Prevalence and predictors of intimate partner violence against men in Kisumu slums, Kenya

Background

Men in sub-Saharan Africa experience intimate partner violence, with few reporting their cases to the legal authorities or coming out for assistance. Consequently, data on the prevalence and drivers of intimate partner violence in different parts of sub-Saharan Africa are inadequate. Therefore, this study was designed to investigate the prevalence and predictors of intimate partner violence against men in Kisumu slums, Kenya.

Methods

This retrospective cross-sectional study included 398 randomly selected male participants from Kisumu slums, sampled data collected from Community Health Volunteers. We used a multinomial regression analysis to assess determinants and forms of violence.

Results

A total of 398 respondents out of 438 eligible men participated in the survey. The prevalence of intimate partner violence against men was 76.1%. From the multinomial regression, men who were married or living together, compared with never married, were 2.13 times more likely to have experienced physical violence (95% CI = 0.91-4.97, p = 0.080) and 2.41 times more likely to have experienced economic violence (95% CI = 1.20-4.84, p = 0.013). Compared to never married, men who divorced or separated were 5.42 times more likely to have experienced sexual violence (95% CI = 0.97-30.37, p = 0.055). Men who had primary education or less were 2.39 times more likely to have experienced sexual violence (95% CI = 1.02-5.61, p = 0.045). Men who were Muslim, compared with Protestants, were 2.37 times more likely to have experienced psychological or emotional violence (95% CI = 0.87-6.37, p = 0.086).

Conclusions

Sexual, physical, and emotional violence is common among men in Kisumu slums, and the prevalence differs by age, marital status, education, and religion. Safe spaces should be created that will enable men of diverse socio-demographic characteristics to share their experiences of violence by intimate partners. Policies, including education to increasing awareness of this issue, should be enacted to protect men from intimate partner violence.

A novel technology for disinfecting surfaces infested with Candida auris: the UVC chip

Background

The fungal pathogen Candida Auris is increasingly associated with multidrug-resistant infections that are highly expensive for the Health Care System. The spreading of this pathogen can occur, among others, through contact with infected surfaces or medical instruments. This study evaluated the efficacy of a novel UVC chip, novel alternative to UVC LEDs and lamps, in inactivating Candida auris strain.

Methods

This experimental study was carried out between July and September 2020 at the University of Siena. Candida auris (ATCC 12372) at two known concentrations (1.5X107 and 1.5x106 CFU/ml) at a fixed distance (7,5 cm) from the chip (5.1mW radiant power) was tested, in triplicates, with three exposure times (5, 10 and 15 minutes). Potato Dextrose Agar (PDA) plates without the plate lid and containing Candida auris were exposed to UVC light. Subsequently, the plates were incubated at 36 °C for 48 h. Log reduction between treated and positive control (not exposed to UVC light) samples was calculated.

Results

At 15 minutes, we had the highest inactivation result, mean 4.43 log10, starting from a 1.5x106 CFU/mL concentration. At a higher concentration, 1.5X107 CFU/mL, the reduction had a mean of 3.51 log10.

Conclusions

The results of the experiments showed a significant microbial reduction in relation to the exposure time. The highest level of reduction was reached after 15 minutes of exposure. UVC chip had a relevant biocidal effect on Candida auris and may represent a valuable tool in the prevention of infections caused by this pathogen, which is becoming increasingly prevalent and persistent globally.

Key messages

• The use of UVC Chip decreases surface contamination.

• New technology against healthcare-associated infections.

Household Water Insecurity Is Positively Associated With Household Food Insecurity in Low- and Middle-Income Countries

Objectives

Although water insecurity and food insecurity may be related via various pathways, this relationship has received little attention. Knowing where and among whom water and food insecurities coexist is critical for developing nutrition interventions and policies that are not undermined by concurrent problems with water. The objective of this study, therefore, was to investigate the relationship between water and food insecurities in low- and middle-income countries (LMICs).

Methods

In 2020, Gallup World Poll administered the Individual Water Insecurity Experiences Scale (IWISE, score range 0–36) and the Food Insecurity Experiences Scale (FIES, score range 0–8) to measure water and food insecurities in nationally representative samples from 25 LMICs in four global regions (n = 31,755). As a preliminary analysis, we estimated the odds of food insecurity (FIES score ≥ 4) in relation to water insecurity (IWISE score ≥ 12) for each country and region separately using multivariable logistic regression models adjusted for key covariates including income, urbanicity, and gender.

Results

The prevalence of water insecurity in the full pooled sample was 18.3%, ranging from 14.8% across the Asian countries to 34.4% across the sub-Saharan Africa countries. Of those who were water insecure in the full pooled sample, 68.9% experienced concurrent food insecurity. Adjusting for covariates, the odds of food insecurity in sub-Saharan Africa were 2.70-fold higher (95% CI: 2.39, 3.06) among those with water insecurity. The magnitude of this association was similar in the pooled samples for North Africa (OR: 3.05, 95% CI: 2.30, 4.04), Asia (OR: 3.17, 95% CI: 2.15, 4.67), and Latin America (OR: 2.52, 95% CI: 1.87, 3.40).

Conclusions

In most of the LMICs in our sample, water insecurity was positively associated with food insecurity independently of socioeconomic covariates. Unpacking how and why food and water insecurity relate and how their relationships differ across contexts could help identify if and where interventions to reduce water insecurity are needed concurrently with measures to improve food security and nutrition.

Funding Sources

Carnegie Corporation, Northwestern University, and United States Agency for International Development Cooperative Agreement.

How Schwartz’ Basic Human Values Influence Food Choices in Kenya and Tanzania

Objectives

To identify and describe how values drive food choice of vulnerable consumers in two East African countries, Kenya and Tanzania.

Methods

Secondary data analysis was conducted on focus group discussions from studies in Kenya and Tanzania. A codebook was developed based on Schwartz's theory of basic human values. A priori coding was conducted in NVivo 12 followed by a narrative comparative analysis, which included review by original principal investigators.

Results

Values of conservation (security, conformity, tradition), openness to change (self-directed thought and action, stimulation, indulgence), self-enhancement (achievement, power, face), and self-transcendence (benevolence dependability and caring) were prominent drivers of food choice in both settings. While tradition was an important value in food choice, new social situations and food environments rendered reprioritization, especially pertaining to youth and animal source foods. Openness to change values were readily cited, especially in peri-urban Kenya with many new foods and diverse neighborhoods. Values of independent thought and action were drivers of mothers’ food choices for families. Benevolence security and caring were drivers choices for child feeding and selecting trustworthy food vendors. Many participants described how values existed in tension. For example, changes in livelihood led to a reprioritization of values like stimulation or indulgence over tradition.

Conclusions

Values were important drivers of food choice in both settings, particularly for meat. Future efforts to promote healthy, sustainable diets will require policy and broad consumer support to succeed. Examining the values that drive food choice in different contexts is necessary especially to minimize unintended consequences, controversy, and perhaps opposition in the implementation of policies and programs.

Funding Sources

UK Government's Foreign, Commonwealth, and Development Office and the Bill & Melinda Gates Foundation; the views expressed do not necessarily reflect the UK Government's official policies.

Effectiveness of the Eggs Make Kids Demand-Creation Campaign to Improve Household Availability of Eggs and Egg Consumption in Young Children in Nigeria

Objectives

To determine the effectiveness of the “Eggs Make Kids Smart & Bright and Strong & Active” demand-creation campaign on caregivers’ behavior towards eggs, caregivers’ willingness-to-pay for eggs, the availability of eggs in household, and the consumption of eggs in children 6–59 months of age in Kaduna state, Nigeria.

Methods

An egg demand-creation campaign in Kaduna state targeting families of children 6–59 months of age was implemented between October 2019 and December 2020. A quasi-experimental design was used to evaluate the impact of the campaign. The intervention arm received emotionally compelling radio and TV advertisement and promotional activities and advertising at point-of-purchase, schools, and health facilities about eggs; the comparison arm received no intervention. Children 6–59 months of age in both arms (intervention n = 1359; comparison n = 1485) were assessed 14 months apart before and after the implementation of the intervention. Intent-to-treat analyses with analysis of covariance method were used to assess impact of the intervention on caregivers’ behavior towards eggs, caregivers’ willingness-to-pay for eggs, the availability of eggs in household, and the consumption of eggs in children 6–59 months of age. Analyses were adjusted for possible confounders and perceived effects of SARS-CoV2 on household finances and food consumption.

Results

There was improved prevalence of household egg acquisition in the intervention arm compared to the comparison arm (odds ratio = 1.34, p-value < 0.0001). The intervention arm showed larger improvements in caregiver self-efficacy (β = 0.242, p-value = 0.004) and intent to feed eggs (β = 0.080, p-value = 0.021) than the comparison arm. No effects were found on child egg consumption or caregivers’ willingness-to-pay for eggs.

