Nutrition and Health Improvements After Participation in an Urban Home Garden Program

Leisure Activity, Childhood Starvation, and Risk of Incident Diabetes in Older Adults: Evidence From a Chinese Nationwide Cohort Study

OBJECTIVE

This study explores the impact of leisure activity and the association between childhood starvation and the risk of diabetes in older Chinese adults.

DESIGN

Prospective cohort study based on the Chinese Longitudinal Healthy Longevity Study (CLHLS), a nationwide cohort study in China.

SETTING AND PARTICIPANTS

A total of 4637 older adults aged ≥65 years, all with documented diabetes history, experiences of childhood starvation, and participation in leisure activities were recruited.

METHODS

Childhood starvation exposure was assessed via self-reported responses from a structured questionnaire. The leisure activities were measured by 9 distinctive components and categorized into 3 distinct categories: productive activity, recreational activity, and sedentary activity. Diabetes status was determined by self-reported, physician-diagnosed cases during the follow-up period. Nonparametric survival models were employed for analysis.

RESULTS

Over an average follow-up period of 4.3 years, 215 of 4637 participants (4.6%) reported a confirmed diagnosis of diabetes. Nonparametric survival models showed that those reporting childhood starvation had a higher risk of late-life diabetes [hazard ratio (HR) 1.72, 95% CI 1.21-2.44]. Engaging in productive activity (HR 0.90, 95% CI 0.83-0.99) and recreational activity (HR 0.88, 95% CI 0.77-1.00) was linked with a reduced risk of late-life diabetes. Sedentary activity did not show a significant effect. Further analysis highlighted the interactions effects of leisure activities on diabetes risk across different demographic and historical exposure subgroups.

CONCLUSIONS AND IMPLICATIONS

Engaging in productive and recreational leisure activities was inversely associated with the risk of diabetes in older adults who experienced childhood starvation. Promoting such activities could be beneficial in mitigating long-term diabetes risk related to early-life nutritional deficiencies.

Development and evaluation of food preservation lessons for gardeners: application of the DESIGN process

OBJECTIVE

This study presents the development and evaluation of food preservation lessons for gardeners.

DESIGN

Lessons were developed using the DESIGN process, a nutrition education program planning framework. This study examines the effectiveness of this curriculum at increasing knowledge of proper food preservation practices and increasing participants' confidence in home food preservation, identifies challenges participants experienced with home food preservation and assesses the perceived influence of home food preservation on vegetable intake and aspects of food security. We used the DESIGN process developed by Contento and Koch to develop the curricula and used social cognitive theory to guide the lesson development. Lessons on three types of food preservation (freezing, water bath canning and pressure canning) were developed and presented to adult gardeners. The evaluation consisted of post-lesson surveys and a follow-up survey several months after the lessons.

SETTING

Mid-Michigan, USA.

PARTICIPANTS

Adult gardeners.

RESULTS

Food preservation confidence increased following the lessons. At follow-up, 64 % of participants agreed or strongly agreed that they ate more fruit and vegetables because of preserving food, 57 % of respondents agreed or strongly agreed that they spend less money on food due to preserving, while 71 % reported being better able to provide food for themselves and their family. Lastly, 93 % reported feeling better about where their food comes from and wasting less food due to preserving.

CONCLUSIONS

This study provides evidence that home food preservation may be beneficial in promoting fruit and vegetable intake and food security among gardeners.

Community gardens and urban agriculture: Healthy environment/healthy citizens

Studies are showing that urban community gardening can improve people's psychological and physiological health in myriad ways. Community gardens increase social capital, provide opportunities for altruism, and create accessible and sustainable food sources in urban environments. The purpose of this study was to explore the mental, social, and physical health benefits of participation in an urban community garden in Edmonton, Canada. A focused ethnography was conducted with surveys and semi-structured interviews. Surveys were sent to volunteers and customers of the Green and Gold Garden (GGG). This was followed by focus group interviews with eight volunteers and four customers. The interview format comprised open-ended questions that encouraged participants to share their perceptions of the health and well-being benefits from being at the GGG. Data were coded via inductive coding, and subsequently categorized into themes via an iterative, reflective process. Four health-related themes were generated from thematic analysis: physical health, social health, mental/emotional health, and connection to the global community. Spending time at the GGG improved the respondents' mental health, even during the COVID-19 pandemic, as they reported feelings of altruism, serenity, and connection with nature. Their social health was improved through gathering with other garden members in a sheltered urban green space within the city limits. This study supports the idea that participation in an urban community garden confers health benefits and engenders a greater awareness of, and appreciation for, the local environment and expands one's scope of care to incorporate planetary health.

