Coproduced, arts interventions for nurturing care (0-5 years) in low-income and middle-income countries (LMICs): a realist review

OBJECTIVES

Community-based arts interventions have the potential to support contextually relevant nurturing care programmes and policies that adapt to different settings. Understanding the distinctive features of using the arts in local, culturally specific ways in low/middle-income countries (LMICs); how this varies by context; and gaining a better understanding of the perspectives on desirable outcomes for communities is important evidence that this review generates.

DESIGN

We conducted a realist review of papers that covered outcomes related to child health or development (0-5 years) AND arts-based approaches AND community-based, participatory approaches AND based in LMICs using a range of databases and other networks. A coding framework was developed covering context, intervention, outcomes, mechanisms, study, sustainability, transferability and scalability.

RESULTS

The included papers reported 18 unique interventions. Interventions covered 14 countries, with evidence lacking for South America, Arab countries and parts of Africa. Lead authors came from mostly clinical science-based disciplines and from institutions in a different country to the country/countries studied. Intended outcomes from interventions included clinical, health systems/organisation, changes in practices/behaviours/knowledge/attitudes, and wider social and educational goals. We identified three demi-regularities (semi-predictable patterns or pathways of programme functioning): participatory design based on valuing different sources of expertise; dynamic adaptation of intervention to context; and community participation in arts-based approaches.

CONCLUSIONS

Our findings suggest that arts-based, nurturing care interventions have greater potential when they include local knowledge, embed into existing infrastructures and there is a clear plan for ongoing resourcing of the intervention. Studies with better documentation of the lessons learnt, regarding the intervention delivery process and the power dynamics involved, are needed to better understand what works, for whom and in which contexts.

Designing intervention prototypes to improve infant and young child nutrition in Peru: a participatory design study protocol

INTRODUCTION

Nutrition during the complementary feeding period (6-23 months) is critical to ensure optimal growth and reduce the risk of diet-related disease across the life course. Strategies to reduce multiple forms of malnutrition (stunting, overweight/obesity and anaemia) in infants and young children (IYC) are a key priority in low-income and middle-income countries, including Peru. This study aims to co-design and develop prototypes for interventions to address the multiple forms of malnutrition in IYC in urban Peru, using a participatory design approach.

METHODS AND ANALYSIS

The study will be based within peri-urban communities in two areas of Peru (Lima and Huánuco city). Following the identification of key nutritional challenges for IYC aged 6-23 months through formative research (phase I), we will conduct a series of workshops bringing together healthcare professionals from government health centres and caregivers of IYC aged 6-23 months. Workshops (on idea generation; creating future scenarios; storyboarding and early implementation and feedback) will take place in parallel in the two study areas. Through these workshops, we will engage with community participants to explore, experiment, co-design and iteratively validate new design ideas to address the challenges around IYC complementary feeding from phase I. Workshop outputs and transcripts will be analysed qualitatively using affinity diagramming and thematic analyses. The intervention prototypes will be evaluated qualitatively and piloted with the participating communities.

ETHICS AND DISSEMINATION

Ethical approval for this study was obtained from the Ethical Review Committee of the Instituto de Investigación Nutricional (IIN) Peru (388-2019/CIEI-IIN), Loughborough University (C19-87) and confirmed by Cardiff University. Findings of the participatory design process will be disseminated through a deliberative workshop in Lima, Peru with national and regional government stakeholders, as well as participants and researchers involved in the design process. Further dissemination will take place through policy briefs, conferences and academic publications.

A conceptual framework of urban food security and nutrition in low- and middle-income country settings applied to the Asia-Pacific region

A conceptual framework is presented for enhancing food security and nutrition in urban areas in low- and middle-income countries, highlighting key influencing factors, including food supply chains, community food environments, community infrastructure and services, and numerous underlying individual and household determinants, such as behaviours and dietary practices.

Clustering of diet, physical activity and sedentary behaviour and related physical and mental health outcomes: a systematic review

BACKGROUND

Physical activity (PA), sedentary behaviour (SB) and diet play an important role in the physical and mental health of young people. Understanding how these behaviours cluster, and the impact of clusters on health is important for the development of public health interventions. This review examines the prevalence of clusters of PA, sedentary time, and dietary behaviours, and how clusters relate to physical and mental health indicators among children, adolescents and young adults.

METHODS

Electronic (PubMed, Web of Science and Scopus) and manual searches were conducted for articles that were (i) observational studies including children, adolescents and/or young adults aged 5-24 years, (ii) examined the 'patterning', 'clustering', or 'co-existence' of each of PA, dietary behaviour and SB, and (iii) published in English up to and including July 2022. In addition to information on clustering, data on physical and mental health outcomes were extracted where reported. Included studies were assessed using the Cochrane risk of bias for observational studies. A narrative synthesis was conducted due to high heterogeneity. This review was registered with PROSPERO (CRD42021230976).

RESULTS

Forty-nine cross-sectional studies and four prospective cohort studies from eighteen countries reporting data from 778,415 individual participants were included. A broad range of clusters (n = 172) were found (healthy, unhealthy, and mixed). Mixed clusters were common (n = 98), and clusters of high diet quality, low PA and high SB were more prevalent in girls, while mixed clusters of high PA, high SB and low diet quality were more prevalent in boys. Unhealthy clusters comprising low moderate to vigorous PA, low consumption of fruits and vegetables, and high screen time were prevalent, particularly in those from lower socioeconomic status families. Compared to those with healthy behavioural clusters, those with unhealthy and mixed clusters had a higher adiposity, higher risk of cardiovascular disease, poorer mental health scores, and lower cardiorespiratory fitness.

CONCLUSIONS

PA, SB and diet cluster in healthy, unhealthy and mixed patterns in young people that differ across sociodemographic characteristics. Unhealthy clusters are associated with poorer health outcomes. Intervention strategies targeting un-clustering multiple unhealthy behaviours should be developed and evaluated for their impact on health outcomes.

What is missing in our understanding of urban slum environments and maternal, infant and young child nutrition from publicly available data in Asia and the Pacific?

Given the recent, rapid urbanisation in Asia and the Pacific region, coupled with increases in the triple burden of malnutrition, we need to better understand maternal, infant and young child nutrition (MIYCN) for populations living in urban slum environments. This research used existing large-scale datasets to explore MIYCN indicators for those living in urban slum, compared with urban nonslum, areas. Data since 2015 from available Demographic and Health Surveys (DHS; Afghanistan, India, Indonesia, Myanmar, Pakistan and the Philippines) and Multiple Indicator Cluster Surveys (MICS; Bangladesh, Fiji, Kiribati, Mongolia, Nepal, Thailand and Tuvalu) were analysed. Most urban children in the 13 countries from the region were breastfed within 24 h of birth, with slightly higher rates for those living in slums. Conversely, almost all indicators of infant and young child malnutrition were worse for those in urban slums. For mothers living in slums, underweight prevalence and iron deficiency anaemia were higher while maternal overweight and obesity prevalence were lower. Analysis revealed disparities across countries in the wealth status of those living in slum versus nonslum areas. What is currently missing is representative sampling of households, adequate collection of data both within and across countries, and accurate representation of slum-dwellers in large-scale surveys. Given that limited data for the region show urban poor slum populations are vulnerable to poor nutrition indicators, more data are needed on the poorest urban slum populations to enable effective resource allocation to support optimal MIYCN.

