Community perspectives on maternal and child health during nutrition and economic transition in sub-Saharan Africa

Higher consumption of ultra-processed foods is associated with obesity and abdominal obesity in socially vulnerable Brazilian women

This study aimed to assess the consumption of ultra-processed foods (UPF) and identify their association with obesity and abdominal obesity in adult women of reproductive age living in situations of social vulnerability in Maceió, Northeastern Brazil. This was a cross-sectional study carried out between October 2020 and May 2021. An anthropometric evaluation was carried out to assess obesity and abdominal obesity. A dietary assessment was also conducted using a 24-h food recall to determine the calorie intake from UPF. To estimate intra-individual variability in food consumption, the probabilistic Multiple Source Method was used. These data in the form of tertiles were used to analyse the association between the consumption of UPF and obesity and abdominal obesity. Logistic regressions were used to analyse the association. A directed acyclic graph (DAG) was created for this analysis. This study included 1702 women of which 53.7% were 31 years old or older, and 74.2% lived in poverty. It identified that 36.5% and 38.1% of the women had obesity and abdominal obesity, respectively, and that an average of 33.8% of calories consumed came from UPF. In the analysis of association guided by the DAG, it was observed that women with a high-calorie intake from UPF had a 1.3 times higher probability of being obese. It was also observed that women with a moderate and high-calorie intake from UPF were 1.4 and 1.3 times more likely, respectively, to have abdominal obesity. Thus, it can be concluded that socially vulnerable women in Brazil have a relatively high consumption of UPF and that this condition increases the probability of obesity in this population group.

What works in engaging communities? Prioritising nutrition interventions in Burkina Faso, Ghana and South Africa

BACKGROUND

"Choosing All Together" (CHAT), is a community engagement tool designed to give the public a voice in how best to allocate limited resources to improve population health. This process evaluation explored the mechanisms through which CHAT generates community engagement.

METHOD

The CHAT tool was adapted and implemented for use in two rural communities (Nanoro, Burkina Faso, and Navrongo, Ghana) and one urban township (Soweto, South Africa) to prioritize maternal and child nutrition interventions. Community discussions were audio-recorded, transcribed, and translated into English. Twenty-two transcripts, including six each from Navrongo and Soweto and 10 from Nanoro, were analysed thematically to generate data driven codes and themes to explain mechanisms underlying the CHAT process. The process evaluation was based on the UK MRC process evaluation guidance.

RESULTS

Seven themes describing the functions and outcomes of CHAT were identified. Themes described participants deliberating trade-offs, working together, agreeing on priorities, having a shared vision, and increasing their knowledge, also the skills of the facilitator, and a process of power sharing between participants and researchers. Participants came to an agreement of priorities when they had a shared vision. Trained facilitators are important to facilitate meaningful discussion between participants and those with lower levels of literacy to participate fully.

CONCLUSION

CHAT has been shown to be adaptable and useful in prioritising maternal and child nutrition interventions in communities in Burkina Faso, Ghana, and South Africa. Conducting CHAT in communities over a longer period and involving policy-makers would increase trust, mutual respect and develop partnerships.

Health needs assessment for the double burden of malnutrition: a community-based study on nutrition facilitators and barriers in rural Tanzania

OBJECTIVE

The aim of this study is to explore nutrition-related health needs, the perceptions and beliefs regarding the double burden of malnutrition, as well as barriers and facilitators in accessing nutritious food among the local population in rural Tanzania.

DESIGN

A qualitative study design using semi-structured individual interviews and focus-group discussions (FGD) was used. Basic socio-demographic information was obtained from all participants.

SETTING

The study was conducted in four villages within the catchment area of the Shirati KMT Hospital in Rorya district, in north-western Tanzania.

PARTICIPANTS

Men and women in the reproductive age as well as Community Health Workers (CHW) were included.

RESULTS

In total, we performed fourteen interviews (N 41), consisting of four FGD, one dual and nine individual interviews. The three most significant topics that were identified are the large knowledge gap concerning overweight and obesity as a health problem, changing weather patterns and its implications on food supply and the socio-cultural drivers including gender roles and household dynamics.

CONCLUSION

Environmental and socio-cultural factors play a crucial role in the determinants for DBM, which underlines the importance of understanding the local context and the nutrition practices and beliefs of the communities. Future nutritional interventions should aim towards more inclusion of men in project implementation as well as support of women empowerment. CHW could play a key role in facilitating some of the suggested interventions, including nutritional counselling and increasing awareness on the drivers of the double burden of malnutrition.

