Availability of healthy and unhealthy foods in modern retail outlets located in selected districts of Greater Accra Region, Ghana

Background

Intake of unhealthy foods is linked to the onset of obesity and diet-related non-communicable diseases (NCDs). Availability of unhealthy (nutritionally poor) foods can influence preference, purchasing and consumption of such foods. This study determined the healthiness of foods sold at modern retail outlets- supermarkets and mini-marts in the Greater Accra Region of Ghana.

Methods

All modern retail outlets located in six districts of Greater Accra were eligible. Those < 200 m² of floor area and with permanent structures were categorized as mini-marts; and those ≥200 m² as supermarkets. Shelf length of all available foods were measured. Healthiness of food was determined using two criteria - the NOVA classification and energy density of foods. Thus, ultra-processed foods or food items with >225 kcal/100 g were classified as unhealthy. The ratio of the area occupied by unhealthy to healthy foods was used to determine the healthiness of modern retail outlets.

Results

Of 67 retail outlets assessed, 86.6% were mini-marts. 85.0% of the total SHELF area was occupied by foods categorized as unhealthy (ranging from 9,262 m² in Ashiaman Municipality to 41,892 m² in Accra Metropolis). Refined grains/grain products were the most available, occupying 30.0% of the total food shelf space, followed by sugar-sweetened beverages (20.1% of total shelf space). The least available food group-unprocessed staples, was found in only one high income district, and occupied 0.1% of the total food shelf space. Retail outlets in two districts did not sell fresh fruits or fresh/unsalted canned vegetables. About two-thirds of food products available (n = 3,952) were ultra-processed. Overall, the ratio of ultra-processed-to-unprocessed foods ranged from 3 to 7 with an average (SD) of 5(2). Thus, for every healthy food, there were five ultra-processed ones in the studied retail outlets.

Conclusion

This study reveals widespread availability of ultra-processed foods in modern retail outlets within the selected districts. Toward a healthier food retail environment, public health and food regulators, in partnership with other stakeholders need to institute measures that improve availability of healthy foods within supermarkets and mini-marts.

The Africa Food Environment Research Network (FERN): from concept to practice

Background:

Africa is contending with unhealthy food environments that are, in part, driving increasing rates of overweight, obesity and diet-related non-communicable diseases, alongside persistent undernutrition. This current paradigm requires expanded efforts – both in the volume and nature of empirical research, as well as the tools and capacity of those who conduct it. High quality and context-relevant research supports the development and implementation of policies that create healthy food environments.

Aim and approach:

This paper sets out the concept of the Africa Food Environment Research Network (FERN) initiative recently established by the Measurement, Evaluation, Accountability, and Leadership Support for non-communicable diseases (NCDs) (MEALS4NCDs) prevention project. Central to the Africa FERN initiative are: 1) building research capacity for innovative food environment research in Africa; 2) improving South–South, South–North partnerships to stimulate robust food environment research and monitoring in Africa and 3) sustaining dialogue and focusing priorities around current and future needs for enhanced food environment research and monitoring in Africa.

Conclusion:

The FERN initiative presents an opportune platform for researchers in Africa and the global North to weave the threads of experience and expertise for research capacity building, collaboration and advocacy, to advance food environment research.

The Content and Sources of Breastfeeding Knowledge for New Mothers in the Netherlands

Background:

In the context of decreasing breastfeeding rates and unsuccessful breastfeeding promotion campaigns, a qualitative research project in the Northern part of the Netherlands was initiated.

Objectives:

As part of the overall project, the aim of this study was to explore the content and sources of breastfeeding knowledge among primiparous women. Identifying and categorizing the content and the sources of breastfeeding knowledge could guide professionals such as midwives and maternity nurses as well as others in the women’s surroundings to engage in disseminating knowledge and therefore support women in achieving their breastfeeding goals.

Methods:

We conducted 26 in-depth interviews from the emic perspective with 13 new mothers pre- and postpartum, up to saturation level. Transcripts were analysed applying thematic analysis. As sensitising concepts, the themes identified were divided into two categories: those gained from 'professional' sources and those obtained from 'popular' sources.

Results:

Five knowledge content themes were identified: (1) pros and cons of breastfeeding, (2) how breastfeeding works, (3) individual breastfeeding practice, (4) expressing milk, and (5) formula feeding. ‘Professional’ sources are perceived as more helpful than ‘popular’ sources, whereas ‘intuition’ was inductively identified as an important knowledge source.

Conclusion:

Limited breastfeeding practice exposure, along with the recommendations to breastfeed for six months and perceptions of breastfeeding as ‘natural’ at the same time, generates much pressure in women. Emphasizing all knowledge content in campaigns, addressing a variety of target groups in women’s social environment, and recognizing intuition as an adequate source of knowledge supported by professionals will facilitate women in making informed infant feeding decisions.

