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Wang D, Katalambula LK, Modest AR, Ismail A, Malero A, Bray D, Cinq-Mars H, Tinkasimile A, Sando MM, Vuai S, Fawzi WW. Meals, Education, and Gardens for In-School Adolescents: A Cluster Randomized Trial of an Adolescent Nutrition Intervention Package in Tanzania. J Adolesc Health 2024:S1054-139X(24)00124-1. [PMID: 38597842 DOI: 10.1016/j.jadohealth.2024.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 02/16/2024] [Accepted: 02/21/2024] [Indexed: 04/11/2024]
Abstract
PURPOSE This study aimed to implement and evaluate integrated, school-based nutrition intervention packages for adolescents in Dodoma, Tanzania. METHODS A cluster randomized controlled trial was conducted among six secondary schools in Dodoma, Tanzania. Two schools received the full-intervention package of school meals, nutrition education, school gardens, and community workshops. Two schools received the partial-intervention package without the school meals component. Two schools served as the controls and did not receive any intervention. The intervention was implemented over one academic year. The analytical sample included 534 adolescents aged 14 to 17 at baseline and 286 parents. Outcomes included nutrition knowledge, food preferences, diet quality, food insecurity, physical activity, growth, and anemia. Linear models were used to estimate mean differences, and logistic regression models were used to estimate odds ratios (ORs). RESULTS Compared to the control, both the partial (OR: 0.59; 95% confidence interval [CI]: 0.35, 1.00) and full (OR: 0.49; 95% CI: 0.40, 0.59) interventions were associated with lower odds of poor diet quality among adolescents. Among the parents, both the partial (OR: 0.28; 95% CI: 0.20, 0.40) and full (OR: 0.28; 95% CI: 0.13, 0.58) interventions were associated with lower odds of poor diet quality. The partial (OR: 0.29; 95% CI: 0.18, 0.47) and full (OR: 0.47; 95% CI: 0.30, 0.72) interventions were associated with lower odds of adolescent overweight or obesity. DISCUSSION School-based nutritional intervention packages incorporating multiple actions may improve the diet quality of adolescents and their household members and reduce the double burden of adolescent malnutrition.
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Affiliation(s)
- Dongqing Wang
- Department of Global and Community Health, College of Public Health, George Mason University, Fairfax, Virginia.
| | - Leonard K Katalambula
- Department of Public Health, College of Health Sciences, University of Dodoma, Dodoma, Tanzania
| | | | - Abbas Ismail
- Department of Mathematics and Statistics, College of Natural and Mathematical Sciences, University of Dodoma, Dodoma, Tanzania
| | - Augustine Malero
- Department of Computer Science and Engineering, College of Informatics and Virtual Education, University of Dodoma, Dodoma, Tanzania
| | - Dayana Bray
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Haley Cinq-Mars
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | | | - Said Vuai
- Department of Chemistry, College of Natural and Mathematical Sciences, University of Dodoma, Dodoma, Tanzania
| | - Wafaie W Fawzi
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
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Anthony MG, Hoddinott G, Van Niekerk M, Dewandel I, McKenzie C, Bekker C, Rabie H, Redfern A, van der Zalm MM. The socioeconomic impact of the COVID-19 lockdown on families affected by childhood respiratory illnesses in Cape Town, South Africa. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003020. [PMID: 38547177 PMCID: PMC10977803 DOI: 10.1371/journal.pgph.0003020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 02/22/2024] [Indexed: 04/12/2024]
Abstract
The COVID-19 pandemic impacted families globally, directly and indirectly. Children presenting with respiratory illnesses are affected by emerging health systems and socioeconomic changes in the COVID-19 era. We explored the socioeconomic impacts of the COVID-19 lockdown on families with a respiratory illness diagnosed in their child in Cape Town, South Africa. This study was nested in a prospective observational cohort of children presenting with respiratory symptoms presumptive of COVID-19. We conducted 21 semi-structured interviews to explore the socioeconomic impact of the COVID-19 pandemic on families with a child affected by respiratory illnesses. We used case descriptive analysis and thematically organised common and divergent experiences. We found that socioeconomic challenges in low-income communities were exacerbated: 1) loss of pre-COVID sources of income (loss of income, employment and working hours), 2) shrinking employment opportunities due to business closures and strict preventative measures, 3) family network dependence to cope with financial pressures, 4) impact on education, implicating additional pressures due to lack of resources for adequate home schooling and 5) caregivers' mental health and wellbeing being impacted, causing stress and anxiety due to loss of income. This study shows that the COVID-19 lockdown impacted the socioeconomic aspects of families caring for a child with a respiratory illness. Care became more complicated and adversely impacted the family's emotional well-being and health-seeking behaviour. These impacts should be more carefully considered in order to strengthen health services and global health messaging in future pandemics.
