Effectiveness and Implementation of a Text Messaging mHealth Intervention to Prevent Childhood Obesity in Mexico in the COVID-19 Context: Mixed Methods Study

BACKGROUND

Promoting physical activity (PA) and healthy feeding (HF) is crucial to address the alarming increase in obesity rates in developing countries. Leveraging mobile phones for behavior change communication to encourage infant PA and promote HF is particularly significant within the Mexican context.

OBJECTIVE

This study aims to explore the effectiveness and feasibility of mHealth interventions aimed at promoting PA and HF among primary caregivers (PCs) of Mexican children under the age of 5 years. Additionally, the study aims to disseminate insights gained from intervention implementation amidst the COVID-19 pandemic and assess the potential of behavior change mHealth interventions on a broader population scale.

METHODS

NUTRES, an mHealth intervention, underwent an effectiveness-implementation hybrid trial. Over 36 weeks, participants in the intervention group (IG), totaling 230 individuals, received approximately 108 SMS text messages tailored to their children's age. These messages covered topics such as PA and HF and emphasized the significance of proper child nutrition amidst the COVID-19 pandemic. NUTRES participants were recruited from both urban and rural health units across 2 states in Mexico. Given the COVID-19 context, both baseline and follow-up surveys were conducted via mobile or fixed telephone. The evaluation of effectiveness and implementation used a mixed methods approach. Qualitative analysis delved into participants' experiences with NUTRES and various implementation indicators, including acceptance, relevance, and coverage. Grounded theory was used for coding and analysis. Furthermore, difference-in-differences regression models were used to discern disparities between groups (comparison group [CG] versus IG) concerning knowledge and practices pertaining to infant PA and HF.

RESULTS

Of the total 494 PCs enrolled in NUTRES, 334 persisted until the end of the study, accounting for 67.6% (334/494) participation across both groups. A majority of PCs (43/141, 30.5%, always; and 97/141, 68.8%, sometimes) used the SMS text message information. Satisfaction and acceptability toward NUTRES were notably high, reaching 98% (96/98), with respondents expressing that NUTRES was "good," "useful," and "helpful" for enhancing child nutrition. Significant differences after the intervention were observed in PA knowledge, with social interaction favored (CG: 8/135, 5.9% vs IG: 20/137, 14.6%; P=.048), as well as in HF practice knowledge. Notably, sweetened beverage consumption, associated with the development of chronic diseases, showed divergence (CG: 92/157, 58.6% vs IG: 110/145, 75.9%; P=.003). In the difference-in-differences model, a notable increase of 0.03 in knowledge regarding the benefits of PA was observed (CG: mean 0.13, SD 0.10 vs IG: mean 0.16, SD 0.11; P=.02). PCs expressed feeling accompanied and supported, particularly amidst the disruption of routine health care services during the COVID-19 pandemic.

CONCLUSIONS

While NUTRES exhibited a restricted impact on targeted knowledge and behaviors, the SMS text messages functioned effectively as both a reminder and a source of new knowledge for PCs of Mexican children under 5 years of age. The key lessons learned were as follows: mHealth intervention strategies can effectively maintain communication with individuals during emergencies, such as the COVID-19 pandemic; methodological and implementation barriers can constrain the effectiveness of mHealth interventions; and using mixed methods approaches ensures the complementary nature of results. The findings contribute valuable evidence regarding the opportunities and constraints associated with using mobile phones to enhance knowledge and practices concerning PA and HF among PCs of children under 5 years old.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04250896; https://clinicaltrials.gov/ct2/show/NCT04250896.

Healthy lifestyle interventions within the curriculum in school-age children: systematic review and meta-analysis

Childhood obesity is a major public health challenge. Previous research has identified the impact of school-based interventions for preventing and treating obesity; we hypothesized that when curricular changes are integrated, results could be exponentiated. This study aimed to systematically review and conduct a meta-analysis of the published literature analyzing information about school-based interventions inserted in the curriculum. The Cochrane Handbook methodology was followed. An electronic search was conducted in five databases, with a specific design strategy per database. Randomized controlled trials or quasi-experimental studies of children with nutrition and physical activity (PA) interventions inserted into the school curricula were included. The risk of bias was assessed with the Risk of Bias tool. The mean differences were pooled using a fixed-effects model for the meta-analysis. The certainty of the evidence was evaluated according to the guidelines of the Grading of the Recommendations, Assessment, Development, and Evaluations working group (Protocol ID: CRD42021270557). After the screening and selection process, 12 studies were included. The interventions identified, based on the school curricula, include classroom activities and homework, among others. A meta-analysis with five intervention groups presented an overall mean difference of -0.14 body mass index (BMI) Z-score (95% CI: -0.25, -0.03) after this intervention with high certainty of the evidence. This systematic review and meta-analysis suggest that nutrition and PA lessons inserted into the curricula and supported with additional activities (i.e. homework, workshops, etc.) could increase nutrition knowledge and improve attitudes toward fruit, vegetables, and water consumption, and BMI Z-score reduction.