Conclusions

In Nigeria, a 14-month egg demand creation campaign improved household egg acquisition and benefited caregiver self-efficacy and intent to feed eggs but did not improve child egg consumption. Further research is needed to identify how to increase child egg consumption in the context of availability of eggs in households and favorable caregiver behavior.

Funding Sources

Funding for this study was provided by the Netherland's Ministry of Foreign Affairs.

Household Food Insecurity in Middle- and High-Income Countries Before and During the COVID-19 Pandemic

Objectives

The impact of the pandemic on the prevalence of food insecurity is unclear given the potentially contradictory effects of shocks such as lockdowns versus stabilizers such as income supplements. We examined changes in the prevalence of household food insecurity in five countries from before (2019) to during the pandemic (2020).

Methods

Data were drawn from cross-sectional surveys conducted in Australia, Canada, Mexico, the United Kingdom (UK), and the United States (US) in November/December of 2018,2019, and 2020. Adults aged 18–99 years were surveyed annually (2018: n = 22,731,2019: n = 19,274,2020: n = 21,323). Household food insecurity in the past 12 months was assessed using the Household Food Security Survey Module. Weighted logit models examined changes in the prevalence of living in households affected by food insecurity from 2019 to 2020, adjusting for the prevalence in 2018 and demographic characteristics. Weighted generalized logit models examined changes in the severity of food insecurity.

Results

Adults in Mexico had a higher probability of living in food-insecure households in 2020 compared to 2019 (β = 0.14, p = 0.02). In contrast, decreases in the probability of living in food-insecure households in 2020 compared to 2019 were observed in Australia (β = −0.21, p &lt; .001) and Canada (β = −0.14, p = 0.03). In the UK and the US, no important changes in the prevalence of food insecurity were observed (UK: β = −0.11, p = 0.11, US: β = 0.05, p = 0.42). Changes in the severity of food insecurity within countries are also evident.

Conclusions

Changes in the prevalence of household food insecurity during the pandemic appear to differ across countries. Further analyses will contextualize these differences in relation to varied policy responses to the pandemic, as well as changes in prevalence among subgroups such as those with low incomes.

Funding Sources

A. Pepetone received a stipend from a Canadian Institutes of Health Research (CIHR)/Natural Sciences and Engineering Research Council/Social Sciences and Humanities Research Council Healthy Cities Research Training Platform. Funding for the International Food Policy Study was provided by a CIHR Project Grant, with additional support from Health Canada, the Public Health Agency of Canada (PHAC), and a CIHR-PHAC Applied Public Health Chair held by D. Hammond.

Health-Related Social Needs and Diet Quality in Youth and Young Adults with Youth-Onset Type 1 Diabetes: Cross-Sectional Findings From the SEARCH Food Security Cohort Study

Objectives

This cross-sectional study from the SEARCH Food Security Cohort Study (2018–2020) examined the association between unmet health-related social needs (USN) and diet quality among 821 youth and young adults (YYA) with type 1 diabetes (T1D).

Methods

Daily dietary intake of calcium, dairy, fiber, and fruits and vegetables (F/V) was estimated with the National Cancer Institute dietary screener questionnaire. USN included having one or more of the following: ≥3 affirmations on the USDA Household Food Security Survey Module, not having a personal vehicle in the past year, reporting housing instability over the past 90 days, or reporting health care costs as a big problem. Quantile regression examined associations between the count of USN and diet, and associations between specific social needs and diet, controlling for the presence of the other three needs.

Results

For YYA with T1D (mean age: 22.6 ± 5), 36.9% had 1 + USN, with healthcare unaffordability most prevalent (24.6%), followed by food insecurity (17.5%). Overall diet quality was poor with estimated intakes below dietary guideline recommendations, especially for fiber. Consumption for all nutrients and F/V was lower across the intake distribution among those with 1 + USN, compared to no unmet needs. After adjustment, those with 1 + USN consumed significantly less calcium at the 10th and 25th percentiles (P &lt; 0.05), fiber at the 25th and 50th percentiles (P &lt; 0.05), and F/V at the 25th percentile (P = 0.02), compared to no unmet needs. For housing instability, unreliable transportation, and unaffordable healthcare, no diet quality indicator differed after further controlling for the presence of the other three needs. Independent of the other social needs, food insecurity was associated with lower fiber intake at the 10th, 25th, and 50th percentiles (P &lt; 0.04), and F/V intake at the 50th and 75th percentiles (P &lt; 0.01).

Conclusions

USN were associated with reduced intake of calcium, fiber, and F/V largely due to food insecurity, particularly among participants with lower intake. USN, arising from economic strain, is associated with poorer nutrition.

Funding Sources

National Institute of Diabetes and Digestive and Kidney Diseases.

Perspectives about Food Safety in Diverse Low- and Middle-income Countries

Objectives

Concerns about unsafe food influence food choice and consumption of unsafe foods increase morbidity and mortality, particularly in low- and middle-income countries. Addressing unsafe food is dominated by mitigation of biological and chemical hazards through supply-side risk management, with less emphasis on individuals’ experiences and perspectives of food safety. We aimed to identify and categorize perspectives about food safety in five countries.

Methods

Five studies designed to address drivers of food choice in low- and middle-income countries provided transcripts from 17 focus groups discussions and 303 interviews in Kenya, Ghana, India, Guinea, and Vietnam. We analyzed transcripts using a priori and emergent coding techniques that involved a constant comparative method.

Results

Individuals constructed meaning about food safety through personal experience and social influences. Community and family members contributed knowledge about food safety. Concerns about food safety were influenced by reputations of and relationships with vendors. Concerns were amplified by mistrust of vendors’ purposeful adulteration, unsafe selling practices, and new methods to produce food. Individuals were reassured of food safety by positive relationships with vendors; home-cooked meals; implementation of policies and regulations being followed; vendor adherence to environmental sanitation and food hygiene practices; cleanliness of vendors’ appearance; vendors’ or producers’ agency to use risk mitigation strategies; and transparency in production, processing, and distribution of food.

Conclusions

Individuals’ perspectives about food safety influence food choice behaviors. The success of food-safety policies hinges on consideration of these perspectives.

Funding Sources

The Drivers of Food Choice (DFC) Competitive Grants Program, funded by the Bill & Melinda Gates Foundation and the UK Government's Foreign, Commonwealth & Development Office.

Water Insecurity Is Prevalent and Associated With Constrained Food Choices in Low- and Middle-Income Countries

Objectives

Water insecurity may coincide with and exacerbate food insecurity and poor nutrition and health. The Household Water Insecurity Experiences (HWISE) Scale permits quantification and comparison of water access and use across low- and middle-income countries (LMICs). With Gallup and UNESCO, we collected the first nationally representative data on water insecurity in half the world's population. We investigated the national prevalence of water insecurity and predictors of altered food choice resulting from problems (in quantity, quality, or stability) with water.

Methods

The 2020–2021 Gallup World Poll administered the 12-item HWISE module to individuals ≥ 15 y in 31 countries in Africa, Asia, and South America. Responses to each item were “never,” “1–2 months,” “some, not all months,” and “almost every month” (scored 0–3, total range 0–36) in the prior 12 months. One HWISE item asked the frequency with which respondents changed what was eaten due to water problems. Ordered logistic regression models controlling

for country fixed effects examined the odds of reporting a higher frequency of water-induced changes in food choices in relation to 10-y-increment age groups, sex, rural/urban residence, marital status, education, number of children and adult household members, 27 income brackets, difficulty affording shelter, and social support.

Results

In the seven countries for which data were available at the time of submission (China, Congo Brazzaville, Ghana, Ivory Coast, Mauritius, Uganda, and Zambia, n = 8,916), the national prevalence of water insecurity (HWISE score &gt; 12) ranged from 2.4 ± 0.4% in China to 42.7 ± 2.1% in Zambia. Higher odds of water-induced changes in food choices were found for each additional child (OR: 1.05; 95% CI: 1.02, 1.08) and with difficulty affording shelter (OR: 1.90; 95% CI: 1.69, 2.14). Lower odds of water-induced changes in food choices were found for each higher income bracket (OR: 0.97; 95% CI: 0.96, 0.98) and amongst those with social support (OR: 0.76; 95% CI: 0.67, 0.87) and those &gt; 65 years of age relative to other age groups (ORs ranging from 0.50–0.60; all P &lt; 0.02).

Conclusions

Water insecurity is a concern in many LMICs and may constrain food choices for people experiencing other social and economic hardships.

Funding Sources

Carnegie Corporation and United State Agency for International Development Cooperative Agreement.

Role of Alternative Caregivers in Food Choices for Young Children in Semi-urban and Urban Mexico

Objectives

This work aimed to understand what alternative caregivers value in making food choices for children and the perspectives of alternative caregivers on their role in making food choices to feed children.

