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Madzorera I, Bliznashka L, Blakstad MM, Bellows AL, Canavan CR, Mosha D, Bromage S, Noor RA, Webb P, Ghosh S, Kinabo JL, Masanja H, Fawzi WW. Women's input and decision-making in agriculture are associated with diet quality in rural Tanzania. Front Public Health 2023; 11:1215462. [PMID: 38125846 PMCID: PMC10731380 DOI: 10.3389/fpubh.2023.1215462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 10/30/2023] [Indexed: 12/23/2023] Open
Abstract
Background Women's empowerment is one critical pathway through which agriculture can impact women's nutrition; however, empirical evidence is still limited. We evaluated the associations of women's participation, input, and decision-making in key agricultural and household activities with women's diet quality. Methods We analyzed data from a cross-sectional study of 870 women engaged in homestead agriculture. We used food frequency questionnaires to assess women's diets and computed women's diet quality using the Prime Diet Quality Score (PDQS) (range 0-42), which captures healthy and unhealthy foods. We evaluated women's decision-making in 8 activities, food crop farming, cash crop farming, livestock raising, non-farm economic activities, wage/salary employment, fishing, major household expenditures, and minor household expenditures. Generalized estimating equations (GEE) linear models were used to evaluate associations between (a) women's participation, (b) decision-making, (c) adequate input, (d) adequate extent of independence in decision-making in agriculture, and (e) adequate input in use of agricultural income with their PDQS. Adequate input was defined as input into some, most or all decisions compared to input into few decisions or none. Adequate extent of independence was defined as input to a medium or high extent compared to input to a small extent or none. Findings Median PDQS was 19 (IQR: 16-21). Women's adequate input in decision-making on wage and salary employment (estimate: 4.19, 95% CI: 2.80, 5.57) and minor expenditures were associated with higher PDQS vs. inadequate input. Women with independence in decision-making on livestock production (estimate: 0.97, 95% CI: 0.05, 1.90) and minor household expenditures, and women with adequate decision-making in the use of income from wages/salaries (estimate: 3.16, 95% CI: 2.44, 3.87) had higher PDQS. Participation in agricultural activities was positively associated with PDQS. Conclusions Women's participation and input in decision-making in wage and salary employment, livestock production, and minor household expenditures were strongly associated with the consumption of better-quality diets. Women participating in multiple farm activities were also likely to have better diet quality. This study adds to the growing evidence on the pathways through which women's empowerment may influence women's nutrition in rural Tanzania.
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Affiliation(s)
- Isabel Madzorera
- Division of Community Health Sciences, School of Public Health, University of California, Berkeley, Berkeley, CA, United States
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, United States
| | - Lilia Bliznashka
- Nutrition, Diets, and Health Unit, International Food Policy Research Institute, Washington, DC, United States
| | - Mia M. Blakstad
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, United States
| | - Alexandra L. Bellows
- Department of International Health (Human Nutrition), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Chelsey R. Canavan
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, United States
| | | | - Sabri Bromage
- Institute of Nutrition, Mahidol University, Salaya, Thailand
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, MA, United States
| | - Ramadhani A. Noor
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, United States
| | - Patrick Webb
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, United States
| | - Shibani Ghosh
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, United States
| | - Joyce Ludovick Kinabo
- Department of Food Science Technology, Nutrition and Consumer Sciences, Sokoine University of Agriculture, Morogoro, Tanzania
| | | | - Wafaie W. Fawzi
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, United States
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, MA, United States
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, United States
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Quinn MK, Edmond KM, Fawzi WW, Hurt L, Kirkwood BR, Masanja H, Muhihi AJ, Newton S, Noor RA, Williams PL, Sudfeld CR, Smith ER. Non-specific effects of BCG and DTP vaccination on infant mortality: An analysis of birth cohorts in Ghana and Tanzania. Vaccine 2022; 40:3737-3745. [PMID: 35618557 PMCID: PMC9194613 DOI: 10.1016/j.vaccine.2022.04.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Vaccines may induce non-specific effects on survival and health outcomes, in addition to protection against targeted pathogens or disease. Observational evidence suggests that infant Baccillus Calmette-Guérin (BCG) vaccination may provide non-specific survival benefits, while diphtheria-tetanus-pertussis (DTP) vaccination may increase the risk of mortality. Non-specific vaccine effects have been hypothesized to modify the effect of neonatal vitamin A supplementation (NVAS) on mortality. METHODS 22,955 newborns in Ghana and 31,999 newborns in Tanzania were enrolled in two parallel, randomized, double-blind, placebo-controlled trials of neonatal vitamin A supplementation from 2010 to 2014 and followed until 1-year of age. Cox proportional hazard models were used to estimate associations of BCG and DTP vaccination with infant survival. RESULTS BCG vaccination was associated with a decreased risk of infant mortality after controlling for confounders in both countries (Ghana adjusted hazard ratio (aHR): 0.51, 95% CI: 0.38-0.68; Tanzania aHR: 0.08, 95% CI: 0.07-0.10). Receiving a DTP vaccination was associated with a decreased risk of death (Ghana aHR: 0.39, 95% CI: 0.26-0.59; Tanzania aHR: 0.19, 95% CI: 0.16-0.22). There was no evidence of interaction between BCG or DTP vaccination status and infant sex or NVAS. CONCLUSION We demonstrated that BCG and DTP vaccination were associated with decreased risk of infant mortality in Ghana and Tanzania with no evidence of interaction between DTP or BCG vaccination, NVAS, and infant sex. Our study supports global recommendations on BCG and DTP vaccination and programmatic efforts to ensure all children have access to timely vaccination. CLINICAL TRIALS REGISTRATION Ghana (Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12610000582055) and Tanzania (ANZCTR: ACTRN12610000636055).
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Affiliation(s)
- M K Quinn
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Karen M Edmond
- Department of Women and Children's Health, Kings College London, United Kingdom
| | - Wafaie W Fawzi
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Nutrition, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Lisa Hurt
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, UK
| | - Betty R Kirkwood
- Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Sam Newton
- Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti, Ghana; Kintampo Health Research Centre, Kintampo, Ghana
| | - Ramadhani A Noor
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Paige L Williams
- Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Christopher R Sudfeld
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Nutrition, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Emily R Smith
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Global Health, George Washington University Milken Institute School of Public Health, Washington, DC, USA; Department of Exercise and Nutrition Sciences, George Washington University Milken Institute School of Public Health, Washington, DC, USA.
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Blakstad MM, Mosha D, Bliznashka L, Bellows AL, Canavan CR, Yussuf MH, Mlalama K, Madzorera I, Chen JT, Noor RA, Kinabo J, Masanja H, Fawzi WW. Are home gardening programs a sustainable way to improve nutrition? Lessons from a cluster-randomized controlled trial in Rufiji, Tanzania. Food Policy 2022; 109:102248. [PMID: 35431402 PMCID: PMC9012451 DOI: 10.1016/j.foodpol.2022.102248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Homestead food production (HFP) programs may improve diet and nutrition outcomes by increasing availability of nutrient dense foods such as vegetables and supporting livelihoods. We conducted a pair-matched cluster-randomized controlled trial to investigate whether vegetable home gardens could improve women's dietary diversity, household food security, maternal and child iron status, and the probability of women consuming nutrient-rich food groups. We enrolled 1,006 women of reproductive age (18-49 years) in ten villages in Pwani Region, Eastern Tanzania, matched the villages into pairs according to village characteristics, and randomly allocated villages to intervention or control. Households in the intervention villages received agricultural training, inputs to promote home production of nutritious crops, and nutrition and health education. Data were collected in 2016, 2017, and 2019 and analyzed using linear regression models with propensity score weighting adjusting for individual-level confounders, differential loss to follow-up, and fixed effects for village pairs to accommodate the pair-matched design. Results after one year of the intervention (previously published) found significant improvements in dietary diversity. However, three years after the start of the intervention the difference in dietary diversity disappeared, even though the number of women who grew at least one crop was significantly higher (75 percentage points, 95% CI: 72, 81) in treatment households compared to controls. Barriers to maintaining a home garden, including lack of irrigation opportunities and fencing materials, and social disruption may have precluded sustained impacts from home gardening in this context. Future home garden programs should carefully consider mechanisms and investments needed for sustained impact over time.
