Young women in West and Central Africa have been described by the United Nations as being especially vulnerable to HIV/AIDS. Despite a consensus that increased efforts are necessary to address the needs of this particular demographic, correlates of HIV seropositivity in young West and Central African women have not been systematically described. This study fills this gap using a rich set of publicly available survey data.For this cross-sectional study, we combined HIV test results for young women (age 15-24 years) with information on demographic, cultural and socioeconomic correlates from 17 recent Demographic and Health Surveys (DHS) to estimate odds ratios (OR) from fixed effects logistic regression models accounting for potential individual, household-level and contextual risk factors of HIV seropositivity.The prevalence of HIV seropositivity among young women is higher than for men of the same age in all included surveys, except for the Burkina Faso DHS. An important correlate of HIV seropositivity in young women is early sexual activity  = 1.100, 2.072), while higher education is associated with reduced odds of being HIV positive . No significant correlation has been found for individual HIV awareness, but HIV stigma is negatively associated with HIV seropositivity .The results demonstrate the need to design effective policies addressing behavioral risks in young women. In particular, increasing HIV awareness alone is likely to be insufficient. Instead, information campaigns need to focus on transforming awareness into behavioral change. Moreover, fostering formal education may be an effective tool in the fight against HIV/AIDS. Despite several decades of dedicated research and strong policy commitment, HIV/AIDS remains a major health care challenge in many parts of sub-Saharan Africa, with an estimated 1.2 million newly-infected individuals in the region in 2017 . ImportaGiven these alarming statistics, it is crucial to thoroughly understand the various correlates associated with the elevated HIV risk among young West and Central African women in order to design effective HIV initiatives tailored to local needs. While several previous studies have identified potential risk factors for women, such as early sexual activity  or socioTo address these limitations, the present study exploits a rich data set of recent Demographic and Health Surveys (DHS) from 17 West and Central African countries to systematically investigate a large set of correlates of HIV seropositivity in young women. In doing so, established modelling techniques are used that allow for a distinction of individual-level and contextual variables. The study thereby contributes to the literature by highlighting for an especially vulnerable demographic potential key risk factors that have not previously undergone comparative assessment in the context of this high-priority region.The data used in the present analysis were obtained from the DHS program, a publicly accessible database of cross-sectional surveys administered by ICF International in a large number of low- and middle-income countries . All surHIV blood testing was performed following a standardized protocol, ensuring comparability and confidentiality of results . The outWe estimated a series of increasingly restrictive fixed-effects logistic regression models in order to evaluate the association of individual, household and contextual variables with individual HIV seropositivity. In the most liberal specification, we adjusted for survey-level fixed effects to guard against confounding at the country- or survey-level. In a second step, we further included fixed effects at the level of subnational regions. While this removed the possibility to evaluate regional contextual variables, the inclusion of more restrictive fixed effects allowed us to further relax modeling assumptions. In a next step, we then re-estimated both specifications limiting the analysis to young women who have already heard of HIV/AIDS in order to further assess the role of HIV awareness and stigma, leaving us with a total of four regression models. In contrast to our strategy, several previous studies assessing correlates of HIV seropositivity focused on multi-level modelling rather than fixed-effect approaches . While tt tests were two-sided and tests with type I errors of less than 10% were considered statistically significant.In order to allow for meaningful interpretation of pooled survey results, standard DHS weights were rescaled such that they summed up to the 2018 female population of each country according to World Bank data . MoreoveAll regression models accounted for sociodemographic characteristics, which have been shown to be associated with HIV status in previous analyses ,10. ThisRespondents’ attitudes towards HIV were assessed using a set of binary indicators that were summarized with two index variables representing the fraction of responses reflecting HIV awareness or stigma, respectively . Similarly, we find evidence that never having married is associated with reduced odds of HIV seropositivity , although results do not indicate that polygamy is a statistically significant correlate. In contrast to what was hypothesized, respondents who believe women are justified to ask for condom use if their husbands have a sexually transmitted disease face elevated odds of HIV seropositivity , while both having had multiple sexual partners and not having used a condom at the most recent sexual encounter during the past 12 months turn out to be statistically insignificant.Turning to social and cultural factors, it can be observed that having primary education relative to no education is weakly associated with 42% higher odds of HIV seropositivity , while higher education  but not secondary education is correlated with a reduction in odds. Moreover, we do not find statistically significant evidence that regular television watching or various religious affiliations are associated with the odds of being HIV positive. The results further show that young women living in female-headed homes face significantly higher odds than those in male-headed households  only if no adult male is present. Moreover, large and highly significant odds ratios can be observed for high household wealth quintiles (relative to the poorest quintile), while we find no significant association for the urban vs rural location of households. Among the set of regional variables, neither the fraction of households from the poorest quintile nor average school years turn out to be statistically significant. Similarly, local economic activity, proxied by the average night time light emissions within respondents’ region of residence, is not significantly correlated with HIV status. Finally, we find no statistically significant evidence that the share of respondents who heard of HIV is associated with HIV seropositivity.We assess the robustness of key modelling decisions in the remaining columns 2 to 4. Accordingly, when replacing the contextual variables by regional fixed effects (column 2), results for all individual and household-level variables remain highly persistent, with the exception that the association for primary schooling turns insignificant. Moreover, they remain very similar when estimating the model for the sub-sample of women who have already heard of HIV and adding HIV awareness and stigma scores, regardless of whether the model contains contextual variables (column 3) or regional fixed effects (column 4). While the mean HIV awareness score within a region is negatively associated with HIV seropositivity , no significant association can be observed for individual HIV awareness scores. Moreover, individual HIV stigma correlates with a reduction in the odds of HIV seropositivity .This study describes key prevalence patterns and correlates of HIV seropositivity in young West and Central African women using a large data set of Demographic and Health Surveys from 17 countries. Survey-level prevalence estimates confirm that young women are typically more often HIV positive than men of the same age, suggesting that they are particularly vulnerable. Based on multivariate analyses accounting for regional and country-level confounding, we find that early sexual activity is a highly robust correlate, which is in line with previous results for women of childbearing age in sub-Saharan Africa . HoweverThe previously mentioned importance of early sexual activity seems to provide support for abstinence-based information and education campaigns that are widely implemented throughout sub-Saharan Africa. Evidence from Kenya, however, suggests that such campaigns are unlikely to reduce the incidence of unprotected sex ,22. ProvOur results further show that while higher socioeconomic status is associated with increased odds of HIV seropositivity, high levels of formal education correlate with reduced odds, suggesting that a further strengthening of school systems could be a powerful tool in addressing HIV risks in West and Central Africa. Finally, women residing in households with a female household head and no adult male in the household have elevated odds of HIV seropositivity, which could be explained by the fact that these households may be more likely to have lost household members to AIDS and thus face elevated HIV risks . In contSeveral limitations apply to this study. First, the use of observational cross-sectional data implies that the described associations are not necessarily causal. While efforts were made to address endogeneity with the usage of survey and regional fixed effects, the nature of the data makes it impossible to fully control for confounding at the individual or household level. Second, despite a relatively large sample size, it is important to stress that insignificant associations do not constitute proof for the absence of effects, as power issues might have limited our ability to discover statistically significant relationships. For instance, in a related study on HIV determinants in sub-Saharan Africa , the autTaken together, this article highlights important relationships between HIV seropositivity and potential risk factors in young women. In particular, we identify early sexual activity as an important correlate, but we question the effectiveness of abstinence-related education campaigns. Moreover, our results suggest that increasing HIV awareness alone is likely to be insufficient given an overall lack of association between individual HIV awareness and seropositivity. Instead, more involving strategies may be necessary that reach young people not only on an informational level but also emotionally. Finally, fostering formal education may be powerful in further reducing HIV incidence in West and Central Africa.


