Conceptualizing multi-level determinants of infant and young child nutrition in the Republic of Marshall Islands-a socio-ecological perspective.

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.

Determinants of maternal, infant, and young child nutrition during the 1,000-day window of opportunity in Solomon Islands: A focused ethnographic study.

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.

High double burden of child stunting and maternal overweight in the Republic of the Marshall Islands.

Many low- and middle-income countries are faced with a double burden of malnutrition characterized by a stagnating burden of undernutrition and an increasing prevalence of overweight and obesity often observed both at population and household levels. We used data from the 2017 National Integrated Child Health and Nutrition Survey in the Republic of the Marshall Islands to explore the prevalence of overweight mother-stunted child pairs (mother-child double burden, MCDB). We used bivariate analysis, multivariate logistic regression, and multinomial logistic regression analysis to explore associations between child-, maternal-, and household-level variables and both stunting and MCDB and other types of maternal-child pairs. Our results indicate that nearly three out of four mothers were overweight or obese and one in four households is home to an overweight mother with a stunted child. The risk of child stunting and of MCDB were largely associated with maternal characteristics of lower maternal height, maternal age at birth, years of education, and marital status and household economic status as measured by wealth index and number of household members. These findings support the growing body of evidence showing that the coexistence of high maternal overweight and child stunting (MCDB) has linked root causes to early life undernutrition that are exacerbated by the nutrition transition.

Socio-Ecological Factors That Influence Infant and Young Child Nutrition in Kiribati: A Biocultural Perspective.

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.

Can religion kill? The association between membership of the Apostolic faith and child mortality in Zimbabwe.

Existing literature has been equivocal about the effect of religion on utilization of health service and health outcomes. While followers of particularized theology hypothesis believe that doctrinal teachings, beliefs and values of religious groups directly influence health access and outcomes, the advocates of the selectivity hypothesis claim that the observed disparities between religious groups mainly reflect differential access to social and human capital which in turn determines health access and outcome rather than religion per se. Using household data from the Zimbabwe Multiple Indicator Monitoring Survey 2009, we find that household heads' affiliation with apostolic faith put children under five years old at greater risk of death compared to other religious groups. This effect remains strong even after controlling for a wide range of socio-economic and demographics characteristics of the households in multivariate logit regressions.

Is religion the forgotten variable in maternal and child health? Evidence from Zimbabwe.

The Apostolic faith, a rapidly growing and increasingly influential force in Zimbabwe, has received attention in the literature due to its potential role in shaping its followers' attitudes and behaviours towards health. Existing literature, however, has only examined small cross-section samples from a few confined survey sites or has failed to adequately control for the many factors that may mediate the effects of religion. This paper examines the effects of the Apostolic faith on the usage of maternal health and child immunization services in Zimbabwe. It is based on a nationally representative sample from the 2009 Multi-Indicator Monitoring Survey and employs the established Andersen model on access to health services. Well controlled multivariate logit regression models derived from these data show that an affiliation with the Apostolic faith is a substantial and significant risk factor in reducing the utilization of both maternal and child health services. Moreover, even when the services were least costly and readily available and when gaps along other social and economic factors were limited, as in the case of Bacillus Calmette-Guérin vaccination and one visit to antenatal care, women and children from Apostolic faith families still fared significantly worse than others in accessing them.