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Affiliation(s)
- Mia M Blakstad
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Dominic Mosha
- Ifakara Health Institute, Dar es Salaam, Tanzania
- Africa Academy for Public Health, Dar es Salaam, Tanzania
| | - Lilia Bliznashka
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Alexandra L Bellows
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Chelsey R Canavan
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA
| | | | | | - Isabel Madzorera
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Jarvis T Chen
- Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, MA
| | - Ramadhani A Noor
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, MA
| | - Joyce Kinabo
- Department of Food Science Technology, Nutrition and Consumer Sciences, Sokoine University of Agriculture, Morogoro, Tanzania
| | | | - Wafaie W Fawzi
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, MA
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA
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Yang J, Wang M, Tobias DK, Rich-Edwards JW, Darling AM, Abioye AI, Noor RA, Madzorera I, Fawzi WW. Dietary diversity and diet quality with gestational weight gain and adverse birth outcomes, results from a prospective pregnancy cohort study in urban Tanzania. Matern Child Nutr 2022; 18:e13300. [PMID: 34908233 PMCID: PMC8932689 DOI: 10.1111/mcn.13300] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 10/25/2021] [Accepted: 11/06/2021] [Indexed: 12/15/2022]
Abstract
Healthy maternal diets during pregnancy are an important protective factor for pregnancy‐related outcomes, including gestational weight gain (GWG) and birth outcomes. We prospectively examined the associations of maternal dietary diversity and diet quality, using Minimum Dietary Diversity for Women (MDD‐W) and Prime Diet Quality Score (PDQS), with GWG and birth outcomes among women enrolled in a trial in Tanzania (n = 1190). MDD‐W and PDQS were derived from a baseline food frequency questionnaire. Women were monthly followed until delivery, during which weight was measured. GWG was classified based on the 2009 Institute of Medicine guidelines. Adverse birth outcomes were classified as low birth weight (LBW), small for gestational age, large for gestational age, and preterm birth. 46.2% participants had MDD‐W ≥ 5. Mean score of PDQS was 23.3. Maternal intakes of nuts, poultry, and eggs were low, whereas intakes of sugar‐sweetened beverages and refined grains were high. MDD‐W was not associated with GWG or birth outcomes. For PDQS, compared to the lowest tertile, women in the highest tertile had lower risk of inappropriate GWG (risk ratio [RR] = 0.93, 95% confidence interval [CI]: 0.87–1.00). Women in the middle tertile group of PDQS (RR = 0.72, 95% CI: 0.51–1.00) had lower risk of preterm birth. After excluding women with prior complications, higher PDQS was associated with lower risk of LBW (middle tertile: RR = 0.55, 95% CI: 0.31–0.99, highest tertile: RR = 0.52, 95% CI: 0.29–0.94; continuous per SD: RR = 0.77, 95% CI: 0.60–0.99). Our findings support continuing efforts to improve maternal diet quality for optimal GWG and infant outcomes among Tanzanian women. Maternal diets are a key modifiable determinant of gestational weight gain (GWG) and birth outcomes. We observed suboptimal intakes of healthy proteins and fats and high intakes of refined grains and sugar‐containing foods among well‐nourished pregnant women in urban Tanzania. This study found that higher‐quality maternal diets were associated with lower risks of inappropriate GWG, low birth weight, and preterm birth. This study supports the importance of high maternal diet quality and continuing efforts to promote well‐balanced maternal diets with avoiding both under‐ and over‐nutrition for optimal pregnancy outcomes among Tanzanian populations.
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Affiliation(s)
- Jiaxi Yang
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Molin Wang
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.,Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Deirdre K Tobias
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.,Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Janet W Rich-Edwards
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.,Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anne-Marie Darling
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Ajibola I Abioye
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Ramadhani A Noor
- United Nations Children's Fund (UNICEF), Dar es Salaam, Tanzania
| | - Isabel Madzorera
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Wafaie W Fawzi
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.,Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Mlalama KN, Matemu A, Kosia E, Canavan CR, Bellows AL, Blakstad M, Noor RA, Kinabo J, Fawzi WW, Masanja H, Mosha D. Factors influencing the sustainability of homestead vegetable production intervention in Rufiji, Tanzania: A cross-sectional mixed methods study. PLOS Glob Public Health 2022; 2:e0000531. [PMID: 36962520 PMCID: PMC10022147 DOI: 10.1371/journal.pgph.0000531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/22/2022] [Indexed: 11/19/2022]
Abstract
There is growing evidence that home vegetable gardening interventions improve food security and nutrition outcomes at the family level. Sustainability of many of these community interventions remain a challenge. This study assessed factors influencing the sustainability of homestead vegetable production intervention in Rufiji district, Tanzania, one year after the cessation of external support. This was a community based cross-sectional study using both quantitative and qualitative data collection methods. A total of 247 randomly selected women from households who participated in the homestead vegetable intervention were interviewed using a structured questionnaire. The study held four focus group discussions with women from households that participated in the intervention, and four In-Depth interviews with two extension workers, one community health worker, and one agriculture district officer. Multiple logistic regression for quantitative data and thematic analysis for qualitative data was conducted. About 20.24% (50/247) of households sustained homestead vegetable production for one year after the intervention phased out. Shortage of seeds (adjusted odds ratio = 0.65: CI = 0.46-0.93, p-value 0.018) and either manure or fertilizers (adjusted odds ratio = 1.62: CI = 1.04-2.46, p-value 0.031) were significant factors influencing the sustainability of homesteads vegetable production. In the Focus Group discussions (FGDs) and In-Depth Interview (IDIs), all participating women and extension workers reported high cost of water, destruction from free-grazing animals, agriculture pests and diseases, poor soil fertility, shortage of seeds, and lack of capital affected homestead vegetable production sustainability. Existing individual, community, and system challenges influence the sustainability of external-funded agriculture and nutrition interventions. The study findings underscore the importance of community authorities, scientists, and policymakers in having a well-thought sustainability plan in all promising external-funded interventions.
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Affiliation(s)
- Killian N Mlalama
- Nelson Mandela African Institution of Science and Technology, Arusha, Tanzania
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Athanasia Matemu
- Nelson Mandela African Institution of Science and Technology, Arusha, Tanzania
| | - Efraim Kosia
- Nelson Mandela African Institution of Science and Technology, Arusha, Tanzania
| | - Chelsey R Canavan
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Alexandra L Bellows
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Mia Blakstad
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Ramadhani A Noor
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Joyce Kinabo
- Department of Food Science Technology, Nutrition and Consumer Sciences, Sokoine University of Agriculture, Morogoro, Tanzania
| | - Wafaie W Fawzi
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
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Wang D, Natchu UCM, Darling AM, Noor RA, Hertzmark E, Urassa W, Fawzi WW. Effects of prenatal and postnatal maternal multiple micronutrient supplementation on child growth and morbidity in Tanzania: a double-blind, randomized-controlled trial. Int J Epidemiol 2021; 51:1761-1774. [PMID: 34151973 PMCID: PMC9749718 DOI: 10.1093/ije/dyab117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 05/20/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Maternal micronutrient status is critical for child growth and nutrition. It is unclear whether maternal multiple micronutrient supplementation (MMS) during pregnancy and lactation improves child growth and prevents child morbidity. METHODS This study aimed to determine the effects of prenatal and postnatal maternal MMS on child growth and morbidity. In this double-blind, randomized-controlled trial, 8428 HIV-negative pregnant women were enrolled from Dar es Salaam, Tanzania, between 2001 and 2004. From pregnancy (12-27 weeks of gestation) through to 6 weeks postpartum, participants were randomized to receive daily oral MMS or placebo. All women received daily iron and folic acid during pregnancy. From 6 weeks postpartum through to 18 months postpartum, 3100 women were re-randomized to MMS or placebo. Child-growth measures, haemoglobin concentrations and infectious morbidities were assessed longitudinally from birth to ≤18 months. RESULTS Prenatal MMS led to modest increases in weight-for-age z-scores (mean difference: 0.050; 95% confidence interval: 0.002, 0.099; p = 0.04) and length-for-age z-score (mean difference: 0.062; 95% confidence interval: 0.013, 0.111; p = 0.01) during the first 6 months of life but not thereafter. Prenatal or postnatal MMS did not have benefits for other child outcomes. CONCLUSIONS Whereas maternal MMS is a proven strategy to prevent adverse birth outcomes, other approaches may also need to be considered to curb the high burdens of child morbidity and growth faltering.
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Affiliation(s)
- Dongqing Wang
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | | | - Anne Marie Darling
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Ramadhani A Noor
- United Nations Children's Fund Tanzania, Dar es Salaam, Tanzania
| | - Ellen Hertzmark
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Willy Urassa
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Wafaie W Fawzi
- Corresponding author. Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Building 1, Room 1102, Boston, MA 02115, USA. E-mail:
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Blakstad MM, Mosha D, Bellows AL, Canavan CR, Chen JT, Mlalama K, Noor RA, Kinabo J, Masanja H, Fawzi WW. Home gardening improves dietary diversity, a cluster-randomized controlled trial among Tanzanian women. Matern Child Nutr 2020; 17:e13096. [PMID: 33241924 PMCID: PMC7988851 DOI: 10.1111/mcn.13096] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 09/17/2020] [Accepted: 09/24/2020] [Indexed: 12/12/2022]
Abstract
Homestead food production (HFP) programmes improve the availability of vegetables by providing training in growing nutrient-dense crops. In rural Tanzania, most foods consumed are carbohydrate-rich staples with low micronutrient concentrations. This cluster-randomized controlled trial investigated whether women growing home gardens have higher dietary diversity, household food security or probability of consuming nutrient-rich food groups than women in a control group. We enrolled 1,006 women of reproductive age in 10 villages in Pwani Region in eastern Tanzania, split between intervention (INT) and control (CON) groups. INT received (a) agricultural training and inputs to promote HFP and dietary diversity and (b) nutrition and public health counselling from agricultural extension workers and community health workers. CON received standard services provided by agriculture and health workers. Results were analysed using linear regression models with propensity weighting adjusting for individual-level confounders and differential loss to follow up. Women in INT consumed 0.50 (95% CI [0.20, 0.80], p = 0.001) more food groups per day than women in CON. Women in INT were also 14 percentage points (95% CI [6, 22], p = 0.001) more likely to consume at least five food groups per day, and INT households were 6 percentage points (95% CI [-13, 0], p = 0.059) less likely to experience moderate-to-severe food insecurity compared with CON. This home gardening intervention had positive effects on diet quality and food security after 1 year. Future research should explore whether impact is sustained over time as well as the effects of home garden interventions on additional measures of nutritional status.
