Assessment of the implementation fidelity of the Arctic Char Distribution Project in Nunavik, Quebec

Dietary Intake Estimated From a 24-Hour Recall Questionnaire in the Dene and Métis Communities of the Northwest Territories, Canada

Background

Food security and nutrient deficiencies are frequent issues for people living in northern remote regions of Canada.

Objective

The objective of this study is to describe the nutrient intake of residents living in the Dene/Métis communities of the Dehcho and Sahtú regions of the Northwest Territories.

Methods

A 24-h dietary recall survey was used to collect information from participants of a study completed in 9 communities during the winter seasons of January 2016 to March 2018. Intakes for food groups, vitamins, macroelements, and microelements were calculated. Nutrient intakes were compared with the available DRIs.

Results

In total, there were 197 participants. On average, 37% of their energy was consumed from fat, and fruit/vegetable consumption was low (2.8 servings). Some vitamin levels (i.e., folate and vitamins A, B-6, C, and D) indicated a risk of nutritional deficiency for at least half of the participants. Of the nutrients examined, the nutrients least likely to meet the DRIs, according to the age/sex category of respondents were vitamin D (6%-20%), fiber (0%-11%), and calcium (4%-30%). Males tended to have a higher rate of nutrient adequacy above the DRIs. Importantly, 52% of the childbearing age female participants appeared deficient in folate, 48% deficient in zinc, 41% deficient in B12, and 22% deficient in iron, which might affect pregnancy and children's development.

Conclusions

A focus on supporting a higher intake of nutrient-dense foods would benefit the health of these communities. Nutrition and health promotion programs should be implemented to improve public health efforts in the region.

Identifying Barriers and Pathways Linking Fish and Seafood to Food Security in Inuit Nunangat: A Scoping Review

BACKGROUND

Fish and seafood play an important role in improving food security in Inuit Nunangat. Therefore, this scoping review aims to explore (1) what topics and/or themes have been widely explored in the literature related to barriers and pathways linking fish and seafood to food security; (2) where research, policy, and action gaps exist; and (3) how fisheries currently contribute to food security.

METHODS

A systematic search of peer-reviewed articles was conducted using six databases. Articles were screened by two independent reviewers. Eligible studies included primary research conducted in Inuit Nunangat that explored the roles of fish and seafood in food security.

RESULTS

Thirty-one articles were included for review. Overall, we found that fisheries can influence food security through direct pathways (e.g., consuming fish for nutrition), and through indirect pathways such as increasing household purchasing power (e.g., through employment). Research indicated that policies relating to wildlife and fisheries management need to be integrated with food and health policies to better address food insecurity in Inuit Nunangat.

CONCLUSION

Future research is needed to establish a more robust understanding of the explicit mechanisms that fish and seafood harvest and/or the participation in commercial fisheries alleviates household food insecurity.

Inuit Country Food and Health during Pregnancy and Early Childhood in the Circumpolar North: A Scoping Review

Inuit communities in the Circumpolar North have experienced a nutrition transition characterized by the decreased intake of culturally important, nutrient-rich traditional food (country food), and an increased intake of market food, resulting in concerns over reduced diet quality and emerging chronic diseases. Nutrition in early life is critical for development, may influence health risks in later life, and is an important concern for Inuit community health. The goal of this scoping review was to characterize the nature, extent, and range of the published literature on Inuit country food and health in pregnancy and childhood. A search string was developed and applied to three databases, followed by title and abstract screening and full text review. Articles published between 1995 and 2019 were included, and data were extracted and summarized descriptively. The number of articles generally increased over time, despite the unequal geographic distribution of articles. The majority of the articles focused on environmental contaminants, and one-quarter described nutrient adequacy. Few articles described food security or food safety in pregnancy, and the most utilized quantitative methods. Gaps in understanding of country food use in pregnancy and early childhood highlight areas of future research to support public health policy for this population. Given the critical role of good nutrition in early life and the important contribution country food makes to diet quality for Inuit, further understanding of this interface is warranted.