Shift work characteristics and burnout among nurses: cross-sectional survey

BACKGROUND

Nurses working long shifts (≥12 h) experience higher levels of burnout. Yet other shift characteristics, including fixed versus rotating night work, weekly hours and breaks have not been considered. Choice over shift length may moderate the relationship; however, this has not been tested.

AIMS

To examine the association between shift work characteristics and burnout and exhaustion, and whether choice over shift length influences burnout and exhaustion.

METHODS

Cross-sectional online survey of nursing staff working in the UK and Ireland. We recruited two large National Health Service Trusts, through trade union membership, online/print nursing magazines and social media. We assessed associations using both univariable and multivariable generalized linear models.

RESULTS

We had 873 valid responses. Reports of inadequate staffing levels (odds ratio [OR] = 2.84; 95% confidence interval [CI] 2.08-3.90) and less choice over shift length (OR = 0.20; 95% CI 0.06-0.54) were associated with higher burnout in multivariable models. Similar associations were found for exhaustion, where rarely or never taking breaks was also a predictor (OR = 1.61; 95% CI 1.05-2.52). Nurses who worked long shifts had less choice than those working shifts of 8 h or less (66% of 12-h shift nurses versus 44% 8-h shift nurses reporting having no choice), but choice did not moderate the relationship between shift length and burnout and exhaustion.

CONCLUSIONS

The relationship between long shifts and increased burnout reported previously might have arisen from a lack of choice for those staff working long shifts. Whether limited choice for staff is intrinsically linked to long shifts is unclear.

Resilience and vulnerabilities of urban food environments in the Asia-Pacific region

Rapid urbanisation in the Asia-Pacific region is associated with complex changes to urban food environments. The impact of changing food environments on food purchasing and consumption and the diets and nutritional status of vulnerable groups, especially women and young children, is not well researched in low- and middle-income country cities. This paper aimed to examine: the risks and opportunities for healthy diets for low income populations offered by modernising urban centres; the concept of food deserts in relation to urban food environments in the Asia-Pacific region and how these could be mitigated; and measures to strengthen the resilience of food environments in the region using a case study of the impact of COVID-19 on informal food vendors. Our findings indicate that the dynamic changes in urban food environments in the Asia- Pacific region need to be understood by examining not only modern retail food outlets but also wet markets and informal food outlets, including street foods. Efforts should be made to ensure both modern and traditional outlets provide complementary platforms for convenient, affordable and accessible nutritious foods for urban populations. The resilience of urban food environments to environmental, physical and socio-economic shocks can be strengthened by shortening food supply chains and maximising food production in cities. Support mechanisms targeting urban informal food outlets and street vendors can also strengthen resilience and improve food security. Further research is needed on the impact of urbanising food environments on consumer choices, preferences, diets and health outcomes.

Protocol for a parallel group, two-arm, superiority cluster randomised trial to evaluate a community-level complementary-food safety and hygiene and nutrition intervention in Mali: the MaaCiwara study (version 1.3; 10 November 2022)

BACKGROUND

Diarrhoeal disease remains a significant cause of morbidity and mortality among the under-fives in many low- and middle-income countries. Changes to food safety practices and feeding methods around the weaning period, alongside improved nutrition, may significantly reduce the risk of disease and improve development for infants. We describe a protocol for a cluster randomised trial to evaluate the effectiveness of a multi-faceted community-based educational intervention that aims to improve food safety and hygiene behaviours and enhance child nutrition.

METHODS

We describe a mixed-methods, parallel group, two-arm, superiority cluster randomised controlled trial with baseline measures. One hundred twenty clusters comprising small urban and rural communities will be recruited in equal numbers and randomly allocated in a 1:1 ratio to either treatment or control arms. The community intervention will be focussed around an ideal mother concept involving all community members during campaign days with dramatic arts and pledging, and follow-up home visits. Participants will be mother-child dyads (27 per cluster period) with children aged 6 to 36 months. Data collection will comprise a day of observation and interviews with each participating mother-child pair and will take place at baseline and 4 and 15 months post-intervention. The primary analysis will estimate the effectiveness of the intervention on changes to complementary-food safety and preparation behaviours, food and water contamination, and diarrhoea. Secondary outcomes include maternal autonomy, enteric infection, nutrition, child anthropometry, and development scores. A additional structural equation analysis will be conducted to examine the causal relationships between the different outcomes. Qualitative and health economic analyses including process evaluation will be done.

CONCLUSIONS

The trial will provide evidence on the effectiveness of community-based behavioural change interventions designed to reduce the burden of diarrhoeal disease in the under-fives and how effectiveness varies across different contexts.

TRIAL REGISTRATION

ISRCTN14390796. Registration date December 13, 2021.

Reflections on Digital Maternal and Child Health Support for Mothers and Community Health Workers in Rural Areas of Limpopo Province, South Africa

INTRODUCTION

Digital health support using mobile and digital technologies, such as MomConnect and WhatsApp, is providing opportunities to improve maternal and child healthcare in low- and middle-income countries. Yet, the perspective of health service providers, pregnant women, and mothers as recipients of digital health support is under-researched in rural areas.

MATERIAL AND METHODS

An exploratory-descriptive qualitative research approach was adopted to reflect on the experiences of mothers, community leaders, and community health workers on mobile health opportunities in the context of maternal and child health in rural areas. Purposive sampling was used to select 18 participants who participated in the two focus groups and individual semi-structured interviews for data collection about digital maternal and child health support. The thematic open coding method of data analysis assisted authors in making sense of the given reflections of mothers, community leaders, and healthcare workers about digital health support.

RESULTS

Participants commented on different existing digital support apps and their importance for maternal and child health. For example, MoMConnect, Pregnancy+, WhatsApp, and non-digital resources were perceived as useful ways of communication that assist in improving maternal and child health. However, participants reported several challenges related to the use of digital platforms, which affect following the health instructions given to pregnant women and mothers.

CONCLUSIONS

Participants expressed the significant role of digital support apps in maternal and child health, which is impacted by various challenges. Addressing the lack of digital resources could improve access to health instructions for pregnant women and mothers.

Community perceptions on the factors in the social food environment that influence dietary behaviour in cities of Kenya and Ghana: a Photovoice study

OBJECTIVE

To explore communities' perspectives on the factors in the social food environment that influence dietary behaviours in African cities.

DESIGN

A qualitative study using participatory photography (Photovoice). Participants took and discussed photographs representing factors in the social food environment that influence their dietary behaviours. Follow-up in-depth interviews allowed participants to tell the 'stories' of their photographs. Thematic analysis was conducted, using data-driven and theory-driven (based on the socio-ecological model) approaches.

SETTING

Three low-income areas of Nairobi (n 48) in Kenya and Accra (n 62) and Ho (n 32) in Ghana.

PARTICIPANTS

Adolescents and adults, male and female aged ≥13 years.

RESULTS

The 'people' who were most commonly reported as influencers of dietary behaviours within the social food environment included family members, friends, health workers and food vendors. They mainly influenced food purchase, preparation and consumption, through (1) considerations for family members' food preferences, (2) considerations for family members' health and nutrition needs, (3) social support by family and friends, (4) provision of nutritional advice and modelling food behaviour by parents and health professionals, (5) food vendors' services and social qualities.