Methods

This qualitative study was conducted in low-income semi-urban and urban communities of the State of Mexico, Mexico. Primary caregivers of children aged 12–59 months named people they considered alternative caregivers. A convenience sample was used for the selection of 16 alternative caregivers. Semi-structured interviews were conducted with alternative caregivers. On average interviews lasted 37.2 minutes; interviews were audio-recorded and transcribed verbatim. All Transcriptions were read, coded, and analyzed using a grounded theory approach. NVivo 10 was used for data management and analysis.

Results

Alternative caregivers were related to children as grandmothers (n = 10), fathers (2), aunts (2), uncle (1), and friend (1). Their average age was 52 years. The highest education was technical school and the lowest was no schooling. Most were homemakers. Almost all shared the same house or land with the children. Alternative caregivers chose the foods fed to children based on how nutritious and healthy food was, children, wanting or desiring certain food, their desire of the child to eat well, the affordability of the food, and how appropriate the food was for the age of children. Alternative caregivers described more influence on the process of decisions about food purchase, cooking, and feeding the child when they were closely related to the child and lived in the same household or land. Alternative caregivers who were not as active in all the process of decisions participated with advice to mothers on what to feed the child. When alternative caregivers expressed affection for children, they showed more interest in what children eat.

Conclusions

Alternative caregivers had a substantial role in the process of making food choices for children. Considering how alternative caregivers participate and influence what children eat may be important in efforts to promote healthy food choices for children.

Funding Sources

Office of the Vice President for Research, University of South Carolina

Recommended Actions in Global Nutrition Initiatives That Link Food Environment and Food Choice

Objectives

To understand how actions that link food environment and food choice, recommended by global nutrition initiatives, seek to promote sustainable healthy diets.

Methods

We reviewed recommended actions addressing food environments and food choice by global nutrition initiatives published between 2015 and 2020. Internal debriefing, expert solicitation, and targeted web searches were used to identify 20 documents, with 12 selected for review. Specific action descriptions were used to generate overarching actions present across the documents, were extracted into a matrix, and then were tabulated across overarching actions retaining document affiliation. The content assigned to each overarching action was disaggregated by environmental and individual focus guided by concepts from existing frameworks pertinent to food environments and food choice.

Results

We identified 13 overarching actions from the documents reviewed, ranging from reorienting agricultural priorities for improved nutrition to creating consumer demand for nutritious foods. The documents differed in the extent of detail describing specific actions. Between 3 and 11 documents were represented in each action. Environmental actions focused on building better bridges across the food value chain, regulation, and investment. Regulation ranged from municipal zoning restrictions of food outlets near schools to national and international strengthening of legally binding agreements for nutrient profiling, labeling, and marketing restrictions. Actions addressing individual behavior were fewer and focused on building capacity with special attention to smallholder farmers and women, recognizing their duality as suppliers and consumers, protecting traditional practices, and applied communication strategies to promote healthy diets.

Conclusions

Actions portrayed prioritization of environmental change to achieve healthy diets with some attention to sustainability, but much less detail was presented about what, how, or why individuals may consider changes to their dietary choices. Better linking individuals’ perspective into environmental change may propel the success of active global efforts.

Funding Sources

UK Government's Foreign, Commonwealth & Development Office and the Bill & Melinda Gates Foundation.

Perspectives of Urban Ghanaian Adolescents on Healthy Eating Habits

Objectives

Adolescents are vulnerable to diet-related health risks as they experience major life changes alongside food environment changes. In Ghana, non-communicable diseases (NCDs) are rising, and there is a need to understand what, how and why adolescents eat the way they do. This study explored perspectives of adolescents about healthy and unhealthy eating and relationships to portion sizes.

Methods

The Measurement, Evaluation, Accountability, and Leadership Support for NCDs (MEALS4NCDs) Project is measuring the nature and extent of unhealthy food marketing to support public sector actions to create healthier food environments for Ghanaian children. In July-August 2020, 48 interviews with students (14–17 years old) in six districts across the Greater Accra Region were conducted in schools. Interviews were done in English, audio recorded, and transcribed verbatim. Transcripts were coded with NVivo12 using a thematic analysis.

Results

All students demonstrated basic nutrition knowledge and conceptualized healthy eating as “not eating too much”, “a balanced diet,” “not eating late,” and “not eating cold foods.” Connections between NCDs and consumption of foods high in fat, sugar, and salt were rarely made. All students consumed items contrary to what was described as a healthy diet. Students expressed food safety as indicative of healthy food, emphasizing food prepared in a “hygienic environment by a hygienic person,” “a hot temperature,” and “covered.” Participants did not understand portion sizes beyond “too much of anything is bad” and most stated contexts where they would consume smaller or larger portion sizes, such as around strangers (less) or unsure of next meal (more). Participants admitted that peer pressure and food advertising claims informed their food choices and showed minimal knowledge of marketing tactics. Students voiced their limited agency in food choice decisions, citing financial and cultural constraints.

Conclusions

Students had some nutrition knowledge but limited agency to apply it in daily food choices. Interventions should include educating students and parents on diet-related NCDs and deceptive marketing tactics that promote unhealthy foods.

Funding Sources

International Development Research Centre's Food, Environment & Health Programme, IDRC-Canada. Office of the Vice President for Research, University of South Carolina.

The Role of Stakeholder Framing in Nutrition Agenda-Setting to Address the Double Burden of Malnutrition in Tamil Nadu, India

Objectives

Addressing the double burden of malnutrition in many low- and middle-income countries through double duty strategies requires understanding of how stakeholder framing influences nutrition agenda-setting at the subnational level where policies are translated to address local context. We aimed to identify differences in frames of undernutrition and nutrition-related non-communicable diseases (NCDs) in Tamil Nadu, India and to show how the frames reflect stakeholder intention and action regarding nutrition actions.

Methods

Tamil Nadu is experiencing chronic undernutrition and increasing NCDs and has a history of commitment to addressing undernutrition. We conducted in-depth interviews with stakeholders from nutrition-sensitive disciplines using semi-structured questionnaires (n = 28). Stakeholder responses and established policy process frameworks guided interview coding and thematic analysis.

Results

The frames of undernutrition and NCDs comprised five domains: problem identification, risk factors, target populations, roles for stakeholders, and policy and program response. To address undernutrition, stakeholders consistently identified problems, risk factors, and target populations. Roles and responsibilities for stakeholders were defined, resulting in multisectoral strategies. For NCDs, stakeholders inconsistently identified the same domains, resulting in lack of convergence and bottlenecks to implementing double duty actions.

Conclusions

Nutrition-related NCDs have not reached a critical level of priority and coherence among state-level stakeholders regarding problem identification, risk factors, target populations, responsibility, and solutions, preventing political commitment to addressing them through inclusion in the policy agenda, dedicated resources, and convergence of multisectoral efforts. Development and implementation of multisectoral double duty strategies likely to be effective at the subnational level will require stakeholders to address three challenges in agenda-setting: adequate priority given to the problem, coherence of the policy community, and convergence of actions by multisectoral stakeholders.

Funding Sources

The Bill & Melinda Gates Foundation through POSHAN, led by the International Food Policy Research Institute.

Understanding Food Insecurity Resilience of Refugee Families in the United States

Objectives

This research investigated the experience of household food insecurity among Syrian refugees resettled in the US using the lens of family resilience. The objectives were to understand how refugee families create resilience to food insecurity in the US, how they construct the meaning of food insecurity as a source of stress in comparison to other stressors, and what are the family's capabilities that have played a role in their efforts to reduce food insecurity.

Methods

This qualitative case study was conducted with 9 Syrian refugee families who lived in the Washington metropolitan area for 8 years or less. An Arabic semi-structured interview guide was developed. A maximum of three separate interviews were conducted in each family, one with each of two adults (usually parents) and one with the child. Demographics, information about their network of family and friends in the US, and the Arab Family Food Security Scale were collected. Arabic data from 17 in-depth interviews were analyzed using the family adaptation and adjustment response model.

Results

All 9 families were using food assistance programs (SNAP and/or WIC), and 3 of them were food insecure at the time of the interviews. Although experiences of food insecurity varied between families and over time, most families reported greater food insecurity immediately after arriving in the US with food security improving as additional resources (e.g., SNAP) were accessed. However, being food insecure was not perceived as a stressor to most families because they had lived a difficult life in the country from which they escaped. Their major stressors were fear of losing their jobs and of being unable to pay their bills and rent. Each family had a unique capability, with their own combination of resources and strategies, for maintaining household income and food availability, but social networks consistently played an important role in families’ efforts to reduce food insecurity.

Conclusions

Food insecurity was not perceived as a major stressor because families experienced a broad range of insecurities including finances, housing, and employment. The social network was one of the most important resources that supported families’ capabilities to improve their food status.

Funding Sources

The research is partially funded by a University of South Carolina doctoral research award.

Perspectives on Food Safety and Their Influence on Food Choice in Low- and Middle-Income Countries

Objectives

Current efforts to address food safety through supply-side risk management consider food safety primarily in terms of biological and chemical hazards, ignoring the importance of individuals’ experiences and perspectives. This study aimed to understand how experiences and perspectives of food safety influence food choice in low- and middle-income countries (LMICs).