Seasonal variations in exposure to methylmercury and its dietary sources among pregnant Inuit women in Nunavik, Canada

Among populations living in close connection with the sea, rivers and lakes for subsistence, diet varies according to local monthly wildlife species availability and food preferences. This may lead to variations in methylmercury (MeHg) exposure over a year, although no biomonitoring studies have documented this issue in Circumpolar populations, the most exposed to international Hg emissions. Our aim was to characterize seasonal variations in MeHg exposure among pregnant Inuit women from Nunavik and to identify country foods responsible for these variations. Between October 2016 and March 2017, 97 participants were recruited. Blood mercury (Hg) was tested and hair Hg was measured by centimeter as a surrogate for monthly MeHg exposure over the past year. Latent class growth analysis was conducted to identify groups of pregnant women with similar hair Hg monthly trajectories. Country foods consumption was documented by season. Seasonal daily intakes of MeHg were estimated based on concentrations in country foods. Retrospective monthly hair Hg analyses revealed that MeHg exposure was lowest in winter, and highest in summer and early fall months. Three latent classes (groups) of pregnant women with similar trajectories of monthly hair Hg variations were identified: high (n = 20, 21%), moderate (n = 38, 41%) and low variation (n = 35, 38%). Beluga meat was the country food contributing to most of daily MeHg intake, primarily during summer and fall, and was the only one associated with the odds of being classified into moderate and high variation groups (OR 95% CI: 1.19 [1.01-1.39] and 1.25 [1.04-1.50]). These findings underscore the importance of monthly variations in exposure to MeHg due to the seasonality of local foods consumed and responsible for elevated MeHg exposure. Further studies critically need to understand local diet fluctuations over a year to adequately assess MeHg exposure, adopt timely preventive interventions and evaluate the effectiveness of the Minamata Convention.

Factors influencing variation in implementation outcomes of the redesigned community health fund in the Dodoma region of Tanzania: a mixed-methods study

Introduction

Micro-health insurance (MHI) has been identified as a possible interim solution to foster progress towards Universal Health Coverage (UHC) in low- and middle- income countries (LMICs). Still, MHI schemes suffer from chronically low penetration rates, especially in sub-Saharan Africa. Initiatives to promote and sustain enrolment have yielded limited effect, yet little effort has been channelled towards understanding how such initiatives are implemented. We aimed to fill this gap in knowledge by examining heterogeneity in implementation outcomes and their moderating factors within the context of the Redesigned Community Health Fund in the Dodoma region in Tanzania.

Methods

We adopted a mixed-methods design to examine implementation outcomes, defined as adoption and fidelity of implementation (FOI) as well as their moderating factors. A survey questionnaire collected individual level data and a document review checklist and in-depth interview guide collected district level data. We relied on descriptive statistics, a chi square test and thematic analysis to analyse our data.

Results

A review of district level data revealed high adoption (78%) and FOI (77%) supported also by qualitative interviews. In contrast, survey participants reported relatively low adoption (55%) and FOI (58%). Heterogeneity in adoption and FOI was observed across the districts and was attributed to organisational weakness or strengths, communication and facilitation strategies, resource availability (fiscal capacity, human resources and materials), reward systems, the number of stakeholders, leadership engagement, and implementer’s skills.

At an individual level, heterogeneity in adoption and FOI of scheme components was explained by the survey participant’s level of education, occupation, years of stay in the district and duration of working in the scheme. For example, the adoption of job description was statistically associated with occupation (p = 0.001) and wworking in the scheme for more than 20 months had marginal significant association with FOI (p = 0.04).

Conclusion

The study demonstrates that assessing the implementation processes helps to detect implementation weaknesses and therefore address such weaknesses as the interventions are implemented or rolled out to other settings. Attention to contextual and individual implementer elements should be paid in advance to adjust implementation strategies and ensure greater adoption and fidelity of implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-10013-y.