Exploring the link between home garden use and severe obesity: Insights from a nationwide survey in Tuvalu

Background

Obesity is prevalent and increasing but understudied across Pacific Islanders. Tuvalu is a South Pacific country with a high obesity rate and faces multiple threats of food insecurity. Home garden serves as a sustainable food source and can be a possible intervention for the obesity pandemic in Tuvalu. This study investigated Tuvaluans' home garden use and obesity, and explored factors associated with increased use of home gardens.

Methods

We conducted a nationwide, cross-sectional study in Tuvalu during 2022. Structured questionnaires were administered during the in-person interviews, and trained interviewers measured the height and weight of each participant. The association between home garden use, obesity and severe obesity were tested with univariate and multivariable logistic regression. We also applied overlapping weights to balance the distribution of baseline demographic factors.

Results

The average body mass index was 34.87 kilogrammes (kg) / square metre (m2) among the study population of 1024 adults (630 from Funafuti and 394 from other islands in Tuvalu). Overall, people having home gardens was associated lower odds for severe obesity compared to those without a home garden in overlap weighting models (odds ratio (OR) = 0.946, 95% CI = 0.897-0.997, P = 0.039) and the association was stronger in Funafuti (OR = 0.927, 95% CI = 0.866-0.991, P = 0.027) than in the outlying islands (OR = 0.967, 95% CI = 0.889-1.052, P = 0.435). Furthermore, increased age was positively associated with having a home garden in Funafuti, and smoking showed an inverse association.

Conclusions

Having a home garden is associated with lower odds of severe obesity in Tuvalu, and the association is stronger in Funafuti. Smokers are less likely to have home gardens, and increased age is positively associated with having home gardens. These findings promote more home garden utilisation and provide evidence for targeted interventions in Tuvalu.

Enhancing human resilience beyond COVID-19-related stress: public responses to multi-benefits of home gardening

The SARS-CoV-2 virus has caused a public health crisis globally. Against the backdrop of global resilience, studies have demonstrated the therapeutic value of home gardening as a measure to strengthen human health. However, there is a lack of comparative studies on its benefits across countries. Studies need to examine the role of home gardening in improving public health in various societies to understand and encourage this practice broadly and effectively. We chose Taiwan, Thailand, and Vietnam as case studies, which have suffered substantial pandemic impacts, with millions of infections and thousands of deaths. We explored and compared the perceptions of people on home gardening and its health benefits during the COVID-19 pandemic. We conducted online surveys in three countries between May 1 and September 30, 2022, with a total of 1172 participants. Data were collated on perceived pandemic stress, challenges and solutions in gardening, home gardening intentions, and mental and physical health benefits. In these countries, we found that perceived pandemic stress positively affects home gardening intentions, whereby the motivation of Vietnamese people is the highest. Challenges hinder gardening intentions, while the solutions only positively affect gardening intentions in Taiwan and Vietnam. Home gardening intentions positively affect mental and physical health, whereby there are higher mental health benefits in Taiwanese people than in Thai people. Our findings potentially support public health recovery and promote healthy lifestyles during the COVID-19 pandemic.

The effect of horticultural therapy on older adults in pension institutions: a systematic review

AIMS

To systematically evaluate the effect of horticultural therapy (HT) on older adults in pension institutions.

DESIGN

Systematic review was conducted based on the checklist for PRISMA.

METHODS

The searches were conducted in the Cochrane library, Embase, Web of Science, PubMed, Chinese Biomedical Database (CBM), and the China Network Knowledge Infrastructure (CNKI), from their inception until May 2022. In addition, manual screening of references of relevant studies was performed to identify potential studies. We conducted a review of quantitative studies published in Chinese or English. Experimental studies were evaluated using the Physiotherapy Evidence Database (PEDro) Scale.

RESULTS

A total of 21 studies involving 1214 participants were included in this review, and the quality of the literature was good. Sixteen studies were Structured HT. The effects of HT were significant in terms of physical, physiological, and psychological aspects. In addition, HT improved satisfaction, quality of life, cognition, and social relationships, and no negative events were found.