Burden and contributing factors to overweight and obesity in young adolescents in Addis Ababa, Ethiopia

The prevalence of overweight/obesity in adolescents has increased globally, including in low- and middle-income countries. Early adolescence provides an opportunity to develop and encourage positive health and behavioural practices, yet it is an understudied age group with limited information to guide and inform appropriate interventions. This study aims to determine the prevalence of overweight/obesity in young adolescents, aged between 10 and 14 years attending public schools in Addis Ababa, Ethiopia, and to explore the contributing factors. A cross-sectional school-based study was conducted. Adolescents completed individual questionnaires. Weight (kg) and height (m) measurements were converted to BMI-for-age and gender z-scores. Multivariate regression analysis was conducted to determine the associated factors. The overall prevalence of overweight/obesity was 8% among adolescents aged 10-14 years and it was significantly higher in females (13%) than males (2%). The diet quality for the majority of the adolescents was inadequate, putting them at risk for poor health outcomes. The contributors to overweight/obesity were different between males and females. Age and no access to a flush toilet were negatively associated with overweight/obesity in males and access to a computer, laptop or tablet was positively associated. In females, menarche was positively associated with overweight/obesity. Living with only their mother or another female adult and an increase in physical activity were negatively associated with overweight/obesity. There is a need to improve the diet quality of young adolescents in Ethiopia and understand the reasons why females are less physically active to limit the risk of poor diet-related health outcomes.

Behaviour change interventions improve maternal and child nutrition in sub-Saharan Africa: A systematic review

Evidence that nutrition-specific and nutrition-sensitive interventions can improve maternal and child nutrition status in sub-Saharan Africa is inconclusive. Using behaviour change theory and techniques in intervention design may increase effectiveness and make outcomes more predictable. This systematic review aimed to determine whether interventions that included behaviour change functions were effective. Six databases were searched systematically, using MeSH and free-text terms, for articles describing nutrition-specific and nutrition-sensitive behaviour change interventions published in English until January 2022. Titles, abstracts and full-text papers were double-screened. Data extraction and quality assessments followed Centre for Reviews and Dissemination guidelines. Behaviour change functions of interventions were mapped onto the COM-B model and Behaviour Change Wheel. PROSPERO registered (135054). The search yielded 1193 articles: 79 articles met inclusion criteria, ranging from low (n = 30) to high (n = 11) risk of bias. Many that applied behaviour change theory, communication or counselling resulted in significant improvements in infant stunting and wasting, household dietary intake and maternal psychosocial measures. Interventions with >2 behaviour change functions (including persuasion, incentivisation, environmental restructuring) were the most effective. We recommend incorporating behaviour change functions in nutrition interventions to improve maternal and child outcomes, specifically drawing on the Behaviour Change Wheel, COM-B model (SORT B recommendation). To enhance the designs of these interventions, and ultimately improve the nutritional and psychosocial outcomes for mothers and infants in sub-Saharan Africa, collaborations are recommended between behaviour change and nutrition experts, intervention designers, policy makers and commissioners to fund and roll-out multicomponent behaviour change interventions.

Men’s motivations, barriers to and aspirations for their families’ health in the first 1000 days in sub-Saharan Africa: a secondary qualitative analysis

Introduction

The first 1000 days of life are a critical period of growth and development that have lasting implications for health, cognitive, educational and economic outcomes. In sub-Saharan Africa, gender and social norms are such that many men have little engagement with maternal and child health and nutrition during pregnancy and early childhood. This study explores how men perceive their role in three sites in sub-Saharan Africa.

Methods

Secondary qualitative analysis of 10 focus group discussions with 76 men in Burkina Faso, Ghana and South Africa. Data were thematically analysed to explore men’s perceptions of maternal and child health and nutrition.

Results

Men considered themselves ‘providers’ and 'advisors' within their families, particularly of finances, food and medicines. They also indicated that this advice was out of care and concern for their families’ health. There were similarities in how the men perceive their role. Differences between men living in rural and urban settings included health priorities, the advice and the manner in which it was provided. Across all settings, men wanted to be more involved with maternal and child health and nutrition. Challenges to doing so included stigma and proscribed social gender roles.