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Affiliation(s)
- Mia M Blakstad
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | - Alexandra L Bellows
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Chelsey R Canavan
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Jarvis T Chen
- Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | - Ramadhani A Noor
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Joyce Kinabo
- Department of Food Science Technology, Nutrition and Consumer Sciences, Sokoine University of Agriculture, Morogoro, Tanzania
| | | | - Wafaie W Fawzi
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.,Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
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8
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Madzorera I, Blakstad MM, Bellows AL, Canavan CR, Mosha D, Bromage S, Noor RA, Webb P, Ghosh S, Kinabo J, Masanja H, Fawzi WW. Food Crop Diversity, Women's Income-Earning Activities, and Distance to Markets in Relation to Maternal Dietary Quality in Tanzania. J Nutr 2020; 151:186-196. [PMID: 33244605 PMCID: PMC7779231 DOI: 10.1093/jn/nxaa329] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/28/2020] [Accepted: 10/05/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Women's dietary diversity and quality are limited in low- and middle-income countries (LMICs). Nutrition-sensitive interventions that promote food crop diversity and women's access to income could improve diets and address the double burden of malnutrition in LMICs. OBJECTIVES We examined the associations among food crop diversity and women's income-earning activities with women's diet quality, as well as effect modification by access to markets, in the context of small-holder food production in rural Tanzania. METHODS Data from a cross-sectional study of 880 women from Rufiji, Tanzania, were analyzed. Women's dietary intake was assessed using a food frequency questionnaire. The prime diet quality score (PDQS; 21 food groups; range, 0-42), a unique diet-quality metric for women that captures the healthy and unhealthy aspects of diet, was computed. Generalized estimating equation linear models were used to evaluate the associations of food crop diversity and women's income-earning activities with PDQS, while controlling for socio-economic factors. RESULTS Maternal overweight (24.3%) and obesity (13.1%) were high. The median PDQS was 19 (IQR, 17-21). Households produced 2.0 food crops (SD ± 1.0) yearly. Food crop diversity was positively associated with PDQS (P < 0.001), but the association was strengthened by proximity to markets (P for interaction = 0.02). For women living close (<1.1 km) to markets, producing 1 additional food crop was associated with a 0.67 (95% CI, 0.22-1.12) increase in PDQS, versus a 0.40 (95% CI, 0.24-0.57) increase for women living farther away. The PDQS increased with women's salaried employment (estimate, 0.96; 95% CI, 0.26-1.67). CONCLUSIONS Household food production may interact with access to markets for sales and purchases, while nonfarm income also improves women's diet quality in rural Tanzania. Programs to improve women's diet quality should consider improving market access and women's access to income (source of empowerment), in addition to diversifying production.
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Affiliation(s)
| | - Mia M Blakstad
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Alexandra L Bellows
- Department of International Health (Human Nutrition), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Chelsey R Canavan
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | | | - Sabri Bromage
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Ramadhani A Noor
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Patrick Webb
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Shibani Ghosh
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Joyce Kinabo
- Department of Food Science Technology, Nutrition and Consumer Sciences, Sokoine University of Agriculture, Morogoro, Tanzania
| | | | - Wafaie W Fawzi
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA,Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA,Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
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9
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Ambikapathi R, Passarelli S, Madzorera I, Canavan CR, Noor RA, Abdelmenan S, Tewahido D, Tadesse AW, Sibanda L, Sibanda S, Munthali B, Madzivhandila T, Berhane Y, Fawzi W, Gunaratna NS. Men's nutrition knowledge is important for women's and children's nutrition in Ethiopia. Matern Child Nutr 2020; 17:e13062. [PMID: 32755057 PMCID: PMC7729551 DOI: 10.1111/mcn.13062] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 06/12/2020] [Accepted: 06/17/2020] [Indexed: 12/12/2022]
Abstract
In an effort to address undernutrition among women and children in rural areas of low‐income countries, nutrition‐sensitive agriculture (NSA) and behaviour change communication (BCC) projects heavily focus on women as an entry point to effect nutritional outcomes. There is limited evidence on the role of men's contribution in improving household diets. In this Agriculture to Nutrition trial (Clinicaltrials.gov identifier: NCT03152227), we explored associations between men's and women's nutritional knowledge on households', children's and women's dietary diversity. At the midline evaluation conducted in July 2017, FAO's nutrition knowledge questionnaire was administered to male and female partners in 1396 households. There was a high degree of agreement (88%) on knowledge about exclusive breastfeeding between parents; however, only 56–66% of the households had agreement when comparing knowledge of dietary sources of vitamin A or iron. Factor analysis of knowledge dimensions resulted in identifying two domains, namely, ‘dietary’ and ‘vitamin’ knowledge. Dietary knowledge had a larger effect on women's and children's dietary diversities than vitamin knowledge. Men's dietary knowledge had strong positive associations with households' dietary diversity scores (0.24, P value = 0.001), children's dietary diversity (0.19, P value = 0.008) and women's dietary diversity (0.18, P value < 0.001). Distance to markets and men's education levels modified the effects of nutrition knowledge on dietary diversity. While previous NSA and BCC interventions predominantly focused on uptake among women, there is a large gap and strong potential for men’s engagement in improving household nutrition. Interventions that expand the role of men in NSA may synergistically improve household nutrition outcomes.
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Affiliation(s)
- Ramya Ambikapathi
- Department of Nutrition Science, Purdue University, West Lafayette, Indiana, USA.,Department of Public Health, Purdue University, West Lafayette, Indiana, USA
| | - Simone Passarelli
- Departments of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Isabel Madzorera
- Departments of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Chelsey R Canavan
- Departments of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Ramadhani A Noor
- Departments of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | | | | | - Lindiwe Sibanda
- Food, Agriculture and Natural Resources Policy Analysis Network, Pretoria, South Africa
| | - Simbarashe Sibanda
- Food, Agriculture and Natural Resources Policy Analysis Network, Pretoria, South Africa
| | - Bertha Munthali
- Food, Agriculture and Natural Resources Policy Analysis Network, Pretoria, South Africa
| | | | - Yemane Berhane
- Addis Continental Institute of Public Health, Addis Ababa, Ethiopia
| | - Wafaie Fawzi
- Departments of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Departments of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Departments of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Nilupa S Gunaratna
- Department of Public Health, Purdue University, West Lafayette, Indiana, USA
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10
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Friesen VM, Mbuya MNN, Aaron GJ, Pachón H, Adegoke O, Noor RA, Swart R, Kaaya A, Wieringa FT, Neufeld LM. Fortified Foods Are Major Contributors to Apparent Intakes of Vitamin A and Iodine, but Not Iron, in Diets of Women of Reproductive Age in 4 African Countries. J Nutr 2020; 150:2183-2190. [PMID: 32534454 PMCID: PMC7398785 DOI: 10.1093/jn/nxaa167] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 04/16/2020] [Accepted: 05/19/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Food fortification is implemented to increase intakes of specific nutrients in the diet, but contributions of fortified foods to nutrient intakes are rarely quantified. OBJECTIVES We quantified iron, vitamin A, and iodine intakes from fortified staple foods and condiments among women of reproductive age (WRA). METHODS In subnational (Nigeria, South Africa) and national (Tanzania, Uganda) cross-sectional, clustered household surveys, we assessed fortifiable food consumption. We estimated daily nutrient intakes from fortified foods among WRA by multiplying the daily apparent fortifiable food consumption (by adult male equivalent method) by a fortification content for the food. Two fortification contents were used: measured, based on the median amount quantified from individual food samples collected from households; and potential, based on the targeted amount in national fortification standards. Results for both approaches are reported as percentages of the estimated average requirement (EAR) and recommended nutrient intake (RNI). RESULTS Fortified foods made modest contributions to measured iron intakes (0%-13% RNI); potential intakes if standards are met were generally higher (0%-65% RNI). Fortified foods contributed substantially to measured vitamin A and iodine intakes (20%-125% and 88%-253% EAR, respectively); potential intakes were higher (53%-655% and 115%-377% EAR, respectively) and would exceed the tolerable upper intake level among 18%-56% of WRA for vitamin A in Nigeria and 1%-8% of WRA for iodine in Nigeria, Tanzania, and Uganda. CONCLUSIONS Fortified foods are major contributors to apparent intakes of vitamin A and iodine, but not iron, among WRA. Contributions to vitamin A and iodine are observed despite fortification standards not consistently being met and, if constraints to meeting standards are addressed, there is risk of excessive intakes in some countries. For all programs assessed, nutrient intakes from all dietary sources and fortification standards should be reviewed to inform adjustments where needed to avoid risk of low or excessive intakes.