Methods

The Drivers of Food Choice Competitive Grants Program funded 15 projects that aimed to understand food choice among the poor across 10 LMICs in Sub Saharan Africa and South and South East Asia. Summaries of the role of food safety in decisions about food choice were reviewed with principal investigators from 6 projects with significant findings. We used an iterative process of thematic analysis across all project summaries followed by respondent validation to categorize findings with shared meaning into themes of conditions

and characteristics that either contributed to perceptions of a lack of food safety or to an overall perspective on food safety.

Results

Food was considered to be safe if purchased from vendors who had good food and personal hygiene practices or with whom individuals had positive relationships. Food was also considered to be safe if it was prepared at home. Perceptions of a lack of food safety were increased by fears of adulteration by vendors and contamination in physical environments with poor sanitation or handling practices. Policies and regulations offered increased guarantees of safety but were not always trusted nor convenient, and social networks and the media were important sources of both real and false information about food safety.

Conclusions

Individuals rely on their experiences, attitudes, knowledge, and perceptions in making decisions about what foods to buy, prepare, and consume, and from which sources. Understanding how perspectives of food safety influence food choice can be harnessed to improve food safety and contribute to sustainable healthy diets. Efforts to achieve sustainable healthy diets through behavior change communication or incentives to supply chain actors must acknowledge perspectives on food safety as important drivers of food choice.

Funding Sources

UK Government's Foreign, Commonwealth & Development Office and the Bill & Melinda Gates Foundation.

Food-Choice Values of Elementary School Children and Strategies Used to Influence Mothers’ Food Purchasing Decisions

Objectives

This study aimed to understand the values held by elementary school children in constructing food choices and the strategies they used to influence their mothers’ food purchasing decisions.

Methods

Semi-structured qualitative interviews were conducted with 40 elementary school children (aged 6–11 years) and their mothers living in South Carolina. Food choice information was collected only from children and strategies to influence mothers’ food purchases were collected from both children and mothers. The interviews were audio-recorded, transcribed verbatim, and open-coded. Coding matrices were used to compare children's and mothers’ responses on the children's strategies to influence mothers’ food purchasing decisions.

Results

Children most valued taste, texture, and flavor of the food items, followed by perceived benefits, happiness, craving, following family and friends, the items’ healthfulness, preparation, and presentation when they made food choice decisions. Children reported 157 strategies that they used to influence mothers’ purchasing decisions. Mothers had concordance with 80 strategies that children mentioned. In mother-child dyads, more concordance was observed between mothers and sons than between mothers and daughters. The most common and successful strategies from both the children's and mothers’ perspectives were reasoned requests, repeated polite requests, and referencing friends. Other strategies included offers to contribute money or service, teaming up with siblings, writing a shopping list, and grabbing desired items. Mothers perceived that children had a lot of influence on their food purchasing decisions.

Conclusions

Children were aware of the strategies that would get positive reactions from their mothers. Mothers’ acknowledgement of children's influence on their food purchase decisions suggests that children can serve as change agents for improving mothers’ food purchases if children prefer healthy foods. Interventions are needed for mothers to help address children's strategies to influence mothers to purchase unhealthy foods and make healthy foods more appealing to children instead of yielding to children's requests for unhealthy items.

Funding Sources

SPARC grant and Ogoussan Doctoral Research Award from the University of South Carolina.

Stakeholder Engagement Strategies for Policy and Programmatic Uptake: Lessons from the Drivers of Food Choice Competitive Grants Program

Objectives

This study drew upon experiences of stakeholder engagement in food choice research to advance knowledge about best practices.

Methods

The Drivers of Food Choice Competitive Grants Program aimed to understand food choice in low- and middle-income-countries. All funded proposals included stakeholder engagement strategies. Data were from document review of proposals and reports and semi-structured interviews with the principal investigators of the 15 projects. Interviews were transcribed and uploaded into NVIVO 12. The lead author analyzed interviews thematically using an a priori code list and led discussion of themes and patterns through peer review with co-authors.

Results

Grantees developed and implemented a range of strategies. “Uni-directional” strategies were researcher-driven and informational, did not seek input from the target stakeholder, and included one-way communication such as emails, newsletters, meetings, press releases, technical briefs, newspaper articles, and public engagement efforts. “Bi-directional” strategies sought collaboration with stakeholders. Examples were workshops which sought feedback on stakeholder identification, research questions, methods, results, and recommendations. Grantees used unidirectional strategies to increase buy-in and generate demand for results, which helped promote the use of evidence for decision-making. Bi-directional strategies were integral to knowledge production. Grantees thought that bi-directional engagement enhanced the immediate applicability of the research. Grantees developed more- and less-intensive strategies that involved both bi-and uni-directional engagement, depending on goals for uptake.

Conclusions

This research sheds light on the role of stakeholder engagement strategies in advancing multisectoral nutrition. The current landscape of research and practice is fast-paced and complex; ensuring relevance of research via diverse stakeholder engagement strategies should remain a priority for researchers and funders. Our findings may aid researchers in constructing strategies that are responsive to diverse research programs and goals within complex multisectoral nutrition landscapes.

Funding Sources

UK Government's Department for International Development and Bill & Melinda Gates Foundation.

Dimensions of School Food Environments and Their Association with Anthropometric and Dietary Outcomes in Children: The Healthy Communities Study

Objectives

While it has been recommended that schools be the hub of efforts to improve child nutrition, research describing dimensions of U.S. school nutrition environments is limited. This study used exploratory factor analysis to estimate dimensions of school nutrition environments and examined their association with child anthropometric and dietary measures.

Methods

Cross-sectional analyses of 386 U.S. elementary and middle schools and 4635 children from the national Healthy Communities Study (2013–2015) was conducted. Three complementary instruments to assess the school nutrition environment were used to create 34 variables. Data were collected by observation and surveys. Factor analysis was done with orthogonal rotation. Mixed-effects regression models examined the multivariate-adjusted associations of dimensions of school nutrition environments with child anthropometric and dietary measures accounting for community and school variation.

Results

Six dimensions of school nutrition environments were derived: 1) nutrition education; 2) fruit and vegetable availability; 3) dining environment, including size and crowding; 4) school meal quality, including compliance with competitive food standards, amount of whole grains, and high fat foods; 5) school participation in state and federal nutrition programs; and 6) self-reported implementation of school wellness policies. Higher school meal quality was associated with lower added sugars intake (ß = –0.94, P &lt; 0.01), better dining environment was associated with higher body mass index z scores (ß = 0.04, P = 0.03), and higher implementation of school wellness policies was associated with higher waist circumference (ß = 0.54, P &lt; 0.01).

Conclusions

Schools serving meals of higher nutritional quality had children with lower added sugars intake. Associations between dining environment and BMI-z; and implementation of school wellness policies and waist circumference were counterintuitive and may be due to school selection or the inability of cross-sectional data to capture relationships with longer-term health outcomes. More efforts are needed to identify school nutrition environments that have the greatest impact on child diet and adiposity outcomes.

Funding Sources

National Heart, Lung, and Blood Institute #K01HL131630.

Sustaining Agriculture-Nutrition Interventions: Analysis of Determinants of Village Model Farmer Active Engagement in Nepal

Objectives

Homestead food production (HFP) programs rely on village model farmers (VMFs) for implementation of agriculture-nutrition activities. No studies have assessed sustainability of VMFs. Our objective was to test determinants of VMFs remaining and actively working several years after being selected as VMFs.

Methods

We used cross-sectional monitoring data, collected in 2018 and 2019 among VMFs in Suaahara (2011–2021), a multi-sectoral integrated nutrition program that includes HFP in Nepal. Remaining as a VMF was assessed from self-report. Actively working as a VMF was based on whether s/he was leading an HFP beneficiary group, registered the HFP group, conducting regular group meetings, and engaging in saving and credit activities. Potential socio-economic and demographic determinants were identified a priori: gender, age, education, caste, being a female community health volunteer, socio-economic status, agricultural land size, household size, duration of being a VMF, residing in disaster-affected districts, agro-ecological zone, and number of trainings and inputs received. Multivariable logistic regression was used to estimate adjusted odds ratios among 4732 VMFs.

Results

The odds of remaining and actively working were greater among those with some education compared to those without education. VMFs having more agricultural land were 2.25 and 1.14 times more likely to be remaining and actively working as a VMF, respectively. VMFs working for longer were less likely to remain and be active. More types of trainings and inputs received were associated with greater odds of remaining and actively working as an VMF. VMFs older than 35 y, other caste than Dalit, and living in Mountains and Hills were more likely to remain and actively work. We did not find significant association for household size and richer households.

