Establishing Validity and Cross-Context Equivalence of Measures and Indicators

Cross-Cultural Adaptation and Validation of an Attitude about Euthanasia Scale in Portuguese Older Adults with Mixed Anxiety-Depressive Disorder

On 25 May 2023, the Portuguese parliament approved the decriminalisation of euthanasia for incurable illnesses. As the experiences of other countries show us, it will be a matter of time before mental disorders are addressed. Studying the phenomenon, particularly in vulnerable groups, in advance is essential for proper law drafting. Therefore, instruments that allow an objective assessment and comparison between groups must be available. This study aims to explore the validation of Faria's attitude about euthanasia scale in Portuguese older adults with mixed anxiety-depressive disorder. A sample of 114 older adults with mixed anxiety-depressive disorder collected by convenience in the Psychiatry Department of Senhora da Oliveira Hospital in Portugal was included. The pre-final version of the scale was tested in a small group with good results. The validity of the internal structure was analysed using exploratory factorial analysis. The internal consistency study verified reliability. For construct validity, we assessed the correlation with other validated scales measuring attitudes toward euthanasia, cognitive performance, personality and empathy. The attitude about euthanasia scale showed good internal consistency. One factor was retained in the principal component analysis. Significant correlations verified construct validity. The results support the scale's usefulness and validity. This study makes available a unique instrument to assess the overall tendency of the attitudes towards euthanasia from the European-Portuguese perspective, which can be used, for example, to compare Portuguese with Brazilian older adults suffering from the same disorder. Furthermore, the adapted scale paves the way for other cross-cultural translations, adaptations, validations, and comparative analyses.

Development and validation of a short dietary questionnaire for assessing obesity-related dietary behaviours in young children

There are few short, validated tools to assess young children's obesity-related dietary behaviours, limiting the rapid screening of dietary behaviours in research and practice-based early obesity prevention. This study aimed to develop and assess the reliability and validity of a caregiver-reported short dietary questionnaire to rapidly assess obesity-related dietary behaviours in children aged 6 months to 5 years. The Early Prevention of Obesity in Childhood Dietary Questionnaire (EPOCH-DQ) was developed using a rigorous process to determine content and structural validity. Three age-appropriate versions were developed for (1) infants, aged 6-12 months, (2) toddlers, aged 1-2.9 years and (3) pre-schoolers, aged 3-5 years. The questionnaire (7-15 items) measures dietary behaviours, including diet risk from non-core food and beverage intake, diet quality from vegetable frequency, bread type and infant feeding practices. Test-retest reliability was assessed from repeated administrations 1 week apart (n = 126). Internal consistency, concurrent validity (against a comparison questionnaire, the InFANT Food Frequency Questionnaire), construct validity and interpretability were assessed (n = 209). Most scores were highly correlated and significantly associated (p < 0.05) for validity (rs: 0.45-0.89, percentage agreement 68%-100%) and reliability (intraclass correlation coefficient: 0.61-0.99) for diet risk, diet quality and feeding practice items. The EPOCH-DQ shows acceptable validity and reliability for screening of obesity-related behaviours of children under 5 years of age. The short length and, thus, low participant burden of the EPOCH-DQ allows for potential applications in various settings. Future testing of the EPOCH-DQ should evaluate culturally and socio-economically diverse populations and establish the predictive validity and sensitivity to detect change.

What North American retail food environment indices miss in Guatemala: Cultural considerations for the study of place and health

We evaluated the cross-context validity and equivalence of the US- and Canada-originated Retail Food Environment Index (RFEI) and modified RFEI (mRFEI) against a retail food environment dataset from the indigenous-majority city of Quetzaltenango (Xela), Guatemala. The RFEI/mRFEI failed to identify 77% of retailers and misclassified the healthiness of 42% of the remaining retailers in Xela, inaccurately labeling the city a food swamp. The RFEI/mRFEI are not currently suitable for mapping retail food environments in places like Quetzaltenango. Alternative functional and temporal classifications of retail food environments may provide measures with greater contextual fit, highlighting important cultural considerations for the study of place and dietary health.

Construct validity and reliability of the Canadian Eating Practices Screener to assess eating practices based on 2019 Canada's Food Guide recommendations

For the first time since its introduction, the 2019 Canada's Food Guide (2019-CFG) highlighted specific guidance on eating practices, i.e., recommendations on where, when, why, and how to eat. The Canadian Eating Practices Screener / Questionnaire court canadien sur les pratiques alimentaires was developed to assess eating practices based on the 2019-CFG healthy eating recommendations. The objective of this cross-sectional study was to assess the construct validity and reliability of the Canadian Eating Practices Screener. From July to December 2021, adults (n = 154) aged 18-65 years completed a sociodemographic questionnaire and the screener. Construct validity was assessed by examining variability in screener scores, by comparing screener scores among subgroups with hypothesized differences in eating practices, and by examining the correlation between screener scores and fruit and vegetable intake. Reliability, i.e., internal consistency, was assessed by calculating Cronbach's coefficient alpha. Screener item scores were summed to provide a total score ranging from 21 to 105. The mean screener score was 76 (SD = 8.4; maximum, 105), ranging from 53 (1st percentile) to 92 (99th percentile). Differences in total scores in hypothesized directions were observed by age (p = 0.006), perceived income adequacy (p = 0.09), educational attainment (p = 0.002), and smoking status (p = 0.09), but not by gender or health literacy level. The correlation between screener scores and fruit and vegetable intake was 0.29 (p = 0.002). The Cronbach's coefficient alpha was 0.79, suggesting acceptable to high internal consistency. Study findings provide preliminary evidence of the screener's construct validity and reliability, supporting its use to assess eating practices based on the 2019-CFG healthy eating recommendations.

