Engaging men in maternal, infant and young child nutrition in rural Tanzania: Outcomes from a cluster randomized control trial and qualitative study.

There is growing recognition that engaging men in maternal, infant and young child nutrition (MIYCN) interventions can benefit child health and disrupt harmful gender norms. We conducted a cluster-randomized controlled trial in Tanzania, which engaged men and women in behaviour change via mobile messaging (short message service [SMS]) and traditional interpersonal communication (IPC), separately and in combination. Here, we evaluate intervention effects on individual-level men's MIYCN knowledge and discuss barriers to male engagement. Eligible clusters were dispensary catchment areas with >3000 residents. Forty clusters were stratified by population size and randomly allocated to the four study arms, with 10 clusters per arm. Data on knowledge and intervention exposure were collected from 1394 men through baseline and endline surveys (March-April 2018 and July-September 2019). A process evaluation conducted partway through the 15-18-month intervention period included focus group discussions and interviews. Data were analysed for key trends and themes using Stata and ATLAS.ti software. Male participants in the short message service + interpersonal communication (SMS + IPC) group reported higher exposure to IPC discussions than IPC-only men (43.8% and 21.9%, respectively). Knowledge scores increased significantly across all three intervention groups, with the greatest impact in the SMS + IPC group. Qualitative findings indicated that the main barriers to male participation were a lack of interest in health/nutrition and perceptions that these topics were a woman's responsibility. Other challenges included meeting logistics, prioritizing income-earning activities and insufficient efforts to engage men. The use of a combined approach fusing IPC with SMS is promising, yet countering gender norms and encouraging stronger male engagement may require additional strategies.

Comparison of Patient Versus Trained Observer Assessments of Healthcare Providers' Use of Motivational Interviewing Techniques for Patients Experiencing Depression and Anxiety in the Dominican Republic.

In settings with limited mental health system capacity, integrated care and the improvement of patient-provider communication surrounding common mental disorders is critical to advancing treatment outcomes. We trained primary care providers in the Dominican Republic in motivational interviewing (MI) to improve communication with patients experiencing depression and anxiety. Providers were randomized to an intervention group, which received MI training, or a control group. To evaluate the training's effectiveness, patients assessed their clinical encounters using the Motivational Interviewing Measure of Staff Interaction (MIMSI). Trained research assistants (RAs) rated a sub-set of those interactions using an adapted MIMSI instrument. Overall, patients (n = 36) perceived their interactions with providers (n = 10) very positively; however, the RAs' ratings strongly indicated that providers' application of MI behaviors was insufficient. Patients generally could not distinguish between intervention and control providers. Findings underscore the need to carefully consider optimal training delivery and cultural influences surrounding the implementation of MI mental health interventions in settings where directive communication is highly valued.

Assessing the play and learning environments of children under two years in peri-urban Lima, Peru: a formative research study.

BACKGROUND: Home-based interventions have potential for improving early child development (ECD) in low-resource settings. The design of locally acceptable strategies requires an in-depth understanding of the household context. In this formative research study, we aimed to characterize the home play and learning environments of children 6-23 months of age from low-income households in peri-urban Lima, Peru. METHODS: Drawing on the developmental niche framework, we used quantitative and qualitative methods to understand children's physical and social settings, childcare practices, and caregiver perspectives. We conducted interviews, unstructured video-recorded observations, and spot-checks with 30 randomly selected caregiver-child dyads, 10 from each child age group of 6-11, 12-17, and 18-23 months of age, as well as key informant interviews with 12 daycare instructors. We analyzed the data for key trends and themes using Stata and ATLAS.ti and employed an adapted version of the Indicator of Parent-Child Interaction to evaluate the observations. RESULTS: Children's social settings were characterized by multi-generational homes and the presence of siblings and cousins as play partners. Access to books and complex hand-eye coordination toys (e.g., puzzles, building blocks) in the home was limited (30.0 and 40.0%, respectively). Caregivers generally demonstrated low or inconsistent levels of interaction with their children; they rarely communicated using descriptive language or introduced novel, stimulating activities during play. Reading and telling stories to children were uncommon, yet 93.3% of caregivers reported singing to children daily. On average, caregivers ascribed a high learning value to reading books and playing with electronic toys (rated 9.7 and 9.1 out of 10, respectively), and perceived playing with everyday objects in the home as less beneficial (rated 6.8/10). Daycare instructors reinforced the problems posed by limited caregiver-child interaction and supported the use of songs for promoting ECD. CONCLUSIONS: The features of the home learning environments highlighted here indicate several opportunities for intervention development to improve ECD. These include encouraging caregivers to communicate with children using full sentences and enhancing the use of everyday objects as toys. There is also great potential for leveraging song and music to encourage responsive caregiver-child interactions within the home setting.

Vulnerable families and costly formula: a qualitative exploration of infant formula purchasing among peri-urban Peruvian households.