CONCLUSIONS

The family presents an opportunity for promoting healthy dietary behaviours among family members. Peer groups could be harnessed to promote healthy dietary behaviours among adolescents and youth. Empowering food vendors to provide healthier and safer food options could enhance healthier food sourcing, purchasing and consumption in African low-income urban communities.

Unhealthy Food and Beverage Consumption in Children and Risk of Overweight and Obesity: A Systematic Review and Meta-Analysis

This WHO-commissioned review contributed to the update of complementary feeding recommendations, synthesizing evidence on effects of unhealthy food and beverage consumption in children on overweight and obesity. We searched PubMed (Medline), Cochrane CENTRAL, and Embase for articles, irrespective of language or geography. Inclusion criteria were: 1) randomized controlled trials (RCTs), non-RCTs, cohort studies, and pre/post studies with control; 2) participants aged ≤10.9 y at exposure; 3) studies reporting greater consumption of unhealthy foods/beverages compared with no or low consumption; 4) studies assessing anthropometric and/or body composition; and 5) publication date ≥1971. Unhealthy foods and beverages were defined using nutrient- and food-based approaches. Risk of bias was assessed using the ROBINS-I (risk of bias in nonrandomized studies of interventions version I) and RoB2 [Cochrane RoB (version 2)] tools for nonrandomized and randomized studies, respectively. Narrative synthesis was complemented by meta-analyses where appropriate. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation. Of 26,542 identified citations, 60 studies from 71 articles were included. Most studies were observational (59/60), and no included studies were from low-income countries. The evidence base was low quality, as assessed by ROBINS-I and RoB2 tools. Evidence synthesis was limited by the different interventions and comparators across studies. Evidence indicated that consumption of sugar-sweetened beverages (SSBs) and unhealthy foods in childhood may increase BMI/BMI z-score, percentage body fat, or odds of overweight/obesity (low certainty of evidence). Artificially sweetened beverages and 100% fruit juice consumption make little/no difference to BMI, percentage body fat, or overweight/obesity outcomes (low certainty of evidence). Meta-analyses of a subset of studies indicated a positive association between SSB intake and percentage body fat, but no association with change in BMI and BMI z-score. High-quality epidemiological studies that are designed to assess the effects of unhealthy food consumption during childhood on risk of overweight/obesity are needed to contribute to a more robust evidence base upon which to design policy recommendations. This protocol was registered at https://www.crd.york.ac.uk/PROSPERO as CRD42020218109.

Individual‐level drivers of dietary behaviour in adolescents and women through the reproductive life course in urban Ghana: A Photovoice study

Evidence on the individual‐level drivers of dietary behaviours in deprived urban contexts in Africa is limited. Understanding how to best inform the development and delivery of interventions to promote healthy dietary behaviours is needed. As noncommunicable diseases account for over 40% of deaths in Ghana, the country has reached an advanced stage of nutrition transition. The aim of this study was to identify individual‐level factors (biological, demographic, cognitive, practices) influencing dietary behaviours among adolescent girls and women at different stages of the reproductive life course in urban Ghana with the goal of building evidence to improve targeted interventions. Qualitative Photovoice interviews (n = 64) were conducted in two urban neighbourhoods in Accra and Ho with adolescent girls (13–14 years) and women of reproductive age (15–49 years). Data analysis was both theory‐ and data‐driven to allow for emerging themes. Thirty‐seven factors, across four domains within the individual‐level, were identified as having an influence on dietary behaviours: biological (n = 5), demographic (n = 8), cognitions (n = 13) and practices (n = 11). Several factors emerged as facilitators or barriers to healthy eating, with income/wealth (demographic); nutrition knowledge/preferences/risk perception (cognitions); and cooking skills/eating at home/time constraints (practices) emerging most frequently. Pregnancy/lactating status (biological) influenced dietary behaviours mainly through medical advice, awareness and willingness to eat foods to support foetal/infant growth and development. Many of these factors were intertwined with the wider food environment, especially concerns about the cost of food and food safety, suggesting that interventions need to account for individual‐level as well as wider environmental drivers of dietary behaviours.

Time constraints, eating at home, eating out, cooking skills, food preferences and food safety concerns were identified as key factors influencing dietary behaviours at the individual level in urban Ghana.

Ability to eat nutritious, safe food was largely mediated by income and wealth.

Biological factors, such as pregnancy/lactating status influenced behaviours through medical advice, nutrition knowledge and willingness to promote foetal/infant development.

Many individual‐level factors were intertwined with the wider food environment.

Factors influencing dietary behaviour at different levels need to be considered together when developing interventions/policies for healthier diets.

Improving early childhood development in the context of the nurturing care framework in Kenya: A policy review and qualitative exploration of emerging issues with policy makers

Introduction

The Nurturing Care Framework (NCF) describes "nurturing care" as the ability of nations and communities to support caregivers and provide an environment that ensures children's good health and nutrition, protects them from threats, and provides opportunities for early learning through responsive and emotionally supportive interaction. We assessed the extent to which Kenyan government policies address the components of the NCF and explored policy/decision makers' views on policy gaps and emerging issues.

Methods

A search strategy was formulated to identify policy documents focusing on early childhood development (ECD), health and nutrition, responsive caregiving, opportunities for early learning and security and safety, which are key components of the NCF. We limited the search to policy documents published since 2010 when the Kenya constitution was promulgated and ECD functions devolved to county governments. Policy/decision-maker interviews were also conducted to clarify emerging gaps from policy data. Data was extracted, coded and analyzed based on the components of the NCF. Framework analysis was used for interview data with NCF being the main framework of analysis. The Jaccard's similarity coefficient was used to assess similarities between the themes being compared to further understand the challenges, successes and future plans of policy and implementation under each of the NCF domains.

Results

127 policy documents were retrieved from government e-repository and county websites. Of these, n = 91 were assessed against the inclusion criteria, and n = 66 were included in final analysis. The 66 documents included 47 County Integrated Development Plans (CIDPs) and 19 national policy documents. Twenty policy/decision-maker interviews were conducted. Analysis of both policy and interview data reveal that, while areas of health and nutrition have been considered in policies and county level plans (coefficients >0.5), the domains of early learning, responsive caregiving and safety and security face significant policy and implementation gaps (coefficients ≤ 0.5), particularly for the 0-3 year age group. Inconsistencies were noted between county level implementation plans and national policies in areas such as support for children with disabilities and allocation of budget to early learning and nutrition domains.

Conclusion

Findings indicate a strong focus on nutrition and health with limited coverage of responsive caregiving and opportunities for early learning domains. Therefore, if nurturing care goals are to be achieved in Kenya, policies are needed to support current gaps identified with urgent need for policies of minimum standards that provide support for improvements across all Nurturing Care Framework domains.

Evaluation of the Prevalence of Punctate White Matter Lesions in a Healthy Volunteer Neonatal Population

Hypoxic-ischemic injury is the most common cause of neonatal encephalopathy. T1-weighted punctate white matter lesions have been described in hypoxic-ischemic injury. We have reviewed a healthy volunteer neonatal population to assess the prevalence of punctate white matter lesions in neonates with no clinical signs of hypoxic-ischemic injury. Fifty-two subjects were scanned on a neonatal-specific 3T MR imaging scanner. Twelve patients were excluded due to the lack of T1-weighted imaging, leaving a total of 40 patients (35 term, 5 preterm) assessed in the study. One had a solitary T1-punctate white matter lesion. We concluded that solitary punctate white matter lesions have a low prevalence in healthy neonates.