Feasibility and ethical issues: experiences and concerns of healthcare workers regarding a new RSV prophylaxis programme in Nunavik, Quebec

Background: The respiratory syncytial virus (RSV) is a major cause of hospitalisation in young Inuit children. Prophylaxis with palivizumab is routinely recommended for premature infants and those with severe pulmonary or cardiac diseases. In the fall 2016, the Quebec Ministry of Health expanded the criteria to include healthy full-term (HFT) newborns from Nunavik based on their high RSV hospitalisation rates.Objectives: The aim of this study was to describe the impact of this programme on Nunavik health services during the first RSV season after its implementation (2016-2017) by studying challenges, concerns and needs of healthcare workers (HCWs).Methods: An ethnographic approach was used. Semi-structured interviews focusing on HCWs experiences, and opinions to improve the new programme were conducted with 20 HCWs involved in its implementation.Results: Main reported challenges and concerns were: additional work(over)load, lack of information and evidence about the need and efficacy of palivizumab in HFT newborns, communication issues between stakeholders, and ethical issues regarding the Inuit population.Conclusion: The study revealed significant feasibility and acceptability issues. The programme was highly resource consuming. To address HCWs' concerns, evidence-based data regarding palivizumab effectiveness in HFT infants, as well as consultation and involvement of Inuit population are warranted.

Perfluoroalkyl acids in pregnant women from Nunavik (Quebec, Canada): Trends in exposure and associations with country foods consumption

BACKGROUND

Perfluoroalkyl acids (PFAAs) are persistent and ubiquitous environmental contaminants that potentially disrupt endocrine system functions. While some PFAAs (perfluorooctane sulfonate (PFOS), perfluorooctanoic acid (PFOA)) are regulated, currently used fluorotelomer alcohols (FTOHs) can be transported to the Arctic and are degraded in a number of PFAAs which biomagnify in Arctic wildlife (e.g. perfluorononanoic acid (PFNA), perfluorodecanoic acid (PFDA), perfluoroundecanoic acid (PFUdA)).

OBJECTIVES

From 2004 to 2017, 279 pregnant Inuit women were recruited as part of biomonitoring projects in Nunavik. Our goal was to evaluate: (i) time-trends in plasma/serum PFAAs levels in pregnant Nunavimmiut women between 2004 and 2017; (ii) compare plasma/serum PFAAs levels in Nunavimmiut women in 2016-2017 to those measured in women of childbearing age in the Canadian Health Measure Survey (CHMS); and (iii) evaluate the associations of PFAAs levels with the consumption of country foods and pregnancy and maternal characteristics during pregnancy in the 97 participants recruited in 2016-2017.

METHODS

Individual blood sample were collected for serum or plasma PFAAs (PFOS, PFOA, pentafluorobenzoic acid (PFBA), perfluorohexanoic acid (PFHxA), perfluorobutanesulfonic acid (PFBS), perfluorohexane-1-sulfonic acid (PFHxS), PFNA, PFDA, PFUdA) analyses. Socio-demographic data, pregnancy and maternal characteristics and country foods consumption were documented using a questionnaire. Omega-3 and -6 polyunsaturated fatty acids (PUFA) were measured in red blood cell membranes and their ratio used as a biomarker of marine country foods consumption. Time-trends in PFAAs levels were evaluated using ANCOVA models adjusted for relevant co-variables. Serum/plasma levels of PFAAs in the 97 pregnant women aged 16 to 40 years old and recruited in 2016-2017 were compared to those measured in women aged 18 to 40 years old from the CHMS cycle 5 (2016-2017) using the geometric means (GM) and 95% confidence intervals (95% CI). Multivariate regression analyses were performed to examine associations between concentrations of PFAAs and country foods consumption data.

RESULTS

Statistically-significant downward time trends were noted for concentrations of PFOS, PFOA and PFHxS in pregnant Nunavik women between 2004 and 2017. Conversely, between 2011 and 2016-2017, PFNA, PFDA and PFUdA maternal serum levels increased by 19, 13 and 21% respectively. Among participants in 2016-2017, mean concentrations for PFNA (GM: 2.4 μg/L), PFDA (0.53 μg/L) and PFUdA (0.61 μg/L) were higher than those measured in women aged 18-40 years old in the Cycle 5 (2016-2017) of the CHMS. PFOA (0.53 μg/L) and PFHxS (0.26 μg/L) were lower than in CHMS, whereas PFBA, PFHxA and PFBS were not detected in 2016-2017. Ratios of serum/plasma levels of PFNA/PFOA, PFNA/PFOS, PFNA/PFHxS and PFUdA/PFDA were significantly higher in the 97 pregnant women from Nunavik recruited in 2016-2017 compared to CHMS, highlighting their distinct exposure profile. In multivariate models, PFHxS, PFOS, PFNA, PFDA and PFUdA levels in 2016-2017 were strongly associated with the omega-3/omega-6 PUFA ratio, indicating a positive association between marine country foods consumption and higher exposure to PFAAs.

