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Ngoutane RM, Murray-Kolb LE, Zoma R, Ouédraogo CT, van Zutphen KG, Bruning R, Razakandrainy A, Ransom E, Dalmiya N, Kraemer K, Kodish SR. A Comparative Analysis of Maternal Nutrition Decision-Making Autonomy During Pregnancy-An Application of the Food Choice Process Model in Burkina Faso and Madagascar. Food Nutr Bull 2024; 45:47-56. [PMID: 38126192 PMCID: PMC11047013 DOI: 10.1177/03795721231217554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
BACKGROUND Adequate nutrition has been cited as one of the most critical components for optimal health outcomes during pregnancy. Women in Burkina Faso and Madagascar experience high rates of undernutrition due to lack of knowledge, finances, cultural norms, and autonomy. Therefore, this study aimed (1) to describe typical maternal diets during pregnancy in Burkina Faso and Madagascar, (2) to understand the multilevel factors that influence women's nutrition decision-making, and (3) to explore the extent to which women have nutrition decision-making autonomy during pregnancy. METHODS This study was conducted between October 2020 and February 2021 in Burkina Faso and Madagascar. Semi-structured interviews, focus group interviews, and free lists were conducted among women of reproductive age and pregnant and lactating women. Textual data from interviews were recorded and translated verbatim from local languages into French. The Food Choice Process Model guided textual content analysis using Dedoose software. Free list data were analyzed using cultural domain analysis approaches. RESULTS In Burkina Faso and Madagascar, women primarily consumed staple foods such as rice and tô during pregnancy. Participants cited eating fruits and vegetables when available, while the animal source foods were rarely consumed. Across both contexts, nutrition during pregnancy was influenced by factors that impact food choices, such as social factors, resources, ideals, and personal factors. While women and men in Madagascar had more shared decision-making on critical domains such as finances, men were the primary decision-makers in most areas of inquiry (eg, finances) in Burkina Faso. CONCLUSIONS The lack of adequate diverse diet consumed during pregnancy is primarily due to important factors including social factors and resources. Understanding the ability for women to consume optimal diets during pregnancy is needed to target behavioral change in maternal nutrition programming.
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Affiliation(s)
| | | | | | | | | | - Rachel Bruning
- The Pennsylvania State University, University Park, PA, USA
| | | | | | - Nita Dalmiya
- United National Children’s Fund, New York, NY, USA
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Schwendler TR, Na M, Keller KL, Jensen L, Kodish SR. Observational Methods in Studies of Infant and Young Child Feeding Practices in Low- and Middle-Income Countries: A Twenty-Year Retrospective Review. Nutrients 2024; 16:288. [PMID: 38257180 PMCID: PMC10820610 DOI: 10.3390/nu16020288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 01/24/2024] Open
Abstract
This narrative review describes the observational approaches used to study infant and young child feeding (IYCF) practices in low- and middle-income countries (LMICs) published between 2001 and 2021. Articles were included in this narrative review if they were (1) original peer-reviewed articles published in English in PubMed and Web of Science; (2) published between 1 January 2001, and 31 December 2021; (3) conducted in an LMIC; and (4) employed observations and focused on IYCF practices among children aged 6-59 months. The studies (n = 51) revealed a wide-ranging application of direct meal and full-day observations, as well as indirect spot checks, to study IYCF. The findings revealed that meal observations were typically conducted during a midday meal using precise recording approaches such as video and aimed to understand child-caregiver interactions or specialized nutritious food (SNF) usage. Conversely, full-day observations lasted between 6 and 12 h and often used a field notes-based recording approach. Behaviors occurring outside of mealtime, such as snacking or interhousehold food sharing, were also a primary focus. Finally, spot checks were conducted to indirectly assess SNF compliance during both announced and unannounced visits. This review highlights the adaptability of observations across contexts and their versatility when used as a primary data collection tool to help monitor and evaluate nutrition programs.
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Affiliation(s)
- Teresa R. Schwendler
- 110 Chandlee Laboratory, Department of Nutritional Sciences, The Pennsylvania State University, University Park, PA 16802, USA
| | - Muzi Na
- 110 Chandlee Laboratory, Department of Nutritional Sciences, The Pennsylvania State University, University Park, PA 16802, USA
| | - Kathleen L. Keller
- 110 Chandlee Laboratory, Department of Nutritional Sciences, The Pennsylvania State University, University Park, PA 16802, USA
- 202 Rodney A. Erickson Food Science Building, Department of Food Science, The Pennsylvania State University, University Park, PA 16802, USA
| | - Leif Jensen
- Armsby Building, Department of Agricultural Economics, Sociology, and Education, The Pennsylvania State University, University Park, PA 16802, USA
| | - Stephen R. Kodish
- 110 Chandlee Laboratory, Department of Nutritional Sciences, The Pennsylvania State University, University Park, PA 16802, USA
- 219 Biobehavioral Health Building, Department of Biobehavioral Health, The Pennsylvania State University, University Park, PA 16802, USA
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3
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Materia FT, Smyth JM, Puoane T, Tsolekile L, Goggin K, Kodish SR, Fox AT, Resnicow K, Werntz S, Catley D. Implementing text-messaging to support and enhance delivery of health behavior change interventions in low- to middle-income countries: case study of the Lifestyle Africa intervention. BMC Public Health 2023; 23:1526. [PMID: 37563595 PMCID: PMC10416414 DOI: 10.1186/s12889-023-16388-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 07/25/2023] [Indexed: 08/12/2023] Open
Abstract
The prevalence of non-communicable diseases, such as diabetes and cardiovascular disease, is rising in low- and middle-income countries (LMICs). Health behavior change (HBC) interventions such as the widely used Diabetes Prevention Program (DPP) are effective at reducing chronic disease risk, but have not been adapted for LMICs. Leveraging mobile health (mHealth) technology such as text messaging (SMS) to enhance reach and participant engagement with these interventions has great promise, yet we lack evidence-informed approaches to guide the integration of SMS specifically to support HBC interventions in LMIC contexts. To address this gap, we integrated guidance from the mHealth literature with expertise and first-hand experience to establish specific development steps for building and implementing SMS systems to support HBC programming in LMICs. Specifically, we provide real-world examples of each development step by describing our experience in designing and delivering an SMS system to support a culturally-adapted DPP designed for delivery in South Africa. We outline eight key SMS development steps, including: 1) determining if SMS is appropriate; 2) developing system architecture and programming; 3) developing theory-based messages; 4) developing SMS technology; 5) addressing international SMS delivery; 6) testing; 7) system training and technical support; and 8) cost considerations. We discuss lessons learned and extractable principles that may be of use to other mHealth and HBC researchers working in similar LMIC contexts.Trial registration Clinicaltrials.gov, NCT03342274 . Registered 10 November 2017.
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Affiliation(s)
- Frank T Materia
- Division of Health Services and Outcomes Research, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA.
| | - Joshua M Smyth
- Department of Biobehavioral Health, The Pennsylvania State University, University Park, PA, USA
- Penn State College of Medicine, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Thandi Puoane
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Lungiswa Tsolekile
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Kathy Goggin
- Division of Health Services and Outcomes Research, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA
- School of Medicine, University of Missouri - Kansas City, Kansas City, MO, USA
- School of Pharmacy, University of Missouri - Kansas City, Kansas City, MO, USA
| | - Stephen R Kodish
- Department of Biobehavioral Health, The Pennsylvania State University, University Park, PA, USA
- Department of Nutritional Sciences, The Pennsylvania State University, University Park, PA, USA
| | - Andrew T Fox
- Division of Health Services and Outcomes Research, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Ken Resnicow
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | | | - Delwyn Catley
- School of Medicine, University of Missouri - Kansas City, Kansas City, MO, USA
- Center for Children's Healthy Lifestyles and Nutrition, Children's Mercy Kansas City, Kansas City, MO, USA
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Rodas-Moya S, Giudici FM, Owolabi A, Samuel F, Kodish SR, Lachat C, Abreu TC, van het Hof KH, Osendarp SJM, Brouwer ID, Feskens EJM, Melse-Boonstra A. A generic theory of change-based framework with core indicators for monitoring the effectiveness of large-scale food fortification programs in low- and middle-income countries. Front Nutr 2023; 10:1163273. [PMID: 37426192 PMCID: PMC10324612 DOI: 10.3389/fnut.2023.1163273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/17/2023] [Indexed: 07/11/2023] Open
Abstract
Large-scale food fortification (LSFF) programs are widely implemented in low- and middle-income countries (LMIC) to alleviate micronutrient deficiencies. However, these programs may not achieve the desired impact due to poor design or bottlenecks in program implementation. Monitoring and evaluation (M&E) frameworks and a set of agreed indicators can help to benchmark progress and to strengthen the evidence-base of effectiveness in a standardized way. We aimed to formulate recommendations towards core indicators for evaluating the effectiveness of LSFF programs with their associated metrics, methods, and tools (IMMT). For this, we used a multi-method iterative approach, including a mapping review of the literature, semi-structured interviews with international experts, compilation of a generic Theory of Change (ToC) framework for LSFF program delivery, and selection of IMMT for M&E of LSFF programs at key stages along the ToC delivery framework. Lastly, we conducted exploratory, qualitative interviews with key informants in Nigeria to explore experiences and perceptions related to the implementation of LSFF programs in Nigeria's context, and their opinion towards the proposed set of core IMMT. The literature search resulted in 14 published and 15 grey literature documents, from which we extracted a total of 41 indicators. Based on the available literature and interviews with international experts, we mapped a ToC delivery framework and selected nine core indicators at the output, outcome and impact level for M&E of the effectiveness of LSFF programs. Key informants in Nigeria revealed that the main bottlenecks for implementation of the proposed IMMT are related to the lack of technical capacity, equipment, laboratory infrastructure, and financial resources. In conclusion, we propose a set of nine core indicators for enabling comprehensive M&E of the effectiveness of LSFF programs in LMIC. This proposed set of core indicators can be used for further evaluation, harmonization and integration in national and international protocols for M&E of LSFF programs.