Nitrogen pollution is one of the primary threats to coastal water quality globally, and governmental regulations and marine policy are increasingly requiring nitrogen remediation in management programs. Traditional mitigation strategies  are not always enough to meet reduction goals. Novel opportunities for additional nitrogen reduction are needed to develop a portfolio of long-term solutions. Increasingly, in situ nitrogen reduction practices are providing a complementary management approach to the traditional source control and treatment, including recognition of potential contributions of coastal bivalve shellfish. While policy interest in bivalves has focused primarily on nitrogen removal via biomass harvest, bivalves can also contribute to nitrogen removal by enhancing denitrification . Recent evidence suggests that nitrogen removed via enhanced denitrification may eclipse nitrogen removal through biomass harvest alone. With a few exceptions, bivalve-enhanced denitrification has yet to be incorporated into water quality policy. Here, we focus on oysters in considering how this issue may be addressed. We discuss policy options to support expansion of oyster-mediated denitrification, describe the practical considerations for incorporation into nitrogen management, and summarize the current state of the field in accounting for denitrification in oyster habitats. When considered against alternative nitrogen control strategies, we argue that enhanced denitrification associated with oysters should be included in a full suite of nitrogen removal strategies, but with the recognition that denitrification associated with oyster habitats will not alone solve our excess nitrogen loading problem. Excess nitrogen loading is a leading cause of coastal ecosystem degradation globally . The symNitrogen is particularly challenging to manage because it enters coastal water bodies through both point  and nonpoint  sources and these require different management solutions. In the CWA, point sources  are permitted through the National Pollution Discharge Elimination System . Under nitrogen TMDLs, permits require wastewater treatment facilities to meet nitrogen effluent concentrations and load limitations . These permit efforts have successfully reduced point source loading of nitrogen in several high-profile waterbodies such as Long Island Sound, Tampa Bay, and Chesapeake Bay . While iMany watersheds, however, are dominated by nonpoint source loads rather than point sources of nitrogen . Under aGiven the challenges and limitations associated with managing nitrogen sources, in situ nitrogen reduction practices that remove nutrients from the water after they have entered the waterbody have also been growing in use . These pCrassostrea virginica) and hard clams (Mercenaria mercenaria) have been recently approved for inclusion in local (clams and oysters) and regional (oysters only) nitrogen management  gas  nitrogen to non-reactive di-nitrogen . A variety of nitrogen reduction practices— including both traditional infrastructure and nature-based solutions—have been implemented or proposed, from in situ practices such as stream or wetland restoration to sewering. Beneficiaries could be public agencies seeking to achieve public water quality goals or regulated entities that need to offset nitrogen discharge. In the latter case, nitrogen trading programs have been proposed as a mechanism to enable regulated nitrogen sources to meet nitrogen reduction goals by paying other entities to help meet their nitrogen load requirements (WLA) (Oyster-mediated denitrification can be supported directly through implementation of payment for ecosystem services (PES) programs, whereby producers of ecosystem services  are compensated by beneficiaries to continue providing the services . In PES ts (WLA) . Regulatts (WLA) . This co−1 year−1) of in situ projects would need to be competitive with those incurred by point and nonpoint sources that currently offer credits. Within existing point source trading programs, the price of nitrogen credits is typically less than $10 lb−1 year−1 , integrating bivalve-mediated denitrification into nitrogen management plans could have major impacts on a variety of conservation and resource management plans. For restoration projects, payments for nitrogen removal services would provide a continual, quantifiable benefit that might motivate additional reef restoration activities and lead to an increase in restored acreage in sanctuaries or other areas protected from harvest; similar impacts have been proposed from valuing other services . CurrentTo be effective, the financial and nonfinancial incentive systems acknowledging oyster-mediated denitrification must increase the number of oysters placed in coastal waters through both aquaculture and restoration over what would have occurred in an absence of the program. Additionality is the incremental level of nitrogen removal achieved from what would have occurred in an absence of active management policy efforts. The result would be payments for services that would have been provided anyway, without payment, through the course of normal business operations . AdditioThe impact of any payment of nitrogen removal services program, including credit trading programs, on aquaculture growth will also depend partly on the value of the credit or payments. Economic modeling has suggested that higher credit prices will facilitate growth in the aquaculture industry . The effThe type of financial incentive system can alter the size and characteristics of oyster production. For example, input subsidies can skew oyster investments toward specific types of inputs or production methods. PES systems that relate oyster size to higher levels of oyster processing may lead to changes in the size composition of marketed oysters . For exaEnhancement of oyster populations, whether through aquaculture or reef restoration practices, would also provide additional ecosystem services beyond nitrogen reduction. Ancillary benefits in addition to nitrogen reduction are often a consideration in developing TMDL implementation plans . The filThe nature of in situ oyster-mediated denitrification also means that some sites may not be suitable for this approach . EnvironAvailability of space for cultivation or restoration may present additional challenges . A potenSiting challenges may be addressed through the use of a growing number of GIS-based mapping tools to aid in the identification of appropriate sites that minimize user conflict and have no bacteria-based water quality restrictions . The incDenitrification is a nitrogen removal pathway for many common nitrogen reduction best management practices see , and quaA recent review has identified best practices for documenting oyster-mediated denitrification enhancement associated with either oyster aquaculture or restoration practices . A set of recent recommendations from the Chesapeake Bay Program included site-specific measurements of denitrification to determine local rates due to variability derived from the complex feedbacks that occur between bivalves, the water column, and the reef microbial community . OystersThe rates of nitrogen removal will be dependent on the local environment experienced by a given oyster, especially in terms of average current velocities and phytoplankton and suspended sediment concentrations, as well as the ways that ambient salinity and temperature impact a variety of physiological factors. Physical configuration of the oysters in a reef, and variations in aquaculture cultivation practices, may also impact nitrogen removal. For example, for off-bottom aquaculture, bottom sediment quality and the presence of nitrifying and denitrifying microbes are important. Sites with poor sediment conditions  will result in minimal or no denitrification . ChangesIf widespread use of shellfish-induced denitrification is to occur within water quality management programs, straightforward and low-cost options are needed to quantify the nitrogen removal services from enhanced denitrification . Some evActive use of shellfish-related denitrification as a water quality management option will be greatly increased with the development of sufficiently acceptable models to quantify the levels of nitrogen removal through denitrification. Predicting denitrification in estuarine settings is not a new modeling challenge. A process-based model for simulating sediment biogeochemistry processes in coastal ecosystems was initially developed by Reduced complexity models that are designed for end-user input such as the farm aquaculture resource management (FARM) model also estimate nitrogen removal . While aModeling and quantification efforts should be evaluated within the policy context of ambient water quality management. Water quality managers may consider the level of certainty and confidence in nitrogen removal practices to generate specific levels of nitrogen control. In the policy context, uncertainty of model estimates of oyster-mediated denitrification enhancement should be evaluated against the uncertainties and costs  associatWater quality managers commonly accept and rely on average removal efficiencies for nonpoint source practices that have considerable observed ranges in control effectiveness . For exaThis summary shows the potential of, and challenges to, inclusion of oyster denitrification in nitrogen management programs. In many respects, oyster denitrification is not unique to water quality management, as denitrification is an important nitrogen reduction pathway for many land based nonpoint source practices . VerificOyster-mediated denitrification enhancement is emerging as one of several nitrogen reduction tools employed by resource managers, and the discussion here illustrates its potential to contribute to coastal and estuarine nitrogen management. Similar arguments could be made for consideration of denitrification enhancement by other organisms, such as clams, mussels, and wetland plants . RecogniGiven the noted benefits and challenges associated with integrating oyster-mediated denitrification into nitrogen reduction plans, an adaptive management approach will be critical for successfully implementing new practices and integrating them into the broader approach to nitrogen management. Adaptive management, which is an iterative process by which management actions are modified in response to progress on achieving objectives, is thought to be useful for dealing with the inherent uncertainty in the management of complex systems . AdaptivIn summary, it is clear that more tools are needed to reduce excess anthropogenic nitrogen in estuaries. For bivalve shellfish such as oysters, we should consider the full potential for nitrogen reduction, including denitrification, and methods to incentivize these in situ practices. Current science is able to directly measure microbially-mediated denitrification and the scientists are actively developing more robust tools to estimate these rates with both empirical relationships and mechanistic models. Finally, the adaptive management framework employed by coastal and estuarine resource managers is sufficiently sophisticated to integrate this nuance into both restoration and aquaculture contexts, with a diversity of potential implementation frameworks.