Conclusions

Age, education, caste, agricultural land size, household wealth, time since becoming a VMF, and number of trainings and inputs received were important determinants of VMFs remaining and actively working in the program. Examining these factors can help selection of front-line workers to ensure their engagement and sustainability.

Funding Sources

United States Agency for International Development (USAID) under Cooperative Agreement No. AID-367-A-16–00006.

Adolescent Students Experiencing Hunger Consume Less Healthy Diets: Evidence from the Global School-Based Student Health Survey in 95 Countries

Objectives

This study tested whether adolescent students who experienced hunger in 95 countries consumed less healthy diets.

Methods

Data were self-reported by adolescent students aged 11–18 years old from the Global School-Based Student Health Survey (2003–2016) in 95 countries. Hunger was affirmed if going hungry due to lack of food in home sometimes, most of the time, or always during the past 30 days. Dietary outcomes were measured by frequencies of having fruits, vegetables, and soft drinks per day, and eating from fast-food restaurants per week. The first two outcomes (i.e., fruits and vegetables) were measured in all 95 country surveys from 2003–2016 (n = 333,062); the latter two (i.e., soft drink and fast foods) were measured in 71 country surveys from 2009–2016 (n = 262,241). Each dietary outcome was analyzed separately using linear mixed-model regression with age and sex as fixed effects and the variation among countries (intercept and slope), among schools, and among classrooms as random effects.

Results

Adolescent students who experienced hunger had less frequent intake of fruits and vegetables and more frequent intake of soft drinks daily (β = −0.0715, −0.0348, and 0.0526, respectively), but hunger was not associated with eating from fast-food restaurants. The differences associated with hunger in frequency of intake of fruits, vegetables, and soft drinks in adolescent students varied across countries, with standard deviations of the differences of 0.126, 0.0844, and 0.115, respectively, across countries. That is, for example, the difference in fruit intake associated with hunger ranged across countries, using ± 2 standard deviations, from −0.324 to 0.181 times per day. The analogous ranges for vegetables and soft drinks were −0.204, 0.134 and −0.177, 0.283.

Conclusions

Adolescent students who experienced hunger were less likely to consume healthy diets globally; the magnitude of the association varied across countries.

Funding Sources

None.

Health Systems Strengthening Efforts Help to Improve the Delivery of Maternal Nutrition Interventions in Antenatal Care in Uttar Pradesh (UP), India but Gaps Remain

Objectives

Frontline workers (FLWs) deliver essential nutrition services to reduce maternal undernutrition in India, but coverage and quality remain sub-optimal. Alive & Thrive aimed to strengthen delivery of interpersonal counselling, community mobilization and micronutrient supplements through the government antenatal care (ANC) platform in UP. We studied pathways through which the nutrition-intensified ANC (I-ANC) was intended to impact FLWs capacity, knowledge, and service delivery, compared to standard ANC (S-ANC).

Methods

We used a cluster-randomized design with cross-sectional surveys at baseline (2017) and endline (2019), ∼500 FLWs per survey. Differences between I-ANC and S-ANC were compared along six impact pathway components (training, availability of materials, supportive supervision, knowledge, service delivery, and counselling content) using mixed-effects regression adjusted for clustering.

Results

Training exposure was higher in I-ANC than S-ANC (9 percentage points, pp). Nutrition training topics were low-moderate (30–60%) in both arms. Job aids were more available in I-ANC (70–80%) than S-ANC (30–40%). Supply of iron-folate and calcium supplements were low in both arms, with 10–50% having stock-outs. FLWs in I-ANC were more likely to receive supervision visits (7 pp), but gaps remained in both arms. Compared to S-ANC, FLWs in I-ANC had higher knowledge on diet diversity (6 pp), adequate intake (10 pp), iron-folate (10 pp) and calcium supplements (30 pp), pregnancy weight gain (20–30 pp), and early breastfeeding (5 pp), but similarly low knowledge of exclusive breastfeeding. ANC check-ups by FLWs were 20 pp higher in I-ANC. FLWs in I-ANC did more counselling on adequate diet, supplements, and weight gain (10–20 pp). Counselling on diet diversity and breastfeeding were low in both arms.

Conclusions

Health systems strengthening efforts helped improve the delivery of maternal nutrition interventions in antenatal care in this context, but gaps remain. Several health system elements along the program pathway – supply chain management, training, supervisory practices – require strengthening to further improve FLW knowledge and nutrition service delivery.

Funding Sources

Bill & Melinda Gates Foundation, through Alive & Thrive, managed by FHI 360.

Coherence Among Sectors and Stakeholders Differentiates Districts in Rwanda That Did and Did Not Improve Child Stunting

Objectives

Focusing on national trends can mask sub-national differences in reducing undernutrition. Using qualitative data, we aimed to understand differences in stunting reduction rates in Rwanda through the roles of commitment to improve nutrition and coherence across sectors and administrative levels in implementing Rwanda's multisectoral nutrition policy.

Methods

For this study, we purposefully selected 5 districts in which stunting decreased (reduced) and 5 where it increased or stagnated (non-reduced). We conducted 58 semi-structured interviews with district leaders (n = 38) and frontline workers (n = 20) from sectors involved in implementing Rwanda's nutrition policy. Interviews focused on topics related to commitment and coherence in nutrition. Responses were coded to capture themes on changes and challenges in commitment and coherence and were compared between reduced and non-reduced districts.

Results

Respondents from reduced districts were more likely to define commitment to nutrition as optimal implementation of policy whereas those from non-reduced districts tended to focus more on financial commitments to improving nutrition. Differences in coherence between the two district types mainly revolved around the implementation of Rwanda's District Plans to Eliminate Malnutrition (DPEMs). Respondents from reduced compared to non-reduced districts were more likely to report optimal DPEM implementation, including regularly conducting nutrition planning meetings, using data from different sectors to assess plans and progress in improving nutrition outcomes, and having better integration of the agriculture and nutrition sectors. In contrast, respondents from non-reduced districts were more likely to report limitations in their relationships with various national level stakeholders and in their nutrition and/or monitoring and evaluation (M&E) capacities. In turn, several people in non-reduced districts requested additional training on these topics.

Conclusions

Coherence among sectors and stakeholders and capacity in nutrition and M&E were stronger in reduced districts. Enhancing these in non-reduced districts may lead to greater stunting reduction.

Funding Sources

The Dutch Government through SNV and the Voice for Change Partnership Programme (V4CP) and A4NH led by IFPRI.

Role of Social Networks in Maternal Food Choice for Children Ages 1 to 5 Years Old in Rural Mexico

Objectives

To understand the role of mothers’ social networks in the food choices that mothers make for their children ages 1 to 5 years old in rural Mexico.

Methods

In-depth interviews were conducted with 46 participants from 3 rural communities between November and December 2016. The interviews inquired about participants’ child-feeding practices, personal and local beliefs about child feeding, and individuals with whom participants discussed food. All interviews were in Spanish, audio-recorded, transcribed verbatim, verified for quality, and analyzed using the constant comparative method.

Results

The networks that participants described in relation to food choice were largely interconnected and embedded within the social space of their communities. These networks were household family, non-household family, community, children's initial school, and health and pantry personnel. Participants described the functions of each network for the feeding of their children. These functions ranged from directly intervening on feeding behavior in the most proximal network, i.e., household family, to providing formal feeding and nutritional guidance in the most peripheral network, i.e., health and pantry personnel. Some networks had unique functions that no other network had, while some functions were shared across networks. Across the networks, professionals, participants’ mothers and mothers-in-law, community senior women, and other women with children emerged as trusted figures whom mothers would turn to for child-feeding advice. Participants were in constant interaction with their social networks and rarely turned to only one advisor. Participants expressed striking a balance between the input received, what they make of it, and eventually weighing their children's responses, resources available, and situations in which interactions occur and food choice is made for children.

Conclusions

Social networks have vital functions in establishing norms for food choices made for children. The multiplicity of child-feeding advisors may be especially important in strategies that seek to promote healthy food choices for children during developmental years to foster healthy eating patterns.

Funding Sources

SPARC Graduate Research Grant from University of South Carolina.

Strengthening Nutrition Interventions in Antenatal Care Services Had Modest Impacts on Diet Diversity, Micronutrient Intake, and Breastfeeding in Uttar Pradesh, India

Objectives

Interventions to improve maternal nutrition are poorly integrated into antenatal care (ANC) services in India. Alive & Thrive aimed to strengthen delivery of micronutrient supplements and intensify interpersonal counseling and community mobilization implemented through government ANC services. We evaluated the impact of nutrition-intensified ANC (I-ANC) compared to standard ANC (S-ANC) on diet diversity, consumption of iron-folic acid (IFA) and calcium supplements, and early breastfeeding practices.

Methods

We used a cluster-randomized design with cross-sectional surveys at baseline (2017) and endline (2019) (n ∼660 pregnant women and 1800 recently delivered women per survey) and a process evaluation. We derived difference-in-difference effect estimates, adjusted for geographic clustering, gestational age, infant age, and sex.