Development of the Canadian Eating Practices Screener to assess eating practices based on 2019 Canada's Food Guide recommendations

In 2019, Health Canada released a new iteration of Canada's Food Guide (2019-CFG), which, for the first time, highlighted recommendations regarding eating practices, i.e., guidance on where, when, why, and how to eat. The objective of this study was to develop a brief self-administered screener to assess eating practices recommended in the 2019-CFG among adults aged 18-65 years. Development of the screener items was informed by a review of existing tools and mapping of items onto 2019-CFG recommendations. Face and content validity were assessed with experts in public health nutrition and/or dietary assessment (n = 16) and individuals from Government of Canada (n = 14). Cognitive interviews were conducted with English-speaking (n = 16) and French-speaking (n = 16) adults living in Canada to assess face validity and understanding of the screener items. While some modifications were identified to improve relevance or clarity, overall, the screener items were found to be relevant, well-constructed, and clearly worded. This comprehensive process resulted in the Canadian Eating Practices Screener/Questionnaire court canadien sur les pratiques alimentaires, which includes 21 items that assess eating practices recommended in the 2019-CFG. This screener can facilitate monitoring and surveillance efforts of the 2019-CFG eating practices as well as research exploring how these practices are associated with various health outcomes.

Measuring Food Security among American Indian and Alaska Native Adults: Validity Evidence Supports the Use of the US Department of Agriculture Module

BACKGROUND

Inequities in access, availability, and affordability of nutritious foods produced by settler colonialism contribute to high rates of food insecurity among American Indian and Alaska Native (AI/AN) households. Efforts to understand the influences of food security programming among AI/AN individuals in the United States are constrained by the absence of validity evidence for food security assessments for this population.

OBJECTIVE

This study assessed whether AI/AN adult responses on the Food Security Survey Module provide an accurate assessment of food security prevalence, especially when compared with other racial and ethnic groups.

DESIGN

A correlational design with the cross-sectional 2019 National Health Interview Survey was used to address the research objective.

PARTICIPANTS AND SETTING

The 2019 National Health Interview Survey contains a sample (N = 30,052) representative of the resident civilian noninstitutionalized population.

MAIN OUTCOME MEASURES

The primary outcome was food security, as characterized by the 10-item US Department of Agriculture Adult Food Security Survey Module. The module evaluates whether insufficient finances result in perceived food shortages and a reduction in the quantity and/or quality of food intake during the prior 30 days.

STATISTICAL ANALYSES PERFORMED

Data were analyzed by racial and ethnic subsamples to assess scale dimensionality (confirmatory factor analysis), Item Response Theory item analysis, differential item functioning, and external validity (χ2 tests).

RESULTS

Results supported the use of the 10-item module for racial and ethnic groups. However, differential item functioning effect sizes exceeded criteria for the Asian, AI/AN, and Hispanic respondents when compared with White respondents. Food security was not significantly related to all expected correlates in the AI/AN subsample.

CONCLUSIONS

Compelling evidence is presented for validity of the FSSM scores in determining food security status of AI/AN adults. Qualitative inquiry that explores how culture influences the way food security is conceptualized and experienced is warranted.

Development of the Healthy Eating Index-Toddlers-2020

The Healthy Eating Index-Toddlers-2020 (HEI-Toddlers-2020) is a measure for assessing how well a set of foods aligns with new guidance in the Dietary Guidelines for Americans, 2020-2025 (DGA) for toddlers aged 12 through 23 months. This new tool was developed using consistent features and the guiding principles of the HEI. The HEI-Toddlers-2020, like HEI-2020, has 13 components reflecting all constituents of dietary intake, except for human milk or infant formula. These components include the following: Total Fruits, Whole Fruits, Total Vegetables, Greens and Beans, Whole Grains, Dairy, Total Protein Foods, Seafood and Plant Proteins, Fatty Acids, Refined Grains, Sodium, Added Sugars, and Saturated Fats. Healthy dietary patterns for toddlers have unique considerations reflected in the scoring standards for Added Sugars and Saturated Fats. Toddlers have lower energy intake relative to high nutrient needs and added sugars should be avoided. Another distinctive difference is that there is no recommendation to limit saturated fats to <10% of energy intake in this age group; however, saturated fats cannot be unlimited without displacing the energy available to achieve other food group and subgroup goals. Calculations using the HEI-Toddlers-2020, like the HEI-2020, result in a total score and a set of individual component scores that reveal a dietary pattern. The release of a HEI-Toddlers-2020 will enable assessment of diet quality that aligns with the DGA and support additional methodological research to examine needs specific to each life stage and how to model trajectories of healthy dietary patterns.

Development of the Canadian Food Intake Screener to assess alignment of adults' dietary intake with the 2019 Canada's Food Guide healthy food choices recommendations

NOVELTY

The Canadian Food Intake Screener was developed to rapidly assess alignment of adults' dietary intake over the past month with the Food Guide's healthy food choices recommendations. The screener was developed and evaluated through an iterative process that included three rounds of cognitive interviews in each of English and French, along with ongoing feedback from external advisors and face and content validity testing with a separate panel of content experts. The 16-question screener is intended for use with adults, aged 18-65 years, with marginal and higher health literacy in research and surveillance contexts in which comprehensive dietary assessment is not possible.

A Decade of Dietary Assessment Methodology Research at the National Institutes of Health, 2012-2021

BACKGROUND

Assessment of individual and population-level dietary intake is critical for public health surveillance, epidemiology, and dietary intervention research. In recognition of that need, the National Insitutes of Health (NIH) has a history of funding research projects designed to support the development, implementation, and refinement of tools to assess dietary intake in humans.

OBJECTIVES

This report provides data and information on NIH-funded dietary intake assessment methodological research over the period of 2012-2021.

METHODS

Data were extracted from an internal NIH data system using the Research, Condition, and Disease Categorization (RCDC) spending category for Nutrition. Data were then examined to identify research focused on dietary assessment tools or methods to capture or analyze dietary intake.