Overview of Systematic Reviews of Health Interventions for the Prevention and Treatment of Overweight and Obesity in Children

(1) Background: The importance of studying the health interventions used to prevent and treat overweight and obesity in school-aged children is imperative. This overview aimed to summarize systematic reviews that assess the effects of school-based, family, and mixed health interventions for preventing and treating overweight and obesity in school-aged children. (2) Methods: The Cochrane Collaboration methodology and PRISMA statement were followed. A search was conducted using terms adapted to 12 databases. Systematic reviews reporting interventions in children from six to 12 years old with an outcome related to preventing or treating obesity and overweight were included. Studies with pharmacological or surgical interventions and adolescents were excluded. (3) Results: A total of 15,226 registers were identified from databases and citation searching. Of those, ten systematic reviews published between 2013 and 2022 were included. After the overlap, 331 interventions for children between 6 and 12 years old were identified, and 61.6% involved physical activity and nutrition/diet intervention. Multicomponent intervention, combining physical activity with nutrition and behavioral change, school-based plus community-based interventions may be more effective in reducing overweight and obesity in children. (4) Conclusions: Plenty of interventions for childhood overweight and obesity aimed at prevention and treatment were identified, but there is a gap in the methodological quality preventing the establishment of a certain recommendation.

Digital marketing of formula and baby food negatively influences breast feeding and complementary feeding: a cross-sectional study and video recording of parental exposure in Mexico

Background

Objective

Methods

Results

Conclusions

Alternative caregivers` role in food choices for young children in semi-urban and urban Mexico

Alternative caregivers (i.e., someone besides the primary caregiver who also takes care of children) make food choices for children. This study investigated what alternative caregivers consider when making food choices for children and their perspectives on their role in making food choices to feed children. In-depth interviews were conducted with 16 alternative caregivers of children aged 1-5 years old in semi-urban and urban areas of the State of Mexico in Mexico. Interviews were recorded, transcribed, coded, and analyzed using constant comparative method. Alternative caregivers described spaces and situations that exposed children to food while under their care. Alternative caregivers who spent longer periods of time with the child described more involvement in what the child ate. Healthy or nutritious food, cost of food and affection for children were important considerations for alternative caregivers when deciding what to feed the child. Alternative caregivers had a substantial role in child feeding, decisions about cooking, and advising mothers on how to feed their children. Efforts to promote healthy food choices for children should include targeting of alternative caregivers.

Physical Activity in Mexican High Schools

BACKGROUND

We evaluated the association between availability of specific physical activity (PA) spaces and PA practices among adolescents within Mexican high schools (HS).

METHODS

Data were collected through an online survey applied to principals or person in charge of 4023 Mexican HS during the 2015-2016 school year. Adequate PA was defined as moderate to vigorous intensity PA for ≥60 minutes/day, ≥5 days/week, whereas PA-specific spaces were considered those that were available and specifically designed/used for PA. HS demographic factors were explored as covariates. Associations were estimated using a logistic regression model.

RESULTS

From total participating HS, 83.10% had at least 1 PA-specific space and 31.07% had adequate PA practices. A higher number of PA-specific spaces was associated with greater adequate PA practices (33% to 61%). Possibilities for adequate PA increased when: physical education (PE) classes were led by a designated PE teacher (OR 2.39; 95%CI: 2.03-2.83); the number of enrolled students was higher (OR 1.78; 95%CI, 1.43-2.22 and OR 2.23; 95% CI, 1.71-2.89, second and third tertile, respectively); HS financing sources were autonomous or private (OR 1.76; 95% CI, 1.19-2.60); and HS were located in northern Mexico (OR 1.27; 95%CI, 1.02-1.57).

CONCLUSION

PA-specific spaces, designated PE teachers, and financing sources are important factors in achieving adequate PA within Mexican high schools.

Factors Associated With Dietary Quality During Initial and Later Stages of the COVID-19 Pandemic in Mexico

Background: The COVID-19 pandemic disrupted the global economy and modified lifestyles. The aim of our study was to identify factors associated with dietary quality, and their frequency, in Mexican adults at the initial and later stages of the pandemic.

Methods: Two online surveys were conducted between June and July 2020 (n = 3,131) and between November and December 2020 (n = 1,703 including non-participants from 1st round). A diet quality score was estimated using a short instrument to measure the consumption of several healthy/unhealthy food items. Linear regression models were used to identify the association between pandemic related factors and the diet quality score, adjusted by sociodemographic characteristics. The 2nd round was weighted to represent the 1st round.

Results: During the 1st and 2nd rounds only ~12% of the sample perceived that their intake of healthy food decreased, relative to before the pandemic; ~20% perceived that their intake of unhealthy foods increased. Diet quality remained similar between the 1st and 2nd round. The following factors were negatively associated with diet quality: Eating food prepared away-from-home; going out to work ≥4 times/week; decreased time for food preparation; decreased interest in eating healthy; eating more due to anxiety, depression, or boredom; food insecurity; and stockpiling junk food. Purchasing food using a mixed modality of both in-store and home delivery was positively associated with diet quality. With the exception of eating more due to anxiety (reported by 47% of participants), all these factors were reported by a minority of participants during the first round (≤15%). During the 2nd round, there was an increase in the frequency of participants who reported eating food prepared away-from-home, going out to work ≥4 times/week, having less time to prepare food, being more interested in eating healthfully, and a decrease in participants eating more due to anxiety, depression or boredom, or stockpiling junk food.

Conclusions: Most participants perceived that their dietary intake improved during both initial and later stages of the pandemic. This might be related to factors associated with higher dietary quality, such as not going out to work, eating homemade food, and online grocery shopping.