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Affiliation(s)
- Santiago Rodas-Moya
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
| | - Francesca M. Giudici
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
| | - Adedotun Owolabi
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
| | - Folake Samuel
- Department of Human Nutrition and Dietetics, College of Medicine, Faculty of Public Health, University of Ibadan, Ibadan, Oyo State, Nigeria
| | - Stephen R. Kodish
- Department of Nutritional Sciences and Biobehavioral Health, Pennsylvania State University, University Park, PA, United States
| | - Carl Lachat
- Department of Food Technology, Safety and Health, Faculty of Bioscience Engineering, Ghent University, Ghent, Belgium
| | - Taymara C. Abreu
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
- Department of Epidemiology and Data Science, Amsterdam UMC, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Karin H. van het Hof
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
| | - Saskia J. M. Osendarp
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
- The Micronutrient Forum, Washington, DC, United States
| | - Inge D. Brouwer
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
| | - Edith J. M. Feskens
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
| | - Alida Melse-Boonstra
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
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Kodish SR, Allen BGS, Salou H, Schwendler TR, Isanaka S. Conceptualising factors impacting nutrition services coverage of treatment for acute malnutrition in children: an application of the Three Delays Model in Niger. Public Health Nutr 2023; 26:1074-1081. [PMID: 34620262 PMCID: PMC10346043 DOI: 10.1017/s1368980021004286] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 09/16/2021] [Accepted: 10/05/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVE The Three Delays Model is a conceptual model traditionally used to understand contributing factors of maternal mortality. It posits that most barriers to health services utilisation occur in relation to one of three delays: (1) Delay 1: delayed decision to seek care; (2) Delay 2: delayed arrival at health facility and (3) Delay 3: delayed provision of adequate care. We applied this model to understand why a community-based management of acute malnutrition (CMAM) services may have low coverage. DESIGN We conducted a Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) over three phases using mixed methods to estimate programme coverage and barriers to care. In this manuscript, we present findings from fifty-one semi-structured interviews with caregivers and programme staff, as well as seventy-two structured interviews among caregivers only. Recurring themes were organised and interpreted using the Three Delays Model. SETTING Madaoua, Niger. PARTICIPANTS Totally, 123 caregivers and CMAM program staff. RESULTS Overall, eleven barriers to CMAM services were identified in this setting. Five barriers contribute to Delay 1, including lack of knowledge around malnutrition and CMAM services, as well as limited family support, variable screening services and alternative treatment options. High travel costs, far distances, poor roads and competing demands were challenges associated with accessing care (Delay 2). Finally, upon arrival to health facilities, differential caregiver experiences around quality of care contributed to Delay 3. CONCLUSIONS The Three Delays Model was a useful model to conceptualise the factors associated with CMAM uptake in this context, enabling implementing agencies to address specific barriers through targeted activities.
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Affiliation(s)
- Stephen R Kodish
- Pennsylvania State University, Departments of Nutritional Sciences and Biobehavioral Health, 110 Chandlee Lab, University Park, PA16802, USA
| | - Ben GS Allen
- Technical Support Team, GNC Technical Alliance, Action Against Hunger Canada, Toronto, Canada
| | | | - Teresa R Schwendler
- Pennsylvania State University, Departments of Nutritional Sciences and Biobehavioral Health, 110 Chandlee Lab, University Park, PA16802, USA
| | - Sheila Isanaka
- Epicentre, Research Department, Paris, France
- Harvard T.H. Chan School of Public Health, Departments of Nutrition and Global Health and Population, Boston, MA, USA
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Schwendler TR, Rowel D, Abdulloeva S, Jayawickrama H, de Silva C, Romano O, Senarath U, Kodish SR. A comparison of observed feeding practices of infants and young children aged 6-23 months to national responsive feeding recommendations in Sri Lanka. Matern Child Nutr 2023:e13522. [PMID: 37072687 DOI: 10.1111/mcn.13522] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 02/26/2023] [Accepted: 04/02/2023] [Indexed: 04/20/2023]
Abstract
To describe the extent to which Sri Lankan caregivers follow current national responsive feeding recommendations and the factors limiting and enabling those behaviours. Study design. This ethnographic substudy was conducted using a four-phase, mixed methods formative research design across rural, estate and urban sectors of Sri Lanka. Data collection methods. Data were collected using direct meal observations and semistructured interviews. Participants including infants and young children aged 6-23 months (n = 72), community leaders (n = 10), caregivers (n = 58) and community members (n = 37) were purposefully sampled to participate in this study. Data analysis. Observational data were summarized using descriptive statistics while textual data were analysed thematically using Dedoose. Findings were then interpreted vis-à-vis six national responsive feeding recommendations. During observed feeding episodes, caregivers were responsive to nearly all food requests (87.2% [34/39]) made by infants and young children. Many caregivers (61.1% [44/72]) also positively encouraged their infant and young child during feeding. Despite some responsive feeding practices being observed, 36.1% (22/61) of caregivers across sectors used forceful feeding practices if their infant or young child refused to eat. Interviews data indicated that force-feeding practices were used because caregivers wanted their infants and young children to maintain adequate weight gain for fear of reprimand from Public Health Midwives. Despite overall high caregiver knowledge of national responsive feeding recommendations in Sri Lanka, direct observations revealed suboptimal responsive feeding practices, suggesting that other factors in the knowledge-behaviour gap may need to be addressed.
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Affiliation(s)
- Teresa R Schwendler
- Department of Nutritional Sciences, Pennsylvania State University, State College, Pennsylvania, USA
| | - Dhammica Rowel
- United Nations Children's Fund, Sri Lanka, Colombo, Sri Lanka
| | | | | | | | - Olivia Romano
- Department of Nutritional Sciences, Pennsylvania State University, State College, Pennsylvania, USA
| | - Upul Senarath
- Department of Community Medicine, University of Colombo, Colombo, Sri Lanka
| | - Stephen R Kodish
- Department of Nutritional Sciences, Pennsylvania State University, State College, Pennsylvania, USA
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Grey K, Kodish SR, Namohunu SA, Losi J, Matean M, Palaniappan U, Northrup-Lyons M, Cherian A, Gwavuya S, McLean J, Erasmus W. Determinants of maternal, infant, and young child nutrition during the 1,000-day window of opportunity in Solomon Islands: A focused ethnographic study. Front Nutr 2023; 9:1082161. [PMID: 36742003 PMCID: PMC9893623 DOI: 10.3389/fnut.2022.1082161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 12/30/2022] [Indexed: 01/20/2023] Open
Abstract
Introduction This focused ethnographic study used qualitative, ethnographic, and participatory methods to explore determinants of maternal, infant, and young child nutrition (MIYCN) during the first 1,000 days of life as part of efforts to address the double burden of malnutrition in Solomon Islands. Methods An iterative study design was used to first explore and then confirm findings related to food and nutrition security and social and behavioral determinants of MIYCN in urban and rural settings. The first phase included in-depth interviews, household observations, free lists, and seasonal food availability calendar workshops while the second phase included focus group discussions, pile sorts, participatory community workshops, and repeated household observations. Results and discussion We found that MIYCN is shaped by a complex interaction of factors at the macro- and micro-levels. At the macro-level, globalization of the food system, a shifting economy, and climate change are driving a shift toward a delocalized food system based on imported processed foods. This shift has contributed to a food environment that leaves Solomon Islanders vulnerable to food and nutrition insecurity, which we found to be the primary determinant of MIYCN in this context. At the micro-level, this food environment leads to household- and individual-level food decisions that often do not support adequate MIYCN. Multi-sectoral interventions that address the macro- and micro-level factors shaping this nutrition situation may help to improve MIYCN in Solomon Islands.