Associations between socioeconomic position and young people's physical activity and sedentary behaviour in the UK: a scoping review

OBJECTIVE

To examine the evidence on the associations between socioeconomic position and young people's physical activity and sedentary behaviours in the UK.

DESIGN

Scoping review.

DATA SOURCES

PubMed, SCOPUS and Web of Science databases were searched for articles published up to and including January 2021.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Observational studies in children and adolescents (aged 5-18 years) from the UK that had assessed associations between at least one indicator of socioeconomic position and at least one outcome of physical activity and/or sedentary behaviour.

DATA EXTRACTION AND SYNTHESIS

Data were extracted by one reviewer and 20% were double checked. Indicators of socioeconomic position were tabulated with domains of physical activity and sedentary behaviour.

RESULTS

Fifty-seven publications were included in the review; 37 publications from 19 studies (k=23) of children and 21 publications from 15 studies (k=23) of adolescents. Most studies were cross-sectional. 63% of studies of children, and 40% of studies of adolescents assessed Index of Multiple Deprivation. Eighteen studies measured physical activity in children, 13 measured sedentary behaviour. Eleven studies of adolescents included a measure of physical activity, 10 included a measure of sedentary behaviour. Among children and adolescents, the association between socioeconomic position and measures of either physical activity or sedentary behaviour was highly variable depending on the measure of both socioeconomic position used and the behavioural outcome, with the exception of higher family affluence which was consistently associated with higher reported physical activity among adolescents.

CONCLUSION

Physical activity and sedentary behaviours of children and adolescents in the UK are complex and influenced by multiple indicators of socioeconomic position that are, in most cases, different across age stages, outcomes examined and measurement tools. Greater consistency in the use and measures of socioeconomic position as well as outcomes of behaviour are required for robust country-specific meta-analyses.

How well do covariates perform when adjusting for sampling bias in online COVID-19 research? Insights from multiverse analyses

COVID-19 research has relied heavily on convenience-based samples, which-though often necessary-are susceptible to important sampling biases. We begin with a theoretical overview and introduction to the dynamics that underlie sampling bias. We then empirically examine sampling bias in online COVID-19 surveys and evaluate the degree to which common statistical adjustments for demographic covariates successfully attenuate such bias. This registered study analysed responses to identical questions from three convenience and three largely representative samples (total N = 13,731) collected online in Canada within the International COVID-19 Awareness and Responses Evaluation Study ( www.icarestudy.com ). We compared samples on 11 behavioural and psychological outcomes (e.g., adherence to COVID-19 prevention measures, vaccine intentions) across three time points and employed multiverse-style analyses to examine how 512 combinations of demographic covariates (e.g., sex, age, education, income, ethnicity) impacted sampling discrepancies on these outcomes. Significant discrepancies emerged between samples on 73% of outcomes. Participants in the convenience samples held more positive thoughts towards and engaged in more COVID-19 prevention behaviours. Covariates attenuated sampling differences in only 55% of cases and increased differences in 45%. No covariate performed reliably well. Our results suggest that online convenience samples may display more positive dispositions towards COVID-19 prevention behaviours being studied than would samples drawn using more representative means. Adjusting results for demographic covariates frequently increased rather than decreased bias, suggesting that researchers should be cautious when interpreting adjusted findings. Using multiverse-style analyses as extended sensitivity analyses is recommended.

The future of the drug phenomenon and drug monitoring in Europe until 2030

 

We are living in an era of fast and fundamental changes with an uneven impact on geographies and generations. The pace of the social transformations and technology innovations is accelerating and outpacing policies and responses in place. Also, the European drug situation and drug markets are becoming more complex and dynamic, with important implications for the EU drug monitoring system and research. Therefore the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) conducted the first ‘futures exercise' to inform the agency's strategic reflection on how to improve the response of the EU monitoring system in the context of rapid changes in the information environment and new information needs. The EMCDDA piloted the usefulness of the foresight approach for transforming the agency and its monitoring activities into a more sensitive and agile system, which could, in turn, help increase Europe's preparedness for future challenges in health and security areas. The ‘futures exercise' applied the horizon-scanning method to study events, issues, and trends affecting the drug area and went far beyond the drugs or the addiction field and the European region. It analysed global drivers of change that may have in the future implications for the drugs situation, drug monitoring and related responses. The methods applied ranged from literature review, thematic analysis, workshops and expert panels. It had a robust participatory component to enable stakeholders representing different disciplines and countries to contribute to and benefit from the process. Out of 14 Megatrends, five were selected as most significant for the drugs field, and the future EMCDDA work: technological change, climate change and environmental degradation, diversified inequalities, shifts in health challenges and population. Moreover, four categories of emerging changes in the drugs field were identified: shifts in drug policy, the discourse of addictions, drug markets and drug services.

Key messages

Foresight is a valuable tool for analysis going beyond specific areas of expertise and recognising that a single-issue focus is often insufficient in dealing with emerging threats and opportunities. A participatory approach contributes to building a shared vision of the major drivers of change impacting the drugs field, information needs and future developments in the EU drug monitoring system.

Effect of a baby-friendly workplace support intervention on exclusive breastfeeding in Kenya

Exclusive breastfeeding (EBF) during the first 6 months of life is crucial for optimizing child growth, development and survival, as well as the mother's wellbeing. Mother's employment may hinder optimal breastfeeding, especially in the first 6 months. We assessed the effectiveness of a baby-friendly workplace support intervention on EBF in Kenya. This pre-post intervention study was conducted between 2016 and 2018 on an agricultural farm in Kericho County. The intervention targeted pregnant/breastfeeding women residing on the farm and consisted of workplace support policies and programme interventions including providing breastfeeding flexi-time and breaks for breastfeeding mothers; day-care centres (crèches) for babies near the workplace and lactation centres with facilities for breast milk expression and storage at the crèches; creating awareness on available workplace support for breastfeeding policies; and home-based nutritional counselling for pregnant and breastfeeding women. EBF was measured through 24-h recall. The effect of the intervention on EBF was estimated using propensity score weighting. The study included 270 and 146 mother-child dyads in the nontreated (preintervention) group and treated (intervention) group, respectively. The prevalence of EBF was higher in the treated group (80.8%) than in the nontreated group (20.2%); corresponding to a fourfold increased probability of EBF [risk ratio (RR) 3.90; 95% confidence interval (CI) 2.95-5.15]. The effect of the intervention was stronger among children aged 3-5 months (RR 8.13; 95% CI 4.23-15.64) than among those aged <3 months (RR 2.79; 95% CI 2.09-3.73). The baby-friendly workplace support intervention promoted EBF especially beyond 3 months in this setting.

Urban physical food environments drive dietary behaviours in Ghana and Kenya: A photovoice study

We identified factors in the physical food environment that influence dietary behaviours among low-income dwellers in three African cities (Nairobi, Accra, Ho). We used Photovoice with 142 males/females (≥13 years). In the neighbourhood environment, poor hygiene, environmental sanitation, food contamination and adulteration were key concerns. Economic access was perceived as a major barrier to accessing nutritionally safe and healthy foods. Home gardening supplemented household nutritional needs, particularly in Nairobi. Policies to enhance food safety in neighbourhood environments are required. Home gardening, food pricing policies and social protection schemes could reduce financial barriers to safe and healthy diets.