Functions of social networks in maternal food choice for children in Mexico

Food choice for children has important implications in establishing early‐life dietary habits and preferences. Food choice for children has been studied as parent–child dyad dynamics, but little is known about the extended system of relationships in maternal food choice for children. The objective of this study was to understand the functions of mothers' social networks in the food choices that mothers make for their children ages 1 to 5 years old in rural Mexico. In‐depth interviews were conducted with 46 participants in three rural communities. The interviews inquired about participants' child‐feeding practices, personal and local beliefs about child feeding and the individuals with whom they had conversations about food and child feeding. All interviews were conducted in Spanish, audio‐recorded, transcribed verbatim, verified for quality and analysed using the constant comparative method. Five interconnected networks emerged, consisting of household family, non‐household family, community, children's initial school and health and nutritional programme personnel. Each network had functions in food choice that ranged from shared food decision‐making in the household family network to imparting formal dietary guidance in the health and nutritional programme personnel network. Across the networks, professionals, participants' mothers and mothers‐in‐law, community senior women and other women with children emerged as prominent figures whom participants would turn to for child‐feeding advice. These findings provide empirical evidence that social networks, as an organized system of interconnected relationships, have vital functions in establishing social norms for food choices made for children that can be leveraged to promote healthy food choices.

Breastfeeding practices in Mexico: Results from the National Demographic Dynamic Survey 2006-2018

Although actions have been taken to improve breastfeeding in Mexico, trends over the last decade and their associated factors have not been analysed. We estimated trends in breastfeeding practices at the national, rural/urban, and regional level indigenous ethnicity and socio-economic level, and their associated factors using the National Demographic Dynamics Survey (2006, 2009, 2014 and 2018). We assessed breastfeeding indicators of women with children <24 months according to The World Health Organization recommendations. Logistic regressions models of pooled data were used to estimate trends and associations with biological and sociodemographic characteristics. Between 2006 and 2018, the prevalence of ever breastfed increased from 91.8% to 94.2% (p < 0.001), whereas early initiation of breastfeeding increased from 40.8% to 59.7% (p < 0.001), with similar increments by urban/rural level. Between 2009 and 2018, the prevalence of exclusive breastfeeding in children <6 months increased from 13.0% to 20.7% (p < 0.001). The largest increase was seen in Mexico City, in nonindigenous women and those with a high socio-economic status, whereas indigenous women and those from the South had the lowest or no improvements. Breastfeeding education during pregnancy [odds ratio (OR) 1.3; 95% confidence interval (CI) 1.1-1.5] was positively associated with exclusive breastfeeding, whereas being employed (OR 0.8; 95% CI 0.6-0.9) was negatively associated. Breastfeeding practices improved but are still far from recommendations. Implementing strategies like breastfeeding counselling and programmes and policies that promote and support breastfeeding for poor, indigenous, single and working mothers should be a priority for the government to ensure that all children have the best start in life.

Assessing Barriers to and Facilitators of Designing a Feasible Colorectal Cancer Screening Program in Mexico City

PURPOSE

We undertook a formative qualitative research study to identify optimal participant recruitment, education, and follow-up strategies to facilitate colorectal cancer (CRC) screening in Mexico City.

METHODS

This study included semistructured individual and focus group interviews with different stakeholders: 36 average-risk laypeople, 16 public health care leaders, 10 primary care personnel, and 4 endoscopy unit personnel. The study protocol was approved by the National Institute of Public Health Institutional Review Board. Written informed consent was obtained from all participants. We analyzed data using the constant comparison method under the theoretical perspectives of the Consolidated Framework for Implementation Research and the Health Belief Model. Tailored CRC screening educational materials—video, postcard, poster, and brochure—were developed on the basis of our findings. Materials were then pretested in 6 additional focus groups and adjusted accordingly.

RESULTS

We found multiple barriers and facilitators in different dimensions of the CFIR for successful implementation of a FIT-based CRC screening program in this community. The main barriers were the following: inner context related: understaffing and personnel resistance to new programs; individual health care personnel related: CRC misinformation and work overload; outer setting related: underinvestment in primary care and public insecurity; lay individual related: a lack of CRC awareness, low risk perception, and fear of finding out about a serious disease; and intervention related: test costs. Among the principal facilitators were the following: inner setting: a shared perception of a good working environment and strong leadership at the selected clinic; intervention related: FIT test is perceived as easy to do, and potential users liked the idea that the sample can be obtained in the privacy of their homes. Educational materials we tailored on the basis of these findings and were found to be acceptable, understandable, and culturally competent by lay participants.

CONCLUSION

Our study allowed for the design of a feasible FIT-based CRC screening program and culturally competent materials that will be used to enhance participation.

Development of a Live Coding Scheme to Assess Food Acceptance Among Infants and Toddlers in Naturalistic Settings

Objectives

Small-quantity lipid-based nutrient supplements (SQ-LNS) are designed to address malnutrition among infants and toddlers during complementary feeding. There is currently limited research assessing children's acceptability (i.e., behavioral response to the taste) of these supplements, and acceptability may predict long term consumption of these foods. We aimed to adapt a video coding protocol for use in naturalistic settings to determine child food acceptance.

Methods

Infants (ages 7 to 24 months) were fed two versions of an SQ-LNS (sweetened, unsweetened) mixed with a familiar food (e.g., infant oatmeal, banana) by mothers at two different study sites: a laboratory in Denver, Colorado (n = 56; 86% Non-Hispanic White) and family homes in the state of Morelos, Mexico (n = 62). Trained coders used a video coding (VC) scheme to rate child acceptance of each spoon offer using a 4-point scale (0 = refusal, 1 = enforced, 2 = acceptance, 3 = anticipation). The VC scheme was subsequently adapted for use as: 1) a live coding (LC) scheme to be used in participant homes, and 2) a video live coding (VLC) scheme to be used as a reliability check on the LC scheme. The LC scheme was tested with a sample of infants and caregivers (n = 20) selected using stratified sampling [infant age, supplement group (sweetened, unsweetened)] from the Mexico trial. One coder rated the infants’ responses to the SQ-LNS while observing the feeding interaction in the home. A second coder rated the same infants’ responses while later watching a video of the feeding (VLC). To simulate LC, the second coder did not pause the video. Intra-class correlation coefficients (ICC) were calculated to assess inter-rater reliability between sites and coding methods.