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Affiliation(s)
- Kelsey Grey
- Nourish Global Nutrition, Vancouver, BC, Canada,*Correspondence: Kelsey Grey,
| | - Stephen R. Kodish
- Chandlee Lab, Department of Nutritional Sciences, Pennsylvania State University, University Park, PA, United States,Chandlee Lab, Department of Biobehavioral Health, Pennsylvania State University, University Park, PA, United States
| | | | - Jill Losi
- Ministry of Health and Medical Services, Honiara, Solomon Islands
| | | | | | | | | | | | - Judy McLean
- Nourish Global Nutrition, Vancouver, BC, Canada
| | - Wendy Erasmus
- United Nations Children’s Fund (UNICEF) Pacific, Suva, Fiji
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Ruggiero CF, Moore AM, Marini ME, Kodish SR, Jones DE, McHale SM, Savage JS. Resource dilution in maternal feeding practices after birth of a secondborn. Appetite 2023; 180:106367. [PMID: 36356911 PMCID: PMC9910362 DOI: 10.1016/j.appet.2022.106367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/15/2022] [Accepted: 11/05/2022] [Indexed: 11/09/2022]
Abstract
Firstborn children have higher prevalence of obesity than secondborn siblings. The birth of a sibling typically results in resource dilution when mothers begin to divide their time and attention between two children. This mixed-methods analysis applies the family systems process of resource dilution to test the hypothesis that characteristics of the secondborn impact how parents feed the firstborn. Participants (n = 76) were mothers of consecutively born firstborn and secondborn siblings who participated in the INSIGHT trial and an observational cohort. Quantitative analyses involved multilevel models to test if characteristics of secondborns (temperament at 16 weeks, appetite at 28 weeks) were associated with maternal feeding practices of firstborns (structure and control-based feeding) at 1, 2, and 3 years, adjusting for firstborn child characteristics. A purposive subsample (n = 30) of mothers participated in semi-structured interviews to contextualize potential sibling influences on maternal feeding practices during infancy and toddlerhood. Quantitative data showed secondborn temperament and appetite were associated with how mothers fed their firstborn. Qualitative data explained maternal feeding practices in three primary ways: 1) Mothers explained shifting predictable meal and snack routines after birth of the secondborn, but did not perceive sibling characteristics as the source; 2) Family chaos following the secondborn's birth led to "survival mode" in feeding; and 3) Social support was protective against feeding resource dilution. The family systems process of resource dilution is a focus for future research and support for families during key transitions and a direction for efforts to reduce risk for child obesity.
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Affiliation(s)
- Cara F Ruggiero
- Center for Childhood Obesity Research, 129 Noll Laboratory, The Pennsylvania State University, University Park, PA, 16802, USA; Nutritional Sciences, 110 C Chandlee Laboratory, The Pennsylvania State University, University Park, PA, 16802, USA.
| | - Amy M Moore
- Center for Childhood Obesity Research, 129 Noll Laboratory, The Pennsylvania State University, University Park, PA, 16802, USA.
| | - Michele E Marini
- Center for Childhood Obesity Research, 129 Noll Laboratory, The Pennsylvania State University, University Park, PA, 16802, USA.
| | - Stephen R Kodish
- Nutritional Sciences, 110 C Chandlee Laboratory, The Pennsylvania State University, University Park, PA, 16802, USA; Department of Biobehavioral Health, 219 Biobehavioral Health Building, The Pennsylvania State University, University Park, PA, 16802, USA.
| | - Damon E Jones
- Edna Bennett Pierce Prevention Research Center, 314 Biobehavioral Health Building, The Pennsylvania State University, University Park, PA, 16802, USA.
| | - Susan M McHale
- Department of Human Development and Family Studies, 114 Henderson, The Pennsylvania State University, University Park, PA, 16802, USA.
| | - Jennifer S Savage
- Center for Childhood Obesity Research, 129 Noll Laboratory, The Pennsylvania State University, University Park, PA, 16802, USA; Nutritional Sciences, 110 C Chandlee Laboratory, The Pennsylvania State University, University Park, PA, 16802, USA.
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9
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Rodas-Moya S, Giudici FM, Mudyahoto B, Birol E, Kodish SR, Lachat C, Abreu TC, Melse-Boonstra A, van het Hof KH, Brouwer ID, Osendarp S, Feskens EJM. Critical review of indicators, metrics, methods, and tools for monitoring and evaluation of biofortification programs at scale. Front Nutr 2022; 9:963748. [PMID: 36313073 PMCID: PMC9607891 DOI: 10.3389/fnut.2022.963748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 09/26/2022] [Indexed: 11/13/2022] Open
Abstract
Sound monitoring and evaluation (M&E) systems are needed to inform effective biofortification program management and implementation. Despite the existence of M&E frameworks for biofortification programs, the use of indicators, metrics, methods, and tools (IMMT) are currently not harmonized, rendering the tracking of biofortification programs difficult. We aimed to compile IMMT for M&E of existing biofortification programs and recommend a sub-set of high-level indicators (HLI) for a harmonized global M&E framework. We conducted (1) a mapping review to compile IMMT for M&E biofortification programs; (2) semi-structured interviews (SSIs) with biofortification programming experts (and other relevant stakeholders) to contextualize findings from step 1; and (3) compiled a generic biofortification program Theory of Change (ToC) to use it as an analytical framework for selecting the HLI. This study revealed diversity in seed systems and crop value chains across countries and crops, resulting in differences in M&E frameworks. Yet, sufficient commonalities between implementation pathways emerged. A set of 17 HLI for tracking critical results along the biofortification implementation pathway represented in the ToC is recommended for a harmonized global M&E framework. Further research is needed to test, revise, and develop mechanisms to harmonize the M&E framework across programs, institutions, and countries.
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Affiliation(s)
- Santiago Rodas-Moya
- Division of Human Nutrition and Health, Wageningen University, Wageningen, Netherlands,*Correspondence: Santiago Rodas-Moya,
| | - Francesca M. Giudici
- Division of Human Nutrition and Health, Wageningen University, Wageningen, Netherlands
| | - Bho Mudyahoto
- HarvestPlus, c/o International Food Policy Research Institute, Washington, DC, United States
| | - Ekin Birol
- Edmund A. Walsh School of Foreign Service, Global Human Development Program, Washington, DC, United States
| | - Stephen R. Kodish
- Department of Nutritional Sciences and Biobehavioral Health, Pennsylvania State University, University Park, PA, United States
| | - Carl Lachat
- Department of Food Technology, Safety and Health, Faculty of Bioscience Engineering, Ghent University, Ghent, Belgium
| | - Taymara C. Abreu
- Division of Human Nutrition and Health, Wageningen University, Wageningen, Netherlands,Department of Epidemiology and Data Science, Amsterdam UMC, Location VUmc, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Alida Melse-Boonstra
- Division of Human Nutrition and Health, Wageningen University, Wageningen, Netherlands
| | - Karin H. van het Hof
- Division of Human Nutrition and Health, Wageningen University, Wageningen, Netherlands
| | - Inge D. Brouwer
- Division of Human Nutrition and Health, Wageningen University, Wageningen, Netherlands
| | - Saskia Osendarp
- Division of Human Nutrition and Health, Wageningen University, Wageningen, Netherlands,The Micronutrient Forum, Washington, DC, United States
| | - Edith J. M. Feskens
- Division of Human Nutrition and Health, Wageningen University, Wageningen, Netherlands
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Dou N, Shakya E, Ngoutane RM, Garnier D, Kouame OR, Dain AL, Garg A, Kodish SR, Caulfield LE, Murray‐Kolb LE, Na M. Promising trends and influencing factors of complementary feeding practices in Côte d'Ivoire: An analysis of nationally representative survey data between 1994 and 2016. Matern Child Nutr 2022; 19:e13418. [PMID: 36069310 PMCID: PMC9749586 DOI: 10.1111/mcn.13418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 07/13/2022] [Accepted: 07/18/2022] [Indexed: 12/15/2022]
Abstract
Poor complementary feeding (CF) challenges early childhood growth. We examined the trends and influencing factors of CF practices among children aged 6-23 months in Côte d'Ivoire. Using data from Demographic and Health Surveys (DHS, 1994-2011) and Multiple Indicator Cluster Surveys (MICS, 2000-2016), the trends and predictors of World Health Organization-United Nations International Children's Emergency Fund CF indicators including the timely introduction of complementary foods (INTRO), minimum meal frequency (MMF), minimum dietary diversity (MDD) and minimum acceptable diet (MAD) were determined. Using 2016 MICS data, we applied multivariate logistic regression models to identify factors associated with CF indicators. Between 1994 and 2016, the mean proportion of children aged 6-8 months achieving INTRO was 56.9% and increased by about 25% points since 2006. Over 2011-2016, the proportion of children aged 6-23 months meeting MMF, MDD and MAD increased from 40.2% to 47.7%, 11.3% to 26.0% and 4.6% to 12.5%, respectively. Older children and those from urban households had higher odds of meeting MDD and MAD. Maternal TV watching was associated with higher odds of meeting MDD. The secondary or higher education levels of mothers significantly predicted higher odds of meeting INTRO and MDD. Currently, breastfeeding was also positively associated with odds of meeting MMF and MAD. Children from poorer households had lower odds of meeting MMF, MDD and MAD. Despite the improvements, CF practices remain suboptimal in Côte d'Ivoire. Influencing factors associated with CF were distributed across individual, household and community levels, calling for future programmes and policies to implement multi-level strategies to improve young children's diet in Côte d'Ivoire.