Listening in noisy or complex sound environments is difficult for individuals with normal hearing and can be a debilitating impairment for those with hearing loss. Extracting meaningful information from a complex acoustic environment requires the ability to accurately encode specific sound features under highly variable listening conditions and segregate distinct sound streams from multiple overlapping sources. The auditory system employs a variety of mechanisms to achieve this auditory scene analysis. First, neurons across levels of the auditory system exhibit compensatory adaptations to their gain and dynamic range in response to prevailing sound stimulus statistics in the environment. These adaptations allow for robust representations of sound features that are to a large degree invariant to the level of background noise. Second, listeners can selectively attend to a desired sound target in an environment with multiple sound sources. This selective auditory attention is another form of sensory gain control, enhancing the representation of an attended sound source while suppressing responses to unattended sounds. This review will examine both “bottom-up” gain alterations in response to changes in environmental sound statistics as well as “top-down” mechanisms that allow for selective extraction of specific sound features in a complex auditory scene. Finally, we will discuss how hearing loss interacts with these gain control mechanisms, and the adaptive and/or maladaptive perceptual consequences of this plasticity. Auditory scene analysis— the ability to segregate specific sound features from multiple overlapping sources— is essential for extracting meaningful information from a complex sound environment . The claLike humans, many animals— such as birds , frogs , and othMost natural sounds, including human speech, are characterized by dynamic changes in acoustic energy across spectral and temporal domains . In ordeNatural acoustic scenes are characterized by stimuli that can vary over a wide range of sound levels, roughly 10–12 orders of magnitude . The audDynamic range adaptation to mean sound level is observed across multiple levels of the auditory system, most notably at the AN , inferioThe auditory system is not only exposed to a wide range of sound levels, but any acoustic scene may be comprised of a relatively large or restricted subset of intensities across this spectrum. Thus, in addition to adapting to mean sound level, auditory neurons must be able to modulate their response properties to changes in the variance or contrast of sound levels present in the environment . ContrasThe combined effect of dynamic range adaptation and contrast gain control is to minimize the influence of background noise on auditory feature encoding. Indeed, by the level of the ACx, adaptation to mean level and contrast enables speech sounds to be represented in a way that is robust to the presence of background noise . HoweverIn a natural environment, multiple sound sources often originate from different locations and being able to identify the spatial location of distinct sound sources is a key component to auditory scene analysis. Binaural cues, such as interaural time (ITD) and level (ILD) differences, are essential for localizing sounds in space. The medial superior olive (MSO) and lateral superior olive (LSO) of the auditory brainstem are the initial sites of ITD and ILD processing in the mammalian auditory system, respectively. These brainstem nuclei contain coincidence detecting neurons that encode ITD and ILD differences by comparing the timing of converging inputs from the ipsilateral and contralateral ear with submillisecond precision . Becausein vivo recordings from the ACx of mice trained to detect a target sound in background noise shortly after a change in the background contrast have provided some of the first evidence that cortical gain modulation and sound detection behavior are modulated by contrast in a parallel manner in the same subjects  of cortical neurons. In a series of experiments where ferrets were trained to discriminate a tonal target in the presence of background noise stimuli that were comprised of TORCs , it was demonstrated that the STRFs of ACx neurons dynamically adapt to the stimulus features, enhancing responses to the target frequency while reducing responses to the non-target spectral and temporal features  Fritz e, 2005a. While the above studies indicate that top-down attentional signals dynamically reshape receptive fields in the primary ACx in a task-specific manner, an important question that remains is the anatomical locus of these top-down signals. As sound information ascends through the auditory system, neurons preferentially encode more abstract sound entities or categorizations rather than detailed spectrotemporal features . This abBehavioral task engagement is not only associated with attention driven changes to sound feature encoding but has also been shown to directly influence the degree of bottom-up adaptation to statistical changes in sound. For instance, a recent study revealed that the magnitude of dynamic range adaptation in the IC of macaques was enhanced in animals actively engaged in a tone-in-noise detection task compared to when they were passively listening to the same stimuli . RecordiAnimal studies have clearly demonstrated that attentional state and experience can influence auditory response properties and adaption to sound stimulus statistics. Parallel human studies have provided evidence that this attention-driven plasticity is indeed important for auditory scene analysis. In human ACx, selective attention enhances psychophysical performance through increases in neural gain . IncreasThe level of noise invariance is also highly regulated by the directionality of the attended source in humans, suggesting that hierarchical cortical processing allows for spectrotemporal feature extraction that is strongly spatially modulated . High-deThis section has highlighted our current understanding of behavioral state influences on auditory processing and the evidence for top-down regulation of feature encoding and adaptation in the auditory system. However, several questions remain to be answered. For instance, despite strong evidence for attentional gain control and task-dependent receptive field plasticity in the auditory system, it is still unclear if gain modulation can sufficiently account for the receptive field changes seen with task engagement . In addiThe combination of bottom-up adaptations to the sound statistical environment and top-down modulation of receptive field properties greatly effects sound feature encoding in the auditory system and is likely to impact our ability to listen to target sound sources in a noisy environment. There is also evidence that these bottom-up and top-down adaptations directly interact, as task engagement can modulate how auditory neurons adapt to changes in incoming stimulus statistics. An important question, therefore, is if these bottom-up and top-down adaptations converge on common neuronal mechanisms. Does attention co-opt the circuits that mediate bottom-up gain adaptations, or do top-down and bottom-up gain control rely on independent mechanisms that can interact in complex ways? There are number of cellular and circuit mechanisms that may be used to implement gain adaptations to changes in incoming stimulus statistics and/or selective attention . This seVm) can multiplicatively regulate tuned neural responses , which also receives collateral inputs from the MSO , superior olivary complex (SOC) and even the cochlea  Winer e. While wHow do descending auditory projections contribute to stimulus statistic adaptation? While cortical silencing has significant effects on neuronal excitability in the MGB and IC, this manipulation does not affect contrast gain control  or mean Within this section we have provided a summary of our current understanding of cellular and circuit mechanisms that contribute to bottom-up and top-down adaptation throughout the auditory system. We have focused on both local synaptic and circuit interactions between excitatory and inhibitory neurons as well long-range connections between auditory regions that play essentials roles in adaptive sound processing. The role of specific interneuron subclasses and their specialized contributions to subcortical and cortical microcircuits remains an active area of interest in sensory processing. In particular, the contribution of specific interneuron classes to bottom-up stimulus statistic adaptation and top-down task-dependent receptive-field plasticity remains to be fully elucidated. While recent work has indicated that PV neurons are unlikely to mediate contrast gain control in the ACx, the role of other interneuron subtypes is less well understood. Recent computational studies have suggested that top-down inhibitory neurons that disinhibit bottom-up cortical circuits, similar to the VIP neuron circuit motif described above, can explain the attentional effects of auditory tuning properties . HoweverOne of most prominent and disabling disruptions associated with hearing loss is the inability to hear in noisy environments. Difficulties hearing in noise could be due to a general reduction in audibility and degraded encoding of incoming