Building knowledge, optimising physical and mental health and setting up healthier life trajectories in South African women (Bukhali): a preconception randomised control trial part of the Healthy Life Trajectories Initiative (HeLTI)

INTRODUCTION

South Africa's evolving burden of disease is challenging due to a persistent infectious disease, burgeoning obesity, most notably among women and rising rates of non-communicable diseases (NCDs). With two thirds of women presenting at their first antenatal visit either overweight or obese in urban South Africa (SA), the preconception period is an opportunity to optimise health and offset transgenerational risk of both obesity and NCDs.

METHODS AND ANALYSIS

Bukhali is the first individual randomised controlled trial in Africa to test the efficacy of a complex continuum of care intervention and forms part of the Healthy Life Trajectories Initiative (HeLTI) consortium implementing harmonised trials in Canada, China, India and SA. Starting preconception and continuing through pregnancy, infancy and childhood, the intervention is designed to improve nutrition, physical and mental health and health behaviours of South African women to offset obesity-risk (adiposity) in their offspring. Women aged 18-28 years (n=6800) will be recruited from Soweto, an urban-poor area of Johannesburg. The primary outcome is dual-energy X-ray absorptiometry derived fat mass index (fat mass divided by height²) in the offspring at age 5 years. Community health workers will deliver the intervention randomly to half the cohort by providing health literacy material, dispensing a multimicronutrient supplement, providing health services and feedback, and facilitating behaviour change support sessions to optimise: (1) nutrition, (2) physical and mental health and (3) lay the foundations for healthier pregnancies and early child development.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Human Ethics Research Committee University of the Witwatersrand, Johannesburg, South Africa (M1811111), the University of Toronto, Canada (19-0066-E) and the WHO Ethics Committee (ERC.0003328). Data and biological sample sharing policies are consistent with the governance policy of the HeLTI Consortium (https://helti.org) and South African government legislation (POPIA). The recruitment and research team will obtain informed consent.

TRIAL REGISTRATION

This trial is registered with the Pan African Clinical Trials Registry (https://pactr.samrc.ac.za) on 25 March 2019 (identifier: PACTR201903750173871).

PROTOCOL VERSION

20 March 2022 (version #4). Any protocol amendments will be communicated to investigators, Institutional Review Board (IRB)s, trial participants and trial registries.

Perspective: Food Environment Research Priorities for Africa-Lessons from the Africa Food Environment Research Network

Over the last 2 decades, many African countries have undergone dietary and nutrition transitions fueled by globalization, rapid urbanization, and development. These changes have altered African food environments and, subsequently, dietary behaviors, including food acquisition and consumption. Dietary patterns associated with the nutrition transition have contributed to Africa's complex burden of malnutrition-obesity and other diet-related noncommunicable diseases (DR-NCDs)-along with persistent food insecurity and undernutrition. Available evidence links unhealthy or obesogenic food environments (including those that market and offer energy-dense, nutrient-poor foods and beverages) with suboptimal diets and associated adverse health outcomes. Elsewhere, governments have responded with policies to improve food environments. However, in Africa, the necessary research and policy action have received insufficient attention. Contextual evidence to motivate, enable, and create supportive food environments in Africa for better population health is urgently needed. In November 2020, the Measurement, Evaluation, Accountability, and Leadership Support for Noncommunicable Diseases Prevention Project (MEALS4NCDs) convened the first Africa Food Environment Research Network Meeting (FERN2020). This 3-d virtual meeting brought researchers from around the world to deliberate on future directions and research priorities related to improving food environments and nutrition across the African continent. The stakeholders shared experiences, best practices, challenges, and opportunities for improving the healthfulness of food environments and related policies in low- and middle-income countries. In this article, we summarize the proceedings and research priorities identified in the meeting to advance the food environment research agenda in Africa, and thus contribute to the promotion of healthier food environments to prevent DR-NCDs, and other forms of malnutrition.

You can't report your feelings: The hidden labor of managing threats to safety by women in global public health fieldwork

Increasing job market demand for and availability of Canadian and U.S. global academic health programs in post-secondary education increases student demand to participate in internationally based fieldwork, while supportive resources remain weakly developed. Previous studies indicate provisions to protect the health, safety, and well-being of women students remain inadequately addressed during training, while more research to identify needs, expectations, gaps, and best practices would inform policy and practice to improve conditions for women working off-campus on global public health studies. One approach, reported here, is to document and better understand the lived experience of U.S. or Canadian women graduate students participating in global public health fieldwork. Participant in-depth phenomenological interviews and guided writing exercises aimed to capture lived experience descriptions for 25 women. A phenomenology of practice was applied throughout the research process, following Max van Manen's qualitative methodology approach. Loss of environmental familiarity, combined with graduate students' lack of power, created considerable hidden labor described by women in working to keep themselves safe from sexual and gender-based violence (SGBV) while participating in global public health fieldwork. Women shared specific experiences exemplifying how this can be both alleviated and/or intensified through a range of negotiated strategies, coping styles, and management techniques. Additionally, women recalled laboring as students to avoid or reduce instances of SGBV, that then, precluded them from having any material "of substance" to report once returned home. These findings offer new meaning structures, language for a foreign experience, or ways to describe, conceive of, and respond to global public health fieldwork that hold the potential to positively affect individuals' experiences, institutional understanding, and thus practice, of future women students in global public health.