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Affiliation(s)
- Nan Dou
- Department of Nutritional Sciences, College of Health and Human DevelopmentThe Pennsylvania State UniversityUniversity ParkPennsylvaniaUSA
| | - Evaniya Shakya
- Department of Nutritional Sciences, College of Health and Human DevelopmentThe Pennsylvania State UniversityUniversity ParkPennsylvaniaUSA
| | - Raphia M. Ngoutane
- Department of Nutritional Sciences, College of Health and Human DevelopmentThe Pennsylvania State UniversityUniversity ParkPennsylvaniaUSA
| | | | - Oka R. Kouame
- National Nutrition Programme, Ministry of Health and Public HygieneAbidjanCôte d'Ivoire
| | | | | | | | - Laura E. Caulfield
- Department of International Health, Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Laura E. Murray‐Kolb
- Department of Nutrition Science, College of Health and Human SciencesPurdue UniversityWest LafayetteIndianaUSA
| | - Muzi Na
- Department of Nutritional Sciences, College of Health and Human DevelopmentThe Pennsylvania State UniversityUniversity ParkPennsylvaniaUSA
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11
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Ruggiero CF, Moore AM, Marini ME, Kodish SR, McHale SM, Savage JS. A mixed methods study of siblings’ roles in maternal feeding practices in early childhood: an application of the learning from experience process. Int J Behav Nutr Phys Act 2022; 19:64. [PMID: 35672783 PMCID: PMC9171978 DOI: 10.1186/s12966-022-01302-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/19/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Firstborn children have higher rates of obesity compared to secondborns, perhaps due, in part, to differential feeding practices. Despite the centrality of siblings in family life and potential for influence, almost nothing is known about the role of siblings in parent feeding practices in early childhood.
Methods
Participants (n = 117) were mothers of consecutively born siblings. Firstborns participated in an RCT that compared a responsive parenting intervention designed for primary prevention of obesity against a safety control. Secondborns participated in an observational cohort. Multilevel models tested whether and how firstborn characteristics (temperament, appetite, rapid weight gain) at 16 weeks and 1 year were associated maternal feeding practices of secondborns in infancy at 16 weeks, 28 weeks, and 1 year (food to soothe) and at ages 1, 2, and 3 years (structure-and control-based feeding practices). A purposive subsample (n = 30) of mothers also participated in semi-structured interviews to further illuminate potential sibling influences on maternal feeding practices during infancy and toddlerhood.
Results
Firstborn characteristics did not predict secondborn feeding in infancy (all ps > 0.05). Firstborn negative affect, however, predicted mothers’ less consistent mealtime routines (b (SE) = − 0.27 (0.09); p = 0.005) and more pressure (b (SE) = 0.38 (0.12); p = 0.001). Firstborn appetite predicted mothers’ less frequent use of food to soothe (b (SE) = − 0.16 (0.07); p = 0.02) when secondborns were toddlers. Firstborn surgency, regulation, and rapid weight gain, however, did not predict secondborn feeding practices during toddlerhood (all ps > 0.05). Interviews with mothers revealed three ways that maternal experiences with firstborns informed feeding practices of secondborns: 1) Use of feeding practices with secondborn that worked for the firstborn; 2) Confidence came from firstborn feeding experiences making secondborn feeding less anxiety-provoking; and 3) Additional experiences with firstborn and other factors that contributed to secondborn feeding practices.
Conclusions
Some firstborn characteristics and maternal experiences with firstborns as well as maternal psychosocial factors may have implications for mothers’ feeding practices with secondborns. Together, these mixed methods findings may inform future research and family-based interventions focused on maternal feeding of siblings in early childhood.
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12
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Kodish SR, Matean M, Grey K, Palaniappan U, Northrup-Lyons M, Yalvigi A, Gwavuya S, Mclean J, Erasmus W. Conceptualizing multi-level determinants of infant and young child nutrition in the Republic of Marshall Islands-a socio-ecological perspective. PLOS Glob Public Health 2022; 2:e0001343. [PMID: 36962875 PMCID: PMC10022247 DOI: 10.1371/journal.pgph.0001343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 11/23/2022] [Indexed: 12/24/2022]
Abstract
The East and Pacific region includes 14 Pacific Island Countries where, between 2000 and 2016, indicators of stunting, wasting, and micronutrient deficiencies have plateaued or worsened, while rates of overweight, obesity, and associated disease have risen. The Republic of Marshall Islands (RMI) is no exception: maternal and child nutrition indicators have not improved in decades. A study of the contemporary factors shaping the RMI nutrition situation was needed for informing policy and tailoring interventions. This formative study had an iterative design utilizing qualitative methods. An exploratory Phase 1 included 59 semi-structured interviews with community members, 86 free lists with caregivers, 8 participatory workshops, and 20 meal observations (round 1). Findings were synthesized to inform a confirmatory Phase 2 where 13 focus groups, 81 pile sorts, 15 meal observations (round 2), and 2 seasonal food availability workshops were conducted. Textual data were analyzed thematically using NVivo while cultural domain analysis was conducted in Anthropac. RMI faces interrelated challenges that contribute to a lack of nutritious and local food availability, which is compounded by high food costs relative to household incomes. A decades-long cultural transition from local to processed diets has resulted in infant and young child diets now characterized by morning meals of doughnuts, bread, and ramen with tea, coffee, or Kool-Aid and afternoon meals that include rice with canned meats (e.g., store-bought chicken, hot dogs). Individual preferences for processed food imports have increased their supply. Low maternal risk perception toward nutrition-related illnesses may further explain sub-optimal diets. Improving the RMI food environment will require approaches that align with the multi-level determinants of sub-optimal diets found in this study. As the ten-year 2013 RMI Food Security Policy soon ends, study findings may be used to inform new policy development and investments for improving the nutrition situation.