sound input as a consequence of hearing loss. However, studies have shown that speech perception and hearing in noise difficulties are present even when cochlear amplification is accounted for Sensorineural hearing loss is often associated with overt damage to sensory hair cells, resulting in elevated sound detection thresholds  Schmied. PermaneWhile there are three times as many outer hair cells (OHC) than inner hair cells (IHC), virtually all (∼95%) afferent signals from the cochlea are relayed to the central auditory system via IHCs synapsing on type 1 spiral ganglion neurons (SGNs)  Spoendl. AccumulThe difference in detection between quiet and noisy conditions following cochlear degeneration may be due in part to peripheral mechanisms. Spared AN fibers maintain normal thresholds and tuning following IHC or SGN degeneration and detecting tones in quiet may only require a small fraction of surviving peripheral afferents . InteresLoss of afferent drive to the central auditory system— be it due to ototoxic drugs, sensorineural hearing loss, or acoustic deprivation— have been shown to result in a compensatory increase in neuronal gain in the central auditory system, a phenomenon termed central gain enhancement  Gerken . Gain in+/K+ ATPase pump inhibitor ouabain, which selectively destroys type-I SGNs, or chinchillas treated with the anti-cancer agent carboplatin, which selectively destroys IHCs in these animals, have shown that recovery in tone detection thresholds in quiet (What are the perceptual consequences of central gain enhancement? There is growing evidence that central gain enhancement is associated with restoration of hearing thresholds in quiet . Parallein quiet  correspoin quiet  (Chamberin quiet . Howeverin quiet . Interesin quiet . This exin quiet . Indeed,in quiet  or noisein quiet  (Radziwoin quiet . These rRecent evidence suggests the intriguing notion that central gain changes that support restoration of sound processing in quiet backgrounds may actively interfere with auditory circuit mechanisms that normally support adaptation to background noise. While thresholds in quiet are remarkably normal in animals with severe cochlear degeneration, performance in hearing damaged animals was much worse when challenged with a tone-in-noise detection task  Lobarin. ExaminaThe mechanisms of central gain enhancement remain to be completely elucidated; however, several lines of evidence suggest that a combination of increased excitatory neuronal function and, in particular, decreased inhibitory function contribute to this experience-dependent plasticity . Recent In addition to having sizeable impact on bottom-up sound processing and adaptation, hearing loss is also likely to affect top-down regulation of sound feature encoding. There is a well-characterized relationship between hearing loss and cognitive decline, although the directionality and mechanisms are strongly debated . It is nWe live in a world full of sounds. The auditory system employs a variety of adaptive coding strategies , 2 to nain vivo manipulation of putative generators of bottom-up and top-down adaptations. It is also possible that different forms of auditory plasticity can interfere with each other, as may be the case with sensorineural hearing loss.A number of synaptic and circuit mechanisms are used to implement adaptive coding strategies in the auditory system , includiListening in noisy environments poses additional challenges for those with hearing loss . This diIn summary, the studies reviewed here indicate that the auditory system is highly adaptive, modulating its response properties to best fit the current environmental and/or behavioral goals. These adaptations appear to be crucial for optimal representation of sounds under diverse conditions and for listening in complex auditory environments. Further understanding of the mechanisms mediating bottom-up and top-down adaptations to sound processing, as well as the interaction between them, is crucial for harnessing the auditory system’s vast potential to compensate for difficult listening conditions, particularly following sensorineural hearing loss.BA and HG wrote the manuscript together and approved of the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The purpose of this study was to test the feasibility and preliminary efficacy of Promoting Positive Care Interactions (PPCI)—a four step intervention designed to establish positive care interactions between staff and residents with cognitive impairment or dementia in Assisted Living (AL). Initially designed as a traditional on-site intervention, PPCI was later transformed to be conducted remotely through webinar and virtual meetings due to challenges related to onsite engagement in AL during the COVID-19 pandemic. Additionally, the study adopted shorter timeline, a single group pretest-posttest design, and limited recruitment to staff only; 17 care staff were recruited, and data was collected via online surveys and interviews. PPCI was successfully implemented as intended with considerable stakeholder engagement. Findings demonstrated feasibility and promising staff adoption of PPCI. Continued research is needed to optimize the quality of care interactions in AL and evaluate whether online approach to staff training can change staff behavior.


Baseline incisors were compared. In a unilateral mandible pilot study, defects—ranging from critical size defect to complete ramus osteotomies—were created to assess effect on dentition . Within 90% confidence intervals, animals showed no baseline left/right differences in their incisors. There are apparent dental changes associated with unilateral defect type and location. Thus, at baseline, animals exhibit statistically significant incisor symmetry and there is an apparent relationship between mandible defect and incisor growth. The baseline symmetry proven here sets the stage to study the degree to which hemi-mandible destabilizing procedures result in measurable & reproducible disruption of dental asymmetry. In a validated model, an implant designed to function under load that prevents incisor asymmetry would provide supporting evidence that the implant has clinically useful load-bearing function.Animals with elodont dentition and unfused mandible symphyses are hypothesized to have symmetric incisor morphology. Since these animals maintain their teeth by gnawing, they may provide physiologic feedback on mechanical function when unilateral mandible defects are created that manifest as ipsilateral changes in tooth structure. This defect model would potentially generate important information on the functional/mechanical properties of implants. Rats’ and rabbits’ mandibles and teeth are analyzed with µCT at baseline and post-intervention ( The larger project of which this study is a part is to develop a craniofacial load-bearing defect model that enables physiologic identification of the minimum mechanical properties required in a bone graft to reconstitute a defect in a highly stressed skeletal zone. This model would ideally possess the following attributes: 1) allow for an objective quantifiable measure of physiologically relevant mechanical function in bone, (2) provide longitudinal information on the function of a skeletal unit; function that is degraded by a defect but restored with skeletal reconstitution, (3) allows for the implantation of plates and/or load-bearing bone substitutes in the test (defect) region, and (4) be relevant and translatable to human applications. Animal models currently described in the literature such as those using implanted strain gauges, either fail to meet all of these criteria or introduce confounding variables that have been shown to alter the animal’s masticatory behavior  biomechanical effect. This corroborates past observations that the CSD could function as a negative surgical control with a consistent, reproducible result ,8. The larger [intermediate] defect in the rat mandibular ramus presents some challenge in terms of avoiding injury to important structures. The space in which to place a defect is relatively small—the trajectory of the reserve crown in the mandible has it curving posteriorly  and superiorly  abutting the anterior ramus limiting the anterior  extent of the defect. Though there is some room to work superiorly while protecting the NVB, there is little room for error working posteriorly as any extension of the defect in this direction risks fracture of the tail (angle) of the mandible. Despite the challenge, it can be created in the rat and, like the CSD, caused no changes to the dentition. In the rabbit the intermediate defect is easily extended to over 20 mm (extending superiorly from the inferior mandible border) without injuring the dentition or the NVB. This defect also appeared to have no impact on the incisor growth at any point examined by CT. In both animals, eating and masticatory recovery with these larger-than-CSD defects (ID) occurred in the same time frame as animals with the smaller CSD. The CRO caused unmistakable changes in both the rat and rabbit with distinct loss of normal morphology of the ipsilateral incisor including longer ipsilateral tooth growth . In both animals, the preserved morphology in the contralateral incisor indicates that the animal is able to continue using that