Evaluating the integration of strategic priorities within a complex research-for-development funding program

This paper examines the application of Complexity Theory constructs to a research-for-development program evaluation and presents an overview of the implications and promising approaches for evaluating complex programs. We discuss lessons learned from an evaluation completed for the International Development Research Centre's Food, Environment and Health (FEH) program, which investigated the integration and outcomes of five strategic program priorities: partnerships, southern leadership, gender and equity, scale, and environmental sustainability. We present interpretations from a secondary, thematic content analysis that categorized evaluation findings across four complexity constructs: emergence, unpredictability, contradiction and self-organization. Viewing the evaluation through these constructs surfaced some important features of the FEH program to date, specifically its evolving approach, adaptiveness to emergent issues, non-linear outcomes, and self-organizing agents, which had several implications for the evaluative process. We conclude that the most appropriate evaluation designs for complex funding programs are participatory (to explore all stakeholders' influence), adaptive (to capture the unexpected) and assess external contexts. The application of complexity constructs may be useful for evaluators to gain a deeper understanding of how program contexts change in the face of complexity and why some evaluation methods work more effectively than others.

Providing Measurement, Evaluation, Accountability, and Leadership Support (MEALS) for Non-communicable Diseases Prevention in Ghana: Project Implementation Protocol

Background: This study describes the rationale, adaptation, and final protocol of a project developed to address the increase in obesity and nutrition-related non-communicable diseases (NR-NCDs) in Ghana. Code-named the Measurement, Evaluation, Accountability, and Leadership Support for NCDs (MEALS4NCDs) project, it aims to measure and support public sector actions that create healthy food marketing, retail, and provisioning environments for Ghanaian children using adapted methods from the International Network for Food and Obesity/NCDs Research Monitoring and Action Support (INFORMAS).

Methods: The protocol for this observational study draws substantially from the INFORMAS' Food Promotion and Food Provision Modules. However, to appraise the readiness of local communities to implement interventions with strong potential to improve food environments of Ghanaian children, the MEALS4NCDs protocol has innovatively integrated a local community participatory approach based on the community readiness model (CRM) into the INFORMAS approaches. The setting is Ghana, and the participants include health and nutrition policy-makers, nutrition and food service providers, consumers, school authorities, and pupils of Ghanaian basic schools.

Results: The study establishes a standardized approach to providing implementation science evidence for the prevention of non-communicable diseases (NCDs) in Ghana. It demonstrates feasibility and the innovative application of the INFORMAS expanded food promotion and food provision modules, together with the integration of the CRM in a lower-middle income setting.

Conclusion: The research will facilitate the understanding of the processes through which the INFORMAS approach is contextualized to a lower-middle income African context. The protocol could be adapted for similar country settings to monitor relevant aspects of food environments of children.

Building the field of food systems research: commentary on a research funder's role

Background

The Food, Environment, and Health (FEH) program of the International Development Research Centre (IDRC) aims to improve the health of low- and middle-income country populations by generating evidence, innovations, and policies that reduce the health and economic burdens of preventable chronic and infectious diseases. A predominant focus of the FEH program is research related to consumer food environments that promote or enable healthy and sustainable shifts in consumption. An evaluation of the FEH program, led by the University of Toronto, provided an opportunity to analyse the approach and role of a development funder in building the field of food systems research.

Discussion

In this commentary, we provide an external evaluator’s perspective on the IDRC’s contributory role in building the field of food systems research, based on a secondary analysis of findings from a recent FEH program evaluation. We used the field-building framework outlined in Di Ruggiero et al. (Health Res Policy System, 2017) to highlight the strengths and challenges of the FEH’s approach to field-building and determined that the program aligns with six of the seven features of the framework. The FEH program has enhanced support and awareness for food systems research, provided organized funding and capacity-building opportunities, multilevel activity to support research and its use, and strong scientific leadership, and set significant standards and exemplars. However, we also found that not all sociopolitical environments have fully recognized or valued food systems research and its use for policy change.

Conclusion

The FEH program’s field-building approach can be situated within the field-building framework, and it has been successful in laying the groundwork for building the field of food systems, particularly consumer food environments research. However, supportive external environments and further investments may be needed to achieve a critical mass of capacity, continue building communities of practice, and influence policy. The FEH program approach may serve as an exemplar and comparator for other research funding agencies looking to develop strategic research programming in the field of food systems research.

Use of Expressed Breastmilk at Two Weeks Postpartum Is Associated With Early Cessation and Non-exclusive Breastmilk Feeding for Six Months in a Cohort of Vulnerable Women

Objectives

Pumping and feeding expressed breastmilk (EBM) in the early postpartum period are common but may not support longer-term breastfeeding outcomes. Our objectives were to examine in a cohort of vulnerable mothers of term-born infants: i) the prevalence of EBM feeding; and ii) associations between EBM use at two weeks and any and exclusive breastmilk feeding over the first six months postpartum.