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Affiliation(s)
- Stephen R Kodish
- Department of Nutritional Sciences, Pennsylvania State University, University Park, Pennsylvania, United States of America
- Department of Biobehavioral Health, Pennsylvania State University, University Park, Pennsylvania, United States of America
| | - Maryam Matean
- Nourish Global Nutrition, Vancouver, British Columbia, Canada
| | - Kelsey Grey
- Nourish Global Nutrition, Vancouver, British Columbia, Canada
| | | | | | - Akshata Yalvigi
- College of Medicine, Pennsylvania State University, Hershey, Pennsylvania, United States of America
| | | | - Judy Mclean
- Nourish Global Nutrition, Vancouver, British Columbia, Canada
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13
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Kodish SR, Isokpunwu C, Osunkentan T, Imohe A, Ejembi CL, Chitekwe S, Wagt AD, Mathema P. Acceptance and compliance with micronutrient powder (MNP) among children aged 6-23 months in northern Nigeria. PLOS Glob Public Health 2022; 2:e0000961. [PMID: 36962580 PMCID: PMC10022258 DOI: 10.1371/journal.pgph.0000961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 08/29/2022] [Indexed: 03/26/2023]
Abstract
This study sought to understand the utilization patterns and influencing factors of micronutrient powder (MNP) use among children aged 6-23 months in northern Nigeria as part of formative research to inform the design of an infant and young child feeding (IYCF) intervention. It had an iterative, multi-phase design whereby mixed methods data were collected from 144 households participating in an 8-week home-feeding trial. During the first four weeks, 12-hour direct observations were conducted with 24 households using MNP. Over the next four weeks, 18 of the same households were observed. In-depth interviews were also conducted among 27 caregivers to understand factors related to utilization. Unannounced spot checks (n = 86) were also conducted to gauge MNP compliance. Most households (76.7%) (66/86) adhered to instructions for using MNP (Adamawa (34/44 = 77.3%) and Kebbi (32/42 = 76.2%)). Facilitating factors to MNP adherence were identified, most notably the high ease of utilization, with 90.0% of caregivers indicating the MNP was 'easy' or 'very easy' to use. Several barriers to MNP compliance were identified and organized into three domains: product-related (e.g. difficulty opening sachet), child-related (e.g. not finishing fortified staple), and caregiver-related (e.g. difficulty making food daily). In Kebbi and Adamawa, MNP was accepted and utilized according to guidelines among most study participants. Findings may be used for scaling up MNP within a more comprehensive IYCF intervention in northern Nigeria.
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Affiliation(s)
- Stephen R Kodish
- Department of Nutritional Sciences, Pennsylvania State University, University Park, Pennsylvania, United States of America
- Department of Biobehavioral Health, Pennsylvania State University, University Park, Pennsylvania, United States of America
| | | | - Tobi Osunkentan
- Nutrition Section, United Nations Children's Fund (UNICEF), Abuja, Nigeria
| | - Annette Imohe
- Nutrition Section, United Nations Children's Fund (UNICEF), Abuja, Nigeria
| | | | - Stanley Chitekwe
- Nutrition Section, United Nations Children's Fund (UNICEF), Abuja, Nigeria
| | - Arjan de Wagt
- Nutrition Section, United Nations Children's Fund (UNICEF), Abuja, Nigeria
| | - Pragya Mathema
- Nutrition Section, United Nations Children's Fund (UNICEF), Abuja, Nigeria
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14
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Kodish SR, Farhikhtah A, Mlambo T, Hambayi MN, Jones V, Aburto NJ. Leveraging the Scaling Up Nutrition Movement to Operationalize Stunting Prevention Activities: Implementation Lessons From Rural Malawi. Food Nutr Bull 2021; 43:104-120. [PMID: 34747237 DOI: 10.1177/03795721211046140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The rural district of Ntchisi is in the central region of Malawi. Among children aged 6 to 23 months, the stunting prevalence is 40% to 50%. To address this high prevalence, the World Food Programme, with cooperating partners, supported the Government of Malawi to implement an integrated stunting prevention program entitled The Right Foods at the Right Time from 2013 to 2018. OBJECTIVE To provide implementation lessons learned from systematic documentation of how the Scaling Up Nutrition (SUN) movement, combined with other international and national initiatives and policies, was translated into tailored programming. METHODS During program conception, early design, and implementation, this descriptive study systematically documented the process of translating SUN principles and government policies into an operational stunting prevention program in rural Malawi. RESULTS We identified 8 factors that contributed to successful translation of policy into program activities: (1) well-structured National SUN framework, (2) reliable coordination platforms and district ownership, (3) systematic and evidence-informed program design, (4) multiple forms of data used to inform program planning, (5) multisectoral implementation approaches to stunting prevention, (6) innovation in technology to improve overall program efficiency, (7) systematic collaboration among diverse stakeholders, and (8) strong public health nutrition capacity of program team members. CONCLUSIONS Lessons from this nutrition program in Ntchisi, Malawi, provide one case illustrating how the SUN movement, government policies, and global evidence base can be operationalized into tailored programming for improving nutrition.
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Affiliation(s)
- Stephen R Kodish
- United Nations World Food Programme Headquarters, Rome, Italy.,The Pennsylvania State University, University Park, PA, USA
| | - Arghanoon Farhikhtah
- United Nations World Food Programme Headquarters, Rome, Italy.,Food and Agriculture Organization of the United Nations, Rome, Italy
| | - Trust Mlambo
- United Nations World Food Programme, Lilongwe, Malawi
| | | | - Vanessa Jones
- United Nations World Food Programme Headquarters, Rome, Italy
| | - Nancy J Aburto
- United Nations World Food Programme Headquarters, Rome, Italy.,Food and Agriculture Organization of the United Nations, Rome, Italy
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15
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Shah B, Krishnan N, Kodish SR, Yenokyan G, Fatema K, Burhan Uddin K, Rahman AKMF, Razzak J. Applying the Three Delays Model to understand emergency care seeking and delivery in rural Bangladesh: a qualitative study. BMJ Open 2020; 10:e042690. [PMID: 33361169 PMCID: PMC7759951 DOI: 10.1136/bmjopen-2020-042690] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The Three Delays Model has been commonly used to understand and prevent maternal mortality but has not been systematically applied to emergency medical conditions more generally. The objective of this study was to identify delays in emergency medical care seeking and delivery in rural Bangladesh and factors contributing to these delays by using the Three Delays Model as a framework. DESIGN A qualitative approach was used. Data were collected through focus group discussions and in-depth interviews using semistructured guides. Two analysts jointly developed a codebook iteratively and conducted a thematic analysis to triangulate results. SETTING Six unions in Raiganj subdistrict of Bangladesh. PARTICIPANTS Eight focus group discussions with community members (n=59) and eight in-depth interviews with healthcare providers. RESULTS Delays in the decision to seek care and timely receipt of care on reaching a health facility were most prominent. The main factors influencing care-seeking decisions included ability to recognise symptoms and decision-making power. Staff and resource shortages and lack of training contributed to delays in receiving care. Delay in reaching care was not perceived as a salient barrier. Both community members and healthcare providers expressed interest in receiving training to improve management of emergency conditions. CONCLUSIONS The Three Delays Model is a practical framework that can be useful for understanding barriers to emergency care and developing more tailored interventions. In rural Bangladesh, training community members and healthcare providers to recognise symptoms and manage acute conditions can reduce delays in care seeking and receiving adequate care at health facilities.
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Affiliation(s)
- Bansari Shah
- Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Nandita Krishnan
- Prevention and Community Health, The George Washington University Milken Institute of Public Health, Washington, DC, USA
| | - Stephen R Kodish
- Nutritional Sciences and Biobehavioral Health, Pennsylvania State University, University Park, Pennsylvania, USA
| | - Gayane Yenokyan
- Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Kaniz Fatema
- Center for Injury Prevention and Research, Dhaka, Bangladesh
| | | | | | - Junaid Razzak
- Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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16
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Rios-Castillo I, Alvarado K, Kodish SR, Molino J, Ávila R, Lebrija A. Educación alimentaria y nutricional para reducir la obesidad en escolares de Panamá: protocolo de estudio. Rev Esp Nutr Hum Diet 2020. [DOI: 10.14306/renhyd.24.1.776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
El sobrepeso en escolares representa un creciente problema de salud pública en Panamá. El objetivo es desarrollar y validar un programa de intervención en educación alimentaria y nutricional (EAN) contra el sobrepeso y la obesidad en escolares de Panamá bajo la perspectiva de una política pública intersectorial de salud y educación. La intervención se basa en el cambio de conducta bajo el modelo socio-ecológico que favorezca la adopción de comportamientos alimentarios y de estilos de vida más saludables. Se trata de un estudio en 768 escolares de diseño cuasi experimental, pre-post intervención, prospectivo y sin grupo control, de tipo observacional explicativo en instituciones de educación básica general del sector público en tres Distritos de Panamá Oeste: La Chorrera, Capira y Chame. Se seleccionaron 5 escuelas, la escuela Victoria DˈSpinay y La Herradura en el Distrito de La Chorrera, la escuela Hernando Bárcenas en el Distrito de Capira y las escuelas El Espavé y Berta Elida Fernández en el Distrito de Chame. El protocolo fue registrado en la plataforma internacional de ensayos Nº ISRCTN28920505. Se obtendrán datos sociodemográficos, antropométricos, nutricionales y alimentarios; de seguridad alimentaria; y de conocimiento, actitud, percepción y comportamiento sobre alimentación y estilos de vida saludables de marzo a diciembre de 2019 durante la implementación del programa intersectorial denominado “Escuelas Saludables” del Ministerio de Salud y del Ministerio de Educación de Panamá. Se describirán y compararán los datos utilizando estadística paramétrica y no paramétrica. El protocolo de estudio fue revisado y aprobado por el Comité de Bioética de la Universidad de Panamá (Ref. CBUP/Nº075/2019), registrado en la Dirección General de Salud (DIGESA) del MINSA (Nº 881). Se solicitará consentimiento informado firmado por parte de los acudientes y asentimiento por cada niño participante. Los resultados del estudio serán difundidos ampliamente en revistas indexadas de revisión de pares y en congresos de salud y nutrición.Número de registro de protocolo: ISRCTN28920505.