side. The continued use was consistent behaviorally with continued mastication and food consumption . Also, both rat and rabbit with narrow gap CRO demonstrated complete bony healing of the defect with apparent synchronous restoration of incisor morphology (and symmetry). As expected, the healing and dental changes occurred more quickly in the rat than the rabbit. In the rat, the wide-gap CRO did not heal and resulted in irreversible (in the study time frame) and dramatic elongation of the ipsilateral incisor with relative maintenance of the contralateral morphology. Somewhat surprisingly in the rabbit wide-gap CRO, was the restored incisor symmetry (at 10 weeks) despite the fact that the defect repair zone did not appear fully ossified. The symmetry indicates an apparent return of functional use. It is not clear whether a fibrous non-union in the defect zone was undergoing a delayed healing process or had already healed in a bony union that was interrupted by a re-fracture. A larger study with a longer duration, more frequent imaging, and histopathological analysis of the mandible specimen is needed to better examine this. The explanted mandible specimens in this study were subjected to 4-point mechanical testing (not described in this manuscript) which rendered them poorly suited for histological fixation.Therefore, based on the critical size and intermediate defects in the anterior ramus, there was no correlation between defect volume and tooth morphology. As the defect volume increases (particularly for rats), the risk of neural vascular bundle damage increases. If such damage occurs, this does result in changes in tooth morphology. If the defect is a complete osteotomy between the ramus and mandible body, then ipsilateral tooth morphology is clearly impacted. Based on this, we conclude that, in the anterior ramus, defect volume alone does not seem to affect tooth morphology assuming bony continuity remains between the ramus & body and both dental tissue and NVB are protected. To induce tooth morphological changes  it is necessary to either damage the neurovascular bundle or cause a frank fracture of the mandible that separates the tooth-bearing mandible from the ramus to which the muscles of mastication largely insert.This study justifies further exploration of a full osteotomy defect model in both rats and rabbits for developing load-bearing bone substitutes, bone adhesives, or prosthetics such as resorbable plating systems. The unique dentition of these animals allows for real time feedback on the functional biomechanics of an implanted hemi-mandible. The pre-defect dentition serves as a baseline reference, and related to the non-bony symphysis, there is some evidence in this study that the contralateral (non-defected) side can also serve as a reference for functional mastication. If validated these models could help identify the minimum mechanical requirements that a synthetic bone substitute, adhesive or plate must possess to provide load-bearing skeletal support in the mandible. An important limitation of this study is related to study size. This is particularly true for the defect model development. Further studies will be necessary examining each individual defect and its associated effect on dentition in sufficient sample size to generate reliable and reproducible data. Another limitation is the lack of histomorphometry as a means to better understand the underlying biology. For example, to better understand these models for testing bone substitute materials, future studies would ideally be informed by an examination of bone healing and vascular watersheds. Finally, mechanical testing of the specimen would also yield important information and this work is ongoing. Advantages of the rat are lower cost and convenience which includes ease of housing and care. Related to its high metabolic rate, the incisors grow more quickly than they do in rabbits—its incisors can grow as much as 1 mm/day as opposed to 2–3 mm/week in rabbit incisors . There are indications that the rabbit mandible model, despite the greater expense and other inconveniences, would be more suitable. Most obviously, the rabbit mandible is physically larger than the rat making surgical procedures less technically demanding. Anatomically, the rabbit incisor reserve crown does not extend beyond the diastema which is anterior to the reserve crowns of the cheek teeth. The defect in the anterior ramus can easily be created without injuring the reserve crowns of any teeth. In contrast, the rat incisor reserve crown extends fully under the cheek teeth and abuts the anterior ramus making it more challenging, though certainly not impossible, to create the defect without causing some dental damage.While the focus of this study was on rabbit incisors, rabbit cheek teeth are also continuously growing, allowing for additional sources of data compared to the rat which has brachyodont cheek teeth that do not continuously erupt. We focused only on incisors due to their rate of growth. Typically, rabbit incisors grow about 2–3 mm/week whereas the cheek teeth grow about 3 mm/month . TherefoImportantly, rabbits appear to exhibit basic multicellular unit remodeling that is naturally occurring (like humans), while rats have limited intra-cortical bone remodeling in the absence of external stimuli  Rabbits,Another reason to consider the rabbit as a strong preclinical model for testing load-bearing bone substitute materials stems from studies of the temporomandibular joint which have indicated similarities in the masticatory apparatus between rabbits and humans ,26. The A validated animal model described here could also enable a more precise preclinical examination of requisite geometric properties for dental implantology. For instance, prior work on patients receiving dental implants that were 4 by 4 mm (as opposed to 8.5 mm long implants) exhibited four month results clinically comparable to the longer implant . HoweverµCT and high resolution CBCT are effective means for non-invasive quantifiable assessment of dental morphology in both rat and rabbit. The continuously erupting teeth in these laboratory animals exhibit left-right symmetry in the normal state. The rabbit, due to size and anatomy, is more amenable as a model. Creating a defect larger than a 5 mm CSD in the rat while preserving vital dental and neurovascular structures is possible but requires more skill. There appears to be a relationship between hemi-mandible stability and ipsilateral tooth growth in elodont dentition. In order to validate this as an animal model for in-vivo mechanical strength testing, future work on appropriate sample sizes and utilizing the dental metrics developed here will need to add more frequent imaging as well as histopathological analysis of mandible specimens.


GAA variant identified and those in whom the observed genotype is of uncertain clinical significance.Measurement of alpha-glucosidase activity on dried blood spots has been the main method to screen for Pompe disease, but a paradigm shift has been observed in recent years with the incorporation of gene panels and exome sequencing in molecular diagnostic laboratories. An 89-gene panel has been available to Canadian physicians since 2017 and was analyzed in 2030 patients with a suspected muscle disease. Acid alpha-glucosidase activity was measured in parallel in dried blood spots from 1430 patients. Pompe disease was diagnosed in 14 patients, representing 0.69% of our cohort. In 7 other patients, low enzyme activities overlapping those of Pompe disease cases were attributable to the presence of pseudodeficiency alleles. Only two other patients had enzymatic activity in the Pompe disease range, and a single heterozygous pathogenic variant was identified. It is possible that a second variant could have been missed; we suggest that RNA analysis should be considered in such cases. With gene panel testing increasingly being performed as a first-tier analysis of patients with suspected muscle disorders, our study supports the relevance of performing reflex enzymatic activity assay in selected patients, such as those with a single  GAA gene, which encodes an acid alpha-glucosidase enzyme .Enzymatic activity measurement as a reflex test can also be used to reclassify variants of uncertain significance in certain circumstances. In particular, as illustrated by our patient carrying a pathogenic variant and the variant of uncertain significance c.1805C>T (p.Thr602Ile), a low enzyme activity consistent with Pompe disease may contribute to reclassify the latter as likely pathogenic, according to ACMG guidelines . Indeed,cenarios ; [https:We conclude that a combined approach, using DNA sequencing followed by dried blood spot acid alpha-glucosidase activity assay as a reflex test when indicated, can be recommended as best practice to identify Pompe disease patients in the molecular era. Although the rate of diagnosis of Pompe disease is similar in LGMD patients using gene panels or WES compared to enzymatic screening, reflex enzymatic testing potentially decreases the risk of missing a diagnosis when only one pathogenic variant is detected by DNA sequencing, and may also be used to confirm or rule out a diagnosis of Pompe disease following the observation of a genotype of uncertain clinical significance.