Methods

We pooled data from two studies conducted with participants (n = 316) at three Toronto sites implementing the Canada Prenatal Nutrition Program, an initiative targeting vulnerable families. Socio-demographic data were collected prenatally or at two weeks postpartum. Household food insecurity was assessed at six months using the Canadian Community Health Survey module. A standardized questionnaire was administered prospectively at two weeks and two, four and six months postpartum to collect data on infant feeding practices in the previous two weeks. Descriptive statistics and logistic regression analyses were performed.

Results

The mean age of participants was 32 years, 91% were born outside Canada and 38% had lived in Canada less than three years. Nearly half (44%) reported household food insecurity. All participants initiated breastfeeding and 34% reported EBM use at two weeks postpartum. This declined to 24% at two months, 14% at four months and 8% at six months postpartum. Over the six-month follow-up period, 20% discontinued any breastmilk feeding and only 16% practiced exclusive breastmilk feeding. In adjusted models, EBM use at two weeks was associated with breastmilk feeding cessation (OR 2.75; 95% CI: 1.4–5.2) and non-exclusive breastmilk feeding for six months postpartum (OR 4.32; 95% CI 1.8–10.5).

Conclusions

EBM use in the first two weeks was a predictor of early cessation and non-exclusive breastmilk feeding for six months postpartum in our cohort of vulnerable women living in an urban Canadian context and accessing prenatal nutrition programs. Further research is needed to determine whether early EBM use is a marker for breastfeeding difficulties or undermines longer-term breastfeeding outcomes.

Funding Sources

Canadian Institutes of Health Research; The Sprott Foundation: Joannah and Brian Lawson Centre for Child Nutrition.

Protocol for a cluster randomised trial evaluating a multifaceted intervention starting preconceptionally-Early Interventions to Support Trajectories for Healthy Life in India (EINSTEIN): a Healthy Life Trajectories Initiative (HeLTI) Study

INTRODUCTION

The Healthy Life Trajectories Initiative is an international consortium comprising four harmonised but independently powered trials to evaluate whether an integrated intervention starting preconceptionally will reduce non-communicable disease risk in their children. This paper describes the protocol of the India study.

METHODS AND ANALYSIS

The study set in rural Mysore will recruit ~6000 married women over the age of 18 years. The village-based cluster randomised design has three arms (preconception, pregnancy and control; 35 villages per arm). The longitudinal multifaceted intervention package will be delivered by community health workers and comprise: (1) measures to optimise nutrition; (2) a group parenting programme integrated with cognitive-behavioral therapy; (3) a lifestyle behaviour change intervention to support women to achieve a diverse diet, exclusive breast feeding for the first 6 months, timely introduction of diverse and nutritious infant weaning foods, and adopt appropriate hygiene measures; and (4) the reduction of environmental pollution focusing on indoor air pollution and toxin avoidance.The primary outcome is adiposity in children at age 5 years, measured by fat mass index. We will report on a host of intermediate and process outcomes. We will collect a range of biospecimens including blood, urine, stool and saliva from the mothers, as well as umbilical cord blood, placenta and specimens from the offspring.An intention-to-treat analysis will be adopted to assess the effect of interventions on outcomes. We will also undertake process and economic evaluations to determine scalability and public health translation.

ETHICS AND DISSEMINATION

The study has been approved by the institutional ethics committee of the lead institute. Findings will be published in peer-reviewed journals. We will interact with policy makers at local, national and international agencies to enable translation. We will also share the findings with the participants and local community through community meetings, newsletters and local radio.

TRIAL REGISTRATION NUMBER

ISRCTN20161479, CTRI/2020/12/030134; Pre-results.

Protocol for a randomised trial evaluating a preconception-early childhood telephone-based intervention with tailored e-health resources for women and their partners to optimise growth and development among children in Canada: a Healthy Life Trajectory Initiative (HeLTI Canada)

INTRODUCTION

The 'Developmental Origins of Health and Disease' hypothesis suggests that a healthy trajectory of growth and development in pregnancy and early childhood is necessary for optimal health, development and lifetime well-being. The purpose of this paper is to present the protocol for a randomised controlled trial evaluating a preconception-early childhood telephone-based intervention with tailored e-health resources for women and their partners to optimise growth and development among children in Canada: a Healthy Life Trajectory Initiative (HeLTI Canada). The primary objective of HeLTI Canada is to determine whether a 4-phase 'preconception to early childhood' lifecourse intervention can reduce the rate of child overweight and obesity. Secondary objectives include improved child: (1) growth trajectories; (2) cardiometabolic risk factors; (3) health behaviours, including nutrition, physical activity, sedentary behaviour and sleep; and (4) development and school readiness at age 5 years.

METHOD AND ANALYSIS

A randomised controlled multicentre trial will be conducted in two of Canada's highly populous provinces-Alberta and Ontario-with 786 nulliparous (15%) and 4444 primiparous (85%) women, their partners and, when possible, the first 'sibling child.' The intervention is telephone-based collaborative care delivered by experienced public health nurses trained in healthy conversation skills that includes detailed risk assessments, individualised structured management plans, scheduled follow-up calls, and access to a web-based app with individualised, evidence-based resources. An 'index child' conceived after randomisation will be followed until age 5 years and assessed for the primary and secondary outcomes. Pregnancy, infancy (age 2 years) and parental outcomes across time will also be assessed.