RESULTS

Over the decade of 2012-2021, NIH supported 46 grants and 2 large contracts specific to dietary assessment methods development. The top 6 Institutes and Offices funding dietary assessment methods research were identified. Most projects were limited to adults. Projects ranged from novel methods to capture dietary intake, and refinement of analytical methods, to biomarkers of dietary intake. One key contract supported the automated self-administered 24-h dietary assessment tool (ASA24), a widely used, free tool available to the research community for assessing dietary intake.

CONCLUSIONS

NIH's support for dietary assessment methods development over this 10-y period was small but grew over time with an expanding number and variety of methods, data sources, and technological advancements in the assessment of dietary intake. NIH remains committed to supporting research seeking to advance the field of dietary assessment methods research.

Relative validity and reproducibility of WHO indicators for assessment of feeding practices in children under two years of age

The study aimed to evaluate relative validity and reproducibility of seven WHO indicators of dietary practices in children aged 6-23.9 months. Data from probabilistic sample of children who used primary healthcare services in Rio de Janeiro, Brazil were collected using a 24h dietary recall (24HR) and a closed questionnaire (Q1) on feeding in the day before the study. The last one was reapplied (Q2) around 16 days later. Validity was assessed by comparing the prevalence rates estimated by 24HR and Q1 and calculating the positive (PPV) and negative (NPV) predictive values, sensitivity (Se), specificity (Sp), and accuracy index (AI) for the resulting indicators. For reproducibility, estimated prevalence rates based on Q1 and Q2 were compared and the kappa index and prevalence-adjusted bias-adjusted kappa were estimated. Of the seven estimated indicators, the prevalence of two was overestimated (Continued breastfeeding: 50.0% vs 40.0%; Sweet beverage consumption: 65.1% vs 52.7%) and the prevalence of one was underestimated (Zero vegetable or fruit consumption: 6.5% vs 18.1%). For most indicators, Se and PPV were higher than Sp and NPV. The prevalence rates determined with Q1 and Q2 were similar for 6 indicators. More than half showed good, very good or excellent agreement.

Measuring Contraceptive Autonomy at Two Sites in Burkina Faso: A First Attempt to Measure a Novel Family Planning Indicator

There is growing consensus in the family planning community around the need for novel measures of autonomy. Existing literature highlights the tension between efforts to pursue contraceptive targets and maximize uptake on the one hand, and efforts to promote quality, person-centeredness, and contraceptive autonomy on the other hand. Here, we pilot a novel measure of contraceptive autonomy, measuring it at two Health and Demographic Surveillance System sites in Burkina Faso. We conducted a population-based survey with 3,929 women of reproductive age, testing an array of new survey items within the three subdomains of informed choice, full choice, and free choice. In addition to providing tentative estimates of the prevalence of contraceptive autonomy and its subdomains in our sample of Burkinabè women, we critically examine which parts of the proposed methodology worked well, what challenges/limitations we encountered, and what next steps might be for refining, improving, and validating the indicator. We demonstrate that contraceptive autonomy can be measured at the population level but a number of complex measurement challenges remain. Rather than a final validated tool, we consider this a step on a long road toward a more person-centered measurement agenda for the global family planning community.

Body Composition in Youths Aged 10‒17 Years by Deuterium Oxide Dilution, Air Displacement Plethysmography, and DXA: Validation of the Medical Body Composition Analyzer Bioimpedance Device by a 4-Compartment Model

BACKGROUND

The medical body composition analyzer (mBCA) incorporates advances in multifrequency technology and has been validated using a 4-compartment (4C) model in adults but not in youths aged <18 y.

OBJECTIVES

This study aimed to formulate a 4C model based on 3 reference methods and develop and validate a body composition prediction equation for the mBCA in youths aged 10‒17 y.

METHODS

The body density of 60 female and male youths was measured by air displacement plethysmography, total body water by deuterium oxide dilution, and BMC by DXA. Data from the equation group (n = 30) were used to formulate a 4C model. The all-possible-regressions method was used to select variables. The model was validated in a second cohort (n = 30) in a random split design. The accuracy, precision, and potential bias were evaluated by the Bland and Altman procedure.

RESULTS

Mean age, weight (W), height (H), waist circumference, and z-score of BMI were 13.6 ± 2.3 y, 54.5 ± 15.5 kg, 156 ± 11.9 cm, 75.5 ± 10.9 cm, and 0.70 ± 1.32 z, respectively. The prediction equation was as follows: FFM in kg (FFM_kg) = ([0.2081] ∗ [W] + [0.8814] ∗ [H²_cm/R_Ω] + [0.2055 ∗ Xc_Ω])-15.343; R² = 0.96; standardized root-mean-square error (SRMSE) = 2.18 kg. FFM did not differ between the 4C method (38.9 ± 12.0 kg) and the mBCA (38.4 ± 11.4 kg) (P > 0.05). The relationship between these 2 variables did not deviate from the identity line, was not significantly different from 0, and the slope was not significantly different from 1.0. In the precision prediction model of mBCA, the R² value was 0.98 and SRMSE was 2.1. No significant bias was found when regressing differences between methods and their means (P = 0.08).

CONCLUSIONS

The equation for the mBCA was accurate, precise, had no significant bias, had substantial strength of agreement and could be used in this age group when subjects were preferentially within the constraints of a specified body size.