Results

Coverage of interventions was high at endline; 70–90% women were contacted by frontline workers at home or nutrition centers. Women in the I-ANC arm were significantly more likely to have received counseling on core nutrition messages (10–18 percentage points [pp]) than those in the S-ANC arm. Dietary diversity improved modestly among pregnant women in the I-ANC arm compared to the S-ANC arm (effect: 8.3 pp). The number of food groups consumed increased slightly over time but remained low in both arms. The percentage of women who consumed 100 + IFA improved equally in both arms (from 8 to 25%). Small significant impacts were observed for any consumption of IFA and calcium supplements (effects 10.3 and 12.4 pp, respectively). Significant impacts were also observed for non-prelacteal feeding (effect: −6.3 pp) and exclusive breastfeeding (effect: 7.4 pp) but not for early initiation of breastfeeding. The process evaluation found that system-level and supply-chain challenges, household context, and local diet preferences affected implementation and uptake.

Conclusions

Intensifying nutrition in existing government ANC services resulted in modest improvements in maternal nutrition practices. Dietary diversity and consumption of supplements remained sub-optimal. Additional efforts are needed for further improvement of maternal nutrition services.

Funding Sources

Bill & Melinda Gates Foundation, through Alive & Thrive, managed by FHI 360.

Double Burden of Malnutrition: The Role of Framing in Development of Political Priority in the Context of Rising Diet-related Non-communicable Diseases in Tamil Nadu, India (P22-005-19)

Objectives

In low- and middle-income countries, non-communicable disease (NCD) prevalence is increasing while undernutrition persists, resulting in a double-burden of malnutrition. How policy actors frame malnutrition may shape policy, programming, and investment. In India, where NCDs are rising rapidly and undernutrition persists throughout the country, much of food and health policy is decentralized, but little is known of how the double burden of malnutrition is understood at the state level. This study aimed to identify and compare frames and priorities for nutrition used by relevant policy actors to help understand the narrative emerging around policy solutions for the double burden of malnutrition.

Methods

Key informants in the health, nutrition, and agriculture fields were identified from policy documents and purposive and snowball sampling. In-depth, semi-structured interviews were held with 28 key informants including international policy advocates, government officials, and state-level implementers in Tamil Nadu. Interviews were audio-recorded, transcribed, and coded with Nvivo 12. Major themes were identified using elements from prior published work: actor power, internal frame, issue characteristics, evaluative dimensions of target populations, priorities emphasized, and potential effects of the frame or likely policy result.

Results

Different actors reported differing priorities for the double burden of malnutrition. There was almost universal concern about stunting and anemia in children and women and consensus on sanitation and dietary diversity as causes of undernutrition, but a lack of clarity regarding diet-related NCDs. Respondents were unclear about which populations to target for the double burden, compared to clear targeting of women and children to address undernutrition. They described lack of convergence or clear roles for actors addressing the double burden, unlike for undernutrition.

Conclusions

There is a lack of consensus on the causes, manifestation, and solutions for the double burden of malnutrition within the policy community. Creating a shared narrative is critical for cohesive and efficient programming to address the double burden of malnutrition.

Funding Sources

Bill & Melinda Gates Foundation through POSHAN, led by International Food Policy Research Institute.

An Agricultural and Finance Intervention Improved Dietary Intake and Nutritional Status of Children Living in HIV-affected Households in Western Kenya (P10-129-19)

Objectives

To test whether an intervention that was shown previously to have improved food security, dietary intake of adults, and HIV health outcomes also improved dietary intake and nutritional status of children living in HIV-affected households.

Methods

The study was conducted in the Nyanza Region, Kenya where two health facilities were randomly assigned as intervention or control arms. The intervention included a human-powered water pump, a microfinance loan to purchase farm commodities, and training in sustainable farming practices and financial management. One hundred children (6 to 60 months of age) were enrolled in each arm from households with HIV-infected adults 18 to 49 years old on antiretroviral therapy and with access to surface water and land. Children were assessed beginning in April 2012 and every three months for one year. Data were collected on dietary intake, height, weight, and mid-upper arm circumference (MUAC). The difference in differences from first visit and in linear trends over visits were tested using fixed-effects regression models.

Results

Compared to the control arm, children in the intervention arm had a larger increase in weight at the 12-month visit (β: 0.42, 95% CI: 0.08, 0.76) and increase in MUAC at the 6-month visit (β: 0.28, 95% CI: 0.08, 0.49), with no difference in changes in height over time. Compared to the control arm, the intervention arm had a larger increasing linear trend over time in intake of staples (β: 0.22, 95% CI: 0.02, 0.44), fruits and vegetables (β: 0.42, 95% CI: 0.10, 0.75), and meat (β: 0.07, 95% CI: 0.03, 0.12), and a larger decreasing linear trend in intake of condiments (β: -0.16, 95% CI: -0.23, -0.09) and tea (β: -0.12, 95% CI: -0.19, -0.05), with no differences in intake of eggs, dairy and fat over time.

Conclusions

This intervention that improved food security, dietary intake, and HIV health outcomes of HIV-infected adults also improved dietary intake and nutritional status of children living in those households. Multisectoral agricultural and financial interventions have the potential to improve the nutritional status of HIV-affected children in rural Kenya and should be further explored.

Funding Sources

National Institute of Mental Health.

Paths Linking Maternal Resources for Care to Child Growth and Early Childhood Development in Bangladesh (P11-125-19)

Objectives

The study aimed to determine the paths through which resources for care were associated with child growth and development. We hypothesized that resources could have been directly associated with child outcomes or indirectly through care behaviors. Child growth could also have mediated the association between care resources and development.

Methods

We used the baseline Alive & Thrive data from Bangladesh (n = 803 mothers and their 12–23.9-month children). Child outcomes were height-for-age z score (HAZ) and motor and language development. Care resources were maternal education, knowledge, height, body mass index (BMI), mental well-being, decision-making autonomy, employment, support in chores, and perceived support. Care included dietary diversity, cleanliness, immunization, stimulation, and adequate care. Path analyses accounting for potential confounders and clustering were used.

Results

Education, knowledge, health, autonomy and support were associated with child outcomes. Height (β = 0.054), BMI (β = 0.033), and mental well-being (β = 0.024) had direct associations with child HAZ. Knowledge (β = 0.0038) and perceived support (β = 0.013) were associated HAZ via immunization. Height (β = 0.034) and mental well-being (β = 0.015) were associated with motor development via HAZ. Knowledge (β = 0.0024) and perceived support (β = 0.0075) were associated with motor development via immunization and then HAZ. Autonomy (β = 0.085) and perceived support (β = -0.24) had a direct association with language. Education was associated with language via cleanliness (β = 0.011). Knowledge and perceived support had associations with language via cleanliness, and immunization and then HAZ. Height (β = 0.016), BMI (β = 0.0094), and mental well-being (β = 0.0070) were associated with language via HAZ.

Conclusions

Care resources were associated with growth and development directly and via care. Child growth mediated the associations between resources and child development. Strengthening various maternal resources and integration of growth and development interventions may improve child outcomes.

Funding Sources

Bill & Melinda Gates Foundation and the governments of Canada and Ireland through Alive & Thrive, managed by FHI 360, and the Patrice L. Engle Dissertation Grant in Global Early Child Development.

Stressful Life Changes Affect Nutrition-Related Health Outcomes Among US Army Soldiers (P18-070-19)

Objectives

This prospective cohort study aimed to determine if experiencing stressful life changes were associated with an earlier onset of adverse nutrition-related health outcomes among US Army Soldiers. An additional aim was to determine which stressful life changes were most associated with these outcomes and if there were gender differences in the magnitude of the associations.

Methods

Stressful life changes were changes in marital status, combat deployment or returning from deployment, relocation, adding a child, change in rank, change in occupation, or development of a physical limitation to duty. Nutrition-related health outcomes were hyperlipidemia diagnosis, substantial weight gain, or weight-related separation from the Army. Using longitudinal data from the Stanford Military Data Repository representing all active-duty Soldiers who were age 17–62 between 2011 and 2014 (n = 827,126), event history analysis was used to model the association of stressful life changes with nutrition-related outcomes.

Results

Marriage was found to raise the odds of substantial weight gain three months later by 1.24 times (95% CI: 1.16, 1.32) for men and 1.68 times (95% CI: 1.51, 1.89) for women. Developing a physical duty limitation raised the odds of hyperlipidemia two months later by 1.42 times (95% CI: 1.15, 0.75) for men and 1.83 times (95% CI: 1.01, 3.32) for women and the odds of substantial weight gain two months later by 3.16 times (95% CI: 2.89, 3.44) in men and 1.69 times (95% CI: 1.36, 2.08) in women.

Conclusions

Differences in the magnitude of associations show stressful life changes affect male and female Soldiers differently. Identifying times after stressful life changes when the risk of developing an undesirable health outcome is highest offers new possibilities for proactively addressing health. Findings could guide the timing of interventions to mitigate the effects of stress on health in military and civilian populations.

