Maternal Decision-Making Input and Health-Seeking Behaviors Between Pregnancy and the Child's Second Birthday: A Cross-Sectional Study in Nepal.

OBJECTIVES: Maternal health-seeking behaviors are critical to improving maternal and child health in low-income countries. This study investigates associations between maternal decision-making input and their health-seeking behaviors in the first 1000-day period between pregnancy and a child's second birthday in Nepal. METHODS: We used data from a cross-sectional survey conducted in 2018 in 16 districts of Nepal. Among the 3648 households surveyed, 1910 mothers of a child 0 to 24 months with complete data were included for analyses. Logistic regression was used to examine associations between decision-making input and the utilization of antenatal, delivery and postnatal care services, and attendance at health mothers' group (HMG) meetings. We also used negative binomial regression to assess the relationship between her decision-making input and participation in growth monitoring and promotion (GMP) in the 6 months prior to the survey. For each relationship examined, we adjusted for clustering, as well as potentially confounding factors at individual and household levels. RESULTS: After adjusting for confounders, maternal decision-making input had a small but positive and significant association with receiving at least 4 antenatal care visits (OR = 1.09, 95% CI 1.02, 1.17), attendance at GMP in the 6 months prior to the survey (IRR = 1.02, 95% CI 1.00, 1.04), and HMG attendance (OR = 1.10, 95% CI 1.03, 1.17), but not with receiving at least 3 postnatal care visits or delivering in a health institution. CONCLUSIONS FOR PRACTICE: Our findings indicated that empowering women and mothers in household decision-making might warrant greater attention when developing future policies and programs in Nepal.

Degree of exposure to interventions influences maternal and child dietary practices: Evidence from a large-scale multisectoral nutrition program.

The prevalence of maternal and child malnutrition in Nepal is among the highest in the world, despite substantial reductions in the last few decades. One effort to combat this problem is Suaahara II (SII), a multi-sectoral program implemented in 42 of Nepal's 77 districts to improve dietary diversity (DD) and reduce maternal and child undernutrition. Using cross-sectional data from SII's 2017 annual monitoring survey, this study explores associations between exposure to SII and maternal and child DD. The study sample included 3635 mothers with at least one child under the age of five. We focused on three primary SII intervention platforms: interpersonal communication (IPC) by frontline workers, community mobilization (CM) via events, and mass media through a weekly radio program (Bhanchhin Aama); and also created an exposure scale to assess the dose-response relationship. DD was measured both as a continuous score and as a binary measure of meeting the recommended minimum dietary diversity of consuming foods from at least 5 of 10 food groups for mothers and at least 4 of 7 food groups for children. We used linear and logistic regression models, controlling for potentially confounding factors at the individual and household level. We found a positive association between any exposure to SII platforms and maternal DD scores (b = 0.09; p = 0.05), child (aged 2-5 years) DD scores (b = 0.11; p = 0.03), and mothers meeting minimum dietary diversity (OR = 1.16; p = 0.05). There were significant, positive associations between both IPC and CM events and meeting minimum DD (IPC: OR = 1.31, p = 0.05; CM: OR = 1.37; p<0.001) and also between CM events and DD scores (b = 0.14; p = 0.03) among mothers. We found significant, positive associations between mass media and meeting minimum DD (OR: 1.38; p = 0.04) among children aged 6-24 months and between mass media and DD scores (b = 0.15; p = 0.01) among children aged 2-5 years. We also found that exposure to all three platforms, versus fewer platforms, had the strongest association with maternal DD scores (b = 0.45; p = 0.01), child (aged 2-5 years) DD scores (b = 0.41; p<0.001) and mothers meeting MDD (OR = 2.33; p<0.001). These findings suggest that a multi-pronged intervention package is necessary to address poor maternal and child dietary practices and that the barriers to behavior change for maternal diets may differ from those for child diets. They also highlight the importance of IPC and CM for behavior change and as a pre-requisite to mass media programs being effective, particularly for maternal diets.

Using Systems Thinking to train future leaders in global health.

Systems Thinking provides a useful set of concepts and tools that can be used to train students to be effective and innovative global health leaders in an ever-changing and often chaotic world. This paper describes an experiential, multi-disciplinary curriculum that uses Systems Thinking to frame and analyse global health policies and practices. The curriculum uses case studies and hands-on activities to deepen students' understanding of the following concepts: complex adaptive systems, dynamic complexity, inter-relationships, feedback loops, policy resistance, mental models, boundary critique, leverage points, and multi-disciplinary, multi-sectoral, and multi-stakeholder thinking and action. A sample of Systems Thinking tools for analysing global health policies and practices are also introduced.