Complementary and alternative metrics for tracking population-level trends in child linear growth

Stunting prevalence is commonly used to track population-level child nutritional status. However, other metrics derived from anthropometric datasets may be used as alternatives to stunting or provide complementary perspectives on the status of linear growth faltering in low- and middle-income countries (LMICs). Data from 156 Demographic and Health Surveys in 63 LMICs (years 2000 to 2020) were used to generate 2 types of linear growth metrics: (i) measures of location of height distributions (including stunting) for under-5 years (<5y) and 2 to 5 years (2-5y); (ii) model-derived metrics including predicted mean height-for-age z-score (HAZ) at 0, 2, and 5 years; interval slopes of HAZ, height-for-age difference (HAD), and growth delay (GD) from 1 month to 2 years (1mo-2y) and 2-5y; and the SITAR intensity parameter (SITAR-IP) for <5y. Using Spearman's rank correlation coefficient (r), metrics were considered alternatives to stunting if very strongly correlated with stunting (|r|≥0.95) and at least as strongly correlated as stunting with selected population indicators (under 5y mortality, gross domestic product, maternal education). Metrics were considered complementary if less strongly correlated with stunting (|r|<0.95) yet correlated with population indicators. We identified 6 of 15 candidate metrics (stunting 2-5y, mean HAZ <5y and 2-5y, p25 HAZ <5y and 2-5y, predicted HAZ at 2y) as potential alternatives to stunting and 6 as complementary metrics (SITAR-IP, predicted HAZ at 5y, HAZ slope 1m-2y, HAD slope 1m-2y, GD slopes 1m-2y and 2-5y). Three metrics (HAZ slope 2-5y, HAD slope 2-5y years and predicted HAZ at birth) had weak correlations with population indicators (|r| ≤ 0.43). In conclusion, several linear growth metrics could serve as alternatives to stunting prevalence and others may be complementary to stunting in tracking global progress in child health and nutrition. Further research is needed to explore the real-world utility of these alternative and complementary metrics.

Food Insecurity among American Indian and Alaska Native People: A Scoping Review to Inform Future Research and Policy Needs

Food insecurity, defined as insufficient access to nutritious foods, is a social determinant of health that may underpin health disparities in the US. American Indian and Alaska Native (AI/AN) individuals experience many health inequities that may be related to food insecurity, but no systematic analyses of the existing evidence have been published. Thus, the objective of this scoping review was to assess the literature on food insecurity among AI/AN individuals and communities, with a focus on the prevalence of food insecurity and its relations to sociodemographic, nutrition, and health characteristics. Systematic search and data extraction processes were used. Searches were conducted on PubMed as well as peer-reviewed journal and government websites. Of 3174 identified references, 34 publications describing 30 studies with predominantly AI/AN sample populations were included in the final narrative synthesis. Twenty-two studies (73%) were cross-sectional and the remaining 8 (27%) described interventions. The weighted average prevalence of food insecurity across the studies was 45.7%, although estimates varied from 16% to 80%. Most studies used some version of the USDA Food Security Survey Modules, although evidence supporting its validity in AI/AN respondents is limited. Based on the review, recommendations for future research were derived, which include fundamental validity testing, better representation of AI/AN individuals in federal or local food security reports, and consideration of cultural contexts when selecting methodological approaches. Advances in AI/AN food insecurity research could yield tangible benefits to ongoing initiatives aimed at increasing access to traditional foods, improving food environments on reservations and homelands, and supporting food sovereignty.

Development, Validity, and Cross-Context Equivalence of the Child Food Insecurity Experiences Scale for Assessing Food Insecurity of School-Age Children and Adolescents

BACKGROUND

Children ages 6 to 17 years can accurately assess their own food insecurity, whereas parents are inaccurate reporters of their children's experiences of food insecurity. No globally applicable scale to assess the food insecurity of children has been developed and validated.

OBJECTIVES

We aimed to develop a globally applicable, experience-based measure of child and adolescent food insecurity and establish the validity and cross-contextual equivalence of the measure.

METHODS

The 10-item Child Food Insecurity Experiences Scale (CFIES) was based on items previously validated from questionnaires from the United States, Venezuela, and Lebanon. Cognitive interviews were conducted to check understanding of the items. The questionnaire then was administered in 15 surveys in 13 countries. Other items in each survey that assessed the household socioeconomic status, household food security, or child psychological functioning were selected as criterion variables to compare to the scores from the CFIES. To investigate accuracy (i.e., criterion validity), linear regression estimated the associations of the CFIES scores with the criterion variables. To investigate the cross-contextual equivalence (i.e., measurement invariance), the alignment method was used based on classical measurement theory.

RESULTS

Across the 15 surveys, the mean scale scores for the CFIES ranged from 1.65 to 5.86 (possible range of 0 to 20) and the Cronbach alpha ranged from 0.88 to 0.94. The variance explained by a 1-factor model ranged from 0.92 to 0.99. Accuracy was demonstrated by expected associations with criterion variables. The percentages of equivalent thresholds and loadings across the 15 surveys were 28.0 and 5.33, respectively, for a total percentage of nonequivalent thresholds and loadings of 16.7, well below the guideline of <25%. That is, 83.3% of thresholds and loadings were equivalent across these surveys.

CONCLUSIONS

The CFIES provides a globally applicable, valid, and cross-contextually equivalent measure of the experiences of food insecurity of school-aged children and adolescents, as reported by them.

Evaluation of the Healthy Eating Food Index (HEFI)-2019 measuring adherence to Canada's Food Guide 2019 recommendations on healthy food choices

The objective of this study was to evaluate the construct validity and reliability of the Healthy Eating Food Index-2019 (HEFI-2019), which was developed to measure adherence to Canada's Food Guide 2019 (CFG-2019) recommendations on healthy food choices. Dietary intake data from 24-hour dietary recalls in the 2015 Canadian Community Health Survey-Nutrition were used for that purpose. Multidimensionality was examined using principal component analysis. Mean scores were compared among subgroups of the population. The association between scores and energy intake was assessed using Pearson correlations. Cronbach's alpha was calculated to assess reliability. The estimated mean HEFI-2019 score (/80) was 43.1 (95% CI, 42.7 to 43.6) among Canadians aged 2 years and older. The first and 99th percentiles were 22.1 and 62.9 points. The mean HEFI-2019 score for smokers was 7.2 points lower than for non-smokers (95% CI, -8.5 to -5.9). The HEFI-2019 was weakly correlated with energy intake (r = -0.13; 95% CI, -0.20 to -0.06). The principal components analysis revealed at least 4 dimensions. Cronbach's alpha was 0.66 (95% CI, 0.63 to 0.69). Evidence of construct validity and internal consistency support the use of the HEFI-2019 to assess adherence to CFG-2019's recommendations on healthy food choices. Novelty: Examination of the HEFI-2019's psychometric properties is needed prior to implementation. Analyses support the construct validity and internal consistency of the HEFI-2019. Interpretation of the total HEFI-2019 score must be accompanied by its components' scores, considering it assesses multiple dimensions of food choices.

