Self-monitoring improved child feeding among low educated slum mothers in Bangladesh, a pilot study

Issue

Child undernutrition in urban slums is the most serious but least addressed health problem in many LMICs including Bangladesh. Slum children are deprived of adequate feeding as advocated by WHO. Face-to-face contact to monitor adherence to child feeding recommendations is costly. We aimed to identify if a visual aid for self-monitoring, in the form of a pictorial calendar, could assist illiterate slum mothers to self-regulate their child feeding behaviours and increase adherence to recommended child feeding practices.

Description of the practice: A mixed method study was conducted (Randomised Controlled Trial + semi-structured qualitative interviews) over four weeks in a slum area of Dhaka city. Thirty-four mothers to child aged 6-23 months having <5 years of education were recruited. Mothers randomized to intervention arm (n = 17) received an hour of complementary feeding education along with a pictorial calendar and color-coded stickers representing food groups. The control arm received the education session only. The primary outcome was Minimum Dietary Diversity (MDD: ≥4 food groups in past 24 hours); the Generalised Estimation Equations (GEE) with a log link and binomial family was used to test treatment by time interactions.

Results

The proportion of achieving MDD was more common (RR 1.2, 95%CI 0.8, 1.8) among mothers from intervention arm compared to control mothers. Intervention mothers were more likely to identify the appropriate food groups compared to control mothers. More than 80% of the mothers completed the calendar for all 28 days of study duration. During qualitative interviews, most mothers (4/5) stated that the pictorial calendar acted as a reminder for them.

Lessons

An encouraging tendency towards better complementary feeding and better knowledge was seen among the intervention mothers compared to controls. Future research with a larger sample is needed to establish the significance of effect size.

Key messages

Pictorial calendar appeared to help sustain knowledge and improve feeding practices. Self-monitoring using a pictorial calendar could be a good visual aid for low-educated mothers from low socio-economic status.

Effects of integrated interventions on growth and development of young children: A meta-analysis

Background

We did a systematic review to understand: (a) the effects of integrated versus usual care on the developmental outcomes and nutritional status of children under five years; and (b) which intervention characteristics are associated with positive effects.

Methods

We searched eight electronic databases for studies published between January 2013 and September 2019. Eligible studies were Randomised Controlled Trials (RCTs) and non-randomised controlled studies of integrated nutrition and stimulation interventions with child growth and developmental outcomes. We extracted data on intervention characteristics including delivery strategies, behaviour change techniques, intervention intensity and delivery personnel. We meta-analysed data for Length-for-age/Height-for-age Z scores (LAZ/HAZ) and cognitive, motor and language development scores, and conducted subgroup analyses by main intervention characteristics.

Results

Twenty-two unique RCTs met the inclusion criteria, of which 16 were included in the meta-analysis. Compared to the usual care, pooled Effect Sizes (ES) showed small to medium benefits of integrated interventions on cognitive (n = 15, ES 0.64; 95% CI: 0.39, 0.88) and language development scores (n = 10, ES 0.47, 95% CI: 0.21, 0.73) but heterogeneity was high (I2>75%). We found no significant effects of interventions on motor development scores (n = 12, ES 0.31, 95% CI: -0.02, 0.64) or LAZ/HAZ scores (n = 8, ES -0.03, 95% CI: -0.11, 0.03). The effects of interventions on developmental outcomes did not differ by intervention characteristics, and heterogeneity remained high in sub-group analyses.

Conclusions

Integrated nutrition and stimulation interventions had significant effects on cognitive and language development, but no detectable effect on motor development or linear growth. Our ability to identify intervention characteristics linked to positive effects can be improved by standardising the reporting of implementation processes.

Key messages

More high-quality trials with longer follow-up duration are needed to examine the role of integrated nutrition and stimulation interventions on growth and developmental outcomes. Future research should map the characteristics of integrated nutrition and stimulation interventions following standardised guidelines to understand their influence on the outcomes reported.

Cultural participation and all-cause mortality, with possible gender differences: an 8-year follow-up in the HUNT Study, Norway

BACKGROUND

Cultural activities can promote health and longevity, but longitudinal studies examining a broad spectrum of participation are scarce. This study investigated the gender-specific association between all-causes of mortality and participation in single types of cultural activities, amount and participation frequency.

METHODS

We used cohort data from the Nord-Trøndelag Health Study (HUNT Study), Norway (2006-2008), resulting in 35 902 participants, aged 20 and above. Cultural participation in receptive and creative activities was measured. HRs were reported for partially and fully adjusted models.