CONCLUSION

As an affordable non-pharmacological intervention with a wide range of effects, horticultural therapy is suitable for older adults in pension institutions and is worth promoting in pension institutions, communities, homes, hospitals, and other institutions that require long-term care.

A home gardening intervention to improve vegetable consumption among urban poor children: A study protocol for randomised controlled trial

Background: One of the key importance of vegetable consumption is to obtain sufficient micronutrients, dietary fibre, and for the prevention of childhood obesity. Most Malaysian children did not meet the recommended intake of vegetable consumption, and this is especially vulnerable among the urban poor population due to food insecurity. Efforts are needed to promote vegetable consumption that fall short of the recommended intake level. Aim: This trial aims to examine the effectiveness of the "GrowEat" project, as a nutrition intervention programme integrated with home gardening activities to improve vegetable consumption among urban poor children in Kuala Lumpur, Malaysia. Methods: This is a single-blinded parallel two-arm cluster randomised controlled trial (RCT) that include 134 children. Two zones in Kuala Lumpur will be randomly selected, and three low-cost housing flats from each zone will be selected as the intervention and control groups respectively. The trial is designed based on the social cognitive theory (SCT). Children from the intervention group (n = 67) will attend a 12-week programme, which consists of home garden-based activities, gardening and nutrition education session. Assessment will be conducted for both groups at three time points: baseline, post-intervention and follow-up phase at 3 months after the intervention. Conclusion: We anticipate positive changes in vegetable consumption and its related factors after the implementation of the "GrowEat" project. The current intervention may also serve as a model and can be extended to other urban poor population for similar interventions in the future to improve vegetable consumption, agriculture and nutrition awareness.

The feasibility of implementing food-based dietary guidelines and food graphics in Ethiopia

This study aimed to test the acceptability, cultural appropriateness, consumers' understanding, and practicality of the Ethiopian food-based dietary guideline's messages, tips, and food graphics. A qualitative study design was applied with focus group discussions and key informant interviews. Four different participant groups were included: 40 consumers, 15 high-level nutrition experts, 30 frontline community health extension workers (HEWs), and 15 agriculture extension workers (AEWs) to incorporate different stakeholder perspectives. Data collection was conducted using 7 focus group discussions (FGDs) and 30 key informant interviews (KIIs). Collected data were coded and analyzed using QSR International NVivo V.11 software. Most of the study participants were highly interested in implementing the dietary guidelines once these guidelines are officially released. Based on the participants' views, most of the messages align with the current nutrition education materials implemented in the country except the messages about physical activity and alcohol intake. However, participants suggested defining technical terms such as ultra-processing, whole grain, safe and balanced diet in simpler terms for a better understanding. Practicality, affordability, availability, and access to the market were the major barriers reported for adherence to the guidelines. To be more inclusive of cultural and religious beliefs, findings show that the guideline should address fasting and traditional cooking methods. In conclusion, the dietary guidelines were well received by most stakeholders. They are thought to be feasible once feedback on wording, affordability, availability, and access is considered in the messages, tips, and graphic designs.

Contribution of Home Gardens to Sustainable Development: Perspectives from A Supported Opinion Essay

Home gardening has a long history that started when humans became sedentary, being traditionally considered an accessible source of food and medicinal plants to treat common illnesses. With trends towards urbanization and industrialization, particularly in the post-World War II period, the importance of home gardens as important spaces for growing food and medicinal plants reduced and they began to be increasingly seen as decorative and leisure spaces. However, the growing awareness of the negative impacts of agricultural intensification and urbanization for human health, food quality, ecosystem resilience, and biodiversity conservation motivated the emergence of new approaches concerning home gardens. Societies began to question the potential of nearby green infrastructures to human wellbeing, food provisioning, and the conservation of traditional varieties, as well as providers of important services, such as ecological corridors for wild species and carbon sinks. In this context. and to foster adaptive and resilient social-ecological systems, our supported viewpoint intends to be more than an exhaustive set of perceptions, but a reflection of ideas about the important contribution of home gardens to sustainable development. We envision these humble spaces strengthening social and ecological components, by providing a set of diversified and intermingled goods and services for an increasingly urban population.