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Affiliation(s)
- Michaile G. Anthony
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Margaret Van Niekerk
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Isabelle Dewandel
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Carla McKenzie
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Carien Bekker
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Helena Rabie
- Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Andrew Redfern
- Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Marieke M. van der Zalm
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Carducci B, Dominguez G, Kidd E, Janes K, Owais A, Bhutta ZA. Pivoting school health and nutrition programmes during COVID-19 in low- and middle-income countries: A scoping review. J Glob Health 2024; 14:05006. [PMID: 38236689 PMCID: PMC10795858 DOI: 10.7189/jogh.14.05006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2024] Open
Abstract
Background Preventive and promotive interventions delivered by schools can support a healthy lifestyle, positive development, and well-being in children and adolescents. The coronavirus disease 2019 (COVID-19) pandemic presented unique challenges to school health and nutrition programmes due to closures and mobility restrictions. Methods We conducted a scoping review to examine how school health and nutrition programmes pivoted during the COVID-19 pandemic, and to provide summative guidance to stakeholders in strategic immediate and long-term response efforts. We searched MEDLINE, Embase, PsycINFO, and grey literature sources for primary (observational, intervention, and programme evaluations) and secondary (reviews, best practices, and recommendations) studies conducted in low- and middle-income countries from January 2020 to June 2023. Programmes that originated in schools, which included children and adolescents (5-19.9 years) were eligible. Results We included 23 studies in this review. They varied in their adaptation strategy and key programmatic focus, including access to school meals (n = 8), health services, such as immunisations, eye health, and water, sanitation, and hygiene-related activities (n = 4), physical activity curriculum and exercise training (n = 3), mental health counselling and curriculum (n = 3), or were multi-component in nature (n = 5). While school meals, physical activity, and mental health programmes were adapted by out-of-school administration (either in the community, households, or virtually), all health services were suspended indefinitely. Importantly, there was an overwhelming lack of quantitative data regarding modified programme coverage, utilisation, and the impact on children and adolescent health and nutrition. Conclusions We found limited evidence of successful adaptation of school health and nutrition programme implementation during the pandemic, especially from Asia and Africa. While the adoption of the World Health Organization health-promoting school global standards and indicators is necessary at the national and school level, future research must prioritise the development of a school-based comprehensive monitoring and evaluation framework to track key indicators related to both health and nutrition of school-aged children and adolescents.
