organisation (< 3, 3 to 6, > 6 years), job position (domiciliary and other care worker), and current dementia care intensity (≤ 8, 9 to 39, > 40 hours/week) were also measured. Independent samples T-tests and ANOVA were used to analyse the differences (IBM SPSS 27). Results 87.6% of professionals were women (mean age 48.6±9.8 years). 52.5% worked more than 6 years in the organisation, 53.3% were in the job position of domiciliary care workers, and for 52.1% the current dementia care intensity was 9 to 39 hours/week. Caregiver burden mean scores achieved were 26.7±4.0 (PCTB) and 9.7±6.2 (ZBI-12). The significant difference was found in the PCTB by job position with the higher burden in domiciliary care workers (mean score 26.0 + 4.2, p < 0.05). No significant differences were observed in the PCTB and the ZBI-12 by the length of work in the organisation and current dementia care intensity. Conclusions Specific scales for assessing professionals’ caregiver burden are useful to uncover areas for intervention. Structuring the interventions by taking the care staff subjective feelings of burden into account is important for future improvements in institutional care. (Grant support: VEGA no. 1/0372/20). Key messages

Post systolic shortening by speckle tracking echocardiography as a predictor for cardiovascular events in patients with type 2 diabetes

Abstract Background Post systolic shortening (PSS), measured by speckle tracking echocardiography has emerged as a novel method to evaluate left ventricular function and has been linked to adverse outcomes. Purpose Our aim was to assess if the presence of pathological PSS had prognostic value in the prediction of major cardiovascular events in a cohort of patients with type-II diabetes (T2D). Method Three-hundred-and-sixty-four patients with T2D in the CARDIPP study (Cardiovascular Risk factors in Patients with Diabetes – a Prospective study in Primary care) underwent echocardiography between 2005 and 2009. All patients were evaluated with strain analysis by speckle tracking. PSS was defined as any myocardial contraction occurring after aortic valve closure (Figure 1). Pathological PSS was defined as a post systolic index (PSI) >5% where PSI was calculated as: (peak global longitudinal strain – peak systolic longitudinal strain) / (peak global longitudinal strain) x 100. The composite endpoint of any major cardiovascular event (MACE) was defined as the diagnosis of or death in heart failure, myocardial infarction, or stroke. Cox proportional hazard ratios (HR) with 95% confidence intervals were calculated and were adjusted for sex, age, body mass index, hypertension, smoking, previous cardiovascular events and HbA1c. Results Mean follow-up time was 11.2±2.3 years. Patients with pathological PSS had an increased unadjusted risk of MACE, (HR 3.73, 95% CI 2.06–6.76), which persisted after adjustment (HR 2.20, 95% CI 1.11–4.37) as compared to subjects without pathological PSS. When adding PSS to a risk prediction model including Global Longitudinal Strain (GLS), the adjusted HR (95% CI) for MACE was 2.94 (1.33–6.52) for subjects with reduced GLS (lower limit of normal −16%) and PSI >5%, compared to those with normal GLS and PSI ≤5%. Adverse events were more common in subjects with the combination of pathological PSS and GLS (Figure 2). Conclusions Our results suggest that PSS may provide important additional prognostic information in patients with T2D. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): This work was funded by grant support from FORSS, the Research Council of Southeastern Sweden and from FUTURUM, the Research Council of Jönköping.