A participatory practice study for the improvement of sub-regional health vulnerabilities: a qualitative study

Background

This study aimed to explore the experiences of the residents of Samho-dong with the health environment in the local community, and their in-depth opinions on health promotion using a photovoice methodology. Alternatives to improve health among the residents of Samho-dong were also discussed with the local residents, with the aim of translating suggestions from the discussion into practice.

Methods

A total of 195 photographs taken by the 15 participants over the course of 7 weeks were collected, along with 96 photovoice activity logs and transcription data from 5 rounds of focus group discussions. The photovoice activity logs consisted of the photographer’s name, the dates photos were taken, and a series of responses to the following SHOWeD questions: “What do you SEE here?”, “What is really HAPPENING?”, “How does this situation or scenario affect OUR lives/health?”, “WHY does this problem or strength Exist?”, “What can we DO about it?”. Direct content analysis was used for analysis.

Results

The analysis yielded a total of 247 semantic units, which were categorized into the themes, “the good, but insufficiency, living environment in Samho-dong,” “the health environment in Samho-dong needs improvement,” “small efforts to improve Samho-dong,” and “points of improvement for a better Samho-dong”. Samho-dong was found to have a poorer walking and transportation infrastructure than other regions, even though it was a town with a large elderly population. The dark streets in the residential complex made participants hesitate to engage in afternoon activities, and the insufficient traffic environment made it difficult to live a natural daily life by solving food, clothing, and shelter. Participants have made various attempts to solve areas that need improvement in the Samho-dong, which has led to actual improvement. It was analyzed that in order to make Samho-dong better, it was necessary to improve the perception of residents in Samho-dong and cooperate with the local community.

Conclusions

This study was significant in that it enabled the in-depth exploration and identification of areas of improvement from the participants’ perception of their health environment, considering that as residents, they are the direct stakeholders of the community health environment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14111-x.

How Gardening in Detroit Influences Physical and Mental Health

Gardening has the potential to improve health by providing access to nature, vegetables, and physical activity. However, scarce research exists on the health impacts of gardening on racial and ethnic minority urban populations in the United States. This study used qualitative interviews to examine the perceived physical and mental health effects of gardening in a primarily African American sample of 28 gardeners. Prominent physical health impacts attributed to gardening included providing an enjoyable source of activity, management of chronic diseases, and improved physical functioning. Participants also reported that gardening improved their mood, relieved stress, was an important part of their spirituality, contributed to their personal growth, and provided an opportunity for helping others. These findings suggest that gardening may improve physical and mental health among diverse groups.

The Socio-Cultural Benefits of Urban Agriculture: A Review of the Literature

Despite extensive literature on the socio-cultural services of urban open spaces, the role of food-producing spaces has not received sufficient attention. This hampers advocacy for preserving and growing urban agricultural activities, often dismissed on justifications that their contributions to overall food supply are negligible. To understand how the social benefits of urban agriculture have been measured, we conducted a systematic review of 272 peer-reviewed publications, which drew on insights from urban agriculture sites in 57 different countries. Through content analysis, we investigated socio-cultural benefits in four spheres: engaged and cohesive communities, health and well-being, economic opportunities, and education. The analysis revealed growth in research on the social impacts of gardens and farms, with most studies measuring the effects on community cohesion and engagement, followed by increased availability and consumption of fruits and vegetables associated with reduced food insecurity and better health. Fewer studies assessed the impact of urban farming on educational and economic outcomes. Quantifying the multiple ways in which urban agriculture provides benefits to people will empower planners and the private sector to justify future investments. These findings are also informative for research theorizing cities as socio-ecological systems and broader efforts to measure the benefits of urban agriculture, in its many forms.