CONCLUSIONS

The exposure of pregnant women to long-chain PFAAs (PFNA, PFDA and PFUdA) increased from 2004 to 2017 in Nunavik. Associations noted between PFAAs levels and the omega-3/omega-6 ratio highlights the importance of implementing additional strict regulations on PFAAs and their precursors to protect the high nutritional quality and cultural importance of country foods in Nunavik.

Using implementation science theories and frameworks in global health

In global health, researchers and decision makers, many of whom have medical, epidemiology or biostatistics background, are increasingly interested in evaluating the implementation of health interventions. Implementation science, particularly for the study of public policies, has existed since at least the 1930s. This science makes compelling use of explicit theories and analytic frameworks that ensure research quality and rigour. Our objective is to inform researchers and decision makers who are not familiar with this research branch about these theories and analytic frameworks. We define four models of causation used in implementation science: intervention theory, frameworks, middle-range theory and grand theory. We then explain how scientists apply these models for three main implementation studies: fidelity assessment, process evaluation and complex evaluation. For each study, we provide concrete examples from research in Cuba and Africa to better understand the implementation of health interventions in global health context. Global health researchers and decision makers with a quantitative background will not become implementation scientists after reading this article. However, we believe they will be more aware of the need for rigorous implementation evaluations of global health interventions, alongside impact evaluations, and in collaboration with social scientists.

A scoping review of traditional food security in Alaska

BACKGROUND

Food insecurity is a public health concern. The pillars of food security include food access, availability and utilisation. For some indigenous peoples, the pillars may focus on traditional foods.

OBJECTIVE

To conduct a scoping review on traditional foods and food security in Alaska.

DESIGN

Google Scholar and the High North Research Documents were used to search for relevant primary research using the following terms: “traditional foods”, “food security”, “access”, “availability”, “utilisation”, “Alaska”, “Alaska Native” and “indigenous”.

RESULTS

Twenty four articles from Google Scholar and four articles from the High North Research Documents met the inclusion criteria. The articles revealed three types of research approaches, those that quantified traditional food intake (n=18), those that quantified food security (n=2), and qualitative articles that addressed at least one pillar of food security (n=8).

CONCLUSIONS

Studies that estimate the prevalence of traditional food insecurity in Alaska are virtually absent from the literature. Instead most studies provide a review of factors related to food security. Research investigating dietary intake of traditional foods is more prevalent. Future research should include direct measurements of traditional food intake and food security to provide a more complete picture of traditional food security in Alaska.

Psychometric validation of the household food insecurity access scale among Inuit pregnant women from Northern Quebec

Background

Globally, food insecurity is a major public health concern. In North America, it is particularly prevalent in certain sub-groups, including Indigenous communities. Although many Indigenous and remote communities harvest and share food, most food security assessment tools focus on economic access. This study describes the psychometric evaluation of a modified Household Food Insecurity Access Scale (HFIAS), developed for mixed economies, to assess food insecurity among pregnant Inuit women.

Methods

The HFIAS was administered to 130 pregnant women in Nunavik (Arctic region of Quebec), Canada. Data were fit to a Rasch Rating Scale Model (RSM) to determine the discrimination ability of the HFIAS. Person parameter (Theta) estimates were calculated based on the RSM to provide a more accurate scoring system of the modified HFIAS for this population. Theta values were compared to known correlates of food insecurity.

Results

Comparative fit indices showed preference for a modified version of the HFIAS over the original. Theta values displayed a continuum of severity estimates and those values indicating greater food insecurity were consistently linked to known correlates of food insecurity. Participants living in households with more than 1 hunter (Theta = -.45) or more than 1 fisher (Theta = -.43) experienced less food insecurity than those with no hunters (Theta = .48) or fishers (Theta = .49) in their household. The RSM indicated the scale showed good discriminatory ability. Subsequent analyses indicated that most scale items pertain to the classification of a household as moderately food insecure.

Conclusions

The modified HFIAS shows potential for measuring food insecurity among pregnant women in Nunavik. This is an efficient instrument that can inform interventions targeting health conditions impacting groups that obtain food through both monetary and non-monetary means.