97Effectiveness of baby-friendly workplace support interventions on exclusive breastfeeding in Kenya: a propensity score-weighted analysis

Background

Exclusive breastfeeding (EBF) during the first six months of life is crucial for optimising child’s growth, development and survival. Mother’s employment may hinder optimal breastfeeding. We assessed the effectiveness of a workplace support intervention on EBF in Kenya.

Methods

This quasi-experimental study employing a pre-post intervention design was conducted between 2016 and 2018 on an agricultural farm in Kericho County. The intervention targeted pregnant/breastfeeding women residing on the farm and consisted of: day-care centers, sensitization on available workplace baby-friendly policies, and home-based nutritional counselling of pregnant and breastfeeding women. The effect of the interventions on EBF was estimated using propensity score weighting.

Results

The study included 223 and 146 mother-infant dyads in the non-treated (pre-intervention) and treated (intervention) groups, respectively. The prevalence of EBF was 20.2% in the non-treated group and 80.8% in the treated group; corresponding to a 4-fold increased probability of EBF (RR 3.99; 95% CI 2.95–5.15). In age-stratified results, the effect of the interventions was stronger among children aged 3-5 months (RR 8.13; 95% CI 4.23–15.64) than among those aged &lt; 3 months (RR 2.79; 95% CI 2.09–3.73).

Conclusions

The baby-friendly workplace support intervention promoted EBF especially beyond three months in this setting.

Key messages

Maintaining EBF while working is more likely when employers provide the support that women need to do so. Workplace policies and programmes to support women to combine work with breastfeeding are needed.

The African urban food environment framework for creating healthy nutrition policy and interventions in urban Africa

This study developed, validated, and evaluated a framework of factors influencing dietary behaviours in urban African food environments, to inform research prioritisation and intervention development in Africa. A multi-component methodology, drawing on concept mapping, was employed to construct a framework of factors influencing dietary behaviours in urban Africa. The framework adapted a widely used socio-ecological model (developed in a high-income country context) and was developed using a mixed-methods research approach that comprised: i. Evidence synthesis consisting of a systematic review of 39 papers covering 14 African countries; ii. Qualitative interview data collected for adolescents and adults (n = 144) using photovoice in urban Ghana and Kenya; and iii. Consultation with interdisciplinary African experts (n = 71) from 27 countries, who contributed to at least one step of the framework (creation, validation/evaluation, finalisation). The final framework included 103 factors influencing dietary behaviours. Experts identified the factors influencing dietary behaviours across all the four levels of the food environment i.e. the individual, social, physical and macro levels. Nearly half (n = 48) were individual-level factors and just under a quarter (n = 26) were at the macro environmental level. Fewer factors associated with social (n = 15) and physical (14) environments were identified. At the macro level, the factors ranked as most important were food prices, cultural beliefs and seasonality. Factors ranked as important at the social level were household composition, family food habits and dietary practices. The type of food available in the neighbourhood and convenience were seen as important at the physical level, while individual food habits, food preferences and socioeconomic status were ranked highly at the individual level. About half of the factors (n = 54) overlap with those reported in an existing socio-ecological food environment framework developed in a high-income country context. A further 49 factors were identified that were not reported in the selected high-income country framework, underlining the importance of contextualisation. Our conceptual framework offers a useful tool for research to understand dietary transitions in urban African adolescents and adults, as well as identification of factors to intervene when promoting healthy nutritious diets to prevent multiple forms of malnutrition.

Communities and employers show a high level of preparedness in supporting working mothers to combine breastfeeding with work in rural Kenya

Community Readiness Model (CRM) through pragmatic mixed methods design, combining quantitative CRM survey with qualitative data, was used to assess the level of preparedness and readiness among local leaders, employers and community members in supporting working mothers to combine breastfeeding with work. The study was conducted in one of the tea state farms in Kericho County of Kenya. A total of 17 purposively selected men (fathers), lactating mothers, peer educators, health professionals (doctors, nurses and nutritionists), tea plantation managers and grandmothers were interviewed. The CRM that has six different dimensions was applied to determine the stage of readiness to support working mothers to combine breastfeeding with work. Community Readiness Score (CRS) was calculated descriptively as mean ± standard deviation (SD). Thematic analysis using NVIVO software was used to analyse qualitative data. We found that the mean (±SD) CRS was 7.3 (1.9), which corresponded to the third highest level of the nine stages or the ‘stabilization’ stage of community readiness. Dimensionally, the mean CRS was the highest (8.3 ± 1.9) for leadership followed by community efforts (7.5 ± 2.1), whereas the lowest CRS was observed for knowledge of efforts (6.6 ± 2.3) and availability of resources (6.6 ± 1.9). In conclusion, high level of readiness to support working women to combine work with breastfeeding with suboptimal knowledge of efforts and availability of resources was observed in the area. Future interventions should focus on enabling the community to feel more comfortable and creating detailed and refined knowledge on combining breastfeeding with work.

Assessment of the feasibility and potential effectiveness of a baby-friendly workplace support initiative in rural Kenya: a study protocol

<p class="abstract"><strong>Background:</strong> Employment poses a barrier in achieving the World Health Organization’s recommendation of exclusive breastfeeding for the first six months of life. Effective strategies and evidence to improve breastfeeding for women working in the agricultural sector – the main employer for women in Kenya – is lacking. This study aimed to inform (with evidence) the design and implementation of a scalable model of workplace support for breastfeeding in an agricultural setting in Kenya; as well as investigated the model’s potential operational feasibility and potential effectiveness, and its cost-effectiveness.</p><p class="abstract"><strong>Methods:</strong> The study employed a mixed methods approach and participatory methods at the pre-implementation, implementation and post-implementation phases. The pre-implementation phase generated evidence to inform the implementation. Mothers with children under 12 months were interviewed at the pre-implementation (2016) and post-implementation (2018) phase. Managers, supervisors, decision and policy makers, as well as other community members were also targeted. Statistical methods will include analysis of covariance and logistic regression. Additionally, cost-effectiveness and cost-benefit analyses will be done. Qualitative data will be analysed <em>in vivo</em>, using thematic analysis technique.</p><p class="abstract"><strong>Conclusions: </strong>Findings from this study aimed to inform the potential feasibility and potential effectiveness of a baby-friendly workplace support for breastfeeding initiative in an agricultural setting with a goal of improving child nutrition and health. The findings also contribute to policy and practice in Kenya by informing the development of workplace support guidelines.</p><p class="abstract"><strong>Trial Registration:</strong> ISRCTN registry, ISRCTN 64692465; date of registration: 21 December 2016 – retrospectively registered, http://www.isrctn.com/ISRCTN64692465.</p>

Observational study of the relationship between nurse staffing levels and compliance with mandatory nutritional assessments in hospital

BACKGROUND

In the UK, it is recommended that hospital patients have their nutritional status assessed within 24 h of admission using the Malnutrition Universal Screening Tool (MUST). The present study aimed to examine the association between nurse staffing levels and missed nutritional status assessments.

METHODS

A single-centre, retrospective, observational study was employed using routinely collected MUST assessments from 32 general adult hospital wards over 2 years, matched to ward nurse staffing levels. We used mixed-effects logistic regression to control for ward characteristics and patient factors.