Conclusion

Men want a greater engagement in improving maternal and child health and nutrition but felt that their ability to do so was limited by culture-specified gender roles, which are more focused on providing for and advising their families. Involving both men and women in intervention development alongside policymakers, health professionals and researchers is needed to improve maternal and child health and nutrition.

Beneficiary and Local Stakeholder Participation in Community-Based Nutrition Interventions

Beneficiary and local stakeholder participation is an essential element to the success of community-based nutrition interventions. We sought to define active participation and review the available evidence on beneficiary and local stakeholder participation in community-based nutrition interventions in Africa. From reviewing the literature, we provide a reflective assessment on the process and findings. Participation falls on a continuum of community involvement from passive (no real involvement) to empowerment and community ownership (full active involvement). However, we found a clear gap in the research on defining active participation and identifying what constitutes active participation on behalf of beneficiaries and local stakeholders. However, progress was found; evidence included the use of participatory methods to engage beneficiaries and local stakeholders in the assessment and design phase. Beneficiary and local stakeholder participation in delivering interventions has moved forward with quantitative measures from process evaluation and implementation science. Research has started on the extent of beneficiary engagement (as recipients) and connecting this to outcomes. Evaluation has benefited from qualitative inquiry with insights from participants on engagement itself, and the barriers and facilitators to engagement. Yet questions remain in each study phase around defining and quantifying active participation and in understanding the personal, social, and motivational elements of active participation. We offer a simple framework to stimulate thought and commitment to research on participation in community-based nutrition interventions.

Children born during the hunger season are at a higher risk of severe acute malnutrition: Findings from a Guinea Sahelian ecological zone in Northern Ghana

Heightened food insecurity in the hunger season increases the risk of severe acute malnutrition (SAM) in childhood. This study examined the association of season of birth with SAM in a Guinean Sahelian ecological zone. We analyzed routine health and sociodemographic surveillance data from the Navrongo Health and Socio-demographic Surveillance System collected between 2011 and 2018. January-June, the period of highest food insecurity, was defined as the hunger season. We defined moderate acute malnutrition as child mid-upper arm circumference (MUAC) between 115 mm and 135 mm and SAM as MAUC ≤ 115 mm. We used adjusted logistic regression to quantify the association between the season of birth and SAM in children aged 6-35 months. From the 29,452 children studied, 24% had moderate acute malnutrition. Overall, 1.4% had SAM, with a higher prevalence (1.8%) in the hunger season of birth. Compared with those born October-December, adjusted odds ratios (aOR) and 95% confidence interval (95% CI) for SAM were increased for children born in the hunger season: January-March (1.77 [1.31-2.39]) and April-June (1.92 [1.44-2.56]). Low birth weight, age at an assessment of nutritional status, and ethno-linguistic group were also significantly associated with SAM in adjusted analyses. Our study established that being born in the hunger season is associated with a higher risk of severe acute malnutrition. The result implies improvement in the food supply to pregnant and lactating mothers through sustainable agriculture or food system change targeting the hunger season may reduce the burden of severe acute malnutrition.

Culture and community perceptions on diet for maternal and child health: a qualitative study in rural northern Ghana

Background

This study explored cultural and community perceptions of optimal diet for maternal and child health in northern Ghana.

Methods

This was an exploratory cross-sectional study using qualitative methods for data collection. Data were collected between March and April 2019 consisting of 10 focus group discussions with men and women community members between 18 and 50 years in the Kassena-Nankana districts of Ghana. Data were organised using QSR NVivo 12 qualitative software to facilitate thematic analysis.

Results

All study participants recognised the importance of an optimal diet for mother, child and better pregnancy and breastfeeding outcomes. However, there were different cultural beliefs and taboos about what foods are healthy and non-healthy for women at different stages of the reproductive period. Foods perceived to be unhealthy for pregnant women were fatty foods and fresh meat (uncooked or unprocessed meat) due to the belief that they can lead to delivery complications, which many women feared. In addition, some participants relayed the cultural belief that pregnant woman should not eat eggs because it would make the child a thief. Lactating mothers are not to eat foods such as vigna subterranean known locally as bambara bean and “gari” (local meal made from cassava) because it is believed to inhibit breastmilk production. Participants emphasised that food insecurity and economic constraints meant women could not achieve optimal diet and could not afford to be selective in food choices.

Conclusion

Community members recognized the importance of optimal nutrition but were constrained by poverty and cultural barriers. A dual approach which targets improvements of local food production and economic empowerment in combination with community-based discussion and education of the impacts of food taboos on health, should facilitate improvement in the diets of women and future generations.