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Affiliation(s)
- Bianca Carducci
- Centre for Global Child Health, Hospital for Sick Children, Peter Gilgan Centre for Research, and Learning (PGCRL), Toronto, Canada
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Georgia Dominguez
- Centre for Global Child Health, Hospital for Sick Children, Peter Gilgan Centre for Research, and Learning (PGCRL), Toronto, Canada
| | - Emily Kidd
- Centre for Global Child Health, Hospital for Sick Children, Peter Gilgan Centre for Research, and Learning (PGCRL), Toronto, Canada
| | - Karlie Janes
- Centre for Global Child Health, Hospital for Sick Children, Peter Gilgan Centre for Research, and Learning (PGCRL), Toronto, Canada
| | - Aatekah Owais
- Centre for Global Child Health, Hospital for Sick Children, Peter Gilgan Centre for Research, and Learning (PGCRL), Toronto, Canada
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Peter Gilgan Centre for Research, and Learning (PGCRL), Toronto, Canada
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada
- Centre of Excellence in Women, and Child Health, Aga Khan University, Karachi, Pakistan
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Balikoowa R, Ojiambo D, Emuron L, Siu G, Mbabazi-Mpyangu C, Kikooma JF, Mugambwa J, Nuwagaba RD, Baluku MM, Onen D. Children's lived experience and perceptions of community members' influence on their schooling: a study in Uganda. Front Psychol 2023; 14:1045737. [PMID: 37539008 PMCID: PMC10394695 DOI: 10.3389/fpsyg.2023.1045737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 06/26/2023] [Indexed: 08/05/2023] Open
Abstract
Introduction Global and national initiatives have successfully increased access to public education in low- and middle-income countries. However, many students in rural regions in these countries have high rates of absenteeism and drop-out, and low levels of academic engagement. Together, these significantly limit children's academic performance and achievement. One strategy that addresses these barriers seeks to engage members of the wider local community in schools. Most previous research focuses on adults' perspectives even though the potential benefit of community engagement is greatest when learners perceive it to be positive. Past research has also focused on community members structured engagement in activities within schools. This research provides a wider exploration of children's lived experience and perceptions concerning community members' influence on their schooling and learning. The aim was to gain a rich picture of how primary school students in rural Uganda perceive that community members' behavior helps or hinders their education. Methods Qualitative data from students 10 to 13 years of age were collected through individual interviews that used the draw-and-talk technique (n = 20) and four focus group discussions. Results Seven broad categories of community members' actions were perceived to be positive (conflict resolution; supporting students' physical well-being; encouraging learning and positive behavior; reducing truancy; providing food and financial support; collective community work; and political representation). Four categories of community members' actions were perceived to have a negative influence (creating barriers to attending school; noise and other distractions; insecurity; and theft and vandalism). Discussion We conclude that carefully structured community involvement in schooling may improve the emotional and material support that facilitates students' continued school attendance and their motivation for learning. However, we also identify some limits on the role that local communities may be able to play in overcoming the challenges facing education in low- and middle-income countries.
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Affiliation(s)
- Richard Balikoowa
- Department of Educational, Social and Organizational Psychology, School of Psychology, College of Humanities and Social Sciences, Makerere University, Kampala, Uganda
| | - Deborah Ojiambo
- Department of Educational, Social and Organizational Psychology, School of Psychology, College of Humanities and Social Sciences, Makerere University, Kampala, Uganda
| | - Lydia Emuron
- Directorate of Higher Degrees, Kampala International University, Kampala, Uganda
| | - Godfrey Siu
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Christine Mbabazi-Mpyangu
- Department of Religious Studies, School of Liberal and Performing Arts, College of Humanities and Social Sciences, Makerere University, Kampala, Uganda
| | - Julius Fred Kikooma
- Department of Educational, Social and Organizational Psychology, School of Psychology, College of Humanities and Social Sciences, Makerere University, Kampala, Uganda
- Directorate of Research and Graduate Training, Makerere University, Kampala, Uganda
| | - Joshua Mugambwa
- Faculty of Management, Makerere University Business School, Kampala, Uganda
| | - Rachael Daphine Nuwagaba
- Department of Educational, Social and Organizational Psychology, School of Psychology, College of Humanities and Social Sciences, Makerere University, Kampala, Uganda
| | - Martin M. Baluku
- Department of Educational, Social and Organizational Psychology, School of Psychology, College of Humanities and Social Sciences, Makerere University, Kampala, Uganda
| | - David Onen
- East African School of Higher and Development, Makerere University, Kampala, Uganda
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School Lunch Programs and Nutritional Education Improve Knowledge, Attitudes, and Practices and Reduce the Prevalence of Anemia: A Pre-Post Intervention Study in an Indonesian Islamic Boarding School. Nutrients 2023; 15:nu15041055. [PMID: 36839412 PMCID: PMC9962024 DOI: 10.3390/nu15041055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 02/12/2023] [Accepted: 02/17/2023] [Indexed: 02/23/2023] Open
Abstract
Indonesians face serious health issues that arise from malnutrition, particularly in children who are under unfavorable dietary environments. The present study established a school meal program consisting of dietary and educational interventions and evaluated its impact on promoting continuous improvement in dietary behavior among junior and senior high school students in Indonesia. A total of 319 students belonging to an Islamic Boarding School participated in the pre-post intervention study for 9 months. All participants were assessed based on their Knowledge, Attitude, and Practice (KAP). A subgroup of 115 participants who were anemic and underweight was examined for dietary intake, nutrition status, and hemoglobin level. The KAP test scores for both nutrition and hygiene showed a significant increase for all students and the undernutrition group post-intervention. Protein, iron, and vitamin C intake significantly improved. Although there were no significant improvements in nutrition status, there was a significant increase in the hemoglobin level and a reduction in the prevalence of anemia from 42.6% to 21.7%. Thus, school meal program that combines dietary and educational interventions may effectively improve anemia in undernourished students as well as enhance the knowledge, attitudes, and practices related to health, nutrition, and hygiene in junior and senior high school students.