ARTERIAL HYPERTENSION AMONG PATIENTS WITH SICKLE CELL DISEASE: ASPECTS OF A COHORT IN JUIZ DE FORA, BRAZIL

Identify the frequency of hypertension in a cohort of patients with SCD, correlating socio-epidemiological and nosological data. A longitudinal study carried out from March 2013 to November 2017. A total of 483 patients with SCD and active registration at FundaçãoHemominas Juiz de Fora (JFO) were included. The diagnosis was confirmed by DNA analysis. A total of 208 patients were excluded for loss of follow up or refusal of the informed consent, resulting in 275 patients analyzed in this cohort. This research was approved by Ethics Committee (n° 419.415). The grant support was given by FundaçãoHemominas and National Institutes of Health HHSN2682011000071. The patients in this study were evaluated for socioeconomic data and SCD complications. The majority of patients were children (54.9%), female (54.2%), and genotype HbSS or HbSβ0 (68.4%). The majority of children (59.6%) had social benefits, while only 31.5% of adults had these benefits. Smoking was more present within men (35.4%) than in women (26.3%). 59.2% of women had already been pregnant. The mean value for SO2 in children was 93.8% and, in adults, 92.8%. High rates of ACS were obtained, occurring in 64.2% of children and 58.9% of adults. Both Hypertrophic cardiomyopathy and dilated cardiomyopathy were more common in adults. Finally, hypertension was diagnosed in 35 patients, in a prevalence of 12.7%, in this amount, 3 patients were children. According toWorld Health Organization (WHO) cardiovascular diseases are the main causes of death in the world. Hypertension is one of the main risk factors for a patient to develop a heart problem, especially when associated with other factors such as Sickle Cell Disease (SCD). It is possible to assume that the chances of hypertension are higher in adults patients and in those who have SCD. Furthermore, social benefits could be a protective factor. Hypertension was associated with the presence of severe SCD genotypes, pregnancy and smoking. Two of these factors are not supposed to occur in children, what may justify the lower prevalence of hypertension in this group.

Accidental Flibanserin Ingestion in Children Causing Acute Respiratory and Central Nervous System Depression: What Health Care Professionals Need to Know.

Department of Psychiatry and Neurobehavioral Sciences, University of Virginia School of Medicine, Charlottesville, Virginia Department of Psychiatry, University of California, San Diego School of Medicine, San Diego, the Department of Psychiatry and Neuroscience, University of California, Riverside, Riverside, and the Neuroscience Education Institute, San Diego, California Guidelines for Letters. Letters posing a question or challenge to an article appearing in Obstetrics & Gynecology should be submitted within 8 weeks of the article’s publication online. Letters received after 8 weeks will rarely be considered. Letters should not exceed 350 words, including signatures and 5 references. Letters will be published at the discretion of the Editor. The Editor may send the letter to the authors of the original paper so their comments may be published simultaneously. The Editor reserves the right to edit and shorten letters. Letters should be submitted using the Obstetrics & Gynecology online submission and review system, Editorial Manager (http://ong.edmgr.com). Financial Disclosure Dr. Clayton has served as a consultant to AbbVie Inc., Brii Biosciences, Fabre-Kramer, Field Trip Health, Janssen Research & Development, LLC, Mind Cure Health, Ovoca Bio PLC, Praxis Precision Medicines, PureTech Health, S1 Biopharma, Sage Therapeutics, Takeda/Lundbeck, Vella Bioscience, Inc., and WCG MedAvante-ProPhase. She has received grants from Daré Bioscience, Janssen, Praxis Precision Medicines, Relmada Therapeutics, Inc., and Sage Therapeutics. She holds royalties/copyrights with Ballantine Books/Random House, Changes in Sexual Functioning Questionnaire, and Guilford Publications. She holds shares/restricted stock units with Euthymics, Mediflix LLC, and S1 Biopharma. Dr. Stahl has served as a consultant to Acadia, Alkermes, Allergan, AbbVie, Axsome, Clearview, Eisai Pharmaceuticals, Gedeon Richter, Intra-Cellular Therapies, Karuna, Levo Therapeutics, Lundbeck, Merck, Neurocrine, Otsuka, Relmada, Sage Therapeutics, Sunovion, Supernus, Taliaz, Teva, Tris Pharma, and VistaGen. He holds options in Genomind, Lipidio, and Delix. He has served on speakers bureaus for Acadia, Lundbeck, Otsuka, Perrigo, Servier, Sunovion, and Teva, and he has received research and/or grant support from Acadia, Allergan/AbbVie, Avanir, Braeburn Pharmaceuticals, Eisai, Eli Lilly, Harmony Biosciences, Indivior, Intra-Cellular Therapies, Ironshore, Neurocrine, Otsuka, Pear Therapeutics, Sage, Shire, Sunovion, Supernus, and Torrent. Editorial support for this Letter to the Editor was performed by Kayt Scott, PhD, Sarah A. Laredo, PhD, and Lauren Hummel, BA, each of Arbor Scientia, supported by Sprout Pharmaceuticals, Inc., according to Good Publication Practices (GPP3). All opinions, conclusions, and data interpretation lie with the authors. The authors have served in the past as consultants to Sprout but received no payment for writing this letter. Support for logistics was provided by Sprout to the agency Arbor Scientia.