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Affiliation(s)
- Valerie M Friesen
- Global Alliance for Improved Nutrition, Geneva, Switzerland,UMR204 Nutripass, Institut de Recherche pour le Développement (IRD), IRD/Université de Montpellier/SupAgro, Montpellier, France,Address correspondence to VMF (e-mail: )
| | | | - Grant J Aaron
- Global Alliance for Improved Nutrition, Geneva, Switzerland
| | - Helena Pachón
- Rollins School of Public Health, Emory University, Atlanta, GA, USA,Food Fortification Initiative, Atlanta, GA, USA
| | | | - Ramadhani A Noor
- Africa Academy for Public Health, Dar es Salaam, Tanzania,Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Rina Swart
- Department of Dietetics and Nutrition, University of the Western Cape, Cape Town, South Africa
| | - Archileo Kaaya
- Department of Food Technology and Nutrition, College of Agricultural and Environmental Sciences, Makerere University, Kampala, Uganda
| | - Frank T Wieringa
- UMR204 Nutripass, Institut de Recherche pour le Développement (IRD), IRD/Université de Montpellier/SupAgro, Montpellier, France
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11
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Noor RA, Abioye AI, Hertzmark E, Darling AM, Aboud S, Mugusi FM, Sudfeld CR, Spiegelman D, Fawzi WW. Impaired Hematological Status Increases the Risk of Mortality among HIV-Infected Adults Initiating Antiretroviral Therapy in Tanzania. J Nutr 2020; 150:2375-2382. [PMID: 32621487 PMCID: PMC7540061 DOI: 10.1093/jn/nxaa172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 02/06/2020] [Accepted: 05/26/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Hematological status may predict HIV disease progression and mortality among adults initiating highly active antiretroviral therapy (HAART). OBJECTIVES We aimed to examine the relation of anemia and iron status at HAART initiation with survival and morbidity outcomes. METHODS We conducted a case-cohort study of 570 HIV-infected adults initiating HAART who were enrolled in a trial of multivitamins in Tanzania. Hemoglobin, serum ferritin, and hepcidin concentrations were assessed at HAART initiation and participants were followed up monthly. We adjusted serum ferritin for inflammation using a regression correction method to characterize hematological status. Cox proportional hazards models were used to estimate HRs for mortality and incident clinical outcomes. RESULTS We found an 83% prevalence of anemia, 15% prevalence of iron deficiency anemia, and 66% prevalence of anemia of chronic diseases (ACD). The prevalence of elevated iron was 33% and 19% had iron deficiency (ID). After multivariate adjustment, severe anemia (HR: 2.57; 95% CI: 1.49, 4.45) and ACD (HR: 4.71; 95% CI: 2.91, 7.62) were associated with increased risk of mortality as compared with nonanemic participants. In addition, both ID (HR: 2.65; 95% CI: 1.08, 7.78) and elevated iron (HR: 2.83; 95% CI: 2.10, 3.82) were associated with increased risk of mortality as compared with normal iron concentrations. Severe anemia and elevated iron concentrations were associated with incident wasting and >10% weight loss (P values <0.05). CONCLUSIONS Anemia and both ID and elevated iron were associated with increased mortality among HIV-infected adults initiating HAART. Safety and efficacy studies including anemia etiology, timing of HAART initiation, and dose of iron supplementation among HIV patients appear warranted.This trial was registered at clinicaltrials.gov as NCT00383669.
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Affiliation(s)
| | - Ajibola I Abioye
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Ellen Hertzmark
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Anne M Darling
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Said Aboud
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Ferdinand M Mugusi
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Christopher R Sudfeld
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA,Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Donna Spiegelman
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA,Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA,Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA,Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA, USA,Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Wafaie W Fawzi
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA,Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA,Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
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12
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Abioye AI, Aboud S, Premji Z, Etheredge AJ, Gunaratna NS, Sudfeld CR, Noor RA, Hertzmark E, Spiegelman D, Duggan C, Fawzi W. Hemoglobin and hepcidin have good validity and utility for diagnosing iron deficiency anemia among pregnant women. Eur J Clin Nutr 2020; 74:708-719. [PMID: 31624364 PMCID: PMC7162716 DOI: 10.1038/s41430-019-0512-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 09/24/2019] [Accepted: 09/27/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND/OBJECTIVES Screening and diagnosis of iron deficiency anemia (IDA) is cumbersome as it may require testing for hemoglobin, ferritin, and an inflammatory biomarker. The aim of this study was to compare the diagnostic capacity of hematologic biomarkers to detect IDA among pregnant women in Tanzania. SUBJECTS/METHODS We pooled data from an iron supplementation trial of 1500 iron-replete pregnant woman and a prospective cohort of 600 iron-deficient pregnant women. Receiver operating characteristic curves (ROC) for hematologic biomarkers were used to assess the sensitivity, specificity, and area under the curve (AUC) for iron deficiency (ID) and iron deficiency anemia (IDA), crude, or corrected for inflammation. Regression models assessed the relationship of baseline biomarker categories (gestational age <27 weeks) and IDA at delivery. RESULTS Hemoglobin had the largest AUC for crude ID (0.96), while hepcidin had the largest AUC for corrected ID (0.80). The optimal hepcidin cutoff for the diagnosis of corrected IDA based on maximal sensitivity and specificity was ≤1.6 µg/L. An hepcidin cutoff of <4.3 µg/L had a sensitivity of 95% for regression-corrected ID. Among iron-replete women who did not receive iron, the association of baseline hemoglobin >110 g/L with IDA at delivery (RR = 0.73; 95% CI: 0.47, 1.13) was attenuated. Baseline hepcidin >1.6 µg/L was associated with reduced risk of anemia at delivery by 49% (95% CI: 27%, 45%). CONCLUSIONS Ascertaining hemoglobin and hepcidin levels may improve the targeting of iron supplementation programs in resource-limited countries, though hepcidin's high costs may limit its use.
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Affiliation(s)
- Ajibola I Abioye
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Said Aboud
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Zulfiqarali Premji
- Department of Parasitology/Medical Entomology, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Analee J Etheredge
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - Christopher R Sudfeld
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ramadhani A Noor
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ellen Hertzmark
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Donna Spiegelman
- Center on Methods for Implementation and Prevention Science, Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Christopher Duggan
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Wafaie Fawzi
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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13
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Lweno ON, Sudfeld CR, Hertzmark E, Manji KP, Aboud S, Noor RA, Masanja H, Salim N, Shahab-Ferdows S, Allen LH, Fawzi WW. Vitamin B12 is Low in Milk of Early Postpartum Women in Urban Tanzania, and was not Significantly Increased by High dose Supplementation. Nutrients 2020; 12:E963. [PMID: 32244279 PMCID: PMC7230874 DOI: 10.3390/nu12040963] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 03/23/2020] [Accepted: 03/28/2020] [Indexed: 01/21/2023] Open
Abstract
The effect of maternal multivitamin supplementation on breast milk vitamin B12 concentrations has not been examined in Tanzania, where the prevalence of maternal plasma B12 insufficiency is 25.6%. Multivitamins (containing 50 µg vitamin B12) or placebo were provided during pregnancy and in the postpartum period. Breast milk samples were collected at or around six weeks postpartum from 491 participants in a trial of multivitamins (NCT00197548). Linear and logistic regression models were used to examine the effect of supplements on vitamin B12 concentration in milk and its associations with other variables including potential confounders. Median vitamin B12 concentration in breast milk was 206 pmol/L and 70% of women had levels indicating inadequacy (<310 pmol/L). Multivitamin supplements did not significantly reduce the odds of inadequate vitamin B12 in breast milk, suggesting suboptimal absorption. A single unit increase in maternal hemoglobin at six weeks was associated with 18% lower odds of inadequate vitamin B12 in breast milk. Participants with higher BMI at baseline had double the odds of having inadequate vitamin B12 than the reference group (<22 kg/m2). Trials to determine the optimal dose, route, and duration of supplementation to improve maternal B12 status in Sub-Saharan Africa are of utmost importance.
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Affiliation(s)
- Omar N. Lweno
- Ifakara Health Institute, Bagamoyo Research and Training Center, P.O. Box 74 Bagamoyo, Tanzania;
| | - Christopher R. Sudfeld
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA; (C.R.S.); (E.H.); (R.A.N.); (W.W.F.)
| | - Ellen Hertzmark
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA; (C.R.S.); (E.H.); (R.A.N.); (W.W.F.)
| | - Karim P. Manji
- Muhimbili University of Health and Allied Sciences, P.O. Box 65001 Dar-es-Salaam, Tanzania; (K.P.M.); (S.A.); (N.S.)
| | - Said Aboud
- Muhimbili University of Health and Allied Sciences, P.O. Box 65001 Dar-es-Salaam, Tanzania; (K.P.M.); (S.A.); (N.S.)
| | - Ramadhani A. Noor
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA; (C.R.S.); (E.H.); (R.A.N.); (W.W.F.)
| | - Honorati Masanja
- Ifakara Health Institute, Bagamoyo Research and Training Center, P.O. Box 74 Bagamoyo, Tanzania;
| | - Nahya Salim
- Muhimbili University of Health and Allied Sciences, P.O. Box 65001 Dar-es-Salaam, Tanzania; (K.P.M.); (S.A.); (N.S.)
| | - Setareh Shahab-Ferdows
- USDA ARS Western Human Nutrition Research Centre, University of California Davis, CA 95616, USA;
| | - Lindsay H. Allen
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, CA 95616, USA;
| | - Wafaie W. Fawzi
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA; (C.R.S.); (E.H.); (R.A.N.); (W.W.F.)