The Pattern of Gestational Weight Gain is Associated with Changes in Maternal Body Composition and Neonatal Size.

OBJECTIVES: The pattern of gestational weight gain (GWG) reflects general nutrient availability to support growing fetal and maternal compartments and may contribute to later health, but how it relates to changes in maternal body composition is unknown. We evaluated how the pattern of GWG related to changes in maternal body composition during pregnancy and infant size at birth. METHODS: A prospective, multi-ethnic cohort of 156 pregnant women and their infants was studied in New York City. Prenatal weights were used to estimate total and rate (kg/week) of GWG by trimester. Linear regression models evaluated the association between trimester-specific GWG group (low, medium, high GWG) [total (low ≤25, high ≥75 percentile) or rate (defined by tertiles)] and infant weight, length and maternal body composition changes from 14 to 37 weeks, adjusting for covariates. RESULTS: Compared to the low gain group, medium/high rate of GWG in the second trimester and high rate of GWG in the third trimester were associated with larger gains in maternal fat mass (ß range for fat Δ = 2.86-5.29 kg, all p < 0.01). For infant outcomes, high rate of GWG in the second trimester was associated with higher birth weight (ß = 356 g, p = 0.001) and length (ß = 0.85 cm, p = 0.002). First and third trimester GWG were not associated with neonatal size. CONCLUSIONS: The trimester specific pattern and rate of GWG reflect changes in maternal body fat and body water, and are associated with neonatal size, which supports the importance of monitoring trimester-specific GWG.

Binational Americans: In their own words.

This qualitative study explores the ethnic identity formation of binational adults, defined as adults with parents who are each of different nationalities. In this sample, all participants were US citizens between the ages of 20 and 34 and most also identified as having biracial backgrounds. Semi-structured interviews were conducted, allowing participants to freely express their life experiences, personal revelations and feelings about their identity and place in the world around them. Results were recorded, transcribed and coded. Personal narratives described how life experiences enabled participants to develop cultural sensitivity, and increased their ability to identify commonalities and differences in concepts of race, ethnicity and culture in and outside the USA.

Does clinical diagnosis indicate ocular chlamydial infection in areas with a low prevalence of trachoma?

The WHO has initiated a global program to eliminate trachoma. This program includes mass antibiotic administrations to reduce the prevalence of Chlamydia trachomatis, the causative agent in trachoma. DNA amplification tests are the most sensitive methods to diagnose C. trachomatis infection, but are expensive and not typically performed in trachoma-endemic areas. Trachoma programs use clinical examination to determine which communities and which individuals within communities would benefit from antibiotic treatment, so understanding the relationship between clinical activity and chlamydial infection is important. In this study, we determine what percent of individuals with clinically active trachoma are infected with chlamydia in low prevalence communities of China and Nepal (with <10% clinical activity in children), and compare this against a high prevalence community of Nepal (with >30% clinical activity in children). In the low prevalence areas, only 8% clinically active cases had evidence of chlamydia. In the high prevalence community, 70% of clinically active cases harbored chlamydia. These results imply that clinical activity is less indicative of infection at a lower prevalence. In the context of a trachoma program, both clinically active cases and the community as a whole may stand to benefit less from antibiotic treatment in lower prevalence areas.

Rapid assessment of trachoma in Hainan Province, China: validation of the new World Health Organization methodology.

This study was undertaken to validate a WHO methodology for the rapid assessment of trachoma. Fourteen villages were chosen by random sampling in two counties in Hainan Province, China. For the rapid assessment, trichiasis patients were identified, 50 children ages 1-10 years were examined for active trachoma, and information was collected on community access to services and community risk factors. To validate the methodology, a prevalence survey was undertaken simultaneously in the same villages. For the prevalence survey, 2428 people from 1606 households in the 14 villages were chosen by random sampling. Very little active trachoma was found by either method, although the rates of trichiasis were more substantial. Ranking of the villages by the two methods for trichiasis was highly correlated (Spearman's correlation coefficient = 0.60, p = 0.02). For active trachoma, the Spearman's correlation coefficient for the ranking of villages by the two methods was 0.40 and not significant (p = 0.14), suggesting that a correlation this close may have been seen by chance alone. The observational data showed all the villages to be at risk of active trachoma (due to poor environmental hygiene conditions), suggesting that this aspect of the WHO methodology overestimates the risk for active trachoma. We conclude that, with the exception of the community assessment of risk, this rapid assessment methodology is a valid tool for the assessment of trichiasis and possibly of active trachoma in rural communities, although the level of active trachoma in this study was too low to effectively validate that aspect of the methodology.