Identification of outcomes in clinical studies of interventions for venous thromboembolism in non‐pregnant adults

Identification of outcomes in clinical studies of interventions for venous thromboembolism in non‐pregnant adults

Prospects for the development of glamping in the Russian Federation

The article reveals the features of the development of glamping in the hospitality industry in Russia. Recently, environmental problems have been of concern to the public more and more, and this trend is being transferred to all spheres of public life, including the hospitality industry. People want to take care of the environment, but accommodation in standard tents is not always suitable for a comfortable stay. The client is looking for comfort, but does not want to spoil the natural environment, and this opportunity is provided by a combination of environmental friendliness of camping and the comfort of a hotel, namely glamping. The article provides detailed statistics on the number of glampings in the Russian Federation, examples of successful implementation of glamping projects. Also, special attention is paid to the project of grant support for business, which is engaged in the construction of glampings. In conclusion, the prospects for the development of glampings in Russia with the aim of developing domestic tourism are determined.

Point: Antenatal corticosteroid treatment in the late preterm period-Are the benefits worth the potential risks?

Point: Antenatal corticosteroid treatment in the late preterm period-Are the benefits worth the potential risks?

Social protection and care: Does the Child Support Grant translate to social justice outcomes for female beneficiaries who receive it on behalf of their children?

Social protection and care: Does the Child Support Grant translate to social justice outcomes for female beneficiaries who receive it on behalf of their children?

Remote Biometric Monitoring of Patients With COVID-19 With Exertional Hypoxia Treated With Supplemental Oxygen

Remote Biometric Monitoring of Patients With COVID-19 With Exertional Hypoxia Treated With Supplemental Oxygen

Clinical and Oncologic Safety in Modern Breast Reconstruction.

Boston, Mass.; and Ann Arbor, Mich. From the Division of Plastic Surgery, Massachusetts General Hospital, Harvard Medical School; and Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School. Received for publication May 16, 2022; accepted May 20, 2022. Disclosure: Dr. Chung receives funding from the National Institutes of Health and book royalties from Wolters Kluwer and Elsevier, and has received grant support from Sonex to study outcomes of carpal tunnel surgery. Dr. Colwell has no financial interests to disclose. Amy S. Colwell, M.D., Division of Plastic Surgery, Massachusetts General Hospital, 15 Parkman Street, Boston, Mass. 02114, [email protected], @DrAmyColwell

Kristin Schreiber, M.D., Ph.D., a Recipient of the 2022 James E. Cottrell, M.D., Presidential Scholar Award

Kristin Schreiber, M.D., Ph.D., a Recipient of the 2022 James E. Cottrell, M.D., Presidential Scholar Award

Context Matters-Child Growth within a Constrained Socio-Economic Environment.

Communities in major cities in developing countries may experience economic vulnerability, which has detrimental consequences for maternal and child health. This study investigated individual-, household-, and community-level factors associated with child growth and resilience of early-grade learners aged 6 to 8 years. Demographic characteristics, depression scale, child wellbeing, and anthropometric measurements were collected on a sample of 162 caregiver–child pairs (children 46% female) who receive the child support grant (cash transfer programme) from five low-income urban communities in the City of Johannesburg, South Africa. Height and weight were converted to z-scores using the WHO Anthroplus software. Multiple linear regression was used to assess factors associated with child health outcomes and multi-level regression to account for community-level factors. Higher income vulnerability was associated with lower weight- and height-for-age z-scores (WAZ and HAZ). Not completing secondary schooling and higher household size were associated with lower HAZ but higher BAZ. Child male sex and caregiver with depression were associated with lower child resilience. Caregiver’s level of schooling and household size remained independent predictors of child growth, while the caregiver’s mental health status independently predicted child resilience. Thus, notwithstanding systemic constraints, there may be modifiable drivers that can help in developing targeted intervention.