'Men are not playing their roles', maternal and child nutrition in Nanoro, Burkina Faso

OBJECTIVE

To collect context-specific insights into maternal and child health and nutrition issues, and to explore potential solutions in Nanoro, Burkina Faso.

DESIGN

Eleven focus groups with men and women from eleven communities, facilitated by local researchers.

SETTING

The study took place in the Nanoro Health district, in the West-Central part of Burkina Faso.

PARTICIPANTS

Eighty-six men (18-55 years) and women by age group: 18-25; 26-34 and 35-55 years, participated in the group discussions.

RESULTS

Participants described barriers to optimal nutrition of mothers and children related to a range of community factors, with gender inequality as central. Major themes in the discussions are related to poverty and challenges generated by socially and culturally determined gender roles. Sub-themes are women lacking access to food whilst pregnant and having limited access to health care and opportunities to generate income. Although communities believe that food donations should be implemented to overcome this, they also pointed out the need for enhancing their own food production, requiring improved agricultural technologies. Given the important role that women could play in reducing malnutrition, these communities felt they needed to be empowered to do so and supported by men. They also felt that this had to be carried out in the context of an enhanced health care system.

CONCLUSIONS

Findings reported here highlight the importance of nutrition-sensitive interventions and women's empowerment in improving maternal and child nutrition. There is a need to integrate a sustainable multi-sectorial approach which goes beyond food support.

Supporting maternal and child nutrition: views from community members in rural Northern Ghana

OBJECTIVE

Despite efforts to improve maternal and child nutrition, undernutrition remains a major public health challenge in Ghana. The current study explored community perceptions of undernutrition and context-specific interventions that could improve maternal and child nutrition in rural Northern Ghana.

DESIGN

This exploratory qualitative study used ten focus group discussions to gather primary data. The discussions were recorded, transcribed and coded into themes using Nvivo 12 software to aid thematic analysis.

SETTING

The study was conducted in rural Kassena-Nankana Districts of Northern Ghana.

STUDY PARTICIPANTS

Thirty-three men and fifty-one women aged 18-50 years were randomly selected from the community.

RESULTS

Most participants reported poverty, lack of irrigated agricultural land and poor harvests as the main barriers to optimal nutrition. To improve maternal and child nutrition, study participants suggested that the construction of dams at the community level would facilitate all year round farming including rearing of animals. Participants perceived that the provision of agricultural materials such as high yield seedlings, pesticides and fertiliser would help boost agricultural productivity. They also recommended community-based nutrition education by trained health volunteers, focused on types of locally produced foods and appropriate ways to prepare them to help improve maternal and child nutrition.

CONCLUSION

Drawing on these findings and existing literature, we argue that supporting community initiated nutrition interventions such as improved irrigation for dry season farming, provision of agricultural inputs and community education could improve maternal and child nutrition.

Double-duty solutions for optimising maternal and child nutrition in urban South Africa: a qualitative study

OBJECTIVE

To obtain a community perspective on key nutrition-specific problems and solutions for mothers and children.

DESIGN

A qualitative study comprising nine focus group discussions (FGD) following a semi-structured interview guide.

SETTING

The township of Soweto in South Africa with a rising prevalence of double burden of malnutrition.

PARTICIPANTS

Men and women aged ≥18 years (n 66). Three FGD held with men, six with women.

RESULTS

Despite participants perceived healthy diet to be important, they felt their ability to maintain a healthy diet was limited. Inexpensive, unhealthy food was easier to access in Soweto than healthier alternatives. Factors such as land use, hygiene and low income played a fundamental role in shaping access to foods and decisions about what to eat. Participants suggested four broad areas for change: health sector, social protection, the food system and food environment. Their solutions ranged from improved nutrition education for women at clinic visits, communal vegetable gardens and government provision of food parcels to regulatory measures to improve the healthiness of their food environment.

CONCLUSIONS

South Africa's current nutrition policy environment does not adequately address community-level needs that are often linked to structural factors beyond the health sector. Our findings suggest that to successfully address the double burden of malnutrition among women and children, a multifaceted approach is needed combining action on the ground with coherent policies that address upstream factors, including poverty. Further, there is a need for public engagement and integration of community perspectives and priorities in developing and implementing double-duty actions to improve nutrition.