ETHICS AND DISSEMINATION

The study has received approval from Clinical Trials Ontario (CTO 1776). The findings will be published in peer-reviewed journals and disseminated to policymakers at local, national and international agencies. Findings will also be shared with study participants and their communities.

TRIAL REGISTRATION NUMBER

ISRCTN13308752; Pre-results.

Mobilizing Knowledge: A Comprehensive Toolkit for Quality Assured Nutrition Data and Piloting Gender Indicators

Objectives

Nutrition International (NI) sought to standardize and add novel indicators to the multiple coverage surveys conducted each year on maternal, newborn, infant and child nutrition programs to assure quality and timely, gender-related data that meets next-generation monitoring needs.

Methods

In collaboration with Campbell Collaboration (CC) and University of Toronto (UT), NI developed a comprehensive step-wise survey toolkit with multiple intervention modules using a systematic process for selecting and contextualizing indicators (NI), validating data quality (NI-UT) and piloting gender indicators derived based on statistical modelling results using Demographic and Health Survey gender and nutrition related data (CC-NI). The resulting Nutrition Information Monitoring Systems (NIMS) toolkit now includes ODK formatted questionnaire templates, quality control and assurance checklists and ready-to-use SPSS syntax for data analysis and interpretation purposes. NIMS derives its results from household-level information through the following modules: zinc and Oral Rehydration Salts coverage for diarrhea treatment, maternal-newborn nutrition, weekly iron-folic acid supplementation among adolescent girls, and infant and young child nutrition – each with selected knowledge components and newly-devised gender-related questions to inform NI's nutrition-sensitive programs. Selected modules were implemented in NI's ten intervention countries 2019–20.

Results

Application of these procedures and quality metrics allowed NI program officers to: 1) systematically assess quality during data collection – identifying and correcting surveyor errors and potential sampling bias in a timely fashion, 2) validate and visually demonstrate data quality to relevant stakeholders, and 3) produce quality assured data within 1–3 weeks, compared to 1–3 months for previous surveys that did not use the NIMS procedures and tools.

Conclusions

This systematic approach facilitated reporting timely, quality assured nutrition program data to inform how NI interventions and gender-related analyses will identify how NI's programming can be more gender-responsive.

Funding Sources

CanWaCH, Global Affairs Canada and Nutrition International.

Use of mobile phones for behavior change communication to improve maternal, newborn and child health: a scoping review

Background

Behavior change communication (BCC) to improve health and caring practices is an integral component of efforts to improve maternal, newborn and child health (MNCH). Mobile phones are widely available in low- and middle-income countries (LMIC), presenting new opportunities for BCC delivery. There is need for delivery science to determine how best to leverage mobile phone technology for BCC to improve MNCH practices.

Methods

We conducted a scoping review of studies and project reports documenting the feasibility, implementation or effectiveness of using mobile phones for BCC delivery related to MNCH in LMIC. Data were extracted and synthesized from three sources: i) systematic search of three electronic databases (PubMed, MedLine, Scopus); ii) grey literature search, including mHealth databases and websites of organizations implementing mHealth projects; iii) consultation with researchers and programme implementers. Records were screened using pre-determined inclusion criteria and those selected were categorized according to their primary intervention delivery approaches. We then performed a descriptive analysis of the evidence related to both effectiveness and implementation for each delivery approach.

Results

The systematic literature search identified 1374 unique records, 64 of which met inclusion criteria. The grey literature search added 32 records for a total of 96 papers in the scoping review. Content analysis of the search results identified four BCC delivery approaches: direct messaging, voice counseling, job aid applications and interactive media. Evidence for the effectiveness of these approaches is growing but remains limited for many MNCH outcomes. The four approaches differ in key implementation elements, including frequency, length and complexity of communication, and potential for personalization. These elements influence resource allocation and are likely to impact effectiveness for BCC targeting complex, habitual MNCH practices.

Conclusions

This scoping review contributes to the evidence-base on the opportunities and limitations of using mobile phones for BCC delivery aiming to improve MNCH practices. The incorporation of mobile phone technology in BCC interventions should be guided by formative research to match both the content and delivery approach to the local context. We recommend five areas for further research, including both effectiveness and implementation studies on specific delivery approaches.

Vulnerable mothers' experiences breastfeeding with an enhanced community lactation support program

The Canada Prenatal Nutrition Program (CPNP) provides a variety of health and nutrition supports to vulnerable mothers and strongly promotes breastfeeding but does not have a formal framework for postnatal lactation support. Breastfeeding duration and exclusivity rates in Canada fall well below global recommendations, particularly among socially and economically vulnerable women. We aimed to explore CPNP participant experiences with breastfeeding and with a novel community lactation support program in Toronto, Canada that included access to certified lactation consultants and an electric breast pump, if needed. Four semistructured focus groups and 21 individual interviews (n = 46 women) were conducted between September and December 2017. Data were analysed using inductive thematic analysis. Study participants reported a strong desire to breastfeed but a lack of preparation for breastfeeding‐associated challenges. Three main challenges were identified by study participants: physical (e.g., pain and low milk supply), practical (e.g., cost of breastfeeding support and maternal time pressures), and breastfeeding self‐efficacy (e.g., concern about milk supply and conflicting information). Mothers reported that the free lactation support helped to address breastfeeding challenges. In their view, the key element of success with the new program was the in‐home visit by the lactation consultant, who was highly skilled and provided care in a non‐judgmental manner. They reported this support would have been otherwise unavailable due to cost or travel logistics. This study suggests value in exploring the addition of postnatal lactation support to the well‐established national CPNP as a means to improve breastfeeding duration and exclusivity among vulnerable women.