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14
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Noor RA, Abioye AI, Darling AM, Hertzmark E, Aboud S, Premji Z, Mugusi FM, Duggan C, Sudfeld CR, Spiegelman D, Fawzi W. Prenatal Zinc and Vitamin A Reduce the Benefit of Iron on Maternal Hematologic and Micronutrient Status at Delivery in Tanzania. J Nutr 2020; 150:240-248. [PMID: 31618430 PMCID: PMC7373818 DOI: 10.1093/jn/nxz242] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/28/2019] [Accepted: 09/11/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Zinc and vitamin A supplementation have both been shown to affect iron status, hemoglobin (Hb) concentration, and anemia in animal and human studies. However, evidence on their combined use in pregnancy, in the context of iron-folic acid (IFA) supplementation, remains limited. OBJECTIVE This study determined the effects of prenatal zinc, vitamin A, and iron supplementation on maternal hematologic and micronutrient status at delivery in Tanzania. METHODS We analyzed 2 large randomized controlled trials, using generalized estimating equations, and examined the effect of daily zinc (25 mg) and vitamin A (2500 IU) supplementation starting in the first trimester of pregnancy compared with placebo (n = 2500), and separately evaluated the safety and efficacy of daily iron (60 mg) supplementation among iron-replete pregnant women (n = 1500). Blood samples from baseline and delivery were tested for Hb, serum ferritin, soluble transferrin receptor, plasma zinc, and zinc protoporphyrin. RESULTS Zinc and vitamin A supplementation were associated with lower Hb concentrations at delivery of -0.26 g/dL (95% CI: -0.50, -0.02 g/dL) and -0.25 g/dL (95% CI: -0.49, -0.01 g/dL), respectively. Vitamin A increased mean ferritin concentrations at delivery (14.3 μg/L, 95% CI: 1.84, 29.11 μg/L), but was associated with increased risk of severe anemia (RR: 1.41; 95% CI: 1.06, 1.88). Among women who were iron replete at baseline, iron supplementation reduced the risk of iron depletion at delivery by 47% (RR: 0.53; 95% CI: 0.43, 0.65). There was no effect of zinc or iron supplements on plasma zinc concentrations. CONCLUSIONS Our findings support existing WHO guidelines on prenatal iron, vitamin A, and zinc supplementation among pregnant women. In this setting, scaling uptake of prenatal iron supplements is warranted, but prenatal zinc and vitamin A supplementation did not benefit maternal hematologic status at delivery. In settings where vitamin A deficiency is endemic, the efficacy and safety of the WHO recommended prenatal vitamin A supplementation require further evaluation.
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Affiliation(s)
- Ramadhani A Noor
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Ajibola I Abioye
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Anne Marie Darling
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Ellen Hertzmark
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Said Aboud
- Department of Microbiology and Immunology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Zulfiqarali Premji
- Department of Parasitology/Medical Entomology, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Ferdinand M Mugusi
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Christopher Duggan
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher R Sudfeld
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Donna Spiegelman
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Wafaie Fawzi
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
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15
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Bellows AL, Canavan CR, Blakstad MM, Mosha D, Noor RA, Webb P, Kinabo J, Masanja H, Fawzi WW. The Relationship Between Dietary Diversity Among Women of Reproductive Age and Agricultural Diversity in Rural Tanzania. Food Nutr Bull 2019; 41:50-60. [PMID: 31840547 DOI: 10.1177/0379572119892405] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Agriculture can influence diets through consumption of home-produced foods or increased purchasing power derived from sale of agricultural commodities. OBJECTIVE This article explores cross-sectional relationships between agricultural diversification and dietary diversity (a proxy for micronutrient adequacy) among women of reproductive age in rural Tanzania. METHODS Dietary diversity was measured using the women's minimum dietary diversity score indicator. Data were analyzed from the baseline survey of a cluster randomized control trial in Rufiji, Tanzania. One woman of reproductive age was randomly surveyed from each eligible household, totaling 1006 individuals. Generalized linear mixed-effects models were used to estimate the relationship between agricultural indicators and dietary diversity. RESULTS Median dietary diversity score for women was 3.00 (interquartile range: 2-3). Approximately 73% of households grew at least 1 crop in the previous year. Women's dietary diversity score was positively associated with cropping diversity (P for trend = .04), ownership of livestock (adjusted coefficient: 0.30; 95% confidence interval [CI]: 0.08-0.44; P = .005), cash crop production (adjusted coefficient: 0.22; 95% CI: 0.03-0.41; P = .02), and production of pulses (adjusted coefficient: 0.50; 95% CI: 0.27-0.74; P < .0001) and other vegetables (adjusted coefficient: 0.64; 95% CI: 0.11-1.17; P = .02). CONCLUSIONS Average dietary diversity is well below the recommended 5 food groups per day, a widely used indicator of micronutrient adequacy. Since the majority of households participate in agriculture, the efforts to promote agricultural diversification and/or specialization and sale of agricultural goods may positively influence dietary diversity and associated health and nutrition outcomes.
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Affiliation(s)
- Alexandra L Bellows
- Department of Global Health and Population, Harvard TH. Chan School of Public Health, Boston, MA, USA
| | - Chelsey R Canavan
- Department of Global Health and Population, Harvard TH. Chan School of Public Health, Boston, MA, USA
| | - Mia M Blakstad
- Department of Global Health and Population, Harvard TH. Chan School of Public Health, Boston, MA, USA
| | | | - Ramadhani A Noor
- Department of Global Health and Population, Harvard TH. Chan School of Public Health, Boston, MA, USA
| | - Patrick Webb
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Joyce Kinabo
- Department of Food Science and Technology, Sokoine University of Agriculture, Morogoro, Tanzania
| | | | - Wafaie W Fawzi
- Department of Global Health and Population, Harvard TH. Chan School of Public Health, Boston, MA, USA
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16
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Nadella P, Smith ER, Muhihi A, Noor RA, Masanja H, Fawzi WW, Sudfeld CR. Determinants of delayed or incomplete diphtheria-tetanus-pertussis vaccination in parallel urban and rural birth cohorts of 30,956 infants in Tanzania. BMC Infect Dis 2019; 19:188. [PMID: 30808282 PMCID: PMC6390320 DOI: 10.1186/s12879-019-3828-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 02/15/2019] [Indexed: 11/29/2022] Open
Abstract
Background Delayed vaccination increases the time infants are at risk for acquiring vaccine-preventable diseases. Factors associated with incomplete vaccination are relatively well characterized in resource-limited settings; however, few studies have assessed immunization timeliness. Methods We conducted a prospective cohort study examining Diphtheria-Tetanus-Pertussis (DTP) vaccination timing among newborns enrolled in a Neonatal Vitamin A supplementation trial (NEOVITA) conducted in urban Dar es Salaam (n = 11,189) and rural Morogoro Region (n = 19,767), Tanzania. We used log-binomial models to assess the relationship of demographic, socioeconomic, healthcare access, and birth characteristics with late or incomplete DTP1 and DTP3 immunization. Results The proportion of infants with either delayed or incomplete vaccination was similar in Dar es Salaam (DTP1 11.5% and DTP3 16.0%) and Morogoro (DTP1 9.2% and DTP3 17.3%); however, the determinants of delayed or incomplete vaccination as well as their magnitude of association differed by setting. Both maternal and paternal education were more strongly associated with vaccination status in rural Morogoro region as compared to Dar es Salaam (p-values for heterogeneity < 0.05). Infants in Morogoro who had fathers and mothers with no education had 36% (95% CI: 22–52%) and 22% (95% CI: 10–34%) increased risk of delayed or incomplete DTP3 vaccination as compared to those with primary school education, respectively. In Dar es Salaam, mothers who attended their first antenatal care (ANC) visit in the 3rd trimester had 1.55 (95% CI: 1.36–1.78) times the risk of delayed or not received vaccination as compared to those with a 2nd trimester booking, while there was no relationship in Morogoro. In rural Morogoro, infants born at home had 17% (95% CI: 8–27%) increased risk for delayed or no receipt of DTP3 vaccination. In both settings, younger maternal age and poorer households were at increased risk for delayed or incomplete vaccination. Conclusion We found some risk factors for delayed and incomplete vaccination were shared between urban and rural Tanzania; however, we found several context-specific risk factors as well as determinants that differed in their magnitude of risk between contexts. Immunization programs should be tailored to address context-specific barriers and enablers to improve timely and complete vaccination. Electronic supplementary material The online version of this article (10.1186/s12879-019-3828-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Emily R Smith
- Departments of Global Health and Population, Boston, MA, USA
| | - Alfa Muhihi
- Africa Academy for Public Health, Dar es Salaam, Tanzania
| | - Ramadhani A Noor
- Departments of Nutrition, Boston, MA, USA.,Africa Academy for Public Health, Dar es Salaam, Tanzania
| | | | - Wafaie W Fawzi
- Departments of Global Health and Population, Boston, MA, USA.,Departments of Nutrition, Boston, MA, USA.,Departments of Epidemiology, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA
| | - Christopher R Sudfeld
- Departments of Global Health and Population, Boston, MA, USA. .,Departments of Nutrition, Boston, MA, USA.