RESULTS

Of 43 451 instances where staffing levels could be linked to a patient for whom an assessment was due, 21.4% had no MUST score recorded within 24 h of admission. Missed assessments varied between wards (8-100%). There was no overall association between registered nurse staffing levels and missed assessments; although higher admissions per registered nurse were associated with more missed assessments [odds ratio (OR) = 1.09, P = 0.005]. Higher healthcare assistant staffing was associated with lower rates of missed assessments (OR = 0.80, P < 0.001). There was a significant interaction between registered nurses and healthcare assistants staffing levels (OR = 0.97, P = 0.011).

CONCLUSIONS

Despite a written hospital policy requiring a nutritional assessment within 24 h of admission, missed assessments were common. The observed results show that compliance with the policy for routine MUST assessments within 24 h of hospital admission is sensitive to staffing levels and workload. This has implications for planning nurse staffing.

A complementary feeding and play intervention improves the home environment and mental development among toddlers in rural India

A cluster randomized trial design was used to test the efficacy of a behaviour change communication intervention on the quality of the home environment and infant development at 15 months of age. Children (n = 600) in rural South India were followed from 3 through 15 months of age. The control group (C group) received the standard of care, the complementary feeding group (CF group) received recommendations on complementary foods and the responsive complementary feeding and play group (RCF&P group) received recommendations on complementary foods plus skills on responsive feeding and play. The intervention was delivered in biweekly home visits to caregivers using flip charts. At postintervention, infants (n = 521) were assessed for development (Bayley-II scales) and their home environment was assessed (Home Observation for Measurement of the Environment [HOME] scale). Cluster adjusted analysis of variance showed no significant differences at baseline. The HOME score at 15 months differed by group, F(2, 38) = 6.41, P = 0.004; the CF and RCF&P groups had higher scores than the C group. Scores on subscales 'Opportunities for Variety in Daily Stimulation' and 'Caregiver Promotion of Child Development' (CPCD) were higher for the RCF&P group than for the C and CF groups. Mental development index (MDI) scores differed by group, F(2, 37) = 3.31, P = 0.04, with the RCF&P group showing higher scores than the C group (P < 0.04); no differences were noted in psychomotor development index (PDI) scores (P = 0.48). The subscales of HOME associated with MDI at 15 months were 'CPCD' and 'Cleanliness of Child' (R2 = 0.076). 'CPCD' was also associated with PDI (R2 = 0.039). A responsive complementary feeding and play intervention delivered through home visits benefitted children's mental development and caregiving environment at 15 months.

Unhealthy eating practices of city-dwelling Africans in deprived neighbourhoods: Evidence for policy action from Ghana and Kenya

Growing urbanisation in Africa is accompanied by rapid changes in food environments, with potential shifts towards unhealthy food/beverage consumption, including in socio-economically disadvantaged populations. This study investigated how unhealthy food and beverages are embedded in everyday life in deprived areas of two African countries, to identify levers for context relevant policy. Deprived neighbourhoods (Ghana: 2 cities, Kenya: 1 city) were investigated (total = 459 female/male, adolescents/adults aged ≥13 y). A qualitative 24hr dietary recall was used to assess the healthiness of food/beverages in relation to eating practices: time of day and frequency of eating episodes (periodicity), length of eating episodes (tempo), and who people eat with and where (synchronisation). Five measures of the healthiness of food/beverages in relation to promoting a nutrient-rich diet were developed: i. nutrients (energy-dense and nutrient-poor -EDNP/energy-dense and nutrient-rich -EDNR); and ii. unhealthy food types (fried foods, sweet foods, sugar sweetened beverages (SSBs). A structured meal pattern of three main meals a day with limited snacking was evident. There was widespread consumption of unhealthy food/beverages. SSBs were consumed at three-quarters of eating episodes in Kenya (78.5%) and over a third in Ghana (36.2%), with those in Kenya coming primarily from sweet tea/coffee. Consumption of sweet foods peaked at breakfast in both countries. When snacking occurred (more common in Kenya), it was in the afternoon and tended to be accompanied by a SSB. In both countries, fried food was an integral part of all mealtimes, particularly common with the evening meal in Kenya. This includes consumption of nutrient-rich traditional foods/dishes (associated with cultural heritage) that were also energy-dense: (>84% consumed EDNR foods in both countries). The lowest socio-economic groups were more likely to consume unhealthy foods/beverages. Most eating episodes were <30 min (87.1% Ghana; 72.4% Kenya). Families and the home environment were important: >77% of eating episodes were consumed at home and >46% with family, which tended to be energy dense. Eating alone was also common as >42% of eating episodes were taken alone. In these deprived settings, policy action to encourage nutrient-rich diets has the potential to prevent multiple forms of malnutrition, but action is required across several sectors: enhancing financial and physical access to healthier foods that are convenient (can be eaten quickly/alone) through, for example, subsidies and incentives/training for local food vendors. Actions to limit access to unhealthy foods through, for example, fiscal and advertising policies to dis-incentivise unhealthy food consumption and SSBs, especially in Ghana. Introducing or adapting food-based dietary guidelines to incorporate advice on reducing sugar and fat at mealtimes could be accompanied by cooking skills interventions focussing on reducing frying/oil used when preparing meals, including 'traditional' dishes and reducing the sugar content of breakfast.

The timing of adrenarche in Maya girls, Merida, Mexico

Background

Adrenarche involves maturation of the hypothalamic‐pituitary‐adrenal axis and increased production of dehydroepiandrosterone and its sulfate ester, dehydroepiandrosterone‐sulfate (DHEA‐S). It occurs at ages 6 to 8 in industrialized populations, marking the transition from childhood to juvenility and cognitive development at middle childhood. Studies in subsistence level populations indicate a later age (8‐9) for adrenarche, but only two such studies currently exist for comparison.

Aims

To investigate adrenarcheal age among Maya girls and its association with body composition and dietary variables. We hypothesized adrenarche would occur earlier given the current dual burden of nutrition in Mexico.

Materials and Methods

25 Maya girls aged 7 to 9 from Merida, Mexico using ELISAs to measure salivary DHEA‐S, standard anthropometry for height, weight, and skinfolds, bioelectrical impedance for body composition variables, as well as a food frequency questionnaire for dietary information.

Results

Our hypothesis was rejected—adrenarche occurred close to 9 years. While no measures of body composition were significantly associated with adrenarcheal status, girls eating meat and dairy products more frequently had significantly higher DHEA‐S levels.

Discussion

Like other populations living in ecologically challenging environments, adrenarche occurred relatively late among Maya girls. Adrenarche has been linked to measures of body composition, particularly, the adiposity or body mass index rebound, but no relevant anthropometric measures were associated, possibly because of the small sample.

Conclusion

Further studies are required to illuminate how adrenarcheal variation relates to developmental plasticity, body composition, pubertal progression, and animal product consumption in other transitional populations.

Investigating foods and beverages sold and advertised in deprived urban neighbourhoods in Ghana and Kenya: a cross-sectional study

OBJECTIVES

The aim of this study was to characterise the local foods and beverages sold and advertised in three deprived urban African neighbourhoods.

DESIGN

Cross-sectional observational study. We undertook an audit of all food outlets (outlet type and food sold) and food advertisements. Descriptive statistics were used to summarise exposures. Latent class analysis was used to explore the interactions between food advertisements, food outlet types and food type availability.