Results

Reliabilities for VC between Denver and Mexico coders were excellent (ICC &gt; .94), as were reliabilities for coders within study sites (ICCs &gt; .95). Reliabilities calculated between coders utilizing different coding methods were moderate (VLC and LC: ICC = .75), good (LC and VC: ICC = .87), or excellent (VC and VLC: ICC = .93).

Conclusions

Our LC scheme demonstrated good reliability with a VC scheme to assess infant acceptability of an SQ-LNS. Since traditional VC is both resource and time-intensive, our LC scheme may be useful for assessing infant food acceptance in resource-limited settings.

Funding Sources

Global Alliance for Improved Nutrition (GAIN).

Lessons Learned and Recommendations from the Implementation of a Live Coding Method to Assess Acceptability of SQ-LNS Supplements in 7- to 24-Month Old Children

Objectives

To assess the feasibility of using a live coding method developed in a laboratory to a naturalistic field setting in Mexico and report lessons learned and recommendations for future use.

Methods

Two coders previously trained to reliability for video-coding of child food acceptance were trained on video live coding (coding video recordings of feeding sessions without pausing or playback) and live coding (LC) in the field. The live coding method was previously piloted and adapted to the Mexican context and common infant feeding practices. From 62 caregivers with 7- to 24-mo children taking part in a randomized field trial, 20 participated in a video-recorded home feeding session. The first 10 offers of food were coded. Each coder individually live coded 10 sessions and video live coded the other 10. Interclass correlation coefficients (ICC) were calculated between coders and with the supervisor to determine reliability.

Results

Four main categories of adaptations were identified: 1) personnel requirements, 2) participant considerations and instructions, 3) elements of setting, and 4) materials. In the Mexican context (and similar settings) we recommend: limiting the number of personnel entering the home to avoid disrupting the child's eating; offering precise instructions to caregivers on the feeding process; limiting distractions from family members; using a fix and a mobile recording device. Successful implementation of child-feeding LC protocols in the field must balance the following considerations: feasibility in the specific field context, local feeding practices, study resources and timelines, and maintaining quality data collection. All adaptations must prioritize LC best practices, including monitoring reliability during the training and LC period, across coders and a supervisor. Reliability levels in the Mexico setting were good (ICC &gt; .80).

Conclusions

LC was feasible and successfully implemented in the Mexican field context. Its piloting in the field setting provided essential information to carry out necessary adaptations to the method prior to implementation. Continued use of this method requires context-specific adaptations aligned with best practice recommendations.

Funding Sources

Global Alliance for Improved Nutrition (GAIN).

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Funding Sources

SPARC Graduate Research Grant from University of South Carolina.

Formative Research Helped Identify Acceptable, Locally Available Foods to Mix with Unsweetened Small-quantity Lipid-based Nutrient Supplement in Mexico (P10-030-19)

Objectives

Appropriate utilisation of home fortificants such as small-quantity lipid-based nutrition supplements (SQ-LNS) requires providing clear and acceptable instructions of use for the target audience. We conducted formative research to identify locally available foods that could be recommended to mix with unsweetened SQ-LNS in Mexico.

Methods

Thirteen caregivers of 7 to 23 month-old children participated in a SQ-LNS tasting session and guided group discussion at a hospital in a semi-urban area in Morelos, Mexico. After sampling the SQ-LNS, caregivers were asked to select 1 or more of the 9 common complementary foods available to mix with 1 sachet of SQ-LNS (20 g). The common complementary foods available, identified from previous research, were: cooked rice, mashed beans, plain yogurt, strawberry-flavoured yogurt, the sweetened dairy snack Danonino, two types of commercial baby food (carrot and pear), banana, and oatmeal. Caregivers tasted and rated the organoleptic properties of SQ-LNS mixed with each of the foods. Subsequently, we conducted a home feeding session in which caregivers selected 1 of the top 4 foods preferred during the tasting session to mix with SQ-LNS (n = 8).

Results

The preferred foods for mixing SQ-LNS in the tasting session were mashed beans (n = 5), cooked rice (n = 2), Danonino (n = 2) and unsweetened yogurt (n = 2). Caregivers preferred these foods because they were considered better in masking the taste of the supplement. During the home feeding session, half of the caregivers selected Danonino to mix with SQ-LNS, and none selected unsweetened yogurt. Some caregivers considered that varying the type of foods used to mix with SQ-LNS could be a useful strategy to improve acceptance and adherence to daily supplementation.

Conclusions

Providing multiple examples of locally available and acceptable complementary foods to mix with SQ-LNS might be necessary to promote daily supplement use in the study context. Formative research is useful for developing recommendations for SQ-LNS use that take into account the customs and preferences of the target population.

Funding Sources

The study was funded by the Government of Canada, as part of the Business Platform for Nutrition Research hosted by the Global Alliance for Improved Nutrition.

Acceptability of Unsweetened Small-quantity Lipid-based Nutrient Supplements in Mexico Among 7 to 24 Month-old Children and Their Caregivers: A Formative Research Study (P10-046-19)

Objectives

Lipid-based nutrient supplements (LNS) have the potential to improve micronutrient status, growth and development of children. While the sweetened version of the supplement has been found to be acceptable, the acceptability of unsweetened LNS is unknown. The study was conducted to examine the acceptability of unsweetened small-quantity LNS (SQ-LNS) among Mexican children and their caregivers.