'It makes you someone who changes with the times': health worker and client perspectives on a smartphone-based counselling application deployed in rural Tanzania

Mobile health (mHealth) applications have been developed for community health workers (CHW) to help simplify tasks, enhance service delivery and promote healthy behaviours. These strategies hold promise, particularly for support of pregnancy and childbirth in low-income countries (LIC), but their design and implementation must incorporate CHW clients' perspectives to be effective and sustainable. Few studies examine how mHealth influences client and supervisor perceptions of CHW performance and quality of care in LIC. This study was embedded within a larger cluster-randomized, community intervention trial in Singida, Tanzania. CHW in intervention areas were trained to use a smartphone application designed to improve data management, patient tracking and delivery of health messages during prenatal counselling visits with women clients. Qualitative data collected through focus groups and in-depth interviews illustrated mostly positive perceptions of smartphone-assisted counselling among clients and supervisors including: increased quality of care; and improved communication, efficiency and data management. Clients also associated smartphone-assisted counselling with overall health system improvements even though the functions of the smartphones were not well understood. Smartphones were thought to signify modern, up-to-date biomedical information deemed highly desirable during pregnancy and childbirth in this context. In this rural Tanzanian setting, mHealth tools positively influenced community perceptions of health system services and client expectations of health workers; policymakers and implementers must ensure these expectations are met. Such interventions must be deeply embedded into health systems to have long-term impacts on maternal and newborn health outcomes.

Impact of smartphone-assisted prenatal home visits on women's use of facility delivery: Results from a cluster-randomized trial in rural Tanzania

BACKGROUND

About half of births in rural Tanzania are assisted by skilled providers. Point-of-care mobile phone applications hold promise in boosting job support for community health workers aiming to ensure safe motherhood through increased facility delivery awareness, access and uptake. We conducted a controlled comparison to evaluate a smartphone-based application designed to assist community health workers with data collection, education delivery, gestational danger sign identification, and referrals.

METHODS

Community health workers in 32 randomly selected villages were cluster-randomized to training on either smartphone (intervention) or paper-based (control) protocols for use during household visits with pregnant women. The primary outcome measure was postnatal report of delivery location by 572 women randomly selected to participate in a survey conducted by home visit. A mixed-effects model was used to account for clustering of subjects and other measured factors influencing facility delivery.

FINDINGS

The smartphone intervention was associated with significantly higher facility delivery: 74% of mothers in intervention areas delivered at or in transit to a health facility, versus 63% in control areas. The odds of facility delivery among women counseled by smartphone-assisted health workers were double the odds among women living in control villages (OR, 1.96; CI, 1.21-3.19; adjusted analyses). Women in intervention areas were more likely to receive two or more visits from a community health worker during pregnancy than women in the control group (72% vs. 60%; chi-square = 6.9; p < 0.01). Previous facility delivery, uptake of antenatal care, and distance to the nearest facility were also strong independent predictors of facility delivery.

INTERPRETATION

Community health worker use of smartphones increased facility delivery, likely through increased frequency of prenatal home visits. Smartphone-based job aids may enhance community health worker support and effectiveness as one component of intervention packages targeting safe motherhood.

TRIAL REGISTRATION

NCT03161184.

Comparison of infant vitamin D supplement use among Canadian-born, immigrant, and refugee mothers

PURPOSE

This study compares knowledge and practice of infant vitamin D supplementation among immigrant, refugee, and Canadian-born mothers.

METHOD

Focus group discussions with 94 mothers of children aged 0 to 3 years recruited from early childhood centers and a refugee health clinic.

FINDINGS

Both immigrant and Canadian-born mothers indicated good knowledge and use of infant vitamin D supplementation. In contrast, Canadian government-assisted refugees were less likely to supplement with vitamin D. The main source of information about vitamin D was public health prenatal classes. Many mothers reported inconsistent guidance from health care providers.

DISCUSSION AND CONCLUSIONS

Exclusively breastfed infants of refugees may be more at risk of vitamin D deficiency. All mothers require clear recommendations, both in clinical and public health settings.

IMPLICATIONS FOR PRACTICE

Mothers, both new Canadian and Canadian-born, require clear and consistent messaging from health professionals. Refugee mothers, however, require more educational support to promote infant vitamin D supplementation.

Exclusive breastfeeding among Canadian Inuit: results from the Nunavut Inuit Child Health Survey

BACKGROUND

Very little population-based research has been conducted around the exclusive breastfeeding practices of Inuit Canadians.