BACKGROUND: Substantial evidence exists surrounding the health risks of breast milk substitutes (BMS) in place of exclusive breastfeeding among infants < 6 months of age in resource-poor settings. Yet, mothers' experiences of selecting and purchasing BMS brands have not been well studied to date. This qualitative study explored the factors influencing BMS purchasing practices, along with the consequences of those decisions, in peri-urban Lima, Peru. METHODS: We conducted in-depth interviews (IDIs) with 29 mothers who had begun mixed-feeding their infants during the first 6 months of life. Interviews explored participants' reasons for initiating infant formula use and their experiences of selecting, purchasing, and providing BMS to their children. Audio recordings were transcribed, coded, and key themes and illustrative vignettes were identified. RESULTS: The primary reported reasons for initiating infant formula use included having received a recommendation for infant formula from a healthcare provider, concerns about an infant's weight gain, and the perception of insufficient breast milk. Mothers tended to initially purchase the BMS brand that had been recommended by a doctor, which was often more expensive than the alternatives. The costs of BMS, which escalated as infants grew, often disrupted the household economy and generated significant stress. While some mothers identified alternatives allowing them to continue purchasing the same brand, others chose to switch to less expensive products. Several mothers began to feed their infants follow-on formula or commercial milk, despite their awareness that such practices were not recommended for infants under 6 months of age. The approval of family members and the absence of an infant's immediate adverse reaction influenced mothers' decisions to continue purchasing these products. CONCLUSIONS: The high costs of BMS may deepen existing socio-economic vulnerabilities and generate new risks for infant health. The continued dedication of resources towards breastfeeding education and support is critical, and strategies would benefit from underscoring the long-term financial and health consequences of infant formula use, and from strengthening women's self-efficacy to refuse to initiate infant formula when recommended. In addition, health providers should be trained in counseling to help women to relactate or return to exclusive breastfeeding after cessation.

Assessing the challenges to women's access and implementation of text messages for nutrition behaviour change in rural Tanzania.

OBJECTIVE: This process evaluation aimed to understand factors affecting the implementation of a government-sponsored short message service (SMS) programme for delivering nutrition information to rural populations, including message access, acceptability and putting messages into action. DESIGN: The study was nested within a larger randomised controlled trial. Cross-sectional data collection included structured surveys and in-depth interviews. Data were analysed for key trends and themes using Stata and ATLAS.ti software. SETTING: The study took place in Tanzania's Mtwara region. PARTICIPANTS: Surveys were conducted with 205 women and 93 men already enrolled in the randomised controlled trial. A sub-set of 30 women and 14 men participated in the in-depth interviews. RESULTS: Among women relying on a spouse's phone, sharing arrangements impeded regular SMS access; men were commonly away from home, forgot to share SMS or did not share them in women's preferred way. Phone-owning women faced challenges related to charging their phones and defective handsets. Once SMS were delivered, most participants viewed them as trustworthy and comprehensible. However, economic conditions limited the feasibility of applying certain recommendations, such as feeding meat to toddlers. A sub-set of participants concurrently enrolled in an interpersonal counselling (IPC) intervention indicated that the SMS provided reminders of lessons learned during the IPC; yet, the SMS did not help participants contextualise information and overcome the challenges of putting that information into practice. CONCLUSIONS: The challenges to accessing and implementing SMS services highlighted here suggest that such platforms may work well as one component of a comprehensive nutrition intervention, yet not as an isolated effort.

Household Contamination of Baby Bottles and Opportunities to Improve Bottle Hygiene in Peri-Urban Lima, Peru.

Feeding of infant formula using contaminated bottles may be an important transmission pathway of enteric pathogens during early life. Determinants of suboptimal bottle hygiene and the feasibility and acceptability of intervention strategies have not been well assessed. We evaluated the extent of bottle contamination, its contributing factors, and options for promoting improved bottle hygiene in a Peruvian shantytown. During Phase 1, we sampled from bottles and caregiver hands (n = 48) and processed for enumeration of total coliform and Escherichia coli colony-forming units. A semi-structured questionnaire captured bottle use and hygiene practices. Phase 2 involved the identification of candidate practices to recommend to caregivers. Phase 3 consisted of a behavioral trial in which 14 caregivers were educated about improved practices for bottle disinfection and later reported on their experiences implementing them. Fecal bacteria were detected in 43.8% of bottles sampled during Phase 1 and in 21.7% of hands. Caregivers overall did not use effective methods for disinfecting bottles, displayed misunderstandings surrounding hygienic practices, and few had ever discussed bottle hygiene with a health provider. Findings from the behavioral trial indicated that the improved practice of brushing the bottle with dish detergent for 30 seconds after every use is preferable to boiling the bottle for several minutes daily as caregivers reported that the brush was simple to use, efficient, and practical. The promotion of a bottle brush and detergent is a feasible and acceptable intervention strategy in peri-urban settings, and future research should evaluate its long-term effectiveness for reducing bottle contamination.

Food purchase patterns indicative of household food access insecurity, children's dietary diversity and intake, and nutritional status using a newly developed and validated tool in the Peruvian Amazon.