Methods

Eligible caregivers of 7 to 24 mo-old children (n = 13) participated in an SQ-LNS tasting session at a hospital in a semi-urban area of the state of Morelos, Mexico. Using a 3-point hedonic scale, they rated the organoleptic characteristics of SQ-LNS (alone and mixed with food) and their willingness to feed it to their child. Subsequently, a focus group discussion was conducted to further explore caregivers’ experiences and perceptions about the supplement. Feeding sessions were carried out in caregivers’ homes, during which children (n = 8) were fed a meal consisting of SQ-LNS (20 g) mixed with a local complementary food (36 g). The amount (g) of meal consumed by the children was measured.

Results

Most women (n = 12) liked the smell of the supplement and more than half (n = 8) liked the appearance. However, less than a quarter liked the taste (n = 3) and texture (n = 2) and more than half (n = 8) perceived that their child would dislike it. Irrespective of caregiver's perception regarding the supplement, a majority (n = 9) reported they would be willing to feed it to their children mostly because of its nutritional content and health benefits. Caregivers reported that they would prefer to mix the supplement with food before feeding to child and would try different strategies including mixing the supplement with foods that are commonly eaten at home that the child likes. When caregivers rated LNS mixed with food, results showed that more than half liked the taste (n = 8) and perceived that their child would like it (n = 9). On average, children consumed 23.8 ± 19.2 g of the meal (equivalent to a proportion of 42 ± 34%).

Conclusions

Although the taste of unsweetened SQ-LNS was not largely accepted, caregivers expressed their willingness to feed the supplement to their children using different strategies. The use of unsweetened SQ-LNS in future studies in this population may be acceptable.

Funding Sources

The study was funded by the Government of Canada, as part of the Business Platform for Nutrition Research hosted by the Global Alliance for Improved Nutrition.

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Funding Sources

SPARC Graduate Research Grant from University of South Carolina.

Experiences and lessons learned for programme improvement of micronutrient powders interventions

Continual course correction during implementation of nutrition programmes is critical to address factors that might limit coverage and potential for impact. Programme improvement requires rigorous scientific inquiry to identify and address implementation pathways and the factors that affect them. Under the auspices of “The Micronutrient Powders Consultation: Lessons Learned for Operational Guidance,” 3 working groups were formed to summarize experiences and lessons across countries regarding micronutrient powder (MNP) interventions for young children. This paper focuses on how MNP interventions undertook key elements of programme improvement, specifically, the use of programme theory, monitoring, process evaluation, and supportive supervision. Methods included a review of published and grey literature, interviews with key informants, and deliberations throughout the consultation process. We found that although much has been written and published about the use of monitoring and process evaluation to inform MNP interventions at small scale, there has been little formal documentation of lessons for the transition from pilot to scaled implementation. Supervision processes and experiences are not documented, and to our knowledge, there is no evidence of whether they have been effective to improve implementation. Improving the efficiency and effectiveness of interventions requires identification of critical indicators for detecting implementation challenges and drivers of impact, integration with existing programmes and systems, strengthened technical capacity, and financing for implementation of effective monitoring systems. Our understanding of programme improvement for MNP interventions is still incomplete, especially outside of the pilot stage, and we propose a set of implementation research questions that require further investigation.

Experiences and lessons learned for delivery of micronutrient powders interventions

An effective delivery strategy coupled with relevant social and behaviour change communication (SBCC) have been identified as central to the implementation of micronutrient powders (MNP) interventions, but there has been limited documentation of what works. Under the auspices of "The Micronutrient Powders Consultation: Lessons Learned for Operational Guidance," three working groups were formed to summarize experiences and lessons across countries regarding MNP interventions for young children. This paper focuses on programmatic experiences related to MNP delivery (models, platforms, and channels), SBCC, and training. Methods included a review of published and grey literature, interviews with key informants, and deliberations throughout the consultation process. We found that most countries distributed MNP free of charge via the health sector, although distribution through other platforms and using subsidized fee for product or mixed payment models have also been used. Community-based distribution channels have generally shown higher coverage and when part of an infant and young child feeding approach, may provide additional benefit given their complementarity. SBCC for MNP has worked best when focused on meeting the MNP behavioural objectives (appropriate use, intake adherence, and related infant and young child feeding behaviours). Programmers have learned that reincorporating SBCC and training throughout the intervention life cycle has allowed for much needed adaptations. Diverse experiences delivering MNP exist, and although no one-size-fits-all approach emerged, well-established delivery platforms, community involvement, and SBCC-centred designs tended to have more success. Much still needs to be learned on MNP delivery, and we propose a set of implementation research questions that require further investigation.

Breastfeeding practices, beliefs, and social norms in low-resource communities in Mexico: Insights for how to improve future promotion strategies

INTRODUCTION

Breastfeeding is recommended exclusively for the first 6 months after birth, with continued breastfeeding for at least 2 years. Yet prevalence of these recommendations is low globally, although it is an effective and cost-effective way to prevent serious infections and chronic illness. Previous studies have reported that social support greatly influences breastfeeding, but there is little evidence on perceived social norms in Mexico and how they affect actual behavior.

OBJECTIVE

Our objective was to investigate breastfeeding intention, practices, attitudes, and beliefs, particularly normative, among low-resource communities in central and southern Mexico.

METHODS

We performed a secondary analysis using the theory of planned behavior with cross-sectional data, which included semi-structured individual interviews with fathers (n 10), 8 focus groups with mothers (n 50), and 8 focus groups with women community leaders (n 44) with a total of 104 participants. Our data also included a quantitative survey among pregnant women and mothers (n 321).