Funding Sources

None. Disclaimer: Authors’ views do not reflect official DoD or Army policy.

Association of Food and General Parenting Practices with Young Children's Dietary Behaviors and the Role of Child Difficulty in Self-regulation (OR03-05-19)

Objectives

Understand the association of food and general parenting practices with young children's dietary behaviors and the role of child difficulty in self-regulation in this relationship.

Methods

Data were from the Early Childhood Longitudinal Study – Birth Cohort. Parent-child dyads with non-missing outcomes at age 5 (i.e., weekly frequency of intake of sugar-sweetened beverages, sweet foods and desserts, salty snack foods, fruits, and vegetables) were used (n = 3,250 boys and 3,150 girls). Analyses were done separately for boys and girls. Regression models with full information maximum likelihood were used accounting for clusters in Stata. Each outcome was regressed on food parenting variables at age 4 (i.e., rules about foods, and meal routines of eating as a family and at a regular time) and covariates. General parenting variables at age 4 (i.e., parent-child interaction, difficulty sticking with rules, harsh discipline, rules about watching television, and rules about bedtime), child difficulty in self-regulation at age 4, and their interactions were then added sequentially.

Results

Better food parenting practices at age 4 were associated with less frequent intake of unhealthy and more frequent intake of healthy foods and beverages in both boys and girls at age 5, with some differences by gender. General parenting practices at age 4 were associated with dietary behaviors differently for boys and girls. Difficulty in self-regulation at age 4 significantly modified the association between parenting practices and child's dietary behaviors for boys (evening meals at a regular time and intake of sweet foods and desserts) and girls (parent-child interaction and intake of sugar-sweetened beverages; difficulty sticking with rules and intake of sweet foods and desserts; rules about foods and intake of fruits and vegetables; and harsh discipline and intake of fruits).

Conclusions

Better food parenting and general parenting practices at age 4 were associated with children's healthy dietary behaviors at age 5. These associations differed by gender and child difficulty in self-regulation. Interventions to improve children's dietary behaviors should target parents and children to promote positive parenting in food and non-food settings and support children with difficulty in self-regulation.

Funding Sources

None.

Household Food Insecurity Is Associated with Higher Adiposity Among U.S. Schoolchildren Ages 10–15 Years (OR02-05-19)

Objectives

This study assesses the relationship between household food insecurity and adiposity, measured as BMI-for-age z-score (BMI-z), overweight/obesity, and waist circumference, as well as dietary intake and diet-related behaviors in US children.

Methods

A total of 5138 US schoolchildren ages 4–15 years from 130 communities in the cross-sectional Healthy Communities Study were included in this analysis. Household food insecurity was self-reported using a validated 2-item screener. Dietary intake was assessed using National Cancer Institute's (NCI) Dietary Screener Questionnaire (DSQ), a 26-item food frequency questionnaire, and dietary behaviors were assessed during a household survey. Data were analyzed using multilevel statistical models, including interaction tests for age, sex, and race/ethnicity.

Results

Food insecure children had a BMI z-score of 0.14 higher (95% CI: 0.06, 0.21) and a waist circumference of 0.91 cm higher (95% CI: 0.18, 1.63) than food secure children. Food insecure children have 1.17 times the odds of being overweight/obesity compared with food secure children (95% CI: 1.02, 1.34). There was no significant interaction by sex or race/ethnicity. Food insecure children consumed more sugar from sugar sweetened beverages (0.36 tsp/day; 95% CI: 0.09, 0.63), and ate breakfast (−0.28 days/week; 95% CI: −0.39, −0.17) and together with family (−0.22 days/week; 95% CI: −0.37, −0.06) less frequently compared to food secure children.

Conclusions

The present study found a significant, positive association between household food insecurity and child adiposity for children ages 10–15 years, as well as for several dietary intake and diet-related behaviors. This research helps disentangle the complex picture of food insecurity as a contributor to childhood obesity and poorer dietary outcomes in diverse populations.

Funding Sources

Research was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number K01HL131630. The authors would also like to acknowledge the Global Food Initiative at the University of California Office of the President for their support of this project.

Satisfying Children's Desire: A Primary Value Driving Parents’ Food Purchasing Decisions for Elementary-school-aged Children in South Carolina (P10-043-19)

Objectives

This study aimed to understand how parents made food purchasing decisions for their elementary-school-aged children and how they adjudicated among different values to make a purchasing decision.

Methods

Semi-structured qualitative interviews were conducted with 40 parents from low-and middle-income families in South Carolina who were primary food shoppers for their elementary-school-aged children and the households. The interviews were audio-recorded, transcribed verbatim, and open-coded. Coding matrices were used to compare parents’ responses on their decision-making process by race/ethnicity and child age.

Results

Parents adjudicated among nine values when they purchased foods and drinks for their elementary-school-aged children. Satisfying children's desire for a food or drink was the primary value parents identified as driving their food purchasing decisions. Parents also valued nutritional quality of the foods, children's acceptance of the foods, convenience of preparation, cost, health needs of the children, and tradition. Parents wanted their children to eat healthy but reported that they might need to compromise with the healthfulness of the foods because of their children's desire for less healthy foods. Although parents perceived that healthy foods, including fresh fruits and vegetables, are expensive, they wanted to accommodate those foods in their shopping list regardless of the cost if their children desired those foods. Strategies that parents applied to make a balance between children's desire, healthfulness of the foods, and price of the foods included purchasing store brand items, seasonal fruits, and items on sale and promotion, as well as setting rules for the children.

Conclusions

Making food purchasing decision for children is complex as children's desire and acceptance of a food are important in parents’ decisions. Despite that parents valued nutritional quality of foods and health needs, they tend to buy less healthy foods to satisfy their children's desire.

Funding Sources

This study was partially funded by a SPARC grant from the University of South Carolina Office of the Vice President for Research and the Olga I. Ogoussan Doctoral Research Award from the Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina.

Examining the Exposure, Timing, and Frequency of Interpersonal Communication Contacts to Improve Infant and Young Child Feeding in Bangladesh, Ethiopia, and Vietnam (P10-138-19)

Objectives

In the context of large-scale interventions to improve infant and young child feeding (IYCF) practices, we examined differences in characteristics of those exposed and not exposed to interventions; exposure to interpersonal communication (IPC), including overlap with other interventions and timing and number of contacts; and relationship between frequency of IPC contacts and IYCF practices.

Methods

We used endline survey data from Bangladesh (2000 mothers with children <2y, 1000 per program group), Ethiopia (1720 mother with children aged 6–23.9 mo, 1360 per group), and Vietnam (2005 mothers with children <2y, 1000 per group). Regression models were used to test differences in exposure to specific or combined interventions between two arms and relationships between the frequency of IPC contacts or exposure to interventions and IYCF practices, adjusted for child age and sex and geographic clustering.

Results

Those exposed to interventions had higher socioeconomic status, food security, and maternal dietary diversity. There was large overlap in exposure to IPC with other interventions in intensive-intervention areas in all 3 countries. On average, mothers received 8 visits in the last 6 mo, 2 visits in the last 3 mo, and 1 visit in the last 6 mo in Bangladesh, Ethiopia, and Vietnam respectively. In Bangladesh, there was a positive, nonsignificant association between intervention exposure and IYCF practices in intensive areas. In Ethiopia, exposure to IPC with other interventions was associated with higher odds of minimum meal frequency (OR: 1.6), minimum dietary diversity (OR: 1.8), and consumption of iron-rich foods (OR: 4.7). In Vietnam, exposure to IPC alone or with mass media was associated with 3.7 and 2.8 higher odds respectively of exclusive breastfeeding. At least monthly visits was associated with higher odds of IYCF practices in Bangladesh and Ethiopia. In Vietnam, any number of IPC visits was associated with 2 times higher odds of exclusive breastfeeding.

Conclusions

Effects of combined behavior-change interventions and frequency of IPC contacts may be context-specific.

Funding Sources

Bill & Melinda Gates Foundation, through Alive & Thrive, managed by FHI 360; and CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), led by the International Food Policy Research Institute.

Stories of Change: How Rwanda Created an Enabling Environment for Reducing Malnutrition (P22-011-19)

Objectives

Eliminating malnutrition is on many countries’ political agendas but knowledge of how enabling environments are created and used is needed. We assessed the drivers of change in stunting reduction among children <5 y of age in Rwanda and contributors to differential reduction over 10–25 y.

Methods

We conducted in-depth interviews on changes in nutrition with nutrition stakeholders at national (n = 32), district (n = 38), and community (n = 20) levels, and community focus group discussions (n = 40) in 10 purposefully selected districts in Rwanda's 5 provinces. In each province, we selected 1 district with decreased stunting and 1 where no change or an increase occurred (2010–2015). We also used regression decomposition analysis to investigate drivers of change in stunting with Demographic and Health Surveys (2005, 2010, and 2015) data.