N = 19). Participants in this study were the 10 active family caregivers . Their updates and reflections during these calls were documented in fieldnotes and analyzed for key themes. Data showed that the pandemic has illustrated the direct costs, both financial and otherwise, that informal dementia carers bear in Jamaica. It also intensified pre-existing challenges faced by family carers. We provide recommendations for sustainable support for family carers.This article provides descriptive insights of the experiences of family caregivers of persons living with dementia during the COVID-19 pandemic. Data were generated as part of a qualitative cross-national project to explore the costs and consequences of providing unpaid dementia care. Participants in Jamaica, who were recruited using community gatekeepers, information booths at health fairs, conferences, and other outreach events, were contacted by telephone to discuss their experiences of the pandemic. When face-to-face in-depth interview data collection was suspended due to the pandemic, ethical approval was received to contact all research participants who were informal unpaid family caregivers, both those whose care recipients had died and those who were active caregivers ( The COVID-19 pandemic has had unprecedented effects on the livelihood and health of people across the globe. However, people living with dementia (PLWD) and their carers stand to be disproportionately affected by both severe illnesses caused by the virus and the socio-economic repercussions of the pandemic . On the In many low- and middle-income countries (LMICs) such as Jamaica, there are very few formalized care services for PLWD. In Jamaica, dementia care is typically provided informally in private households. This is constituted of unpaid –mostly female– family members, with or without assistance from others in the informal care sector, specifically those who are paid in cash and/or lack formal employment contracts . This reThe costs, consequences, and realities of providing unpaid care for PLWD in LMIC contexts like Jamaica is under-researched , and theQualitative data in Jamaica were collected as part of a cross-national project about the costs and consequences of providing unpaid dementia care (other countries were India and Mexico). The project was conducted by two experienced qualitative researchers and a team of more novice qualitative researchers who received in-depth training as part of the larger project. We used a theoretical sampling strategy designed to maximize variation in key social and demographic characteristics likely to influence caregiving experiences see . We aimen = 19) included both active family carers of PLWD (n = 10) and former family carers of PLWD (n = 9). Following the onset of the COVID-19 pandemic in Jamaica in March 2020, ethical approval was received from the London School of Economics and Political Science [REC ref. 000834] in the UK and the University of the West Indies, Mona, Jamaica [ECP 122, 18/19 to contact all participants throughout the pandemic either via telephone or WhatsApp Messenger, depending on the individual participant’s preference. We developed and used open-ended scripts to guide exchanges via telephone and texts . Participants were prompted to share their experiences adjusting to providing care during the pandemic at the time of contact and, based on support needs identified, were made aware of any community support resources available. Interactions ranged between 2–30 minutes, depending on how much the participant was willing to share. We typed detailed summaries of these conversations into a securely stored spreadsheet and conducted inductive thematic content analysis of those summaries using QSR International’s latest NVivo qualitative data management software (Data collected during October 2019 and March 2020 (software .n = 10) at the beginning of the pandemic  despite the significant cost implications.Maintaining social connection. Considering concerns surrounding lack of engagement for the PLWD, three participants shared strategies such as regular telephone audio calls between the PLWD and close friends or relatives to ensure that the PLWD regularly had new conversations or virtual attendance at previously enjoyed activities, such as church, so the PLWD could have social interaction and stimulation.As the pandemic progressed, both participants caring for their spouse shared that their offspring, who all lived abroad, paid them visits. Participants carefully planned these visits and ensured that they maintained all the necessary protocols. They also shared how meaningful these visits were for both the PLWD and themselves as carers. A female carer providing care for her husband described how, despite him being mostly non-verbal, her spouse vocalized to their child “I am so happy to see you” and “You must know how much you mean to me.”Modifying care. One participant from the high SES classification, who used paid care services, discussed moving the PLWD into a part of the house that had less person-traffic. She noted that navigating all the persons in the house, including grandchildren who now had school at home, has been a challenging adjustment. The benefits of having multi-room homes were also evident with another high SES participant, an essential worker, who contracted COVID-19 and reported having to quickly convert a storage room in his home to a quarantine space to keep his mother who is living with dementia safe.Though not prompted by COVID, a participant from a lower SES classification, noted how she moved her grandmother from Kingston to her grandmother’s countryside home in another parish, with a paid care worker previously known to the family, to reduce tension between her aunt and her grandmother. Ongoing COVID-19 movement restrictions coupled with lack of internet connection and phone services in the countryside parish, made it difficult to maintain regular contact with her grandmother after this move.coping strategies, impact on employment, and financial strain.As the primary caregivers of PLWD, participants’ wellbeing and financial status were instrumental to their ability to provide appropriate care. The following sub-themes capture the ways in which the pandemic has impacted participants’ means of providing unpaid care: Coping strategies. At each point of contact, each of the participants expressed concerns around uncertainty, worrying about being alone, and fear of their family members catching the virus. Importantly though, they also spoke about coping strategies including spirituality, gardening, and exercise, noting that these resources offered them a sense of purpose as they continued to navigate the pandemic within their care roles.Impact on employment. The pandemic had different effects on participants’ employment status and by extension their source(s) of income. Two participants who provided care at home noted that their place of employment had embraced remote work at various points during the pandemic which allowed them to spend more time caring for their loved one. For others, however, lack of flexibility to work remotely, as was the case for one participant who identified as an essential worker, often meant having to leave their homes to be at the physical workplace. Another participant noted that her working fewer hours meant that she did not get paid as much as before the pandemic.Financial strain. Amidst increased support needs, four participants from the middle and low SES classification groups shared experiences of financial strain when attempting to fill the resource gaps in their care arrangements. As one participant noted: “...the biggest burden is the financials but other than that things are good…” . Hospital fees and increased costs for paid care were two common expenses among this sub-group of carers. Two participants who provided care in their homes noted that they had to hire additional domestic workers to help with care provision. Because the pandemic negatively affected their own incomes, this need for additional help meant that they had to seek financial assistance from other family members.Thematic analyses indicated that the pandemic has illustrated the direct costs  that informal dementia carers bear in Jamaica. These direct costs existed before COVID and persist during the pandemic despite differences in care setting, SES classification and use of additional formal/paid care services.Direct costs during the pandemic included medical bills for the PLWD and hiring additional paid care workers, both with and without medical qualifications, as dementia symptoms progressed. Inaccessibility to timely medical support services and lack of inclusion of carers of PLWD in protocol considerations  led to instances where participants' family members became ill and were left untreated, or participants attempted to fill the gap by hiring private nurses. This represented additional financial costs for participants, who were already shouldering significant costs of care, amidst a pandemic-induced atmosphere of increased job uncertainty and pay cuts.Before the onset of the COVID-19 pandemic, unpaid carers constructed tailored, informal care systems with the resources available to them. In the context of Jamaica, these care systems existed despite a lack of dementia-specific social safety nets . While tThe restrictions in social engagement during the pandemic have also intensified the need for increased targeted social support for unpaid carers and for PLWD. While participants highlighted the role of their faith and personal social networks during the pandemic, they noted a significant gap in more targeted support options offered to carers of PLWD and for the PLWD themselves. Considering participants' identification of their faith as a coping mechanism, partnerships with places of worship-led support groups to support the needs of caregivers and persons living with dementia may be a useful intervention to formalize existing support available. However, given that some participants expressed challenges accessing previously available support, it will be important to provide diverse modalities of this resource such as offering recordings of any educational sessions asynchronously, sharing content via messaging groups  and willingness to allow for physical delivery of any educational or psycho-social support resources.As Jamaica undergoes population aging and international experts advocate for the need for better management of NCDs in LMICs, especially during the pandemic , these eThe pandemic has illustrated the direct costs  that informal dementia carers bear in Jamaica. The findings suggest that increased care demands amidst diminishing care resources increases the vulnerability of both persons living with dementia and caregivers. While the body of research is growing about the experience of caregivers in the context of developing countries, continued engagement with informal carers is required to influence policy, inform interventions and guide resource allocation for future crises such as natural disasters, to which the region is vulnerable. Without appropriate social safeguards and assistance, persons face increased vulnerability during crises. While these informal care systems have thus far endured throughout the pandemic, this continuity comes at great costs to carers—extensive demands on finances, time, and emotional wellbeing—and with limited options for relief. Governmental organizations, advocacy groups, and places of worship have rallied to provide some support for older adults during the pandemic. However, it is essential to develop evidence-informed, dementia-specific resources and support to ensure that PLWD and their carers from all SES backgrounds live well and do not shoulder excessive burdens.