RESULTS

Women reported supplementing breast milk with water and teas soon after birth, as well as introducing small bites of solid food a few months after birth. Social norms appeared to support breastfeeding, but not exclusive breastfeeding or breastfeeding for periods longer than about a year. This may be partially explained by: a) behavioral beliefs that for the first 6 months breast milk alone is insufficient for the baby, and that water in addition to breast milk is necessary to hydrate an infant and b) normative beliefs related to the appropriateness of breastfeeding in public and as the child gets older.

CONCLUSIONS

Future strategies should focus on positively influencing social norms to support recommended practices, and emphasize the specific reasons behind the recommendations. Future efforts should take a multi-pronged approach using a variety of influences, not only directed at healthcare providers but close family members, including fathers.

Promoting healthful diet and physical activity in the Mexican school system for the prevention of obesity in children

OBJECTIVE

This paper describes the rationale, design, and methods of a two-year randomized controlled trial conducted to evaluate the effectiveness of an environmental intervention in 27 elementary schools in Mexico City.

MATERIALS AND METHODS

There were two units of analysis, school level addressing changes in elementary public part-time schools, and individual-level addressing behavioral changes in students 9 to 11 years of age. Two intensities of an intervention program were implemented (basic and plus), each containing two intervention components: physical activity and nutrition, supported by a communication/education component. Evaluation of the intervention was carried out during the school cycles 2006-2007 and 2007-2008.

RESULTS

Primary outcomes were overweight and obesity prevalence and fitness; environmental and behavioural measures were also examined.

CONCLUSIONS

This is the first institutional multilevel, multifactorial project, consistent with the best practices available in current literature, carried out in Mexico to prevent childhood obesity in schools.

Contribution of formative research to design an environmental program for obesity prevention in schools in Mexico City

OBJECTIVE

This paper describes the methods and key findings of formative research conducted to design a school-based program for obesity prevention.

MATERIALS AND METHODS

Formative research was based on the ecological model and the principles of social marketing. A mixed method approach was used. Qualitative (direct observation, indepth interviews, focus group discussions and photo-voice) and quantitative (closed ended surveys, checklists, anthropometry) methods were employed.

RESULTS

Formative research key findings, including barriers by levels of the ecological model, were used for designing a program including environmental strategies to discourage the consumption of energy dense foods and sugar beverages.

CONCLUSION

Formative research was fundamental to developing a context specific obesity prevention program in schools that seeks environment modification and behavior change.

[Barriers and opportunities for the regulation of food and beverage advertising to children in Mexico]

OBJECTIVE

To identify barriers and opportunities for the regulation of food and beverage advertising to children.

MATERIALS AND METHODS

A qualitative study. Fourteen key informants from the congress, private sector, officials from the ministry of health and academics involved in the issue of regulation of advertising were interviewed.

RESULTS

Barriers identified: conception of obesity as an individual problem, minimization of the negative effects on health, definition of the vulnerability of children bounded to their cognitive development. Facilitators support from various sectors of society regulation, extensive scientific discussion on the subject, successful experience and its lessons on tabacco industry.

CONCLUSION

Mexico has key elements for achieving effective regulation on advertising.

Scripted messages delivered by nurses and radio changed beliefs, attitudes, intentions, and behaviors regarding infant and young child feeding in Mexico

Scalable interventions are needed to improve infant and young child feeding (IYCF). We evaluated whether an IYCF nutrition communication strategy using radio and nurses changed beliefs, attitudes, social norms, intentions, and behaviors related to breastfeeding (BF), dietary diversity, and food consistency. Women with children 6-24 mo were randomly selected from 6 semi-urban, low-income communities in the Mexican state of Morelos (intervention, n = 266) and from 3 comparable communities in Puebla (control, n = 201). Nurses delivered only once 5 scripted messages: BF, food consistency, flesh-food and vegetable consumption, and feed again if food was rejected; these same messages aired 7 times each day on 3 radio stations for 21 d. The control communities were not exposed to scripted messages via nurse and radio. We used a pre-/post-test design to evaluate changes in beliefs, attitudes, norms, and intentions as well as change in behavior with 7-d food frequency questions. Mixed models were used to examine intervention-control differences in pre-/post changes. Coverage was 87% for the nurse component and 34% for radio. Beliefs, attitudes, and intention, but not social norms, about IYCF significantly improved in the intervention communities compared with control. Significant pre-/post changes in the intervention communities compared with control were reported for BF frequency (3.7 ± 0.6 times/d), and consumption of vegetables (0.6 ± 0.2 d) and beef (0.2 ± 0.1 d) and thicker consistency of chicken (0.6 ± 0.2 d) and vegetable broths (0.8 ± 0.4 d). This study provides evidence that a targeted communication strategy using a scalable model significantly improves IYCF.

A matched pair cluster randomized implementation trail to measure the effectiveness of an intervention package aiming to decrease perinatal mortality and increase institution-based obstetric care among indigenous women in Guatemala: study protocol

BACKGROUND

Maternal and perinatal mortality continue to be a high priority problem on the health agendas of less developed countries. Despite the progress made in the last decade to quantify the magnitude of maternal mortality, few interventions have been implemented with the intent to measure impact directly on maternal or perinatal deaths. The success of interventions implemented in less developed countries to reduce mortality has been questioned, in terms of the tendency to maintain a clinical perspective with a focus on purely medical care separate from community-based approaches that take cultural and social aspects of maternal and perinatal deaths into account. Our innovative approach utilizes both the clinical and community perspectives; moreover, our study will report the weight that each of these components may have had on reducing perinatal mortality and increasing institution-based deliveries.