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17
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Kodish SR, Simen-Kapeu A, Beauliere JM, Ngnie-Teta I, Jalloh MB, Pyne-Bailey S, Schwartz H, Wirth JP. Consensus building around nutrition lessons from the 2014-16 Ebola virus disease outbreak in Guinea and Sierra Leone. Health Policy Plan 2019; 34:83-91. [PMID: 30753437 PMCID: PMC6481283 DOI: 10.1093/heapol/czy108] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2018] [Indexed: 11/15/2022] Open
Abstract
There are important lessons learned from the 2014-16 Ebola virus disease outbreak in West Africa. However, there has not been a systematic documentation of nutrition lessons specifically. Therefore, this study sought to generate multiple stakeholder perspectives for understanding the nutrition challenges faced during the Ebola virus disease outbreak, as well as for consensus building around improved response strategies. Participatory workshops with 17 and 19 participants in Guinea and Sierra Leone, respectively, were conducted in February 2017. Workshops followed the Nominal Group Technique, which is a methodological approach for idea generation and consensus building among diverse participants. Those findings were triangulated with qualitative interview data from participants representing government, United Nations bodies, civil society, non-governmental organizations and local communities in both Guinea (n = 27) and Sierra Leone (n = 42). (1) Reduced health system access and utilization, Poor caretaking and infant and young child feeding practices, Implementation challenges during nutrition response, Household food insecurity and Changing breastfeeding practices were five nutrition challenges identified in both Guinea and Sierra Leone. (2) Between settings, 14 distinct and 11 shared organizational factors emerged as facilitators to this response. In Sierra Leone, participants identified the Use of Standard Operating Procedures and Psychosocial counselling, whereas in Guinea, Hygiene assistance was distinctly important. Political will, Increased funding, Food assistance and to a lesser extent, Enhanced coordination, were deemed 'most important' response factors. (3) The top nutrition lessons learned were diverse, reflecting those of nutrition policy, programme implementation, community activity and household behaviours. Disease outbreaks pose widespread nutrition challenges to populations in resource-constrained settings where global health security is not a guarantee. These findings should be considered for emergency nutrition preparedness and inform evidence-based priority setting in the post-Ebola virus context of Guinea and Sierra Leone.
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Affiliation(s)
| | - Aline Simen-Kapeu
- UNICEF West and Central Africa Regional Office, Yoff, Dakar, Senegal
| | | | - Ismael Ngnie-Teta
- UNICEF West and Central Africa Regional Office, Yoff, Dakar, Senegal
| | | | - Solade Pyne-Bailey
- FOCUS 1000, 15 Main Motor Rd, Brookfields, PMB 393, Freetown, Sierra Leone
| | - Helen Schwartz
- Ministry of Health and Sanitation, Youyi Bldg, Brookfields, PMB 393, Freetown, Sierra Leone
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18
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Kodish SR, Bio F, Oemcke R, Conteh J, Beauliere JM, Pyne-Bailey S, Rohner F, Ngnie-Teta I, Jalloh MB, Wirth JP. A qualitative study to understand how Ebola Virus Disease affected nutrition in Sierra Leone-A food value-chain framework for improving future response strategies. PLoS Negl Trop Dis 2019; 13:e0007645. [PMID: 31504036 PMCID: PMC6736239 DOI: 10.1371/journal.pntd.0007645] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 07/19/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND This study sought understand how the 2014-2016 EVD Virus Disease (EVD) outbreak impacted the nutrition sector in Sierra Leone and use findings for improving nutrition responses during future outbreaks of this magnitude. METHODOLOGY This qualitative study was iterative and emergent. In-depth interviews (n = 42) were conducted over two phases by purposively sampling both key informants (n = 21; government stakeholders, management staff from United Nations (UN) agencies and non-governmental organizations (NGO)), as well as community informants (n = 21; EVD survivors, health workers, community leaders) until data saturation. Multiple analysts collaborated in a team-based coding approach to identify key themes using Dedoose software. Findings are presented as both quotations and tables/figures. RESULTS The EVD outbreak effects and the related response strategies, especially movement restriction policies including 21-day quarantines, contributed to disruptions across the food value-chain in Sierra Leone. System-wide impacts were similar to those typically seen in large-scale disasters such as earthquakes. Participants described an array of direct and indirect effects on agricultural production and food storage and processing, as well as on distribution, transport, trade, and retailing. Secondary data were triangulated by interviews which described the aggregate negative effect of this outbreak on key pillars of food security, infant and young child feeding practices, and nutrition. During the humanitarian response, nutrition-specific interventions, including food assistance, were highly accepted, although sharing was reported. Despite EVD impacts across the entire food value-chain, nutrition-sensitive interventions were not central to the initial response as EVD containment and survival took priority. Culturally-appropriate social and behavior change communications were a critical response component for improving health, nutrition, and hygiene-related behaviors through community engagement. CONCLUSIONS Infectious diseases such as EVD have far-reaching effects that impact health and nutrition through interrelated pathways. In Sierra Leone, the entire food value-chain was broken to the extent that the system-wide damage was on par with that typically resulting from large natural disasters. A food value-chain approach, at minimum, offers a foundational framework from which to position nutrition preparedness and response efforts for outbreaks in similar resource constrained settings.
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Isanaka S, Kodish SR, Mamaty AA, Guindo O, Zeilani M, Grais RF. Acceptability and utilization of a lipid-based nutrient supplement formulated for pregnant women in rural Niger: a multi-methods study. BMC Nutr 2019; 5:34. [PMID: 32153947 PMCID: PMC7050705 DOI: 10.1186/s40795-019-0298-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 06/24/2019] [Indexed: 01/20/2023] Open
Abstract
Background In food insecure settings, it may be difficult for pregnant women to meet increased nutritional needs through traditional diets. A promising new strategy to fill nutrient gaps in pregnancy involves the provision of lipid-based nutrient supplements (LNS). We aimed to assess the acceptability and utilization of a 40 g LNS formulation (Epi-E) with increased micronutrient content relative to the recommended daily allowance among pregnant women in rural Niger. Methods We conducted a two-part, multi-methods study among pregnant women presenting to antenatal care in Madarounfa, Niger during two periods (Ramadan and non-Ramadan). Part 1 included two LNS test meals provided at the health center, and Part 2 included a 14-day home trial to simulate more realistic conditions outside of the health center. Open- and closed-ended questions were used to assess organoleptic properties of Epi-E using a 5-point hedonic scale after the test meals, as well as utilization and willingness to pay for Epi-E after the 14-day home trial. Results Participants consumed more than 90% of the test meal in both periods. Epi-E was rated highly in terms of overall liking, color, taste and smell during test meals in both periods (median 5/5 for all); only time, mode and frequency of consumption varied between Ramadan and non-Ramadan periods in observance of daily fasting during the holy month. Conclusion Epi- E, a 40 g LNS formulation with increased micronutrient content, was highly acceptable among pregnant women in rural Niger, and utilization was guided by household and individual considerations that varied by time period. This formulation can be further tested as a potential strategy to improve the nutritional status of pregnant women in this context. Trial registration ClinicalTrials.gov Identifier: NCT02145000. Registered 22 May 2014.