RESULTS

A total of 1905 participants died during the median 8-year follow-up. Mortality risk was higher for non-participants in any receptive or creative activities, except sport event attendees. Gender association was also evaluated: among men, we found similar results as above except for parish work, while women increased their longevity only through creative activity participation. When a number of receptive activities was associated with all-cause mortality, reduced risk occurred with attendance in 2 or 3-4 activities (21% and 31%, respectively). Risk was reduced through creative activities, with participation in 3-5 activities (43%). Gender-specific analyses showed a clear gradient of protective effect in creative activity participation: for men, 28%, 44% and 44% reduction with 1, 2 or 3-5 activities, respectively, and a 28%, 35% and 44% reduction for women.

CONCLUSION

Frequently attending at least one cultural activity influenced longevity. Creative activities lowered mortality in both genders, while receptive activity benefits were mostly found for men. Thus, promoting and facilitating engaged cultural lifestyles are vital for longevity.

We think you can dance! A pilot randomised controlled trial of dance for nursing home residents with moderate to severe dementia

OBJECTIVES

To evaluate the feasibility of a dance program for people with moderate to severe dementia living in nursing homeswith regards to recruitment and retention, assessment tools, intervention safety, attendance and engagement.

DESIGN

Pilot randomised controlled trial with assessments at weeks 0, 16 and 32.

SETTING

A nursing home in Sydney, Australia.

INTERVENTIONS

Experienced dance teachers conducted dance groups (intervention) or music appreciation and socialisation groups (control) for 45min, three times a week for 16 weeks.

MAIN OUTCOME MEASURES

Descriptive statistics for recruitment and retention, adverse events and attendance and engagement.

RESULTS

Recruitment was smooth, attrition was17% over 32 weeks. Engagement during the sessions was high, and no serious falls or behavioural incidents occurred. Average attendance was poorer than anticipated for dance groups (67%) in comparison to music groups (89%). A ceiling effect on the Severe Impairment Battery and the logistical challenges of the Clinical Global Impression of Change meant they may not be optimal tools.

CONCLUSIONS

It is feasible to conduct a study of group dance for people with moderate to severe dementia in residential care. Choice of attention control condition should be reconsidered.

Neighborhood walkability, fear and risk of falling and response to walking promotion: The Easy Steps to Health 12-month randomized controlled trial

In older adults the relationships between health, fall-related risk factors, perceived neighborhood walkability, walking behavior and intervention impacts are poorly understood. To determine whether: i) health and fall-related risk factors were associated with perceptions of neighborhood walkability; ii) perceived environmental attributes, and fall-related risk factors predicted change in walking behavior at 12 months; and iii) perceived environmental attributes and fall-related risk factors moderated the effect of a self-paced walking program on walking behavior. Randomized trial on walking and falls conducted between 2009 and 2012 involving 315 community-dwelling inactive adults ≥ 65 years living in Sydney, Australia. Measures were: mobility status, fall history, injurious fall and fear of falling (i.e., fall-related risk factors), health status, walking self-efficacy and 11 items from the neighborhood walkability scale and planned walking ≥ 150 min/week at 12 months. Participants with poorer mobility, fear of falling, and poor health perceived their surroundings as less walkable. Walking at 12 months was significantly greater in "less greenery" (AOR = 3.3, 95% CI: 1.11-9.98) and "high traffic" (AOR = 1.98, 95% CI: 1.00-3.91) neighborhoods. The intervention had greater effects in neighborhoods perceived to have poorer pedestrian infrastructure (p for interaction = 0.036). Low perceived walkability was shaped by health status and did not appear to be a barrier to walking behavior. There appears to be a greater impact of, and thus, need for, interventions to encourage walking in environments perceived not to have supportive walking infrastructure. Future studies on built environments and walking should gather information on fall-related risk factors to better understand how these characteristics interact.

Long-term changes in leisure time walking, moderate and vigorous exercise: Were they influenced by the national physical activity guidelines?