OBJECTIVES

This research aims to assess the distribution of exclusive breastfeeding among Inuit Canadians and to identify factors associated with exclusive breastfeeding as recommended.

METHODS

We use data from 188 infant-mother dyads who completed the Nunavut Inuit Child Health Survey, a cross-sectional, population-based survey of Inuit children aged 3 to 5 years. A series of multinomial logistic regression models were run to identify factors associated with 4 exclusive breastfeeding durations (≤ 1 month, > 1-< 5.5 months, 5.5-6.5 months, and > 6.5 months).

RESULTS

Of infants, 23% were exclusively breastfed as recommended (ie, between 5.5 and 6.5 months; 95% CI, 16.2-29.3). Many infants (61%) were exclusively breastfed for less than 5.5 months and 16% (95% CI, 10.9-22.0) were exclusively breastfed for more than 6.5 months. Families receiving income support were less likely to discontinue exclusive breastfeeding before 5.5 months (pOR1- < 5.5 months = 0.34; 95% CI, 0.13, 0.85) relative to those not receiving income support, in adjusted models. No other measured factors were significantly related to exclusive breastfeeding duration.

CONCLUSIONS

The majority of Inuit Canadian infants receive suboptimal exclusive breastfeeding. National, provincial, and community-specific interventions to protect, promote, and support exclusive breastfeeding should emphasize not only the benefits of exclusively breastfeeding to 6 months but also the importance of timely introduction of complementary foods into the infant's diet.

Persistent household food insecurity, HIV, and maternal stress in peri-urban Ghana

Background

The mental health of caregivers has been shown to be important for improving HIV prevention and treatment. Household food insecurity affects hundreds of millions of individuals in Sub-Saharan Africa, a region that experiences a disproportionate burden of the HIV pandemic. Both maternal HIV diagnosis and household food insecurity may be linked with maternal stress. This in turn may lead to unhealthy coping behaviors. We examined the independent associations of HIV, persistent household food insecurity and the synergistic effect of both on maternal stress.

Methods

Ghanaian women recruited prenatally from hospitals offering voluntary counseling and testing (VCT) were followed for 12 months after childbirth (N = 232). A locally adapted 7-item version of the US Household Food Security Survey Module was applied at four time points postpartum. We dichotomized participant households as being persistently food insecure (i.e., food insecure at each time point) or not (i.e., food secure at any time point). We dichotomized participant women as not perceiving vs. perceiving stress at 12 months postpartum in reference to the median sample score on the 4-item Cohen’s stress scale. Binary multivariate logistic regression models were used to assess the independent and interactive effects of maternal HIV and persistent household food insecurity on maternal stress.

Results

The proportion of HIV-positive women that lived in severe food insecure households increased over time. By contrast, the HIV-negative group living in severely food insecure households experienced a steady decline across time. HIV-infection (AOR = 2.31, 95% CI 1.29-4.12) and persistent household food insecurity (AOR = 3.55, 95% CI 1.13-11.13) were independently associated with maternal stress in a multivariate model. Being both HIV-positive and persistently food insecure strongly and synergistically increased the risk for maternal perceived stress (AOR = 15.35, 95% CI 1.90-124.14).

Conclusion

In agreement with syndemic theory there is a powerful synergism between maternal HIV diagnosis and household food insecurity on maternal stress. Comprehensive multi-dimensional intervention studies are needed to better understand how to reduce stress among HIV-positive women living in persistently food insecure households and how to reduce the likelihood of food insecurity in HIV-affected households in Sub-Saharan Africa.

Maternal HIV is associated with reduced growth in the first year of life among infants in the Eastern region of Ghana: the Research to Improve Infant Nutrition and Growth (RIING) Project

Children of HIV-infected mothers experience poor growth, but not much is understood about the extent to which such children are affected. The Research to Improve Infant Nutrition and Growth (RIING) Project used a longitudinal study design to investigate the association between maternal HIV status and growth among Ghanaian infants in the first year of life. Pregnant women in their third trimester were enrolled into three groups: HIV-negative (HIV-N, n = 185), HIV-positive (HIV-P, n = 190) and HIV-unknown (HIV-U, n = 177). Socioeconomic data were collected. Infant weight and length were measured at birth and every month until 12 months of age. Weight-for-age (WAZ), weight-for-length (WLZ) and length-for-age (LAZ) z-scores were compared using analysis of covariance. Infant HIV status was not known as most mothers declined to test their children's status at 12 months. Adjusted mean WAZ and LAZ at birth were significantly higher for infants of HIV-N compared with infants of HIV-P mothers. The prevalence of underweight at 12 months in the HIV-N, HIV-P and HIV-U were 6.6%, 27.5% and 9.9% (P < 0.05), respectively. By 12 months, the prevalence of stunting was significantly different (HIV-N = 6.0%, HIV-P = 26.5% and HIV-U = 5.0%, P < 0.05). The adjusted mean ± SE LAZ (0.57 ± 0.11 vs. -0.95 ± 0.12; P < 0.005) was significantly greater for infants of HIV-N mothers than infants of HIV-P mothers. Maternal HIV is associated with reduce infant growth in weight and length throughout the first year of life. Children of HIV-P mothers living in socioeconomically deprived communities need special support to mitigate any negative effect on growth performance.