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17
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Noor RA, Abioye AI, Ulenga N, Msham S, Kaishozi G, Gunaratna NS, Mwiru R, Smith E, Dhillon CN, Spiegelman D, Fawzi W. Large -scale wheat flour folic acid fortification program increases plasma folate levels among women of reproductive age in urban Tanzania. PLoS One 2017; 12:e0182099. [PMID: 28797054 PMCID: PMC5552223 DOI: 10.1371/journal.pone.0182099] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 07/12/2017] [Indexed: 12/26/2022] Open
Abstract
There is widespread vitamin and mineral deficiency problem in Tanzania with known deficiencies of at least vitamin A, iron, folate and zinc, resulting in lasting negative consequences especially on maternal health, cognitive development and thus the nation's economic potential. Folate deficiency is associated with significant adverse health effects among women of reproductive age, including a higher risk of neural tube defects. Several countries, including Tanzania, have implemented mandatory fortification of wheat and maize flour but evidence on the effectiveness of these programs in developing countries remains limited. We evaluated the effectiveness of Tanzania's food fortification program by examining folate levels for women of reproductive age, 18-49 years. A prospective cohort study with 600 non-pregnant women enrolled concurrent with the initiation of food fortification and followed up for 1 year thereafter. Blood samples, dietary intake and fortified foods consumption data were collected at baseline, and at 6 and 12 months. Plasma folate levels were determined using a competitive assay with folate binding protein. Using univariate and multivariate linear regression, we compared the change in plasma folate levels at six and twelve months of the program from baseline. We also assessed the relative risk of folate deficiency during follow-up using log-binomial regression. The mean (±SE) pre-fortification plasma folate level for the women was 5.44-ng/ml (±2.30) at baseline. These levels improved significantly at six months [difference: 4.57ng/ml (±2.89)] and 12 months [difference: 4.27ng/ml (±4.18)]. Based on plasma folate cut-off level of 4 ng/ml, the prevalence of folate deficiency was 26.9% at baseline, and 5% at twelve months. One ng/ml increase in plasma folate from baseline was associated with a 25% decreased risk of folate deficiency at 12 months [(RR = 0.75; 95% CI = 0.67-0.85, P<0.001]. In a setting where folate deficiency is high, food fortification program with folic acid resulted in significant improvements in folate status among women of reproductive age.
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Affiliation(s)
- Ramadhani A. Noor
- Africa Academy for Public Health (AAPH), Dar es Salaam, Tanzania
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Ajibola I. Abioye
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Nzovu Ulenga
- Africa Academy for Public Health (AAPH), Dar es Salaam, Tanzania
- Management Development for Health (MDH), Dar es Salaam, Tanzania
| | - Salum Msham
- Africa Academy for Public Health (AAPH), Dar es Salaam, Tanzania
| | | | - Nilupa S Gunaratna
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Ramadhani Mwiru
- Africa Academy for Public Health (AAPH), Dar es Salaam, Tanzania
| | - Erin Smith
- Helen Keller International, Dar es Salaam, Tanzania
| | | | - Donna Spiegelman
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Wafaie Fawzi
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
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18
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Canavan CR, Noor RA, Golden CD, Juma C, Fawzi W. Sustainable food systems for optimal planetary health. Trans R Soc Trop Med Hyg 2017; 111:238-240. [PMID: 29044366 PMCID: PMC5914329 DOI: 10.1093/trstmh/trx038] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 05/04/2017] [Accepted: 09/01/2017] [Indexed: 11/12/2022] Open
Abstract
Sustainable food systems are an important component of a planetary health strategy to reduce the threat of infectious disease, minimize environmental footprint and promote nutrition. Human population trends and dietary transition have led to growing demand for food and increasing production and consumption of meat, amid declining availability of arable land and water. The intensification of livestock production has serious environmental and infectious disease impacts. Land clearing for agriculture alters ecosystems, increases human-wildlife interactions and leads to disease proliferation. Context-specific interventions should be evaluated towards optimizing nutrition resilience, minimizing environmental footprint and reducing animal and human disease risk.
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Affiliation(s)
- Chelsey R Canavan
- Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA
- Department of Global Health and Population
| | - Ramadhani A Noor
- Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA
- Department of Nutrition
| | - Christopher D Golden
- Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA
- Department of Environmental Health
- Harvard University Center for the Environment, Cambridge, MA, 02138, USA
| | - Calestous Juma
- Harvard Kennedy School, Cambridge, MA, 02138, USA
- Belfer Center for Science and International Affairs
| | - Wafaie Fawzi
- Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA
- Department of Global Health and Population
- Department of Nutrition
- Department of Epidemiology
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19
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Geldsetzer P, Francis JM, Ulenga N, Sando D, Lema IA, Mboggo E, Vaikath M, Koda H, Lwezaula S, Hu J, Noor RA, Olofin I, Larson E, Fawzi W, Bärnighausen T. The impact of community health worker-led home delivery of antiretroviral therapy on virological suppression: a non-inferiority cluster-randomized health systems trial in Dar es Salaam, Tanzania. BMC Health Serv Res 2017; 17:160. [PMID: 28228134 PMCID: PMC5322683 DOI: 10.1186/s12913-017-2032-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 01/17/2017] [Indexed: 11/18/2022] Open
Abstract
Background Home delivery of antiretroviral therapy (ART) by community health workers (CHWs) may improve ART retention by reducing the time burden and out-of-pocket expenditures to regularly attend an ART clinic. In addition, ART home delivery may shorten waiting times and improve quality of care for those in facility-based care by decongesting ART clinics. This trial aims to determine whether ART home delivery for patients who are clinically stable on ART combined with facility-based care for those who are not stable on ART is non-inferior to the standard of care (facility-based care for all ART patients) in achieving and maintaining virological suppression. Methods This is a non-inferiority cluster-randomized trial set in Dar es Salaam, Tanzania. A cluster is one of 48 healthcare facilities with its surrounding catchment area. 24 clusters were randomized to ART home delivery and 24 to the standard of care. The intervention consists of home visits by CHWs to provide counseling and deliver ART to patients who are stable on ART, while the control is the standard of care (facility-based ART and CHW home visits without ART home delivery). In addition, half of the healthcare facilities in each study arm were randomized to standard counseling during home visits (covering family planning, prevention of HIV transmission, and ART adherence), and half to standard plus nutrition counseling (covering food production and dietary advice). The non-inferiority design applies to the endpoints of the ART home delivery trial; the primary endpoint is the proportion of ART patients at a healthcare facility who are virally suppressed at the end of the study period. The margin of non-inferiority for this primary endpoint was set at nine percentage points. Discussion As the number of ART patients in sub-Saharan Africa is expected to rise, this trial provides causal evidence on the effectiveness of a home-based care model that could decongest ART clinics and reduce patients’ healthcare expenditures. More broadly, this trial will inform the increasing policy interest in task-shifting of chronic disease care from facility- to community-based healthcare workers. Trial registration ClinicalTrials.gov: NCT02711293. Registration date: 16 March 2016. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2032-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Pascal Geldsetzer
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA
| | - Joel M Francis
- Management and Development for Health, Plot #802, Mwai Kibaki Road, Mikocheni, Dar es Salaam, Tanzania. .,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA. .,National Institute for Medical Research, 3 Barack Obama Drive, 11101, Dar es Salaam, Tanzania.
| | - Nzovu Ulenga
- Management and Development for Health, Plot #802, Mwai Kibaki Road, Mikocheni, Dar es Salaam, Tanzania
| | - David Sando
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA
| | - Irene A Lema
- Management and Development for Health, Plot #802, Mwai Kibaki Road, Mikocheni, Dar es Salaam, Tanzania
| | - Eric Mboggo
- Management and Development for Health, Plot #802, Mwai Kibaki Road, Mikocheni, Dar es Salaam, Tanzania
| | - Maria Vaikath
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA
| | - Happiness Koda
- Management and Development for Health, Plot #802, Mwai Kibaki Road, Mikocheni, Dar es Salaam, Tanzania
| | - Sharon Lwezaula
- National AIDS Control Program, Lithuli Street, P.O. Box 11857, Dar es Salaam, Tanzania
| | - Janice Hu
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA.,Duke University School of Medicine, Duke University, 8 Duke University Medical Center Greenspace, Durham, NC, 27703, USA
| | - Ramadhani A Noor
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA.,Department of Nutrition, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA.,Africa Academy for Public Health (AAPH), Plot #802, Mwai Kibaki Road, Dar es Salaam, Tanzania
| | - Ibironke Olofin
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA
| | - Elysia Larson
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA
| | - Wafaie Fawzi
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA.,Department of Nutrition, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA
| | - Till Bärnighausen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA.,Institute for Public Health, Faculty of Medicine, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany.,Africa Health Research Institute, Mtubatuba 3935, KwaZulu-Natal, South Africa
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20
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Noor RA, Geldsetzer P, Bärnighausen T, Fawzi W. Do countries rely on the World Health Organization for translating research findings into clinical guidelines? A case study. Global Health 2016; 12:58. [PMID: 27716252 PMCID: PMC5053105 DOI: 10.1186/s12992-016-0196-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 09/09/2016] [Indexed: 01/01/2023] Open
Abstract
Background The World Health Organization’s (WHO) antiretroviral therapy (ART) guidelines have generally been adopted rapidly and with high fidelity by countries in sub-Saharan Africa. Thus far, however, WHO has not published specific guidance on nutritional care and support for (non-pregnant) adults living with HIV despite a solid evidence base for some interventions. This offers an opportunity for a case study on whether national clinical guidelines in sub-Saharan Africa provide concrete recommendations in the face of limited guidance by WHO. This study, therefore, aims to determine if national HIV treatment guidelines in sub-Saharan Africa contain specific guidance on nutritional care and support for non-pregnant adults living with HIV. Methods We identified the most recent national HIV treatment guidelines in sub-Saharan African countries with English as an official language. Using pre-specified criteria, we determined for each guideline whether it provides guidance to clinicians on each of five components of nutritional care and support for adults living with HIV: assessment of nutritional status, dietary counseling, micronutrient supplementation, ready-to-use therapeutic or supplementary foods, and food subsidies. Results We found that national HIV treatment guidelines in sub-Saharan Africa generally do not contain concrete recommendations on nutritional care and support for non-pregnant adults living with HIV. Conclusions Given that decisions on nutritional care and support are inevitably being made at the clinician-patient level, and that clinicians have a relative disadvantage in systematically identifying, summarizing, and weighing up research evidence compared to WHO and national governments, there is a need for more specific clinical guidance. In our view, such guidance should at a minimum recommend daily micronutrient supplements for adults living with HIV who are in pre-ART stages, regular dietary counseling, periodic assessment of anthropometric status, and additional nutritional management of undernourished patients. More broadly, our findings suggest that countries in sub-Saharan Africa look to WHO for guidance in translating evidence into clinical guidelines. It is, thus, likely that the development of concrete recommendations by WHO on nutritional interventions for people living with HIV would lead to more specific guidelines at the country-level and, ultimately, better clinical decisions and treatment outcomes.