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Wineman A, Ekwueme MC, Bigayimpunzi L, Martin-Daihirou A, de Gois V. N. Rodrigues EL, Etuge P, Warner Y, Kessler H, Mitchell A. School Meal Programs in Africa: Regional Results From the 2019 Global Survey of School Meal Programs. Front Public Health 2022; 10:871866. [PMID: 35692321 PMCID: PMC9178184 DOI: 10.3389/fpubh.2022.871866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 04/22/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction School meal programs operate throughout Africa, serving as a social safety net and aiming to improve children's nutrition, influence their dietary choices, and strengthen the agrifood economy through local procurement. Despite their rapid expansion in the past decade, there has been no systematic effort to comprehensively document school feeding activities across the continent. Methods Detailed information on school feeding activities in each country was captured in the Global Survey of School Meal Programs©, which launched in 2019. An invitation to participate was extended to each government, which appointed a national-level respondent to gather information on every large-scale school meal program in the country. Results Forty-one countries in Africa (38 in sub-Saharan Africa) responded to the survey in 2019 with information on 68 large-scale programs that together reached 60.1 million children. Across these countries, the aggregate school feeding budget was USD 1.3 billion. Diversity in school meal programs is evident across regions, country income levels, and levels of national commitment. Coverage rates tended to be highest in southern Africa, in countries with school feeding as a line item in the national budget, and in countries with the greatest domestic share of the school feeding budget. Diversity in the school menu tended to be greatest in programs that sourced food through domestic purchase rather than relying on foreign in-kind donations. To address micronutrient malnutrition, about two-thirds of the programs served fortified foods, and one-quarter included micronutrient supplements. Even as rates of overweight/obesity are rising among African school children, just 10% of school meal programs identified its prevention as an objective. Conclusion The extent to which school meal programs in Africa are supported with domestic funding reflects a dramatic shift in favor of national ownership and domestic food procurement. At the same time, programs have grappled with inadequate and unpredictable budgets and challenges related to supply chains and logistics—impediments that need to be addressed if these programs are to achieve their objectives. Overall, the survey results underscore the important position of school meal programs within African food systems and their potential (if well-designed) to sustainably improve food security, child health, and nutrition.
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Affiliation(s)
- Ayala Wineman
- Global Child Nutrition Foundation, Seattle, WA, United States
- Department of Agricultural, Food, and Resource Economics, Michigan State University, East Lansing, MI, United States
| | - Moses C. Ekwueme
- Global Child Nutrition Foundation, Seattle, WA, United States
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | | | | | | | - Priscilia Etuge
- Global Child Nutrition Foundation, Seattle, WA, United States
- Department of Fisheries and Aquatic Sciences, University of Buea, Buea, Cameroon
| | - Yale Warner
- Global Child Nutrition Foundation, Seattle, WA, United States
| | - Heidi Kessler
- Global Child Nutrition Foundation, Seattle, WA, United States
| | - Arlene Mitchell
- Global Child Nutrition Foundation, Seattle, WA, United States
- *Correspondence: Arlene Mitchell
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Urban Public Food Procurement in Kiambu and Machakos Counties as a Driver of Food and Nutrition Security and Sustainability: A Literature Review and Case Studies. SUSTAINABILITY 2022. [DOI: 10.3390/su14063341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Urban public food procurement can address malnutrition and improve the beneficiary experience at public institutions whilst reshaping food systems to be healthier and more sustainable. We reviewed grey and peer-reviewed literature on urban public food procurement in Kiambu and Machakos counties in Kenya. From the literature, we selected programmes for case study research through stakeholder interviews and targeted literature searching. We searched 11 databases and reviewed 23 relevant articles. The case studies involved early childhood education centre and primary school feeding, hospital food provision, and COVID-19 responses. We found that actionable data and public–private partnerships are enabling factors. Similarly, multistakeholder involvement and governance increase coordination. However, budget constraints threaten programme stability. Procurement criteria focused on nutrition, food quality, and community development, but did not explicitly include environmental sustainability. We linked case studies to the United Nations Sustainable Development Goals 2, 3, 4, 5, 8, and 12. By developing, improving, and scaling public food procurement, urban governments in low- and middle-income countries (LMICs) can reach the most vulnerable whilst improving farmer livelihoods, creating business opportunities, and addressing environmental concerns. This paper contributes implementational insights in Kenyan urban contexts by highlighting opportunities for local and regional policymakers in LMICs and their partners to strengthen public food procurement.