Grand Challenges Canada: inappropriate emphasis and missed opportunities in global health research?

In May 2010, Grand Challenges Canada (GCC) was launched with the mandate to identify global challenges in health that could be supported through the Government of Canada's Development Innovations Fund (DIF: $225 million over five years). The GCC offers a potentially excellent mechanism for taking Canada's participation in global health challenges "to a higher level". Recent GCC announcements raise new questions about the emphasis being placed on technological discovery or "catalytic" research. Missing so far are opportunities that the Fund could offer in order to support innovative research addressing i) health systems strengthening, ii) more effective delivery of existing interventions, and iii) policies and programs that address broader social determinants of health. The Canadian Grand Challenges announced to date risk pushing to the sidelines good translational and implementation science and early career-stage scientists addressing important social, environmental and political conditions that affect disease prevalence, progress and treatment; and the many unresolved challenges faced in bringing to scale proven interventions within resource-constrained health systems. We wish to register our concern at the apparent prioritization of biotechnical innovation research and the subordination of the social, environmental, economic and political context in which human health is either protected or eroded.

Randomized trial of the effect of zinc supplementation on the mental health of school-age children in Guatemala

BACKGROUND

Rates of mental illness in children are increasing throughout the world. Observational studies of depression, anxiety, and attention-deficit hyperactivity disorder suggest that zinc is an alternative treatment.

OBJECTIVE

We examined the effect of zinc supplementation on the mental health of school-age children in Guatemala.

DESIGN

From January to October 2006, we conducted a 6-mo randomized, double-blind, controlled trial comparing zinc supplementation (10 mg ZnO/d for 5 d/wk) with a placebo (10 mg glucose) in 674 Guatemalan children in grades 1-4. Outcome measures included internalizing (ie, depression and anxiety) and externalizing (ie, hyperactivity and conduct disorder) problem behaviors, positive behaviors (ie, socialization and leadership), and serum zinc concentrations.

RESULTS

Zinc and placebo groups did not differ significantly in any behavioral measures at baseline or at follow-up. At baseline, 21.4% of children had serum zinc concentrations <65 μg/dL. At follow-up, both groups improved significantly, and zinc concentrations were higher in the zinc group. Increases in serum zinc concentrations were inversely associated with decreases in depressive symptoms (estimate: -0.01 points per μg Zn/dL; P = 0.01), anxiety (estimate: -0.012 points per μg Zn/dL; P = 0.02), internalizing symptoms (estimate: -0.021 points per μg Zn/dL; P = 0.02), and social skills (estimate: -0.019 points per μg Zn/dL; P = 0.01) in adjusted models that were controlled for child age, sex, socioeconomic status, household, and treatment group.

CONCLUSIONS

Six months of zinc supplementation did not induce differences in mental health outcomes between zinc and placebo groups. However, increases in serum zinc concentrations were associated with decreases in internalizing symptoms (ie, depression and anxiety) in a community-based sample of children at risk of zinc deficiency. This trial was registered at clinicaltrials.gov as NCT00283660.

Food Security and Child Hunger among Recently Resettled Liberian Refugees and Asylum Seekers: A Pilot Study

Little is known about the food insecurity situation among families resettled into the United States as part of the refugee resettlement program. This paper reports on a pilot study examining food insecurity among recently arrived refugee families (n=33). Objectives were to evaluate the usefulness and feasibility of methods to assess the prevalence of food insecurity and child hunger, and to examine associations between child hunger and measures of socio-economic status and measures of acculturation. Results indicated that 85% of households were food insecure, and 42% experienced child hunger. Hunger was more likely to be indicated in households using foods stamps, with lower income, and lower education. Hunger was also more likely to be indicated in households where the primary shopper experienced difficulty shopping and with language. Results are in broad agreement with those reported in other studies and highlight economic and information barriers to achieving food security. These data suggest that further study of food insecurity is warranted among recently resettled refugee communities resettled in the United States.

Effects of dietary supplementation on work performance in Gambian laborers

The effect of food supplementation on productivity of Gambian subsistence farmers was studied during a natural food shortage induced by the annual hungry season. Sixteen men in two groups matched for weight, height, hemoglobin, and physical-work capacity followed a crossover protocol with 6-wk supplementation and control periods. Productivity was assessed over the final 3 wk of each period by quantifying piece-rate-paid road building. Supplementation comprised an ad libitum supply of highly palatable energy-dense food provided three times daily. Outcome variables were total loads transported, loads per working hour, time per load, total energy expenditure assessed by doubly labeled water and heart-rate monitoring, postwork activity, and anthropometry. Body weight decreased during control periods, indicating a real energy deficit, and increased during supplementation in both groups. Supplementation had no significant impact on productivity variables. Energy-deficient men can maintain maximal productivity over short periods if sufficiently motivated but at the expense of body weight.