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Affiliation(s)
- Ramadhani A Noor
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA02115, USA.,Department of Nutrition, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA02115, USA.,Africa Academy for Public Health (AAPH), Plot #802, Mwai Kibaki Road, Dar es Salaam, Tanzania
| | - Pascal Geldsetzer
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA02115, USA.
| | - Till Bärnighausen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA02115, USA.,Africa Health Research Institute, Mtubatuba, 3935, South Africa.,Institute of Public Health, Heidelberg University, 69120, Heidelberg, Germany
| | - Wafaie Fawzi
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA02115, USA.,Department of Nutrition, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA02115, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA02115, USA
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21
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Abioye AI, Aboud S, Premji Z, Etheredge AJ, Gunaratna NS, Sudfeld CR, Mongi R, Meloney L, Darling AM, Noor RA, Spiegelman D, Duggan C, Fawzi W. Iron Supplementation Affects Hematologic Biomarker Concentrations and Pregnancy Outcomes among Iron-Deficient Tanzanian Women. J Nutr 2016; 146:1162-71. [PMID: 27121530 PMCID: PMC4877628 DOI: 10.3945/jn.115.225482] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 03/15/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Iron deficiency is a highly prevalent micronutrient abnormality and the most common cause of anemia globally, worsening the burden of adverse pregnancy and child outcomes. OBJECTIVE We sought to evaluate the response of hematologic biomarkers to iron supplementation and to examine the predictors of the response to iron supplementation among iron-deficient pregnant women. METHODS We identified 600 iron-deficient (serum ferritin ≤12 μg/L) pregnant women, aged 18-45 y, presenting to 2 antenatal clinics in Dar es Salaam, Tanzania using rapid ferritin screening tests, and prospectively followed them through delivery and postpartum. All women received 60 mg Fe and 0.25 mg folate daily from enrollment until delivery. Proportions meeting the thresholds representing deficient hematologic status including hemoglobin <110 g/L, ferritin ≤12 μg/L, serum soluble transferrin receptor (sTfR) >4.4 mg/L, zinc protoporphyrin (ZPP) >70 mmol/L, or hepcidin ≤13.3 μg/L at baseline and delivery were assessed. The prospective change in biomarker concentration and the influence of baseline hematologic status on the change in biomarker concentrations were assessed. Regression models were estimated to assess the relation of change in biomarker concentrations and pregnancy outcomes. RESULTS There was significant improvement in maternal biomarker concentrations between baseline and delivery, with increases in the concentrations of hemoglobin (mean difference: 15.2 g/L; 95% CI: 13.2, 17.2 g/L), serum ferritin (51.6 μg/L; 95% CI: 49.5, 58.8 μg/L), and serum hepcidin (14.0 μg/L; 95% CI: 12.4, 15.6 μg/L) and decreases in sTfR (-1.7 mg/L; 95% CI: -2.0, -1.3 mg/L) and ZPP (-17.8 mmol/L; 95% CI: -32.1, 3.5 mmol/L). The proportions of participants with low hemoglobin, ferritin, and hepcidin were 73%, 93%, and 99%, respectively, at baseline and 34%, 12%, and 46%, respectively, at delivery. The improvements in biomarker concentrations were significantly greater among participants with poor hematologic status at baseline - up to 12.1 g/L and 14.5 μg/L for hemoglobin and ferritin concentrations, respectively. For every 10-g/L increase in hemoglobin concentration, there was a 24% reduced risk of perinatal mortality (RR = 0.76; 95% CI: 0.59, 0.99) and a 23% reduced risk of early infant mortality (RR = 0.77; 95% CI: 0.60, 0.99). The risk of anemia at delivery despite supplementation was predicted by baseline anemia (RR = 2.11; 95% CI: 1.39, 3.18) and improvements in ferritin concentration were more likely to be observed in participants who took iron supplements for up to 90 d (RR = 1.41; 95% CI: 1.13, 1.76). CONCLUSION Iron supplementation decreases the risk of maternal anemia and increases the likelihood of infant survival among iron-deficient Tanzanian pregnant women. Interventions to promote increased duration and adherence to iron supplements may also provide greater health benefits.
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Affiliation(s)
| | - Said Aboud
- Departments of Microbiology and Immunology and
| | - Zulfiqar Premji
- Parasitology/Medical Entomology, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; and
| | - Analee J Etheredge
- Departments of Global Health and Population,,Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | | | | | - Robert Mongi
- Parasitology/Medical Entomology, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; and
| | | | | | | | - Donna Spiegelman
- Nutrition,,Epidemiology, and,Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Christopher Duggan
- Departments of Global Health and Population,,Nutrition,,Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Wafaie Fawzi
- Departments of Global Health and Population,,Nutrition,,Epidemiology, and
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22
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Muhihi A, Sudfeld CR, Smith ER, Noor RA, Mshamu S, Briegleb C, Bakari M, Masanja H, Fawzi W, Chan GJY. Risk factors for small-for-gestational-age and preterm births among 19,269 Tanzanian newborns. BMC Pregnancy Childbirth 2016; 16:110. [PMID: 27183837 PMCID: PMC4869183 DOI: 10.1186/s12884-016-0900-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 05/07/2016] [Indexed: 11/11/2022] Open
Abstract
Background Few studies have differentiated risk factors for term-small for gestational age (SGA), preterm-appropriate for gestational age (AGA), and preterm-SGA, despite evidence of varying risk of child mortality and poor developmental outcomes. Methods We analyzed birth outcome data from singleton infants, who were enrolled in a large randomized, double-blind, placebo-controlled trial of neonatal vitamin A supplementation conducted in Tanzania. SGA was defined as birth weight <10th percentile for gestation age and sex using INTERGROWTH standards and preterm birth as delivery at <37 complete weeks of gestation. Risk factors for term-SGA, preterm-AGA, and preterm-SGA were examined independently using log-binomial regression. Results Among 19,269 singleton Tanzanian newborns included in this analysis, 68.3 % were term-AGA, 15.8 % term-SGA, 15.5 % preterm-AGA, and 0.3 % preterm-SGA. In multivariate analyses, significant risk factors for term-SGA included maternal age <20 years, starting antenatal care (ANC) in the 3rd trimester, short maternal stature, being firstborn, and male sex (all p < 0.05). Independent risk factors for preterm-AGA were maternal age <25 years, short maternal stature, firstborns, and decreased wealth (all p < 0.05). In addition, receiving ANC services in the 1st trimester significantly reduced the risk of preterm-AGA (p = 0.01). Significant risk factors for preterm-SGA included maternal age >30 years, being firstborn, and short maternal stature which appeared to carry a particularly strong risk (all p < 0.05). Conclusion Over 30 % of newborns in this large urban and rural cohort of Tanzanian newborns were born preterm and/or SGA. Interventions to promote early attendance to ANC services, reduce unintended young pregnancies, increased maternal height, and reduce poverty may significantly decrease the burden of SGA and preterm birth in sub-Saharan Africa. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR) – ACTRN12610000636055, registered on 3rd August 2010.