Using an adaption of the Photovoice method, this study explored how food insecurity affected parents’ ability to provide food for their family, their strategies for managing household food insecurity and the impact of food insecurity on their well-being.Parents submitted photos around their families’ experiences with food insecurity. Afterwards, they completed in-depth, semi-structured interviews about their photos. The interviews were transcribed and analysed for thematic content using the constant comparative method.San Francisco Bay Area, California, USA.Seventeen parents (fourteen mothers and three fathers) were recruited from a broader qualitative study on understanding the experiences of food insecurity in low-income families.Four themes were identified from the parents’ photos and interviews. First, parents described multiple aspects of their food environment that promoted unhealthy eating behaviours. Second, parents shared strategies they employed to acquire food with limited resources. Third, parents expressed feelings of shame, guilt and distress resulting from their experience of food insecurity. And finally, parents described treating their children to special foods to cultivate a sense of normalcy.Parents highlighted the external contributors and internal struggles of their experiences of food insecurity. Additional research to understand the experiences of the food-insecure families may help to improve nutrition interventions targeting this structurally vulnerable population. In 2019, 10·5 % of all US households were food-insecure, though the prevalence is higher among households with children (13·6 %), households with young children (14·5 %) and households headed by a single mother (28·7 %). Previous research has shown that food insecurity is associated with lower nutrient intake, lower overall dietary quality, higher levels of diabetes and other chronic conditions,5 and poorer overall health among adults. Food insecurity has also been associated with adverse mental health outcomes in mothers,8. While the mechanisms underlying these associations have not been specifically explored, a number of factors have been proposed to explain the observed associations between food insecurity and adverse health outcomes, including poor access to healthy food,10, neighbourhood risk factors and the experience of psychological distress.Over the past several decades, food insecurity has persisted as a critical health problem in the USA. Food insecurity is defined by the US Department of Agriculture as the ‘limited or uncertain availability of nutritionally adequate and safe foods, or the limited or uncertain ability to acquire acceptable food in socially acceptable ways. Another mixed-methods study of parents in the United Kingdom revealed that parents reduced the size of their meals or skipped meals when food supplies were running low and shielded their children from the experience of food insecurity by relying on low-cost foods or takeaway meals. And finally, results of a qualitative study of low-income mothers who had experienced food insecurity during their own childhoods found that women recalled their parents borrowing food from family members and neighbours, using food stamps and food pantries, stealing and gleaning from the environment, suggesting that some of these experiences had lasting impacts.Another mechanism for the associations between food insecurity and physical and mental health outcomes might be through the strategies used by low-income parents to manage and cope with household food insecurity. Some of these strategies may be protective, such as utilising social support networks, whereas other strategies might be harmful, such as experiencing stress and isolation. Qualitative studies can be particularly insightful in understanding one’s lived experiences, as not all behaviours or coping strategies can be measured through survey instruments. However, only a few studies employing qualitative approaches have focused on understanding parents’ or caregivers’ experiences with food insecurity. In one survey of 746 caregivers of children in South Carolina, analysis of open-ended responses revealed that participants changed their food purchases or shifted their food resources, employed cost-saving grocery shopping strategies, changed their meal patterns and adapted their existing resources at home to adjust their household food supply. Historically, Photovoice has been used to give agency to specific populations who may have little power over the structural forces that impact their day-to-day lives. The main goals of Photovoice are to (1) enable people to record and reflect their community’s strengths and concerns, (2) to promote critical dialogue and knowledge about important issues through discussion of photographs and (3) to reach policymakers. To date, this method has been applied to a variety of research topics at the intersection of public health nutrition and health equity–25. In one Photovoice study of African American caregivers from Washington DC, participants discussed the strategies they employed to feed their children the food they wanted them to eat through navigating their local ‘food desert’ and relying on family, friends and food programmes. Another Photovoice study of Latina mothers who recently immigrated from Central America found that participants desired higher quality, more equitable food in their neighbourhood, the ability to shape foods provided to their children at school and more education around healthy eating and its alignment with their nutrition knowledge. Furthermore, a Photovoice study of twelve minority youth in New York City revealed creative solutions to promote healthier eating behaviours, including more education, better access to and promotion of fresh produce and advocating for healthier foods from the food industry.This study aims to build on existing research using an adaption of the Photovoice methodology to explore parents’ ability to provide food for their family within the context of food insecurity. Photovoice is a method of community-based participatory research that uses visual images to provide insight on the perspectives of individuals through their lived experiences, beliefs and narrativesIn the present study, we adapt the Photovoice method to explore how food insecurity affected parents’ ability to provide food for their family, their strategies for managing household food insecurity and the impact of food insecurity on their well-being. Understanding these dynamics can inform improvements for the structure of food assistance programmes and how to increase access to resources in a socially acceptable way.. In particular, the Photovoice sub-study focused on exploring the challenges that families face in providing food for their children within the context of household food insecurity. Conventionally, Photovoice projects engage the study participants at all stages of research. Adaptations were made to the conventional Photovoice method to facilitate parents’ participation and to complement the emergent themes from the larger qualitative study. In the present study, the researchers formalised the research question, parents submitted their photos and discussed them one-on-one with the study coordinator and the data analysis was conducted by the research team. This study was approved by the University of California, San Francisco Human Research Protection Program.This study took place in the San Francisco Bay Area as a sub-study of a larger qualitative research project on understanding the psychological distress of food insecurity in low-income parents and childrenThe Photovoice sub-study was conducted between June 2016 and January 2017. Parents initially completed in-depth semi-structured interviews with the senior author about their family’s experience of food insecurity and the impact of food insecurity on their psychological well-being. Parents were then provided a fact sheet about the Photovoice sub-study and asked about their interest in participation. Those who expressed interest were given a brief one-on-one training of the Photovoice method and asked to take photos of the daily challenges they faced ‘(in providing food for their children during difficult economic times)’. The parents were encouraged to interpret the research question broadly and to use the photos to describe their personal narratives around food insecurity. Although digital cameras were available for the study participants, all parents opted to use their personal smartphones to take and send photos to the study staff throughout a 2-week period. Written informed consent was obtained from all participants for the Photovoice sub-study.After a 2-week period, each parent completed an in-person 30-min semi-structured interview with the study coordinator to review and discuss their photos in greater detail. Parents were asked to select the photos that were most meaningful to them and to provide more in-depth descriptions of the setting and representation of each photo. Specifically, parents were asked: (1) what made you take the picture?; (2) how does the picture make you feel?; (3) what does the picture illustrate about your day-to-day life, your physical health and/or mental health?; and (4) what do you want lawmakers, advocates or researchers to know about your