SETTING

Three deprived neighbourhoods in African cities: Jamestown in Accra, Ho Dome in Ho (both Ghana) and Makadara in Nairobi (Kenya).

MAIN OUTCOME MEASURE

Types of foods and beverages sold and/or advertised.

RESULTS

Jamestown (80.5%) and Makadara (70.9%) were dominated by informal vendors. There was a wide diversity of foods, with high availability of healthy (eg, staples, vegetables) and unhealthy foods (eg, processed/fried foods, sugar-sweetened beverages). Almost half of all advertisements were for sugar-sweetened beverages (48.3%), with higher exposure to alcohol adverts compared with other items as well (28.5%). We identified five latent classes which demonstrated the clustering of healthier foods in informal outlets, and unhealthy foods in formal outlets.

CONCLUSION

Our study presents one of the most detailed geospatial exploration of the urban food environment in Africa. The high exposure of sugar-sweetened beverages and alcohol both available and advertised represent changing urban food environments. The concentration of unhealthy foods and beverages in formal outlets and advertisements of unhealthy products may offer important policy opportunities for regulation and action.

Reducing screen-time and unhealthy snacking in 9-11 year old children: the Kids FIRST pilot randomised controlled trial

Background

Many young people form unhealthy behavioural habits, such as low intake of fruit and vegetables, high intake of energy-dense snack foods, and excessive sedentary screen-based behaviours. However, there is a shortage of parent-and home-focused interventions to change multiple health behaviours in children.

Methods

Kids FIRST was a 12-week, home- and school-based pilot randomised controlled trial to reduce screen-time and unhealthy snacking with assessments at pre- (baseline) and post-intervention. Four UK schools were randomised to control or one of three interventions targeting reductions in (1) screen-time and unhealthy snacking (ST + Sn), (2) screen-time (ST only), (3) unhealthy snacking (Sn only), and parents with children aged 9–11 years were recruited via schools. Intervention group parents received four online ‘sessions’ and four packages of resources tailored to each group. Children received four 30-min lessons during school time. Children and parents reported their own screen-time behaviours, children reported their own snacking behaviours. Descriptive analyses were undertaken using principles of intention to treat.

Results

Initial feasibility was shown in that this study successfully recruited schools and families into all four study arms and retained them over a period of 13 weeks (retention rate ≥ 74%). Seventy-five children and 64 parents provided full baseline questionnaire data. Reductions in children’s school day and weekend day TV/DVD viewing and computer game use were found in the ST + Sn and ST groups, while self-reported smartphone use increased in these groups. Similar results were found for parents’ TV/DVD, computer and smartphone use in these groups. Little to no changes were found in reports of the dietary variables assessed in any intervention group for children or parents.

Conclusions

These preliminary findings show some promise for the Kids FIRST intervention. Based on these findings, a future full trial should recruit a more diverse sample of families and optimise the intervention and intervention resources to more fully engage parents with the dietary-based components of the intervention programme, where fewer changes were seen. Although most parents reporting receiving the intervention resources, further development work is required to achieve higher levels of engagement. This might include greater parent and child engagement work early in the development of the project.

Trial registration

Retrospectively registered in June 21st 2019 with ClinicalTrials.gov (number NCT03993652).

Cost effectiveness of a community based prevention and treatment of acute malnutrition programme in Mumbai slums, India

Children in slums are at high risk of acute malnutrition and death. Cost-effectiveness of community-based management of severe acute malnutrition programmes has been demonstrated previously, but there is limited evidence in the context of urban slums where programme cost structure is likely to vary tremendously.

This study assessed the cost-utility of adding a community based prevention and treatment for acute malnutrition intervention to Government of India Integrated Child Development Services (ICDS) standard care for children in Mumbai slums. The intervention is delivered by community health workers in collaboration with ICDS Anganwadi community health workers. The analysis used a decision tree model to compare the costs and effects of the two options: standard ICDS services with the intervention and prevention versus standard ICDS services alone. The model used outcome and cost data from the Society for Nutrition, Education & Health Action’s Child Health and Nutrition programme in Mumbai slums, which delivered services to 12,362 children over one year from 2013 to 2014. An activity-based cost model was used, with calculated costs based on programme financial records and key informant interviews. Cost data were coupled with programme effectiveness data to estimate disability adjusted life years (DALYs) averted.

The community based prevention and treatment programme averted 15,016 DALYs (95% Uncertainty Interval [UI]: 12,246–17,843) at an estimated cost of $23 per DALY averted (95%UI:19–28) and was thus highly cost-effective. This study shows that ICDS Anganwadi community health workers can work efficiently with community health workers to increase the prevention and treatment coverage in slums in India and can lead to policy recommendations at the state, and potentially the national level, to promote such programmes in Indian slums as a cost-effective approach to tackling moderate and severe acute malnutrition.

Clustering and correlates of screen-time and eating behaviours among young adolescents

Background

Screen-time and eating behaviours are associated in adolescents, but few studies have examined the clustering of these health behaviours in this age group. The identification of clustered health behaviours, and influences on adolescents’ clustered health behaviours, at the time when they are most likely to become habitual, is important for intervention design. The purpose of this study was to assess the prevalence and clustering of health behaviours in adolescents, and examine the sociodemographic, individual, behavioural, and home social and physical environmental correlates of clustered health behaviours.

Methods

Adolescents aged 11–12 years (n = 527, 48% boys) completed a questionnaire during class-time which assessed screen-time (ST), fruit and vegetable (FV), and energy-dense (ED) snack consumption using a Food Frequency Questionnaire. Health behaviours were categorised into high and low frequencies based on recommendations for FV and ST and median splits for ED snacks. Adolescents reported on their habits, self-efficacy, eating at the television (TV), eating and watching TV together with parents, restrictive parenting practices, and the availability and accessibility of foods within the home. Behavioural clustering was assessed using an observed over expected ratio (O/E). Correlates of clustered behaviours were examined using multivariate multinomial logistic regression.

Results

Approximately 70% reported having two or three health risk behaviours. Overall, O/E ratios were close to 1, which indicates clustering. The three risk behaviour combination of low FV, high ED, and high ST occurred more frequently than expected (O/E ratio = 1.06 95% CI 1.01, 1.15. Individual, behavioural, and social and physical home environmental correlates were differentially associated with behavioural clusters. Correlates consistently associated with clusters included eating ED snacks while watching TV, eating at the TV with parents, and the availability and accessibility of ED snack foods within the home.

Conclusions

There is a high prevalence of screen time and unhealthy eating, and screen time is coupled with unhealthy dietary behaviours. Strategies and policies are required that simultaneously address reductions in screen time and changes to habitual dietary patterns, such as TV snacking and snack availability and accessibility. These may require a combination of individual, social and environmental changes alongside conscious and more automatic (nudging) strategies.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4441-2) contains supplementary material, which is available to authorized users.

Sociocultural factors influencing breastfeeding practices in two slums in Nairobi, Kenya

BACKGROUND

Despite numerous interventions promoting optimal breastfeeding practices in Kenya, pockets of suboptimal breastfeeding practices are documented in Kenya's urban slums. This paper describes cultural and social beliefs and practices that influence breastfeeding in two urban slums in Nairobi, Kenya.