Reproducibility and validity of a food frequency questionnaire to assess cardiovascular health-related food intake among Mexican adolescents

There is a lack of region-adapted tools to evaluate diet as a risk factor for cardiovascular disease (CVD) in adolescents. The study aim was to evaluate the reproducibility and validity of a paper-based and region-adapted food frequency questionnaire (FFQ) designed to assess CVD-related food and nutrient intakes of adolescents from Northwest México. The study design was cross-sectional. The FFQ was developed in a two-step process: prototype designing and a pilot test, with re-tested in a 3-month period, along with two administrations of 24 h-recall (24 hR). Pearson's and intra-class correlation coefficients (PCC and ICC) were assessed. Bland–Altman plots, limits of agreement and quintile classifications were carried out. Participants (n 221) were 53·8 % male, 18·5 ± 0·4 years old. Reproducibility had a median PCC = 0·66 for processed meats, ranging from 0·40 (saturated fat) to 0·74 (fish & shellfish), P = 0·001. ICC ranged from 0·53 (saturated fat) to 0·80 (sodium; and nuts, seeds and legumes), P = 0·001. Validity comparing FFQ1 v. 24 hR mean, PCCs ranged from 0·12 (P = 0·06) to 0·95 (P = 0·001), and ICC from 0·20 (P = 0·048) to 0·88 (P = 0·001); comparing FFQ2 v. 24 hR mean, PCCs ranged from 0·07 (P = 0·25) to 0·46 (P = 0·001), and ICC from 0·15 (P = 0·106) to 0·58 (P = 0·001). The FFQ overestimated the intake of all food groups and nutrients (P < 0·05), while Cohen's κ showed coefficients lower than 0·20. The proposed FFQ represents a moderately validated tool to estimate CVD-related food and nutrient intakes as a risk factor, which can be used in combination with multiple administrations of 24 hRs, as a critical mean in future interventions intended to reduce cardiometabolic risk in adolescents.

Validation of a self-report home food availability checklist against in-home food inventories conducted in low-income Black/African American and Hispanic/Latinx households with preschool-age children

Home food availability (HFA) checklists can be completed by self-report to assess the home food environment. Checklists developed for Black/African American (B/AA) and Hispanic/Latinx (H/L) households are seldom validated against objective approaches such as exhaustive in-home food inventories. This study validated a self-report HFA checklist developed for B/AA and H/L households (n = 97) against researcher-completed HFA checklists verified by exhaustive in-home food inventories. Mean estimates of sensitivity, specificity, and area of the receiver operating curve (ROC), and interrater agreement (Gwet AC1) were calculated to examine the accuracy and agreement of self-reported checklists against direct observation of individual food items. Mean differences in HFA food group scores were compared (self-report vs observed) to examine group-level relative validity. The predictive validity of this self-reported measure on observed scores and dietary intake were also examined with linear regression. The average values for ROC area (average of sensitivity and specificity) ranged from acceptable (0.76 for sweets) to excellent (0.81 for vegetables, fruits). Average interrater agreement values ranged from moderate (0.41-0.60: sweets) to substantial (0.61-0.79: vegetables, fruit, SSBs, savory foods). Self-reported mean scores, compared to observed scores, were higher for vegetables (mean diff: 1.04) and lower for sweets (mean diff: 0.38, p = 0.01), but regression analyses demonstrated that self-reported scores were good predictors of observed scores with absolute error (based on standard deviation of residuals) ranging from ±1.27 to 1.69 points. Self-reported scores also predicted multiple aspects of dietary intake but more so among H/L households. In conclusion, the HFA checklist obtained via self-report performed well based on multiple indicators of validity suggesting that this self-reported measure can be used to assess home food environments among of B/AA and H/L households.

Identifying and Minimizing Errors in the Measurement of Early Childhood Development: Lessons Learned from the Cognitive Testing of the ECDI2030

Challenges in measuring early childhood development (ECD) at scale have been documented, yet little is known about the specific difficulties related to questionnaire design and question interpretation. The purpose of this paper is to discuss the challenges of measuring ECD at scale in the context of household surveys and to show how to overcome them. The paper uses examples from the cognitive interviewing exercises that were conducted as part of the methodological work to develop a measure of ECD outcomes, the ECDI2030. It describes the methodological work carried out to inform the selection and improvement of question items and survey implementation tools as a fundamental step to reduce and mitigate systematic measurement error and improve data quality. The project consisted of a total of five rounds of testing, comprising 191 one-on-one, in-depth cognitive interviews across six countries (Bulgaria, India, Jamaica, Mexico, Uganda, and the USA). Qualitative data analysis methods were used to determine matches and mismatches between intention of items and false positives or false negative answers among subgroups of respondents. Key themes emerged that could potentially lead to systematic measurement error in population-based surveys on ECD: (1) willingness of child to perform task versus ability of child to perform task; (2) performing task versus performing task correctly; (3) identifying letters or numbers versus recognizing letters or numbers; (4) consistently performing task versus correctly performing task; (5) applicability of skills being asked versus observability of skills being asked; and (6) language production versus language comprehension. Through an iterative process of testing and subsequent revision, improvements were made to item wording, response options, and interviewer training instructions. Given the difficulties inherent in population-level data collection in the context of global monitoring, this study’s findings confirm the importance of cognitive testing as a crucial step in careful, culturally relevant, and sensitive questionnaire design and as a means to reduce response bias in cross-cultural contexts.

Estimating trunk fat in children according to sex using basic somatic readings: an opportunity for improving evaluation among girls

BACKGROUND

The fat mass estimators waist-to-height ratio (WHtR) and relative fat mass-pediatric (RFMp) complement the widely accepted body mass index (BMI) in obesity evaluation.