picture? Parents were compensated $40 for their participation..Interviews with the parents were audio-recorded, transcribed and checked for accuracy. Thematic analysis was conducted using an iterative, inductive approach. Initially, a draft codebook was developed after three researchers reviewed all the content from all transcripts and photos. Next, two researchers independently coded the transcripts and photos from the codebook, meeting regularly with the third researcher to revise or refine the initial list of codes until a final codebook was reached. Two researchers then used the final codebook to independently code all transcripts and photos, with discrepancies being resolved by the third researcher. The emergent themes presented in the manuscript follow the key steps for community-based participatory research using Photovoice: (1) selection of photos that accurately represent the community’s needs, (2) identifying emergent themes, issues or theories and (3) contextualising of the photos through the participant’s own wordsA total of seventeen parents (fourteen mothers and three fathers) participated in the Photovoice sub-study. The mean age was 39 years, ranging from 28 to 61 years. Four parents identified as non-Hispanic White, six as Black/African American, three as Hispanic and four as multi-racial, Native Hawaiian/Pacific Islander or American Indian/Alaskan Native. Using the US Department of Agriculture 18-item Household Food Security Survey Module, three parents had low food security and fourteen parents had very low food security.Four primary themes emerged from the parents’ photos and interviews: (1) food environment promotes unhealthy eating, (2) creative strategies to acquire food with limited resources, (3) psychological distress due to food insecurity and (4) treating their children to special foods to cultivate normalcy.Parents described multiple aspects of their food environment that promoted unhealthy eating behaviours. Photos were taken from a variety of food outlets  and described the messaging, pricing and excessive availability of unhealthy foods that constantly encouraged unhealthy eating. In Fig. Figure Parents described how they used creative strategies to acquire enough and a variety of food with limited food resources. One strategy was to shop at multiple stores to take advantage of different food promotions and availability. In Fig. Parents were particularly concerned about the need to provide their children with fresh fruits and vegetables. One mother felt it was so important that her children have access to organic foods that she started a garden at her apartment complex  targeted marketing of unhealthful foods and beverages in low-income communities,34 and (3) the inverse relation between energetic density and price. Parents described these barriers with anger and frustration, demonstrating how the food environment prevented them from making the right nutritional choices for their children despite their desires for their children to eat healthier food.In the first theme, parents discussed the multiple pressures to eat unhealthy food placed on them by their food environment. Foods that were unhealthy, highly processed and high in added sugar were not only found in abundance but sometimes aggressively promoted through competitive pricing and signage. Conversely, fruits and vegetables, fruit juice and other healthy items were limited in availability or out of reach due to their high prices. These findings highlight three systemic barriers to healthy eating that co-exist for low-income families: (1) neighbourhood disparities in access to supermarkets and other food stores,21,36–39. Other strategies like growing their own food and subscribing to a Community Supported Agriculture box demonstrate the importance that food-insecure parents place on fresh fruits and vegetables when feeding their children and are consistent with a prior Photovoice study that equated eating locally with eating healthfully.The second theme identified creative strategies that parents used to maximise their food budget, including shopping at multiple grocery stores and dollar stores. These findings are consistent with prior studies showing how parents and participants in federal food programmes travel farther to shop at their preferred grocery store, use coupons, take advantage of in-store specials and shop at budget stores to stretch their food budget,40–42. As previously documented in a qualitative study of parents with young children, the psychological distress resulting from food insecurity was intimately tied to their perceived ability as a parent to provide for their children. Parents are known to sacrifice the quality and quantity of food to ensure their children have enough to eat,44. Over time, these behaviours or coping strategies may manifest in poorer mental health for the parent, in part due to their recognition that they cannot fully protect their children from the realities of food insecurity.The third theme describes the psychological burden that food-insecure parents experience while trying to feed their families, including feelings of shame, guilt and distress, providing a potential mechanism to explain why food insecurity has been associated with anxiety disorders and clinical depression in previous studies, the present study shows that food-insecure parents use food rewards to protect their children from food insecurity, and perhaps as a coping strategy to relieve their own guilt and distress as parents.The fourth theme illustrates how parents aspire to cultivate normalcy for their children through special foods or treats. Through varied approaches, parents found ways to treat their families to restaurant meals, to brand-name splurges and even to luxurious foods such as crab. While another study found that parents use food rewards to celebrate a special occasion or an achievement, parental distress may moderate this association and deserves further investigation. Furthermore, these findings can inform the development of community programmes or food assistance policies to better support families with alleviating food insecurity. Programmes that increase neighbourhood healthy food availability or provide financial incentives for fruits and vegetables can eliminate some of the barriers to eating healthfully as described by the parents in the present study. Given the strong influence of food insecurity on mental health, additional resources should also be incorporated into food assistance programmes to more holistically address food insecurity and its sequelae.The results of the present study have implications for research and practice. Qualitative studies are useful in providing critical context around the lived experiences of food insecurity. This narrative is important to inform our mechanistic understanding of quantitative studies connecting food insecurity to adverse health outcomes. For example, the present study highlights parents’ psychological distress as a direct result of their experience of food insecurity, which then influenced the foods they provided for their children. While the research on food insecurity and children’s diet and weight status has been inconclusiveThe strength of this study is the use of the adapted Photovoice method to give participants a mode of expression for issues that may be best understood through visual and verbal representation. All participants preferred to submit photos using their own mobile phone cameras, which proved to be an efficient and cost-effective method to gather these data. Through the photos submitted and their subsequent interviews, we are able to gain an in-depth understanding of each parent’s unique struggle with food insecurity that could not have been captured through quantitative research methods., though there is documented variability in participation levels across published Photovoice studies. We were not able to build this level of participation into the present study. However, we believe the themes and narratives highlighted from participants’ individual experiences will contribute to the broader policy discussions on improving food security through our federal food programmes and the researchers are actively disseminating the findings from this and the larger qualitative project through professional and public outlets.This primary limitation of this study is the adaptations made to the Photovoice method to facilitate participation resulted in low levels of participation across the research process. In the conventional Photovoice method, study participants are highly engaged with researchers in formulating the research question, with discussing and analysing the data as a group, and identifying collective points of advocacyThis study provides an important narrative to parents’ intimate experiences of food insecurity, ranging from the impact of their food environment, their creative approaches to stretch their food budget, the impact of food insecurity on their psychological well-being and their attempts to use special foods to promote normalcy. Further research should continue to draw on community-based participatory research methods to engage individuals from food-insecure households in identifying focal areas for research and advocacy and to foster systemic change to food access, food equity and food security.