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Affiliation(s)
- Sheila Isanaka
- 1Epicentre, 8 rue Saint Sabin, 75011 Paris, France.,2Harvard T.H. Chan School of Public Health, 665 Huntington Ave, Boston, MA 02115 USA
| | - Stephen R Kodish
- 2Harvard T.H. Chan School of Public Health, 665 Huntington Ave, Boston, MA 02115 USA
| | - Abdoul Aziz Mamaty
- Epicentre Niger, Quartier Plateau, Bd Maurice Delens Porte 206, 13330 Niamey, Niger
| | - Ousmane Guindo
- Epicentre Niger, Quartier Plateau, Bd Maurice Delens Porte 206, 13330 Niamey, Niger
| | - Mamane Zeilani
- Nutriset SAS, Route du Bois Ricard, 76770 Malaunay, France
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20
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Kodish SR, Grey K, Matean M, Palaniappan U, Gwavuya S, Gomez C, Iuta T, Timeon E, Northrup-Lyons M, McLean J, Erasmus W. Socio-Ecological Factors That Influence Infant and Young Child Nutrition in Kiribati: A Biocultural Perspective. Nutrients 2019; 11:nu11061330. [PMID: 31200550 PMCID: PMC6627610 DOI: 10.3390/nu11061330] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 05/31/2019] [Accepted: 06/04/2019] [Indexed: 11/16/2022] Open
Abstract
This study sought to elucidate the multi-level factors that influence behaviors underlying high childhood stunting and widespread micronutrient deficiencies in Kiribati. This two-phase formative research study had an emergent and iterative design using the socio-ecological model as the guiding theoretical framework. Phase 1 was exploratory while phase 2 was confirmatory. In phase 1, in-depth interviews, free lists, seasonal food availability calendar workshops, and household observations were conducted. In phase 2, focus group discussions, pile sorts, participatory workshops, and repeat observations of the same households were completed. Textual data were analyzed using NVivo software; ethnographic data were analyzed with Anthropac software for cultural domain analysis. We found a combination of interrelated structural, community, interpersonal, and individual-level factors contributing to the early child nutrition situation in Kiribati. Despite widespread knowledge of nutritious young child foods among community members, households make dietary decisions based not only on food availability and access, but also longstanding traditions and social norms. Diarrheal disease is the most salient young child illness, attributable to unsanitary environments and sub-optimal water, sanitation, and hygiene behaviors. This research underscores the importance of a multi-pronged approach to most effectively address the interrelated policy, community, interpersonal, and individual-level determinants of infant and young child nutrition in Kiribati.
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Affiliation(s)
- Stephen R Kodish
- Departments of Nutritional Sciences and Biobehavioral Health, Pennsylvania State University, University Park, PA 16802, USA.
- Nourish Global Nutrition, Vancouver, BC V6H 4A7, Canada.
| | - Kelsey Grey
- Nourish Global Nutrition, Vancouver, BC V6H 4A7, Canada.
| | - Maryam Matean
- Nourish Global Nutrition, Vancouver, BC V6H 4A7, Canada.
| | | | | | - Caitlin Gomez
- Nourish Global Nutrition, Vancouver, BC V6H 4A7, Canada.
| | | | - Eretii Timeon
- Ministry of Health and Medical Services, Bikenibau, Republic of Kiribati.
| | | | - Judy McLean
- Nourish Global Nutrition, Vancouver, BC V6H 4A7, Canada.
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Kodish SR, Rohner F, Beauliere JM, Daffe M, Ayoya MA, Wirth JP, Ngnie-Teta I. Correction: Implications of the Ebola virus disease outbreak in Guinea: Qualitative findings to inform future health and nutrition-related responses. PLoS One 2018; 13:e0204675. [PMID: 30281637 PMCID: PMC6169907 DOI: 10.1371/journal.pone.0204675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
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Rosen JG, Clermont A, Kodish SR, Matar Seck A, Salifou A, Grais RF, Isanaka S. Determinants of dietary practices during pregnancy: A longitudinal qualitative study in Niger. Matern Child Nutr 2018; 14:e12629. [PMID: 29956458 PMCID: PMC6175447 DOI: 10.1111/mcn.12629] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 04/22/2018] [Accepted: 04/25/2018] [Indexed: 11/28/2022]
Abstract
Undernutrition is associated with maternal morbidity and poor pregnancy outcomes. This qualitative study seeks to understand the multilevel factors influencing maternal dietary practices in Niger, including the impact of pregnancy illnesses on diet. Criterion-based, purposive sampling was used to select pregnant women and household members from 24 villages in a rural district of the Maradi Region in south-central Niger. Semistructured interviews (n = 153) and focus group discussions (n = 38) explored 4 primary themes: (a) perceptions of ideal diet during pregnancy, (b) barriers to consuming the ideal diet, (c) coping strategies including dietary responses related to pregnancy illnesses, and (d) changes in perceptions from early to late pregnancy. Longitudinal data collection allowed for repeated interviews of pregnant women to document changes in dietary practices throughout pregnancy. Transcripts were coded using an inductive approach informed by grounded theory methodology. Participants categorized foods into 4 primary dietary taxonomies when discussing ideal maternal diets but cited constraints related to accessibility and availability impeding routine consumption of these foods. Perceptions of "modern," urban foods as healthy, coupled with key structural barriers such as food costs, were identified. Maternal morbidity influenced food consumption, as women reported reducing food intake early in pregnancy in response to illness episodes. Although awareness of optimal foods for supporting healthy pregnancies was moderately high, some misconceptions were observed and multilevel barriers to food security restricted opportunities for consuming these foods. Nutrition-specific and nutrition-sensitive interventions could improve access and availability of acceptable foods for supporting increased dietary intake during pregnancy.
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Affiliation(s)
- Joseph G. Rosen
- Department of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Adrienne Clermont
- Department of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Stephen R. Kodish
- Department of NutritionHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | | | | | | | - Sheila Isanaka
- Department of NutritionHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
- Department of ResearchEpicentreParisFrance
- Department of Global Health and PopulationHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
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Kodish SR, Rohner F, Beauliere JM, Daffe M, Ag Ayoya M, Wirth JP, Ngnie-Teta I. Implications of the Ebola virus disease outbreak in Guinea: Qualitative findings to inform future health and nutrition-related responses. PLoS One 2018; 13:e0202468. [PMID: 30138407 PMCID: PMC6107191 DOI: 10.1371/journal.pone.0202468] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 08/03/2018] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Due to the close relationship between EVD and nutrition, the humanitarian community implemented various nutrition-specific and -sensitive interventions to stem the Ebola Virus Disease (EVD) outbreak in West Africa. Little, however, is known about stakeholder and community members' perspectives toward this response in Guinea. Therefore, we aimed to firstly understand how EVD may have influenced the nutrition situation; and secondly to assess the perceived acceptability and effectiveness of the nutrition response. MATERIALS AND METHODS Using 27 in-depth interviews conducted in April-May 2016, this descriptive, qualitative study had three iterative phases in an emergent design. Phase 1 explored the perceptions of 11 high-level policy and management staff. Phase 2 assessed the views of 16 community members, survivors, and front-line workers. Phase 3 compared the qualitative findings to relevant nutrition indicators from secondary data for final interpretations. A systematic, team-based coding approach using Dedoose software identified key themes during textual analysis. RESULTS Overall, several plausible pathways through an interrelated network of bio-social factors help describe EVD impacts on the nutrition situation of Guinea. At a basic level, complex social dimensions of health, response unpreparedness, and market disruptions were perceived to be major determinants affecting the nutrition situation, especially among IYC. At an underlying level, household food security was negatively impacted, along with weakened care-seeking practices, IYC feeding practices, and coping strategies. Consequently, treatment coverage for childhood illnesses and IYC diets were negatively impacted during the outbreak. In hindsight, most participants had positive perceptions toward the overall EVD response, but described salient considerations for improving upon this nutrition response during future outbreaks. DISCUSSION This study highlighted the complex web of inter-related factors through which EVD was perceived to impact the nutrition situation in Guinea. Considering the multi-level social and behavioral dimensions of health and nutrition is critical for effectively responding to infectious disease outbreaks.