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Nilsson M, Emilsson C, Jonsson A, Tomson G, Meijer S, Östman L, Magnusson U. Stronger efforts are needed to safeguard the nutrition of school aged children. BMJ 2022; 376:o623. [PMID: 35264329 DOI: 10.1136/bmj.o623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Maria Nilsson
- Department of Epidemiology and Global Health, Umeå University, Sweden
| | - Cecilia Emilsson
- Swedish Institute for Global Health Transformation (SIGHT), Royal Swedish Academy of Sciences, Sweden
| | | | | | - Sebastiaan Meijer
- Department of Biomedical Engineering and Health Systems, KTH Royal Institute of Technology, Sweden
| | - Leif Östman
- Department of Education, Uppsala University, Sweden
| | - Ulf Magnusson
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Sweden
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Fram MS, Nguyen HT, Frongillo EA. Food Insecurity among Adolescent Students from 95 Countries Is Associated with Diet, Behavior, and Health, and Associations Differ by Student Age and Sex. Curr Dev Nutr 2022; 6:nzac024. [PMID: 35317415 PMCID: PMC8929982 DOI: 10.1093/cdn/nzac024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 01/18/2022] [Accepted: 02/10/2022] [Indexed: 12/03/2022] Open
Abstract
Background Adolescents' developmental tasks and challenges vary based on age, sex, and social context. Food insecurity affects adolescents, but existing research has been limited to a few country contexts and has treated adolescence as a singular developmental moment with limited consideration of potential differences in how food insecurity relates to developmental experiences based on adolescent age and sex. Objectives We aimed to describe relations between student-reported food insecurity and students' profiles of nutritional, physical activity, school absenteeism, health/mental health, and victimization experiences, and how these differ by student age and sex. Methods Using cross-sectional data from the Global School-based Student Health Survey, we examined adolescent reports of their food security among 337,738 students 11-18 y old from 95 countries. We identified their profiles of focal experiences, and used mixed-effects linear and logistic regression models to examine differences in these profiles by student food insecurity and how these differ by student age and sex. Results Of students, 25.5% aged 11-14 y compared with 30% aged 15-18 y reported food insecurity in the past 30 d. Food insecurity was associated with less frequent fruit and vegetable intake; more frequent soft drink intake; worse mental health; less physical activity; more missed school; higher odds of smoking, drinking, and using drugs; and more bullying victimization and sexual partners. Food insecurity was associated with reduced age- and sex-specific protection: greater substance use among younger adolescents, more sexual partners among older females, and greater worry among younger males. Food insecurity was also associated with increased age-specific risk: greater soft drink consumption among younger adolescents. Conclusions Across countries, adolescent food insecurity was associated with poorer nutritional, mental health, behavioral, and relationship profiles; these associations differed with student age and sex. Food insecurity interventions should attend to adolescent developmental stage and the gendered contexts through which adolescents navigate daily life.
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Affiliation(s)
| | - Hoa T Nguyen
- Institute for Families in Society, College of Social Work, University of South Carolina, Columbia, SC, USA
| | - Edward A Frongillo
- Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
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