AIMS OF THE STUDY

Conduct an easy appraisal of trunk fat and the cardiometabolic risk associated with pediatric obesity.

METHODS

A total of 472 children (39% boys in the total sample) were classified as underweight, normal weight, overweight or obese (nutritional groups, NGs) according to BMI Z-score after initial anthropometric data were obtained and ad hoc exclusion criteria were applied. WHtR and RFMp (% of total fat) were calculated for each group, associations were assessed through multiple linear regression (MLR), and differences between sexes were evaluated (medians, IQR).

RESULTS

The mean age (mean (95% CI)) was 10.8 y (10.1-11.1). The values in the total sample were as follows: WHtR, 0.5 (0.49-0.51) and RFMp%, 32.3 (31.7-33.0). In the overweight group, the values were as follows: WHtR, 0.51 (0.50-0.52) and RFMp(%), 34.2 (33.3-35.1). In the obese group, the values were as follows: WHtR, 0.56 (0.55-0.57) and RFMp(%), 37.8 (36.9-38.6). The associations were as follows (NG; independent variables): In the NG, adjusted R2 values were between 0.74 and 0.78. In the total sample, the beta coefficient was 3.36 (P < 0.001) for RFMp for girls; for waist circumference (WC), the beta coefficient was 2.97 (P < 0.001), and for WHtR the beta coefficients were - 0.01 (p < 0.001) and 0.03 (p < 0.001),for girls and for WC respectively. The sex differences were as follows: BMI exhibited no differences in the NG (Mann-Whitney U). WHtR (median (IQR)) differed (M vs. F) in the total sample (0.49 (0.45-0.54) vs. 0.52 (0.45-0.56), p < 0.004); in the overweight group (0.51 (0.48-0.53) vs. 0.54 (0.51-0.55), p < 0.001); and in the obese group (0.55 (0.52-0.57) vs. 0.57 (0.54-0.60), p < 0.004). RFMp (%) differed in the total group (29.21 (24.27-32.92) vs. 36.63 (30.2-39.51), p < 0.001); in the overweight group (31.24 (28.35-32.35) vs. 37.95 (35.75-38.82), p < 0.001) and in the obese group (35.89 (32.05-36.15) vs. 40.63 (38.27-42.42), p < 0.001).

CONCLUSIONS

WHtR and RFMp are simple and reliable indices that do not require centile charts. Their values, including waist circumference, can be used to estimate the different trunk fat components in boys and girls better than BMI, especially if individuals are overweight or obese. RFMp proved to be more reliable as it considers sex. Both should be included in routine anthropometric readings.

The Individual Water Insecurity Experiences (IWISE) Scale: reliability, equivalence and validity of an individual-level measure of water security

Objective

The lack of a validated and cross-culturally equivalent scale for measuring individual-level water insecurity has prevented identification of those most vulnerable to it. Therefore, we developed the 12-item Individual Water InSecurity Experiences (IWISE) Scale to comparably measure individual experiences with access, use, and stability (reliability) of water. Here, we examine the reliability, cross-country equivalence, and cross-country and within-country validity of the scale in a cross-sectional sample.

Methods

IWISE items were implemented by the Gallup World Poll among nationally representative samples of 43 970 adults (>15 y) in 31 low-income and middle-income countries (LMICs). Internal consistency was assessed with Cronbach’s alpha. Equivalence was tested using multigroup confirmatory factor analysis (MGCFA), the alignment method, and item response theory. Cross-country validity was assessed by regressing mean national IWISE scores on measures of economic, social, and water infrastructure development. Within-country validity was tested with logistic regression models of dissatisfaction with local water quality by IWISE score and regressing individual IWISE scores on per capita household income and difficulty getting by on current income.

Findings

Internal consistency was high; Cronbach’s alpha was ≥0.89 in all countries. Goodness-of-fit statistics from MGCFA, the proportion of equivalent item thresholds and loadings in the alignment models, and Rasch output indicated equivalence across countries. Validity across countries was also established; country mean IWISE scores were negatively associated with gross domestic product and percentage of the population with access to basic water services, but positively associated with fertility rate. Validity within countries was also demonstrated; individuals’ IWISE scores were positively associated with greater odds of dissatisfaction with water quality and negatively associated with lower financial standing.

Conclusions

The IWISE Scale provides an equivalent measure of individual experiences with water access and use across LMICs. It will be useful for establishing and tracking changes in the prevalence of water insecurity and identifying groups who have been ‘left behind’.

Gaps and priorities in assessment of food environments for children and adolescents in low- and middle-income countries

School-aged children and adolescents have complex interactions with their food environments-the point of engagement of individuals with the food system-and are influenced by a diversity of individual, household and organizational factors. Although a wide range of methods have been proposed to define, monitor and evaluate food environments, few are tailored to school-aged children and adolescents. Here, we interrogate published literature on food metrics and methodologies for the characterization of food environments for school-aged children and adolescents living in low- and middle-income counties. We identify key priority actions and potential indicators for better monitoring and evaluation to galvanize policymaking to improve the healthiness of these interactions, which are so crucial to future adult well-being.

Perspective: Nutritional Status as a Biological Variable (NABV): Integrating Nutrition Science into Basic and Clinical Research and Care

The field of nutrition has evolved from one focused primarily on discovery of the identities, metabolic functions, and requirements for essential nutrients to one focused on the application of that knowledge to the development and implementation of dietary recommendations to promote health and prevent disease. This evolution has produced a deeper appreciation of not only the roles of nutrients, but also factors affecting their functions in increasingly complex global health contexts. The intersection of nutrition with an increasingly more complex global health context necessitates a view of nutritional status as a biological variable (NABV), the study of which includes an appreciation that nutritional status is: 1) not limited to dietary exposure; 2) intimately and inextricably involved in all aspects of human health promotion, disease prevention, and treatment; and 3) both an input and an outcome of health and disease. This expanded view of nutrition will inform future research by facilitating considerations of the contexts and variability associated with the many interacting factors affecting and affected by nutritional status. It will also demand new tools to study multifactorial relations to the end of increasing precision and the development of evidence-based, safe, and effective standards of health care, dietary interventions, and public health programs.