Results

Respondents believed peace and security along with improved leadership and decentralization helped to create an enabling environment for change. Rwanda experienced increased political and institutional commitment to nutrition indicated by adoption of a multisectoral policy and reinforced with horizontal coordination platforms and plans at national and sub-national levels, but greater financial commitment is needed according to respondents. Vertical coordination across administrative levels improved through communication, staff working on nutrition at these levels, and relationships between nutrition actors. From respondent reports, health and agricultural programs and increased availability and use of health services helped improve nutrition; differences between study districts included climate change challenges, food insecurity, weak horizontal and vertical coherence, and weak implementation of coordination plans. Supporting this, giving birth in a health facility, attending ≥4 antenatal care visits, antenatal care quality, fertility, parental education, household wealth, and health insurance coverage drove stunting reduction from the regression decomposition analysis.

Conclusions

Leadership, commitment and horizontal and vertical coherence are important for creating enabling environments and providing programs and services that can lead to reduced malnutrition.

Funding Sources

Ministry of Foreign Affairs of Kingdom of Netherlands through SNV Netherlands Development Organization.

Intervention Design Elements Are Associated with Frontline Health Workers’ Performance to Deliver Infant and Young Child Nutrition Services in Bangladesh and Viet Nam (P10-128-19)

Objectives

Frontline health workers (FLW) are needed for delivering interventions at scale to reduce maternal and child undernutrition, but low- and middle-income countries often face inadequate FLW performance. This study aimed to test whether and how intervention design elements such as training, supervision, and mass media improved FLW performance in delivering nutrition services.

Methods

Survey data were collected in 2010 and 2014 as part of impact evaluations of Alive & Thrive (A&T) interventions to improve infant and young child feeding (IYCF) practices in Bangladesh and Vietnam. FLWs in A&T intensive (A&T-I) areas received specialized IYCF training, job aids, and regular supportive supervision. Those in A&T non-intensive (A&T-NI) areas received standard government training and supervision; there was mass media exposure in both areas. Multiple regression was used to test differences in exposure to intervention design elements and performance outcomes between the two intervention areas. Structural equation modeling was conducted to examine the paths from exposure to performance outcomes measured at the FLW and end-user levels.

Results

Compared to FLWs in A&T-NI areas, those in A&T-I areas had higher scores in training (by 1.3–3.6 out of 10 points), supportive supervision (by 0.3–3.5 points), and mass media exposure (by 0.3–3.5 points). These intervention design elements were significantly associated with FLW knowledge and motivation, which in turn improved service delivery. FLW-level performance outcomes contributed to improving end-user-level outcomes such as higher service utilization (β = 0.12–1.04 in Bangladesh and 0.11–0.96 in Vietnam) and maternal knowledge (β = 0.12- 0.17 in Bangladesh and 0.04–0.21 in Vietnam).

Conclusions

Training, supervision, and mass media exposure can contribute to improved FLW service delivery by enhancing knowledge and motivation, which in turn positively influence mother's service utilization and IYCF knowledge. These elements and mechanisms should be considered by policy makers and program implementers when designing interventions or reinforcing the work context of FLWs.

Funding Sources

Bill & Melinda Gates Foundation, through Alive & Thrive, managed by FHI 360.

Intervention for Women in Costa Rica Who Have Food Insecurity and Excess Body Weight: A Cluster Randomized Trial (P04-017-19)

Objectives

This study aimed to develop, implement, and evaluate an intervention to simultaneously reduce food insecurity and body weight. We hypothesized that, when compared with the non-intensive arm, women in the intensive intervention arm would reduce food insecurity and body weight and improve social support for healthy eating, psychological and economic empowerment, and food and physical activity behaviors.

Methods

We conducted a cluster-randomized controlled trial in the Central Canton of the Province of Alajuela. Randomization was at the level of the catchment area of the first level of health care in Costa Rica. This 6-month study compared two arms. The intensive arm consisted of activities at the individual (12 two-hour sessions, three follow-up monthly sessions, and one closing session), household (one workshop with the participants’ household and community members, and homework with family participation), and community (two brochures and one workshop) levels. The non-intensive arm was comprised of three one-hour sessions about healthy lifestyles.

Results

A total of 171 participants were enrolled (83 in intensive and 88 in non-intensive arm). At 6 months the intensive arm had significantly greater decreases from baseline in food insecurity (P = 0.004), body mass index (P = 0.010), and waist circumference (P = 0.001) compared with the non-intensive arm. The intensive arm also had also significantly greater increases in psychological (P = 0.014) and economic empowerment, including a greater increase in the contribution to household support (P = 0.030) and more women that found a job (P = 0.018), compared with the non-intensive arm. Women in the intervention arm had significantly greater changes from baseline in the expected direction in food consumption of fried foods (P = 0.029), sausages (P = 0.038), sugar drinks (P = 0.032), salads (P = 0.032), and beans (P = 0.004) compared to women in the non-intensive arm. We did not find any significant differences between the arms in social support, exercise, and consumption of fruits, vegetables and fast foods.

Conclusions

This intervention demonstrates that it is possible to simultaneously reduce food insecurity and reduce, rather than exacerbate, excess weight gain.

Funding Sources

Office of International Affairs, University of Costa Rica.

Role of Interpersonal Relationships in Mothers’ Foods Choice Decisions for Children Ages 1 < 5 Years in Rural Mexico (P10-051-19)

Objectives

To understand how mothers’ interpersonal relationships influence food choice decisions they make to feed children ages 1 to <5 years old in rural Mexico.

Methods

Semi-structured interviews were conducted with 46 mothers from 3 rural communities in Mexico in November and December 2016. Mothers were asked about their daily activities, their own knowledge about child feeding, the social ties from which they obtain information about child feeding, and local normative beliefs about food. Interviews were audio-recorded, transcribed verbatim, and analyzed using the constant comparative method. Thematic coding was used to identify the underlying values and meanings mothers ascribed to foods and the influential figures in their social circle to understand how interpersonal relationships influenced child feeding decisions.

Results

Most mothers had no formal employment and spent their day in activities such as upkeep of home, caring for their children, getting food, preparing meals, looking after their animals, and harvesting. Most mothers lived in multigenerational households or near relatives. Mothers’ knowledge about child feeding had a foundation in practices from their own mothers, being child caregivers to their siblings, employment as child caregivers in urban settings, and having older children. Mothers had prominent figures who influenced their decisions about child feeding. These figures were older women living in the household, other mothers within their social circle, health and social program personnel, children's fathers, and children themselves. Mothers described specific foods and preparations locally acceptable to feed to children, noting that some beliefs and practices might conflict with others. In making decisions about what to feed their children, mothers appraised who their social ties were and their feeding practices. For example, mothers took in information from other mothers based on their perception of whether the child was well-fed, which included child appearance.

Conclusions

Mothers’ interpersonal relationships played an important role in their child feeding decisions. When designing a program to improve food choice, identifying and accounting for mothers’ key social ties regarding child feeding could enhance positive behavior change.

Funding Sources

SPARC Graduate Research Grant from University of South Carolina.

Implementation Research to Understand and Target Complex Needs: A Case Study of US-based Food Assistance Programming (P10-147-19)

Objectives

The objective of this study was to understand needs among seniors for food and food assistance and to develop a comprehensive taxonomy for these needs.

Methods

A total of 147 seniors were purposively sampled from 12 food-assistance programs in 9 states. Of the 12 programs, 10 provided unprepared foods and 2 provided pre-cooked meals. Data were semi-structured qualitative interviews. Coding and analysis of transcripts followed an inductive qualitative analysis approach. A series of thematic summaries were prepared to reflect the content of the interviews for discussion and refinement of the analytic approach.

Results

An emergent taxonomy comprised 3 categories consisting of abilities and ranges or variants of those abilities. The category of physical ability consists of physical strength, the ability to prepare food, the ability to walk or stand, and health status. These relate to an individual's functional abilities to live and act independently and may be considered pre-conditions for program uptake and benefit distinct from dietary and food security-related needs and limitations. The category of consuming food consists of preferences, accessibility, affordability, and dietary needs. This category highlights the relationship between economic constraints and dietary needs that often necessitates meaningful tradeoffs in consuming the right foods for their health. The category of access and use of transportation consists of own means, friends or family, and public or private services. This category highlights challenges in accessing programs and provides insight into seniors’ experiences of poverty, declining functional abilities, social networks and connectedness, geography, and public services.

Conclusions

The process used to develop the taxonomy and the taxonomy itself provide an exemplar for implementation research when the nature of need is complex and programs integrated across sectors are required to address the need. The taxonomy provides structure to facilitate the identification of key factors in program engagement—and insight into the economic and social environments in which they occur—that translate into needs relevant to the design, targeting, and uptake of food assistance in a diverse population of seniors.

Funding Sources

Enterprise Rent-a-Car Foundation.