Dietary patterns and metabolic syndrome among urbanized Tibetans: A cross-sectional study

The prevalence of metabolic syndrome (MetS) and the major dietary patterns among urbanized Tibetans are unclear. The present study aimed to investigate the prevalence of MetS among Jiarong Tibetans in Aba Plateau, identify the major dietary patterns, and evaluate their association with the risk of MetS. In this cross-sectional study on 476 subjects, 18-80-years-old, dietary intakes were evaluated using a simplified food frequency questionnaire (SFFQ). MetS was defined according to the International Diabetes Federation (IDF) guidelines. Principal component analysis was performed to assess the major dietary patterns. Multivariate logistic regression analysis examined the associations between dietary patterns and the risk of MetS. The prevalence of Mets in the population was 37.6%. Herein, three major dietary patterns were extracted: traditional Tibetan, urbanized, and healthy dietary patterns. After adjusting for potential confounders (Model 1: adjusted for sex and age; Model 2: adjusted for sex, age, smoking status, drinking situation, physical activity level and total energy intake), subjects in the highest tertile of the healthy dietary had a lower risk of MetS compared to those from the lowest tertile. Also, no significant statistical association was established between the risk of MetS and the traditional Tibetan and urbanized diet.

Healthy eating strategies for socioeconomically disadvantaged populations: a meta-ethnography

Purpose: In developed countries, diet-related health inequalities between people with different levels of socioeconomic advantage persist. However, there is limited qualitative evidence to inform the design of effective healthy eating (HE) strategies in socioeconomically disadvantaged populations (SDPs). The purpose of this review was to explore the characteristics influencing HE strategies for SDPs and develop a new understanding of how and why they influence their success.

Methods: A qualitative evidence synthesis using a systematic meta-ethnographic approach. The twelve studies included were conducted in the USA, Canada, Australia, and UK.

Results: The studies described a range of HE strategies, including nutrition education programs, food vouchers, and community gardens. Personal values and sense of pride and autonomy were found to have an influence on participants’ attitudes towards HE strategies. Similarly, social characteristics such as level of social support and opportunities for shared benefits influenced participants’ engagement. Structural characteristics such as the affordability and accessibility of healthy foods determined strategy acceptability and success. Finally, organizational characteristics such as flexibility influenced how well strategies supported the circumstances of participants.

Conclusions: These overlapping characteristics may be used to inform the development, implementation, and evaluation of strategies to improve healthy eating in SDPs.

Decreasing Older Adult COVID-19 Risk Factors Using Digital Technology to Implement a Plant-Based-Diet: An Opinion Paper

UNSTRUCTURED

A disproportionate number of COVID-19 cases affect older, minority populations. Obese older adults are at higher risk for severe COVID-19 complications and lower survival rates; minority older adults often experience higher rates of obesity. A plant-based diet intervention may improve COVID-19 obesity modifiable risk factors. Encouraging the consumption plant-based diets consisting of vegetables, fruits, whole grains, legumes, seeds, and nuts utilizing community outreach strategies and digital technology can contribute to improving COVID-19 risk factors.

Home food procurement impacts food security and diet quality during COVID-19

Background

Home food procurement (HFP) (i.e. gardening, fishing, foraging, hunting, backyard livestock and canning) have historically been important ways that people obtain food. Recently, some HFP activities have grown (e.g. gardening), while other activities (e.g. hunting) have become less common in the United States. Anecdotally, COVID-19 has sparked an increase in HFP evidenced by increased hunting licenses and shortages in seeds and canning supplies. HFP may have positive benefits for food security and diet quality, though research beyond gardening is especially limited in high-income countries.

Methods

We examine HFP activities since the COVID-19 pandemic began, and their relationship to food security and dietary quality using multivariable logit models and matching analysis with a statewide representative survey (n = 600) of residents of Vermont, United States.

Results

We find 29% of respondent households classified as food insecure since COVID-19, and higher prevalence of food insecurity among those experiencing a negative job change since COVID-19, households earning less than $50,000 annually, Hispanic and multi-race respondents. Nearly 35% of respondents engaged in HFP activities since the COVID-19 pandemic began; the majority of those gardened, and more than half pursued HFP activities more intensely than before the pandemic or for the first time. Food insecure households were more likely to pursue HFP more intensely, including more gardening, fishing, foraging, and hunting. Respondents who were food insecure, Black, Indigenous, People of Color, those with a negative job disruption, and larger households all had greater odds of increased intensity of HFP during the COVID-19 pandemic. HFP was significantly associated with eating greater amounts of fruits and vegetables; however, this effect was only significant for food secure households.