METHODS/DESIGN

A matched pair cluster-randomized trial will be conducted in clinics in four rural indigenous districts with the highest maternal mortality ratios in Guatemala. The individual clinic will serve as the unit of randomization, with 15 matched pairs of control and intervention clinics composing the final sample. Three interventions will be implemented in indigenous, rural and poor populations: a simulation training program for emergency obstetric and perinatal care, increased participation of the professional midwife in strengthening the link between traditional birth attendants (TBA) and the formal health care system, and a social marketing campaign to promote institution-based deliveries. No external intervention is planned for control clinics, although enhanced monitoring, surveillance and data collection will occur throughout the study in all clinics throughout the four districts. All obstetric events occurring in any of the participating health facilities and districts during the 18 months implementation period will be included in the analysis, controlling for the cluster design. Our main outcome measures will be the change in perinatal mortality and in the proportion of institution-based deliveries.

DISCUSSION

A unique feature of this protocol is that we are not proposing an individual intervention, but rather a package of interventions, which is designed to address the complexities and realities of maternal and perinatal mortality in developing countries. To date, many other countries, has focused its efforts to decrease maternal mortality indirectly by improving infrastructure and data collection systems rather than on implementing specific interventions to directly improve outcomes.

TRIAL REGISTRATION

ClinicalTrial.gov,http://NCT01653626.

Contribution of formative research to design an environmental program for obesity prevention in schools in Mexico City

Objective. This paper describes the methods and key findings of formative research conducted to design a schoolbased program for obesity prevention. Materials and methods. Formative research was based on the ecological model and the principles of social marketing. A mixed method approach was used. Qualitative (direct observation,indepth interviews, focus group discussions and photo-voice)and quantitative (closed ended surveys, checklists, anthropometry)methods were employed. Results. Formative research key findings, including barriers by levels of the ecological model, were used for designing a program including environmental strategies to discourage the consumption of energy dense foods and sugar beverages. Conclusion. Formative research was fundamental to developing a context specific obesity prevention program in schools that seeks environment modification and behavior change.

Barreras y oportunidades para la regulación de la publicidad de alimentos y bebidas dirigida a niños en México

Objetivos. Identificar barreras y oportunidades para la regulación de la publicidad de alimentos y bebidas para niños. Material y métodos. Estudio cualitativo. Se entrevistó a catorce informantes clave del ámbito legislativo, sector privado, funcionarios de la Secretaría de Salud y académicos involucrados en el tema de la regulación de la publicidad. Resultados. Barreras identificadas: concepción de la obesidad como problema individual, minimización de los efectos negativos sobre la salud, definición de la vulnerabilidad de la niñez acotada a su desarrollo cognitivo. Facilitadores: apoyo de varios sectores de la sociedad, a favor de la regulación, una amplia discusión científica acerca del tema, una experiencia exitosa similar con la industria del tabaco y sus lecciones. Conclusión. México cuenta con elementos clave para lograr una regulación eficaz de la publicidad.

[Use of social marketing to increase water consumption among school-age children in Mexico City]

OBJECTIVE

To increase water consumption in school children in Mexico City through a social marketing intervention.

MATERIALS AND METHODS

Cluster quasi-experimental design. Intervention of three months in schools, including water provision and designed based on social marketing. Reported changes in attitude, knowledge and behavior were compared pre and post intervention.

RESULTS

Children of the intervention group (n=116) increased in 38% (171 ml) water consumption during school time, control group (n=167) decreased its consumption in 21% (140 ml) (p<0.05), according to their reported consumption. In a sub-sample reported consumption of sweetened beverages decreased 437 ml in the IG and 267 ml in the CG (p<0.05).

CONCLUSION

Social marketing and environmental modifications were effective on increasing water consumption among children, strategy that might contribute to mitigate childhood obesity.

[Culturally constructed meanings for consumption of sweetened beverages among schoolchildren in Mexico City]

OBJECTIVE

Demonstrate the importance of the cultural factors that currently motivate Mexican children to consume sweetened beverages and examine their implications for the design of programs for the promotion of healthy lifestyles.

METHODS

A qualitative phenomenological study involving nine peer interviews and four discussion groups was conducted among children aged 9 and 10 years in four public schools in southern Mexico City. The interviews employed nine photographs of beverages that are available in schools and homes. The aim was to identify the culinary rules associated with the consumption of sweetened beverages and the different views held by the children about the beverages. The complete interviews and group discussions were recorded and transcribed. Matrixes were developed for analysis of the subject categories identified during the study. The analysis was based on "continuous comparison" of the statements made by boys and girls, and among students from the four schools.

RESULTS

Two main sociocultural elements, constructed in a given cultural framework, partly explain the children's current consumption patterns. The first, the nearly nonexistent concept that water is for drinking, with water consumption being limited to engagement in physical activity, in contrast to the wide range of circumstances and occasions found for the consumption of a sweetened beverage. Secondly, the identification of three principles that appear to underlie beverage consumption: the combination of salty food with sweet drinks, the important role of sweetened beverages at social events, and the close association between water consumption and the thirst induced by physical effort.

CONCLUSIONS

The results show the importance of considering the role of socially significant elements in dietary practices and the need to also consider these elements when designing interventions for schoolchildren. It is also important to change the children's current views about what they drink, guiding and encouraging them to think of water as a drink to be consumed throughout the day and not only after physical activity. Finally, it is imperative in Mexico to guarantee free access to drinking water in schools and regulate food advertising that targets children.