The Lasting Labor-Market Effects of Cash Transfers: Evidence from South Africa’s Child Support Grant

Abstract Can unconditional cash transfers have long-term benefits for women’s employment in developing countries? This study exploits discontinuous exposure to the South African Child Support Grant for mothers whose children were born one year apart to identify the short- and long-term effects of a positive income shock of roughly $400 ($650 PPP in 2010). In the short term, there is a considerable increase in the probability of being active and looking for a job. Five years after receiving the transfer, mothers who benefited for one year are as likely to be employed as those who never received it; the type of occupation is also similar, other than a small decrease in work in the agricultural sector. Overall, the grant appears to facilitate job search for single mothers in the presence of high search costs, but does not significantly change job prospects.

Ethnoracial inequalities and child mortality in Brazil: a nationwide longitudinal study of 19 million newborn babies

Racism is a social determinant of health inequities. In Brazil, racial injustices lead to poor outcomes in maternal and child health for Black and Indigenous populations, including greater risks of pregnancy-related complications; decreased access to antenatal, delivery, and postnatal care; and higher childhood mortality rates. In this study, we aimed to estimate inequalities in childhood mortality rates by maternal race and skin colour in a cohort of more than 19 million newborns in Brazil. We did a nationwide population-based, retrospective cohort study using linked data on all births and deaths in Brazil between Jan 1, 2012, and Dec 31, 2018. The data consisted of livebirths followed up to age 5 years, death, or Dec 31, 2018. Data for livebirths were extracted from the National Information System for livebirths, SINASC, and for deaths from the Mortality Information System, SIM. The final sample consisted of complete data for all cases regarding maternal race and skin colour, and no inconsistencies were present between date of birth and death after linkage. We fitted Cox proportional hazard regression models to calculate the crude and adjusted hazard ratios (HRs) and 95% CIs for the association between maternal race and skin colour and all-cause and cause-specific younger than age 5 mortality rates, by age subgroups. We calculated the trend of HRs (and 95% CI) by time of observation (calendar year) to indicate trends in inequalities. From the 20 526 714 livebirths registered in SINASC between Jan 1, 2012, and Dec 31, 2018, 238 436 were linked to death records identified from SIM. After linkage, 1 010 871 records were excluded due to missing data on maternal race or skin colour or inconsistent date of death. 19 515 843 livebirths were classified by mother's race, of which 224 213 died. Compared with children of White mothers, mortality risk for children younger than age 5 years was higher among children of Indigenous (HR 1·98 [95% CI 1·92-2·06]), Black (HR 1·39 [1·36-1·41]), and Brown or Mixed race (HR 1·19 [1·18-1·20]) mothers. The highest hazard ratios were observed during the post-neonatal period (Indigenous, HR 2·78 [95% CI 2·64-2·95], Black, HR 1·54 [1·48-1·59]), and Brown or Mixed race, HR 1·25 [1·23-1·27]) and between the ages of 1 year and 4 years (Indigenous, HR 3·82 [95% CI 3·52-4·15]), Black, HR 1·51 [1·42-1·60], and Brown or Mixed race, HR 1·30 [1·26-1·35]). Children of Indigenous (HR 16·39 [95% CI 12·88-20·85]), Black (HR 2·34 [1·78-3·06]), and Brown or Mixed race mothers (HR 2·05 [1·71-2·45]) had a higher risk of death from malnutrition than did children of White mothers. Similar patterns were observed for death from diarrhoea (Indigenous, HR 14·28 [95% CI 12·25-16·65]; Black, HR 1·72 [1·44-2·05]; and Brown or Mixed race mothers, HR 1·78 [1·61-1·98]) and influenza and pneumonia (Indigenous, HR 6·49 [95% CI 5·78-7·27]; Black, HR 1·78 [1·62-1·96]; and Brown or Mixed race mothers, HR 1·60 [1·51-1·69]). Substantial ethnoracial inequalities were observed in child mortality in Brazil, especially among the Indigenous and Black populations. These findings demonstrate the importance of regular racial inequality assessments and monitoring. We suggest implementing policies to promote ethnoracial equity to reduce the impact of racism on child health. MCTI/CNPq/MS/SCTIE/Decit/Bill & Melinda Gates Foundation's Grandes Desafios Brasil, Desenvolvimento Saudável para Todas as Crianças, and Wellcome Trust core support grant awarded to CIDACS-Center for Data and Knowledge Integration for Health.