Factor Structure and Equivalence of Maternal Resources for Care in Bangladesh, Vietnam, and Ethiopia

OBJECTIVES

Resources for care among women are crucial for children's growth and development. The objectives of this cross-sectional study were to determine if: (1) the factor structure of measures of maternal resources for care was comparable across countries and consistent with the theoretical constructs and (2) the measures showed equivalence across contexts.

METHODS

The study included 4400, 4029 and 2746 women from Bangladesh, Vietnam, and Ethiopia, respectively. The measures of resources for care were maternal education, knowledge, height, body mass index, mental well-being, financial autonomy, decision-making, employment, support in chores, and perceived support.

RESULTS

The factor analysis demonstrated that a two-factor solution best explained the structure of resources for care in all three countries. The first factor was associated with financial autonomy and employment in all three countries and with decision-making in two countries. The second factor was associated with education and knowledge in all three countries. The measures of resources for care had measurement equivalence across countries.

CONCLUSION FOR PRACTICE

Resources for care were structurally similar and measurement equivalent across countries and can be used for measurement in low- and middle-income countries. Additional work examining the structure and cross-context equivalence of resources for care in other settings is warranted.

Approaches to Defining Healthy Diets: A Background Paper for the International Expert Consultation on Sustainable Healthy Diets

Background:

Healthy diets promote optimal growth and development and prevent malnutrition in all its forms, including undernutrition, obesity, and diet-related noncommunicable diseases (NCDs).

Objective:

This background paper for the International Expert Consultation on Sustainable Healthy Diets characterizes healthy diets and their implications for food system sustainability.

Methods:

Three complementary approaches to defining healthy diets are compared: World Health Organization (WHO) guidelines or recommendations developed between 1996 and 2019; 2017 Global Burden of Disease (GBD) risk factor study estimates of diet-related risk–outcome associations; and analyses associating indices of whole dietary patterns with health outcomes in population studies and clinical trials.

Results:

World Health Organization dietary recommendations are global reference points for preventing undernutrition and reducing NCD risks; they emphasize increasing intakes of fruits, vegetables (excepting starchy root vegetables), legumes, nuts, and whole grains; limiting energy intake from free sugars and total fats; consuming unsaturated rather than saturated or trans fats; and limiting salt intake. Global Burden of Disease findings align well with WHO recommendations but include some additional risk factors such as high consumption of processed meat; this approach quantifies contributions of diet-related risks to the NCD burden. Evidence on whole dietary patterns supports WHO and GBD findings and raises concerns about potential adverse health effects of foods with high levels of industrial processing.

Conclusions:

Implied shifts toward plant foods and away from animal foods (excepting fish and seafood), and for changes in food production systems have direct relevance to the sustainability agenda.

Agreement in Infant Growth Indicators and Overweight/Obesity between Community and Clinical Care Settings

BACKGROUND

Infants from low-income backgrounds receive nutrition care from both community and clinical care settings. However, mothers accessing these services have reported receiving conflicting messages related to infant growth between settings, although this has not been examined quantitatively.

OBJECTIVE

Describe the agreement in infant growth assessments between community (Special Supplemental Nutrition Program for Women, Infants, and Children) and clinical (primary care providers) care settings.

DESIGN

A cross-sectional, secondary data analysis of infant growth measures abstracted from electronic data management systems.

PARTICIPANTS AND SETTING

Participants included a convenience sample of infants (N = 129) from northeastern Pennsylvania randomized to the WEE Baby Care study from July 2016 to May 2018. Infants had complete anthropometric data from both community and clinical settings at age 6.2 ± 0.4 months. Average time between assessments was 2.7 ± 1.9 weeks.

MAIN OUTCOME MEASURES

Limits of agreement and bias in weight-for-age, length-for-age, weight-for-length, and body-mass-index-for-age z scores as well as cross-context equivalence in weight status between care settings.

STATISTICAL ANALYSIS PERFORMED

Bland-Altman analyses were used to describe the limits of agreement and bias in z scores between care settings. Cross-context equivalence was examined by dichotomizing infants' growth indicators at the 85th and 95th percentile cut-points and cross-tabulating equivalent and discordant categorization between settings.

RESULTS

Strongest agreement was observed for weight-for-age z scores (95% limits of agreement -0.41 to 0.54). However, the limits of agreement intervals for growth indicators that included length were wider, suggesting weaker agreement. There was a high level of inconsistency for classification of overweight/obesity using weight-for-length z scores, with 15.5% (85th percentile cut-point) and 11.6% (95th percentile cut-point) discordant categorization between settings, respectively.

CONCLUSIONS

Infant growth indicators that factor in length could contribute to disagreement in the interpretation of infant growth between settings. Further investigation into the techniques, standards, and training protocols for obtaining infant growth measurements across care settings is required.

Identification of Measurement Needs to Prevent Childhood Obesity in High-Risk Populations and Environments

INTRODUCTION

Children at highest obesity risk include those from certain racial/ethnic groups, from low-income families, with disabilities, or living in high-risk communities. However, a 2013 review of the National Collaborative for Childhood Obesity Research Measures Registry identified few measures focused on children at highest obesity risk. The objective is to (1) identify individual and environmental measures of diet and physical activity added to the Measures Registry since 2013 used among high-risk populations or settings and (2) describe methods for their development, adaptation, or validation.

METHODS

Investigators screened references in the Measures Registry from January 2013 to September 2017 (n=351) and abstracted information about individual and environmental measures developed for, adapted for, or applied to high-risk populations or settings, including measure type, study population, adaptation and validation methods, and psychometric properties.