[The health system of Venezuela]

This paper describes the Venezuelan health system, including its structure and coverage, financial sources, human and material resources and its stewardship functions. This system comprises a public and a private sector. The public sector includes the Ministry of Popular Power for Health (MS) and several social security institutions, salient among them the Venezuelan Institute for Social Security (IVSS). The MH is financed with federal, state and county contributions. The IVSS is financed with employer, employee and government contributions. These two agencies provide services in their own facilities. The private sector includes providers offering services on an out-of-pocket basis and private insurance companies. The Venezuelan health system is undergoing a process of reform since the adoption of the 1999 Constitution which calls for the establishment of a national public health system. The reform process is now headed by the Barrio Adentro program.

Caloric beverage consumption patterns in Mexican children

BACKGROUND

Mexico has seen a very steep increase in child obesity level. Little is known about caloric beverage intake in this country as well as all other countries outside a few high income countries. This study examines overall patterns and trends in all caloric beverages from two nationally representative surveys from Mexico.

METHODS

The two nationally representative dietary intake surveys (1999 and 2006) from Mexico are used to study caloric beverage intake in 17, 215 children. The volume (ml) and caloric energy (kcal) contributed by all beverages consumed by the sample subjects were measured. Results are weighted to be nationally representative.

RESULTS

The trends from the dietary intake surveys showed very large increases in caloric beverages among pre-school and school children. The contribution of whole milk and sugar-sweetened juices was an important finding. Mexican pre-school children consumed 27.8% of their energy from caloric beverages in 2006 and school children consumed 20.7% of their energy from caloric beverages during the same time. The three major categories of beverage intake are whole milk, fruit juice with various sugar and water combinations and carbonated and noncarbonated sugared-beverages.

CONCLUSION

The Mexican government, greatly concerned about obesity, has identified the large increase in caloric beverages from whole milk, juices and soft drinks as a key target and is initiating major changes to address this problem. They have already used the data to shift 20 million persons in their welfare and feeding programs from whole to 1.5% fat milk and in a year will shift to nonfat milk. They are using these data to revise school beverage policies and national regulations and taxation policies related to an array of less healthful caloric beverages.

Physical activity during the school day in public primary schools in Mexico City

OBJECTIVE

To quantify the physical activity (PA) of students and describe the school environment surrounding PA.

MATERIAL AND METHODS

Between November 2005 and March 2006, in Mexico City, we conducted quantitative and qualitative observations to describe the PA and the school context.

RESULTS

Recess and physical education class (PE) were the only opportunities to participate in PA. PE occurred one time per week with a duration of 39.8+/-10.6 minutes which is less than national and international recommendations. Students participated in moderate-to-vigorous PA 29.2+/-17.8% of PE. The dynamics of PE did not promote the inclusion of all students or PA. During recess there was overcrowding of the school patio and no equipment for PA or organization of PA.

DISCUSSION

The PA of students in public schools in Mexico City can be improved by increasing the quantity and quality of PE and increasing opportunities for activity during recess.

Are research priorities in Latin America in line with the nutritional problems of the population?

Objective

Concordance of nutritional research priorities with the related burden of disease is essential to develop cost-effective interventions to address the nutritional problems of populations. The present study aimed to evaluate whether nutrition research priorities are in agreement with the population’s nutritional problems in Latin America.

Design

The epidemiological profile was contrasted with the research priorities and research produced by academic institutions for each country. Qualitative analysis of research production by type of contribution to problem solving was also conducted.

Settings

Nine Latin American countries.

Results

Obesity (high body mass index (BMI)) and micronutrient deficiencies (anaemia) emerged as key problems, followed by stunting, breast-feeding/lactation and low birth weight. Wasting in children and women (low BMI) was uncommon. Concordance of ranked research priorities with the epidemiological profile of the country was generally good for nutrition-related chronic diseases, micronutrients and low birth weight, but not for undernutrition, stunting and breast-feeding. Studies on the efficacy and effectiveness of interventions were uncommon.

Conclusions

The present research agenda insufficiently supports the goal of public health nutrition, which is to ensure the implementation of cost-effective nutrition programmes and policies. A more rational approach to define research priorities is needed.

Maternal knowledge and use of a micronutrient supplement was improved with a programmatically feasible intervention in Mexico

In Mexico, the potential impact on child malnutrition from a nutritional supplement (papilla) delivered through a conditional transfer program (Oportunidades) was attenuated by problems of household utilization. A behavioral change through communication intervention was developed to improve supplement utilization. Our study assessed the efficacy of this intervention through the results of a randomized trial. In 2 states (Veracruz and Chiapas) 2 clusters of communities were randomly assigned to intervention or control groups. Data were obtained from 176-198 mothers in intervention and control communities using a survey questionnaire at preintervention baseline and at a 5-mo follow-up. Concordance between reported and observed behaviors was examined through an observational substudy. The 4 behavioral recommendations were: 1) prepare papilla as a pap; 2) administer the preparation every day; 3) administer it between breakfast and dinner; and 4) administer it only to target children. The intervention resulted in a significant increase (P<0.05) in the prevalence of reported correct behaviors in the intervention group compared with the control for 3 of the behaviors: a mean increase of 42.5% for preparing papilla as pap, 64.4% for daily administration, and 61.5% for giving papilla between breakfast and dinner. Administering to a target child increased significantly in Veracruz (from 51.5% to 90.6%), but not in Chiapas (20.6% to 33.3%). Reported behaviors agreed with observed behaviors in the substudy. With the exception of the target-child administration in Chiapas, adopting the recommendations was culturally acceptable and feasible. The results indicate that improvements in household utilization of the supplement can be achieved with a communication intervention that is potentially feasible for implementation on a large scale within the Oportunidades Program.