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Clermont A, Kodish SR, Matar Seck A, Salifou A, Rosen J, Grais RF, Isanaka S. Acceptability and Utilization of Three Nutritional Supplements during Pregnancy: Findings from a Longitudinal, Mixed-Methods Study in Niger. Nutrients 2018; 10:nu10081073. [PMID: 30103529 PMCID: PMC6115835 DOI: 10.3390/nu10081073] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 08/09/2018] [Accepted: 08/10/2018] [Indexed: 01/07/2023] Open
Abstract
Nutritional status in pregnancy is a key determinant of birth outcomes. In low-income countries, maternal diets are often limited, and daily nutrient supplements are recommended to fill nutrient gaps. As a result, it is important to understand the factors influencing acceptability and utilization of nutrient supplements in these settings. Qualitative data (individual interviews and focus group discussions with pregnant women, household members, and study staff) and quantitative data (unannounced household spot checks) were collected in 24 villages in the Maradi region of south-central Niger. Each village was randomly assigned to one of three study arms, with pregnant women receiving either iron and folic acid (IFA) supplements, multiple micronutrient (MMN) supplements, or medium-quantity lipid-based nutrient supplements (MQ-LNS) for daily consumption during pregnancy. Data were collected longitudinally to capture changes in perspective as women progressed through their pregnancy. Participants accepted all three supplement types, and perceived a wide range of health benefits attributed to supplement consumption. However, several important barriers to appropriate consumption were reported, and rumors about the supplements leading to childbirth complications also decreased utilization. The household spot checks suggested that IFA had the highest level of correct consumption. Overall, despite a stated high level of acceptance and enthusiasm for the supplements among participants and their household members, certain fears, side effects, and organoleptic factors led to decreased utilization. The effectiveness of future programs to improve maternal nutritional status through supplementation may be improved by understanding perceived barriers and facilitating factors among participants and tailoring communication efforts appropriately.
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Affiliation(s)
- Adrienne Clermont
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.
| | - Stephen R Kodish
- Departments of Nutritional Sciences and Biobehavioral Health, Pennsylvania State University, University Park, PA 16802, USA.
| | | | | | - Joseph Rosen
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.
| | | | - Sheila Isanaka
- Department of Research, Epicentre, 75012 Paris, France.
- Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA.
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Isanaka S, Kodish SR, Berthé F, Alley I, Nackers F, Hanson KE, Grais RF. Outpatient treatment of severe acute malnutrition: response to treatment with a reduced schedule of therapeutic food distribution. Am J Clin Nutr 2017; 105:1191-1197. [PMID: 28404577 DOI: 10.3945/ajcn.116.148064] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 03/10/2017] [Indexed: 11/14/2022] Open
Abstract
Background: Community-based management of severe acute malnutrition (SAM) has been shown to be safe and cost-effective, but program coverage remains low. Treatment models that maintain high levels of clinical effectiveness but allow for increased coverage are still needed. A reduced schedule of follow-up, in which children receive clinical follow-up and therapeutic foods on a monthly rather than weekly basis, may be one alternative.Objective: We aimed to describe the safety and feasibility of a monthly distribution of ready-to-use therapeutic food (RUTF) in the treatment of uncomplicated SAM, in terms of clinical response to treatment and household RUTF use.Design: We conducted a nonrandomized pilot intervention study in which 115 children eligible for outpatient treatment of SAM were provided a monthly ration of RUTF. Anthropometric measurements were taken weekly for 4 wk to monitor treatment response. Unannounced household spot checks were conducted over 4 wk to assess household use of RUTF and storage practices.Results: Adequate weight and midupper arm circumference (MUAC) gain were found throughout the 4-wk follow-up period. Observed mean ± SD weight gain from admission was 9.8 ± 6.8 g · kg-1 · d-1 in week 1 and 4.2 ± 2.1 g · kg-1 · d-1 by week 4. Unplanned household spot checks found an average surplus of RUTF sachets compared with the number expected based on the date of distribution and recommended dosing throughout the 4 wk of follow-up. The frequency at which more than the recommended dose was used (i.e., deviance of >2 sachets between available and expected stocks) was 4% and 22% of households visited in week 1 and week 4, respectively.Conclusion: Adequate treatment response and RUTF use in the outpatient treatment of SAM was maintained over 4 wk of follow-up with a monthly schedule of RUTF distribution. This study was registered at clinicaltrials.gov as NCT02994212.
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Affiliation(s)
- Sheila Isanaka
- Departments of Nutrition and .,Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA; and.,Epicentre and
| | | | | | | | | | - Kerstin E Hanson
- Médecins Sans Frontières, Operational Center Paris, Paris, France
| | - Rebecca F Grais
- Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA; and.,Epicentre and
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Kodish SR, Gittelsohn J, Oddo VM, Jones-Smith JC. Impacts of casinos on key pathways to health: qualitative findings from American Indian gaming communities in California. BMC Public Health 2016; 16:621. [PMID: 27449109 PMCID: PMC4957391 DOI: 10.1186/s12889-016-3279-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 07/08/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Three decades ago, casino gaming on sovereign American Indian lands was legalized with differential economic and social implications. While casinos have improved the incomes of tribal communities, there have been both positive and negative findings in relation to health impacts. We sought to understand the perceived pathways by which casinos impact individual and community health through voices of the community. METHODS We conducted semi-structured, interviews with tribal leaders (n =12) and tribal members (n =24) from tribal communities (n = 23) representing different regions of California. We inductively analyzed textual data drawing from Grounded Theory, first using line-by-line coding to identify analytic categories from emergent themes in consideration of the study objective. Then, focused codes were applied to identify salient themes, which we represented through exemplar quotes and an overall conceptual framework. Data were managed and coded using Dedoose software. RESULTS American Indian-owned casinos are perceived to influence the health of tribal communities through three pathways: 1) improving the tribal economy 2) altering the built environment, and 3) disrupting the the social landscape. Forming these pathways are a series of interrelated health determinants. Improvement of the tribal economy, through both job creation for tribal members and improved tribal cash flow, was perceived by participants to both influence health. Specifically, improved cash flow has resulted in new wellness programs, community centers, places for recreation, and improved social services. Higher disposable incomes have led to better financial stability, increased access to healthy food, and more opportunities for physical activity. Yet, higher disposable incomes were perceived to also contribute to negative health behaviors, most notably increased drug and alcohol abuse. Casinos were also perceived to alter built environments, resulting in increased availability and access to unhealthy food. And to a lesser extent, they were perceived to disrupt the social landscape of communities with impacts on tribal community value systems. CONCLUSIONS Casino environments improve economic conditions of tribal communities, but present important social and public health challenges. Policy makers at federal, state, and tribal levels should consider the perceptions of tribal members and leaders when determining policies in light of casino development.
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Affiliation(s)
- Stephen R. Kodish
- />Department of Nutrition, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115 USA
| | - Joel Gittelsohn
- />Department of International Health, Center for Human Nutrition, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD 21205 USA
| | - Vanessa M. Oddo
- />Department of International Health, Center for Human Nutrition, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD 21205 USA
| | - Jessica C. Jones-Smith
- />Department of International Health, Center for Human Nutrition, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD 21205 USA
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Kodish SR, Aburto NJ, Nseluke Hambayi M, Dibari F, Gittelsohn J. Patterns and determinants of small-quantity LNS utilization in rural Malawi and Mozambique: considerations for interventions with specialized nutritious foods. Matern Child Nutr 2016; 13. [PMID: 26787342 DOI: 10.1111/mcn.12234] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 09/18/2015] [Accepted: 09/23/2015] [Indexed: 01/21/2023]
Abstract
Small-quantity, lipid-based nutrient supplements (SQ-LNS) show promise to improve the quality of maternal and child diets, particularly during the first 1000 days of life. The potential of SQ-LNS to impact positively upon nutritional status relies on numerous factors, including complementary dietary intake, disease prevalence and dynamics of household utilization, including sharing practices. Therefore, this study sought to elucidate the patterns and determinants of SQ-LNS utilization among children 6-23 months and potential sharing practices of other household members prior to intervention development. In Ntchisi, Malawi and Cabo Delgado, Mozambique, both rural, agricultural settings, we conducted two home-feeding trials of 8 and 6 weeks, respectively, nested within a larger multi-phase, emergent formative research design. Multiple methods, including in-depth interviews (n = 38), direct meal observations (n = 80), full-day child observations (n = 38) and spot checks of SQ-LNS supply (n = 23), were conducted with households (n = 35 in Malawi; n = 24 in Mozambique). Overall, the SQ-LNS was utilized contrary to its recommended use, with 50% of households in Malawi reporting running out of stock too early and 87% of households in Mozambique either overusing or underusing the product. Utilization of SQ-LNS was manifested in four patterns of overuse and two of underuse and was determined by factors at multiple levels of influence. Maternal and child health efforts need to consider the reasons behind choices by households to overuse or underuse SQ-LNS and design intervention strategies to increase the likelihood of its appropriate utilization.
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Affiliation(s)
- Stephen R Kodish
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, Maryland, USA
| | | | | | | | - Joel Gittelsohn
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, Maryland, USA
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