RESULTS

A total of 38 measures met inclusion criteria. Of these, 30 assessed individual dietary (n=25) or physical activity (n=13) behaviors, and 11 assessed the food (n=8) or physical activity (n=7) environment. Of those, 17 measures were developed for, 9 were applied to (i.e., developed in a general population and used without modification), and 12 were adapted (i.e., modified) for high-risk populations. Few measures were used in certain racial/ethnic groups (i.e., American Indian/Alaska Native, Hawaiian/Pacific Islander, and Asian), children with disabilities, and rural (versus urban) communities.

CONCLUSIONS

Since 2013, a total of 38 measures were added to the Measures Registry that were used in high-risk populations. However, many of the previously identified gaps in population coverage remain. Rigorous, community-engaged methodologic research may help researchers better adapt and validate measures for high-risk populations.

Development and testing of Australian prehospital care quality indicators: study protocol

INTRODUCTION

Historically, ambulance services were established to provide rapid transport of patients to hospital. Contemporary prehospital care involves provision of sophisticated 'mobile healthcare' to patients across the lifespan presenting with a range of injuries or illnesses of varying acuity. Because of its young age, the paramedicine profession has until recently experienced a lack of research capacity which has led to paucity of a discipline-specific, scientific evidence-base. Therefore, the performance and quality of ambulance services has traditionally been measured using simple, evidence-poor indicators forming a deficient reflection of the true quality of care and providing little direction for quality improvement efforts. This paper reports the study protocol for the development and testing of quality indicators (QIs) for the Australian prehospital care setting.

METHODS AND ANALYSIS

This project has three phases. In the first phase, preliminary work in the form of a scoping review was conducted which provided an initial list of QIs. In the subsequent phase, these QIs will be developed by aggregating them and by performing related rapid reviews. The summarised evidence will be used to support an expert consensus process aimed at optimising the clarity and evaluating the validity of proposed QIs. Finally, in the third phase those QIs deemed valid will be tested for acceptability, feasibility and reliability using mixed research methods. Evidence-based indicators can facilitate meaningful measurement of the quality of care provided. This forms the first step to identify unwarranted variation and direction for improvement work. This project will develop and test quality indicators for the Australian prehospital care setting.

ETHICS AND DISSEMINATION

This project has been approved by the University of Adelaide Human Research Ethics Committee. Findings will be disseminated by publications in peer-reviewed journals, presentations at appropriate scientific conferences, as well as posts on social media and on the project's website.

Algorithms for prevention and treatment of incontinence-associated dermatitis

Objective: To build and validate algorithms for prevention and treatment of incontinence-associated dermatitis. Method: A methodological study. An integrative review of articles published from 2009 to 2019 was carried out after a literature search in the main Health Sciences databases for the construction of the algorithms. The algorithms were evaluated by 27 nurses using the Delphi technique. The content validity index was used for data analysis. Results: The judges evaluated the algorithms from inadequate to adequate in the first round of consultation, and from adequate to totally adequate in the second round of consultation. The global content validity index was 0.923 in the first consultation and 1.0 in the second consultation. Conclusion: After reviewing the literature, the algorithms were constructed and validated by professionals with experience in the area, reaching agreement among the judges in the second round of consultation.

Algoritmos para prevenção e tratamento de dermatite associada à incontinência

Objetivo: Construir e validar algoritmos para a prevenção e o tratamento da dermatite associada à incontinência. Método: Estudo metodológico. Para o desenvolvimento dos algoritmos, foi realizada revisão integrativa de artigos publicados de 2009 a 2019 encontrados nas principais bases de dados em ciências da saúde. A avaliação dos algoritmos foi realizada com 27 enfermeiros, utilizando a técnica de Delphi. Para a análise de dados, foi adotado o índice de validade de conteúdo. Resultados: Os juízes consideraram os algoritmos entre inadequados e adequados na primeira avaliação e entre adequados e totalmente adequados na segunda avaliação. O índice de validade de conteúdo geral foi de 0,923 na primeira avaliação e 1,0 na segunda avaliação. Conclusão: Após revisão da literatura, os algoritmos foram construídos e validados por profissionais com experiência na área, obtendo concordância entre os juízes na segunda avaliação.

The Healthy Cooking Index: Nutrition Optimizing Home Food Preparation Practices across Multiple Data Collection Methods

BACKGROUND

Food preparation interventions are an increasingly popular target for hands-on nutrition education for adults, children, and families, but assessment tools are lacking. Objective data on home cooking practices, and how they are interpreted through different data collection methods, are needed.

OBJECTIVE

The goal of this study was to explore the utility of the Healthy Cooking Index in coding multiple types of home food preparation data and elucidating healthy cooking behavior patterns.

DESIGN

Parent-child dyads were recruited between October 2017 and June 2018 in Houston and Austin, Texas for this observational study. Food preparation events were observed and video recorded. Participants also wore a body camera (eButton) and completed a questionnaire during the same event.

PARTICIPANTS/SETTING

Parents with a school-aged child were recruited as dyads (n=40). Data collection procedures took place in participant homes during evening meal preparation events.

MAIN OUTCOME MEASURES

Food preparation data were collected from parents through direct observation during preparation as well as eButton and paper questionnaires completed immediately after the event.

STATISTICAL ANALYSES PERFORMED

All data sets were analyzed using the Healthy Cooking Index coding system and compared for concordance. A paired sample t test was used to examine significant differences between the scores. Cronbach's α and principal components analysis were conducted on the observed Healthy Cooking Index items to examine patterns of cooking practices.

RESULTS

Two main components of cooking practices emerged from the principal components analysis: one focused on meat products and another on health and taste enhancing practices. The eButton was more accurate in collecting Healthy Cooking Index practices than the self-report questionnaire. Significant differences were found between participant reported and observed summative Healthy Cooking Index scores (P<0.001), with no significant differences between scores computed from eButton images and observations (P=0.187).

CONCLUSIONS

This is the first study to examine nutrition optimizing home cooking practices by observational, wearable camera and self-report data collection methods. By strengthening cooking behavior assessment tools, future research will be able to elucidate the transmission of cooking education through interventions and the relationships between cooking practices, disease prevention, and health.