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Affiliation(s)
- Alfa Muhihi
- Ifakara Health Institute, Kiko Avenue, Mikocheni, Dar es Salaam, Tanzania. .,Africa Academy for Public Health, CM Plaza Building, Mwai Kibaki Road, Mikocheni, P.O.Box 79810, Dar es Salaam, Tanzania.
| | - Christopher R Sudfeld
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, USA
| | - Emily R Smith
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, USA
| | - Ramadhani A Noor
- Africa Academy for Public Health, CM Plaza Building, Mwai Kibaki Road, Mikocheni, P.O.Box 79810, Dar es Salaam, Tanzania.,Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, USA
| | - Salum Mshamu
- Africa Academy for Public Health, CM Plaza Building, Mwai Kibaki Road, Mikocheni, P.O.Box 79810, Dar es Salaam, Tanzania
| | - Christina Briegleb
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, USA
| | - Mohamed Bakari
- Africa Academy for Public Health, CM Plaza Building, Mwai Kibaki Road, Mikocheni, P.O.Box 79810, Dar es Salaam, Tanzania
| | - Honorati Masanja
- Ifakara Health Institute, Kiko Avenue, Mikocheni, Dar es Salaam, Tanzania
| | - Wafaie Fawzi
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, USA.,Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, USA.,Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, USA
| | - Grace Jean-Yee Chan
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, USA.,Department of Medicine, Boston Children's Hospital, Boston, USA
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23
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Abioye AI, Isanaka S, Liu E, Mwiru RS, Noor RA, Spiegelman D, Mugusi F, Fawzi W. Gender differences in diet and nutrition among adults initiating antiretroviral therapy in Dar es Salaam, Tanzania. AIDS Care 2015; 27:706-15. [PMID: 25562355 DOI: 10.1080/09540121.2014.996517] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Human immunodeficiency virus (HIV)-infected males have poor treatment outcomes after initiation of antiretroviral therapy (ART) compared to HIV-infected women. Dietary factors might mediate the association between sex and disease progression. However, the gender difference in diet among HIV-infected individuals in sub-Saharan Africa is largely unknown. The objective of this study was to examine differences in dietary intake among HIV-infected men and women. We conducted a cross-sectional analysis of dietary questionnaire data from 2038 adults initiating ART in Dar es Salaam, Tanzania to assess whether nutrient adequacy differed by sex. We dichotomized participants' nutrient intakes by whether recommended dietary allowances (RDAs) were met and estimated the relative risk (RR) of meeting RDAs in males using binomial regression models. We also estimated the mean difference in intake of foods and food groups by gender. We found poorer dietary practices among men compared to women. Males were less likely to meet the RDAs for micronutrients critical for slowing disease progression among HIV patients: niacin (RR = 0.39, 95% confidence interval [CI]: 0.27 to 0.55), riboflavin (RR = 0.81, 95% CI: 0.73 to 0.91), vitamin C (RR = 0.94, 95% CI: 0.89 to 1.00), and zinc (RR = 0.06, 95% CI: 0.01 to 0.24). Intake of thiamine, pantothenate, vitamins B6, B12, and E did not vary by gender. Males were less likely to eat cereals (mean difference [servings per day] = -0.21, 95% CI: -0.44 to 0.001) and vegetables (mean difference = -0.47, 95% CI: -0.86 to -0.07) in their diet, but more likely to have meat (mean difference = 0.14, 95% CI: 0.06 to 0.21). We conclude that male HIV patients have poorer dietary practices than females, and this may contribute to faster progression of the disease in males.
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Affiliation(s)
- Ajibola I Abioye
- a Department of Global Health and Population , Harvard School of Public Health , Boston , MA , USA
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Tinto H, Noor RA, Wanga CL, Valea I, Mbaye MN, D'Alessandro U, Ravinetto RM. Good clinical practice in resource-limited settings: translating theory into practice. Am J Trop Med Hyg 2013; 88:608-13. [PMID: 23553224 PMCID: PMC3617841 DOI: 10.4269/ajtmh.12-0330] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Accepted: 12/18/2012] [Indexed: 11/07/2022] Open
Abstract
A Good Clinical Practices (GCPs) course, based on the combination of theoretical modules with a practical training in real-life conditions, was held in 2010 in Burkina Faso. It was attended by 15 trainees from nine African, Asian, and Latin American countries. There were some discrepancies between the average good results at the end of the theoretical phase and the GCP application during the first days of the practical phase, underlying the difficulties of translating theoretical knowledge into good practices. Most of the findings were not unexpected and reflected the challenges commonly faced by clinical investigators in resource-poor contexts (i.e., the high workload at peripheral health facilities, the need to conciliate routine clinical activities with clinical research, and the risk of creating a double standard among patients attending the same health facility [free care for recruited patients versus user fees for non-recruited patients with the same medical condition]). Even if limited in number and time, these observations suggest that a theoretical training alone may not be sufficient to prepare trainees for the challenges of medical research in real-life settings. Conversely, when a practical phase immediately follows a theoretical one, trainees can immediately experience what the research methodology implicates in terms of work organization and relationship with recruited and non-recruited patients. This initial experience shows the complexity of translating GCP into practice and suggests the need to rethink the current conception of GCP training.
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Affiliation(s)
- Halidou Tinto
- Institut de Recherche en Sciences de la Santé, Direction Régionale de l'Ouest (IRSS)/Centre Muraz, Bobo-Dioulasso, Burkina Faso.
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Bélard S, Issifou S, Hounkpatin AB, Schaumburg F, Ngoa UA, Esen M, Fendel R, de Salazar PM, Mürbeth RE, Milligan P, Imbault N, Imoukhuede EB, Theisen M, Jepsen S, Noor RA, Okech B, Kremsner PG, Mordmüller B. A randomized controlled phase Ib trial of the malaria vaccine candidate GMZ2 in African children. PLoS One 2011; 6:e22525. [PMID: 21829466 PMCID: PMC3145647 DOI: 10.1371/journal.pone.0022525] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Accepted: 06/23/2011] [Indexed: 12/04/2022] Open
Abstract
Background GMZ2 is a fusion protein of Plasmodium falciparum merozoite surface protein 3 (MSP3) and glutamate rich protein (GLURP) that mediates an immune response against the blood stage of the parasite. Two previous phase I clinical trials, one in naïve European adults and one in malaria-exposed Gabonese adults showed that GMZ2 was well tolerated and immunogenic. Here, we present data on safety and immunogenicity of GMZ2 in one to five year old Gabonese children, a target population for future malaria vaccine efficacy trials. Methodology/Principal Findings Thirty children one to five years of age were randomized to receive three doses of either 30 µg or 100 µg of GMZ2, or rabies vaccine. GMZ2, adjuvanted in aluminum hydroxide, was administered on Days 0, 28 and 56. All participants received a full course of their respective vaccination and were followed up for one year. Both 30 µg and 100 µg GMZ2 vaccine doses were well tolerated and induced antibodies and memory B-cells against GMZ2 as well as its antigenic constituents MSP3 and GLURP. After three doses of vaccine, the geometric mean concentration of antibodies to GMZ2 was 19-fold (95%CI: 11,34) higher in the 30 µg GMZ2 group than in the rabies vaccine controls, and 16-fold (7,36) higher in the 100 µg GMZ2 group than the rabies group. Geometric mean concentration of antibodies to MSP3 was 2.7-fold (1.6,4.6) higher in the 30 µg group than in the rabies group and 3.8-fold (1.5,9.6) higher in the 100 µg group. Memory B-cells against GMZ2 developed in both GMZ2 vaccinated groups. Conclusions/Significance Both 30 µg as well as 100 µg intramuscular GMZ2 are immunogenic, well tolerated, and safe in young, malaria-exposed Gabonese children. This result confirms previous findings in naïve and malaria-exposed adults and supports further clinical development of GMZ2. Trial Registration ClinicalTrials.gov NCT00703066
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Affiliation(s)
- Sabine Bélard
- Medical Research Unit, Albert Schweitzer Hospital, Lambaréné, Gabon
| | - Saadou Issifou
- Medical Research Unit, Albert Schweitzer Hospital, Lambaréné, Gabon
| | | | | | | | - Meral Esen
- Medical Research Unit, Albert Schweitzer Hospital, Lambaréné, Gabon
- Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany
| | - Rolf Fendel
- Medical Research Unit, Albert Schweitzer Hospital, Lambaréné, Gabon
- Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany
| | | | | | - Paul Milligan
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Nathalie Imbault
- European Malaria Vaccine Initiative, Statens Serum Institut, Copenhagen, Denmark
| | | | - Michael Theisen
- Department of Clinical Biochemistry and Immunology, Statens Serum Institut and Centre for Medical Parasitology at the Department of International Health, Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Brenda Okech
- African Malaria Network Trust, Dar es Salaam, Tanzania
| | - Peter G. Kremsner
- Medical Research Unit, Albert Schweitzer Hospital, Lambaréné, Gabon
- Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany
| | - Benjamin Mordmüller
- Medical Research Unit, Albert Schweitzer Hospital, Lambaréné, Gabon
- Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany
- * E-mail:
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Noor RA, Thiesen M, Mordmuller B, Milligan P, Atuguba F, Sirima S, Issifou S, Bojang K, Kironde F, Tiono A, Okech B, Chilengi R, Ngoa A, Mukasa K, Jepsen S. Design of a Phase IIb, randomized, controlled, double-blind, multi-centre study to evaluate the efficacy, safety, and immunogenicity of the GMZ2 candidate malaria vaccine in Ugandan, Ghanaian, Burkinabe and Gabonese children aged 12-60 months. Malar J 2010. [PMCID: PMC2963266 DOI: 10.1186/1475-2875-9-s2-p26] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Lang T, Chilengi R, Noor RA, Ogutu B, Todd JE, Kilama WL, Targett GA. Data safety and monitoring boards for African clinical trials. Trans R Soc Trop Med Hyg 2008; 102:1189-94. [DOI: 10.1016/j.trstmh.2008.06.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2008] [Revised: 06/12/2008] [Accepted: 06/12/2008] [Indexed: 11/16/2022] Open
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