Data from the Australian Bureau of Statistics three cross-sectional National Health Surveys, conducted in 1989-1990, 1995-1996 and 2000, were used to examine long-term population responses to the 1996 physical activity (PA) recommendations. Past 2-week recall of the number of times and total minutes spent walking for recreation or sport, and doing moderate and vigorous exercise, were averaged for 1 week to create a measure of 'sufficiently active': >or=5 weekly sessions of >or=150 min/week of at least moderate-intensity activity. With the exception of adults aged>60 years, from 1989 to 2000, there were increases in the prevalence of walking (+8%) and in moderate-intensity exercise (+4%), resulting in a significant decline (-6%) in the proportion of those reporting no leisure-time exercise. Participation in vigorous exercise remained unchanged. There was a 'population shift' in median minutes and sessions of walking from 1995 to 2000, but the prevalence of regular walking (>or=5 times and >or=150 min/week) remained unchanged. A small but significant increase (+2%) in the proportion of adults who met the PA recommendations was noted mainly for men under 60 years and for women aged 45-59 years. The proportion meeting the PA recommendations declined significantly in the most socioeconomically disadvantaged area. These data provide evidence contrary to the observed declines in PA documented by the Active Australia surveillance in the late 1990s. The population may have responded to the 1996 concept of moderate-intensity exercise mainly by walking, but sustainable promotional efforts will be required to build on these gains in the forthcoming decades.

The public health usefulness of the exercise recreation and sport survey (ERASS) surveillance system

BACKGROUND

There is a public health need to monitor habitual participation in physical activity (PA). This report evaluates the usefulness of routine sport and recreation sector collected 'Exercise Recreation and Sport Survey (ERASS)' data from a public health perspective.

METHODS

The ERASS telephone surveys collected information about participation in any PA undertaken for exercise, recreation or sport and the frequency of participation during the previous 12 months from a random sample of 3,400 Australians (aged > or = 15) each quarter. Activities were categorised as Health Enhancing Physical Activities (HEPA) if the activity was of sufficient intensity (METs > or = 3.5). 'Sufficiently active' people reported HEPA > or = 5 days/week and the sedentary group reported HEPA < 0.5 day/week. The total person-days of PA were calculated and main PA types that contributed to HEPA were highlighted.

RESULTS

In 2001, walking accounted for 58% of all HEPA person-days. For females walking (66%), swimming (5.7%) and gym (4.7%) combined accounted for 75% of HEPA days while for males, walking (50%), cycling (8.1%), football (6.2%), jegging (5.6%) and swimming (4.5%) were main contributors. The mean days walked was 2.20 days/week (95% CI; 2.16-2.25) while all other HEPA combined totalled 1.56 days/week (95% CI; 1.52-1.60). Over 12-month period 15.8% of Australians were defined as sedentary and 31% were 'sufficiently active' including 16.8% who reported frequent walking (> or = 5 days/week).

CONCLUSION

ERASS could supplement informational gaps in current PA surveillance. It provides estimates of long-term PA behavioural habits and informs policy makers about the types of activities that contribute to population health.

Overweight, stature, and socioeconomic status among women--cause or effect: Israel National Women's Health Interview Survey, 1998

OBJECTIVE

To determine if short stature and overweight/obesity are predictors of low socioeconomic status (SES), measured by educational attainment.

DESIGN

A cross-sectional study on a random sample carried out through telephone interviews over a period of five months (March through August 1998).

SUBJECTS

A total of 1587 Jewish and Arab Israeli women--773 women age 20-44 years, and 814 women age 45-74 years.

METHODS

Two cross-sectional telephone surveys were conducted; both times, telephone numbers were drawn from the population registry. Multiple logistic regression analysis was used to determine significant predictors of body mass index (BMI), while controlling for population group, parity, smoking, and physical activity.

RESULTS

The level of one's education and one's stature were significantly, independently associated with BMI. Low stature and obesity were indicators of low educational attainment.

LIMITATIONS

The subjects of the study reported their own weight and height. The tendency to overestimate one's height and underestimate one's weight places the accuracy of data under question. However, as there is no reason to believe that the biases in the reports would vary with educational status, the results of the study remain valid.

CONCLUSIONS

Obesity/overweight is directly related to the level of education and inversely to stature. Together, one's level of education and stature may be determinants of low SES. Therefore, in subpopulations with high rates of obesity and short stature, comprehensive programs should include welfare in addition to dietary measures.

Factors associated with smoke-free homes in NSW: results from the 1998 NSW Health Survey

OBJECTIVE

To examine the sociodemographic characteristics associated with smoke-free homes (SFHs) in NSW and specify high-risk groups with a low prevalence of household smoking restrictions.

METHODS

Data were drawn from the 1998 NSW Health Survey, a computer-assisted telephone interview survey of 17,494 randomly selected respondents aged > or = 16 years across NSW (response rate = 70%). Logistic regression analyses, stratified by smoking status, were used.