METHODS

Qualitative data were collected in Korogocho and Viwandani slums through 10 focus group discussions and 19 in-depth interviews with pregnant, breastfeeding women and community health volunteers and 11 key-informant interviews with community leaders. Interviews were audiotaped, transcribed verbatim, coded in NVIVO and analyzed thematically.

RESULTS

Social and cultural beliefs and practices that result to suboptimal breastfeeding practices were highlighted including; considering colostrum as 'dirty' or 'curdled milk', a curse 'bad omen' associated with breastfeeding while engaging in extra marital affairs, a fear of the 'evil eye' (malevolent glare which is believed to be a curse associated with witchcraft) when breastfeeding in public and breastfeeding being associated with sagging breasts. Positive social and cultural beliefs were also identified including the association of breast milk with intellectual development and good child health. The beliefs and practices were learnt mainly from spouses, close relatives and peers.

CONCLUSION

Interventions promoting behavior change with regards to breastfeeding should focus on dispelling the beliefs and practices that result to suboptimal breastfeeding practices and to build on the positive ones, while involving spouses and other family members as they are important sources of information on breastfeeding.

TRIAL REGISTRATION

ISRCTN83692672: December 2013 (retrospectively registered).

Individual, behavioural and home environmental factors associated with eating behaviours in young adolescents

This study aimed to examine individual, behavioural and home environmental factors associated with frequency of consumption of fruit, vegetables and energy-dense snacks among adolescents. Adolescents aged 11-12 years (n = 521, 48% boys) completed a paper-based questionnaire during class-time which included a Food Frequency Questionnaire assessing their consumption of fruit, vegetables, and energy-dense (ED) snacks, and items assessing habits, self-efficacy, eating at the television (TV), eating with parents, parenting practices, and home availability and accessibility of foods. Multiple linear regression analyses showed that eating fruit and vegetables while watching TV and home availability and accessibility of fruit and vegetables were positively associated with frequency of fruit consumption and vegetable consumption, while home accessibility of ED snack foods was negatively associated with frequency of fruit consumption. Habit for eating ED snack foods in front the TV, eating ED snack foods while watching TV, and home availability of ED snacks were positively associated with frequency of ED snack consumption. This study has highlighted the importance of a healthy home environment for promoting fruit and vegetable intake in early adolescents and also suggests that, if snacking while TV viewing occurs, this could be a good opportunity for promoting fruit and vegetable intake. These findings are likely to be useful for supporting the development of multi-faceted interventions and aid us in knowing what advice to give to parents to help them to help their young adolescents to develop and maintain healthy eating habits.

Sitting time and obesity in a sample of adults from Europe and the USA

BACKGROUND

Obesity is a risk factor for many chronic diseases and the prevalence is increasing worldwide. Research suggests that sedentary behaviour (sitting) may be related to obesity.

AIM

To examine the association between sitting time and obesity, while controlling for physical activity, in a large international sample.

SUBJECTS AND METHODS

In total, 5338 adults from the UK, USA, Germany, Spain, Italy, France, Portugal, Austria and Switzerland self-reported their total daily sitting time, physical activity, age, height and weight. BMI (kg/m²), total physical activity (MET-minutes/week) and sitting time (hours/day) were derived. Participants were grouped into quartiles based on their daily sitting time (<4, 4-≤6, 6-≤8 and >8 hours/day) and logistic regression models explored the odds of being obese vs normal weight for each sitting time quartile.

RESULTS

Participants in the highest sitting time quartile (≥8 hours/day) had 62% higher odds of obesity compared to participants in the lowest quartile (<4 hours/day) after adjustment for physical activity and other confounding variables (OR = 1.62, 95% CI = 1.24-2.12, p < .01).

CONCLUSION

Sitting time is associated with obesity in adults, independent of physical activity. Future research should clarify this association using objective measures of sitting time and physical activity to further inform health guidelines.

Prevalence of prenatal brain abnormalities in fetuses with congenital heart disease: a systematic review

OBJECTIVES

Studies have shown an association between congenital heart defects (CHDs) and postnatal brain abnormalities and neurodevelopmental delay. Recent evidence suggests that some of these brain abnormalities are present before birth. The primary aim of this study was to perform a systematic review to quantify the prevalence of prenatal brain abnormalities in fetuses with CHDs.

METHODS

MEDLINE, EMBASE and The Cochrane Library were searched electronically. Reference lists within each article were hand-searched for additional reports. The outcomes observed included structural brain abnormalities (on magnetic resonance imaging (MRI)) and changes in brain volume (on MRI, three-dimensional (3D) volumetric MRI, 3D ultrasound and phase-contrast MRI), brain metabolism or maturation (on magnetic resonance spectroscopy and phase-contrast MRI) and brain blood flow (on Doppler ultrasound, phase-contrast MRI and 3D power Doppler ultrasound) in fetuses with CHDs. Cohort and case-control studies were included and cases of chromosomal or genetic abnormalities, case reports and editorials were excluded. Proportion meta-analysis was used for analysis. Between-study heterogeneity was assessed using the I(2) test.

RESULTS

The search yielded 1943 citations, and 20 studies (n = 1175 cases) were included in the review. Three studies reported data on structural brain abnormalities, while data on altered brain volume, metabolism and blood flow were reported in seven, three and 14 studies, respectively. The three studies (221 cases) reporting on structural brain abnormalities were suitable for inclusion in a meta-analysis. The prevalence of prenatal structural brain abnormalities in fetuses with CHD was 28% (95% CI, 18-40%), with a similar prevalence (25% (95% CI, 14-39%)) when tetralogy of Fallot was considered alone. These abnormalities included ventriculomegaly (most common), agenesis of the corpus callosum, ventricular bleeding, increased extra-axial space, vermian hypoplasia, white-matter abnormalities and delayed brain development. Fetuses with CHD were more likely than those without CHD to have reduced brain volume, delay in brain maturation and altered brain circulation, most commonly in the form of reduced middle cerebral artery pulsatility index and cerebroplacental ratio. These changes were usually evident in the third trimester, but some studies reported them from as early as the second trimester.

CONCLUSION

In the absence of known major aneuploidy or genetic syndromes, fetuses with CHD are at increased risk of brain abnormalities, which are discernible prenatally. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Hierarchical structures of cactus spines that aid in the directional movement of dew droplets

Three species of cactus whose spines act as dew harvesters were chosen for this study: Copiapoa cinerea var. haseltoniana, Mammillaria columbiana subsp. yucatanensis and Parodia mammulosa and compared with Ferocactus wislizenii whose spines do not perform as dew harvesters. Time-lapse snapshots of C. cinerea showed movement of dew droplets from spine tips to their base, even against gravity. Spines emanating from one of the areoles of C. cinerea were submerged in water laced with fluorescent nanoparticles and this particular areole with its spines and a small area of stem was removed and imaged. These images clearly showed that fluorescent water had moved into the stem of the plant. Lines of vascular bundles radiating inwards from the surface areoles (from where the spines emanate) to the core of the stem were detected using magnetic resonance imaging, with the exception of F. wislizenii that does not harvest dew on its spines. Spine microstructures were examined using SEM images and surface roughness measurements (Ra and Rz) taken of the spines of C. cinerea It was found that a roughness gradient created by tapered microgrooves existed that could potentially direct surface water from a spine tip to its base.This article is part of the themed issue 'Bioinspired hierarchically structured surfaces for green science'.