Conclusion

Overall, these results suggest that HFP activities have increased since the start of the COVID-19 pandemic, and may be an important safety net for food insecure households. However, HFP for food insecure households does not translate into the same higher fruit and vegetable intake as found among food secure HFP households, suggesting this population may be trying to maintain intake, or that they may have potential important resource or technical assistance needs. Long-term, HFP activities may have important food security and diet quality impacts, as well as conservation implications, which should be more thoroughly explored. Regardless, the increased interest and intensity of HFP demonstrates opportunities for educational and outreach efforts.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10960-0.

Urban agriculture in times of crisis: the role of home food growing in perceived food insecurity and well-being during the early COVID-19 lockdown

Household food insecurity and poor well-being have increased during the coronavirus disease 2019 (COVID-19) pandemic and resulting lockdown measures. Home food growing has been associated with improved food access and well-being, but it is unknown what role it plays during food supply crises and lockdown. It is also unclear how home food growing and social restrictions may affect opinions about growing food in urban areas (i.e., urban agriculture [UA]).

A cross-sectional online survey was conducted during the UK national lockdown in March-April 2020 to measure home food growing, perceived food insecurity, well-being, and opinions of UA.  The participants were 477 UK-based adults (369 female, mean age 39.57 years ± 13.36); 152 participants were engaged in home food growing prior to the pandemic. Responses were compared to data collected from a separate sample of participants before the pandemic ( N = 583) to explore potential shifts in opinions about UA.

Participants who engaged in home food growing had lower levels of food insecurity ( U _­= 19894.50, z = -3.649, p<.001, r = -.167) and higher well-being ( U = 19566.50, z = -3.666, p<.001, r = -.168) than those not engaged in home food growing. Perceived food insecurity partially mediated the relationship between home food growing and well-being; home food growing was associated with less food insecurity, which in turn was associated with better well-being. There were no differences in opinions of UA compared to the sample of participants from before the pandemic.

Home food growing may have had a protective effect over perceived food security and well-being in the early stages the pandemic. Opinions of UA were positive and unchanged compared to data collected pre-pandemic. Policies that support home food growing and access to suitable growing spaces and resources may be beneficial for food system resilience and well-being.

Is urban growing of fruit and vegetables associated with better diet quality and what mediates this relationship? Evidence from a cross-sectional survey

Urban agriculture (UA), the growing of fruits and vegetables in urban and peri-urban areas, may improve food security and access, public health and dietary quality on both a broad and personal scale. However, there is little research on the relationship between UA and diet, and potential mediating factors are also unclear. This study aimed to investigate if proximity to and engagement with UA is associated with better diet quality, and what accounts for this relationship. UK-based adults (N = 583, 69% Female) completed measures of proximity to and engagement with UA, perceived access to fruits and vegetables, health and ethical food choice motivations, connection with nature, psychological distress and dietary quality in an online survey. Participants were recruited from UA-related groups and the general public. Proposed relationships were analysed using a structural equation model. Greater proximity to and engagement with UA was associated with greater perceived access to fruits and vegetables, more health-related food choice motivations, more ethical-related food choice, feeling more connected with nature, and, surprisingly greater psychological distress. Furthermore, proximity to and engagement with UA was indirectly associated with better diet quality via health-, and ethical-related, food choice motivations. While the direct pathway between proximity to and engagement with UA and diet quality was not significant, UA is associated with better diet quality, partly via healthier and ethical food choice motivations. Upscaling UA may have benefits for dietary quality via these factors, and more research is needed to test causal relationships and understand these complex interactions.

The Primacy of Politics in Public Food Security Policies: The Case of Home Gardens

Home gardens are often conceived as a panacea to contribute to the problem of food insecurity in poor rural and urban households. However, systematic reviews indicate weak evidence of significant impacts on families. This way, there has been an intense discussion about their effectiveness. This research aims to generate knowledge about the relevance of assuming food production in home gardens as an alternative to the home consumption. Two questions drive this paper: what number of home gardens, supported by three different government programs, persists? Moreover, what factors explain their permanence? Our sample constituted 261 beneficiaries, and the collection of data was through face-to-face field surveys and in situ visits to the vegetable garden granted. We show that less than 7.5% of gardens remain in right conditions after two years of establishment. The pleasure and need to produce, family involvement, urban/rural location, and the technology provided are determining factors for permanence. The results support the argument that the high rate of home gardens that fail is related to the primacy of politics in considering the problem of food security as a “lack of assets” to produce. Thus, this suggests that there is a weak link between the problem, policies, and the politics.