RESULTS

Overall, 72% of adults reported having a SFH; 87% of never-smokers, 81% of ex- and 35% of current smokers. The highest percentages of SFHs were reported in households with young children (78%) and with older children (72%) or with adults only (72%). For smokers, SFHs were independently associated with the presence of young children (OR=3.8, 95% CI 3.1-4.7) compared with those who lived alone, but the odds of living in a SFH were only slightly increased for smokers living with older children (aged 6-15) and for those living with adults only (OR=1.9, OR=1.8 respectively). Speaking a language other than English at home, having more than 10 years' education, and being <35 years old were independently and positively associated with SFH. Being employed in smoke-free workplaces increased the likelihood of SFHs for both current and past smokers (OR=1.6, OR=1.2 respectively).

CONCLUSION

Most NSW homes have restrictions on smoking inside, but more than half the households with children and at least one smoker adult are not smoke free.

IMPLICATIONS

Interventions to shape parents' smoking behaviour around older children are warranted. Strategies need to address never-smokers in communities with high prevalence of smoking and adults with lower levels of education. A continued commitment to workplace smoking bans is important as they may affect household smoking restrictions.

Factors associated with inappropriate hospitalization days in internal medicine wards in Israel: a cross-national survey

BACKGROUND

The high costs of health care mandate a quality control system that ensures efficient utilization of hospitalization days.

OBJECTIVES

To obtain a national estimate of the rate of inappropriate hospitalization days in medical wards and to identify the variables associated with inappropriateness.

DESIGN

A 1-day cross-national survey.

SETTING

A sample of internal medicine wards in all public hospitals in Israel. SURVEY POPULATION: The survey population included all patients hospitalized in the ward for at least 24 hours on the survey day.

INSTRUMENTS

We used an adapted version of the appropriateness evaluation protocol (AEP) (Gertman and Restuccia). Reviewers were final year medical students trained to work with the AEP. Final classification of inappropriate days was done by one of the senior investigators.

OUTCOME MEASURE

Utilization of hospitalization days according to the AEP.

RESULTS

A total of 1003 hospitalization days in 33 medical wards in 24 hospitals was surveyed. Of this, 182 (18.1%) of the days were found to be inappropriate. In multiple logistic regression analysis, variables significantly associated with inappropriate days were government versus other hospital ownership (OR, 1.51; CI, 1.15-1.96), diagnosis on admission of acute cardiac event versus other diagnosis (OR, 0.46; CI, 0.27-0.77), and period (first, second or final third) of the stay (OR, 1.61; CI, 1.29-2.03). In 62.6% of the 'inappropriate days', continuation of hospitalization was justified (72% were patients awaiting tests or consultation). In 6.7% of the total days surveyed, no justification for continuation of hospitalization was found.

CONCLUSION

The percentage of inappropriate days found in this study is similar to the means found in studies that were conducted in other countries. Awaiting procedures and consultation is a major cause of inappropriate days and may be an important target for intervention.

International epidemiological and microbiological study of outbreak of Salmonella agona infection from a ready to eat savoury snack--II: Israel

OBJECTIVES

To explain an increase in the incidence of salmonellosis caused by Salmonella agona in Israel between October 1994 and January 1995 in the light of an outbreak of S agona phage type 15 infection in England and Wales caused by consumption of a ready to eat savoury snack produced in Israel.

DESIGN

Epidemiology of S agona in 1994-5 was analysed and two consecutive, case-control studies of 32 and 26 case-control pairs were performed. Phage typing and molecular methods were used to characterise strains of S agona isolated from cases and samples of the snack in Israel and England and Wales.

RESULTS

The increase in the incidence of S agona between October 1994 and January 1995 was countrywide. Cases of infection with group B salmonella increased from 60% to 80% in children under 5 years old. In both case-control studies, cases consumed more of the snack than did controls (4.25 v 2.94 packets per week in the first study (P = 0.086) and 4.04 v 2.37 packets per week in the second study (P = 0.034)). When the two studies were combined there was a significant dose-response relation for the number of packets consumed weekly. Compared with consumption of less than two packets, the odds ratio was 1.43 for between two and six packets and 3.37 for seven or more packets (chi 2 for trend = 5.27, P = 0.02) S agona phage type 15 was isolated from a packet of the snack sold in Israel, and the strain was identical with those isolated from packets and cases in Israel and England and Wales.

CONCLUSIONS

This outbreak of S agona was caused by the contamination of a snack produced in Israel. Even under modern operating conditions, large, widespread international outbreaks of foodborne disease can occur. The success of this investigation resulted from excellent international collaboration between public health authorities.