Food security, defined as the capacity to acquire preferred food at all times, can manifest in many dimensions. Following a mixed methods approach used in India and Burkina Faso, we developed a 58-item experience-based measure in the Peruvian Amazon, based on investigator observations, relevant literature, and pre-testing with community field workers. The tool encompasses seven dimensions of food security and included measures of (1) food purchases, frequency of purchase, and location of acquisition, (2) food expenses, (3) coping mechanisms, (4) preparation of leftover food, (5) food safety (refrigerator access), (6) fishing intensity and (7) selling food. The survey was piloted among 35 randomly selected families from the Malnutrition Enteric Disease (MAL-ED) birth cohort in Santa Clara, Peru and the surrounding communities. Subsequently, based on a focus group discussion, a pile-sorting exercise, and pilot results, we reduced the survey to 36 items to be collected monthly among 203 MAL-ED households from November 2013 to January 2015. Validity and reliability were then assessed using principal component analysis and exploratory factor analysis, revealing four groups of purchase and coping strategy behaviors: (1) Sweets and sugary items, (2) Less preferred, (3) More preferred, and (4) Minimum meal. Internal consistency of the final 22-item scale had an acceptable cutoff of Cronbach's α of 0.73. Criterion and construct validity of the factor groups revealed there were: (1) food purchase patterns that were distinctive to quality and quantity aspects of the Household Food Insecurity Access scale, (2) unique correlations of child's intake of fats, animal source protein, fiber and other micronutrients, (3) household purchase patterns from the "more preferred" group (fish, red meat) associated with child's weight-for-age. Food purchase and frequency, and context-specific behaviors at the household level can be used as surrogates for dietary intake patterns and nutritional status among children. Food purchase and frequency measurement is a quick, objective, non-intrusive survey method that could be used as an indicator for acute changes in household food security status with appropriate pilot testing and validation.

Qualitative Assessment of the Feasibility, Usability, and Acceptability of a Mobile Client Data App for Community-Based Maternal, Neonatal, and Child Care in Rural Ghana.

Mobile phone applications may enhance the delivery of critical health services and the accuracy of health service data. Yet, the opinions and experiences of frontline health workers on using mobile apps to track pregnant and recently delivered women are underreported. This evaluation qualitatively assessed the feasibility, usability, and acceptability of a mobile Client Data App for maternal, neonatal, and child client data management by community health nurses (CHNs) in rural Ghana. The mobile app enabled CHNs to enter, summarize, and query client data. It also sent visit reminders for clients and provided a mechanism to report level of care to district officers. Fourteen interviews and two focus groups with CHNs, midwives, and district health officers were conducted, coded, and thematically analyzed. Results indicated that the app was easily integrated into care, improved CHN productivity, and was acceptable due to its capacity to facilitate client follow-up, data reporting, and decision-making. However, the feasibility and usability of the app were hindered by high client volumes, staff shortages, and software and device challenges. Successful integration of mobile client data apps for frontline health workers in rural and resource-poor settings requires real-time monitoring, program investments, and targeted changes in human resources.

Process Evaluation of a Comprehensive Supermarket Intervention in a Low-Income Baltimore Community.

Supermarket-based interventions are one approach to improving the local food environment and reducing obesity and chronic disease in low-income populations. We implemented a multicomponent intervention that aimed to reduce environmental barriers to healthy food purchasing in a supermarket in Southwest Baltimore. The intervention, Eat Right-Live Well! used: shelf labels and in-store displays promoting healthy foods, sales and promotions on healthy foods, in-store taste tests, increasing healthy food products, community outreach events to promote the intervention, and employee training. We evaluated program implementation through store environment, taste test session, and community event evaluation forms as well as an Employee Impact Questionnaire. The stocking, labeling, and advertising of promoted foods were implemented with high and moderate fidelity. Taste test sessions were implemented with moderate reach and low dose. Community outreach events were implemented with high reach and dose. Supermarket employee training had no significant impact on employees' knowledge, self-efficacy, or behavioral intention for helping customers with healthy purchasing or related topics of nutrition and food safety. In summary, components of this intervention to promote healthy eating were implemented with varying success within a large supermarket. Greater participation from management and employees could improve implementation.

Determinants of Caregivers' Use and Adoption of Household Water Chlorination: A Qualitative Study with Peri-Urban Communities in the Peruvian Amazon.

The gap between the efficacy and the effectiveness of household water treatment in reducing diarrhea-related morbidity indicates the need for a better understanding of the determinants of long-term behavior change. To explore the barriers to drinking water chlorination in the Peruvian Amazon, where diarrhea is endemic among under-5 children, we conducted qualitative research with 23 caregivers from peri-urban communities of Iquitos, Peru. Our inquiry drew on the Transtheoretical Model of behavior change and the Integrated Behavioral Model for Water, Sanitation, and Hygiene to identify the most relevant contextual, psychosocial, and technological determinants of initial action and long-term adoption of chlorination. Our findings suggest that the decision to try out this practice resulted from the combined effect of knowledge of chlorination benefits and product availability and affordability. Progress from action to adoption was influenced by caretakers' understanding of dosage, the packaging of chlorine products, knowledge and skills for multipurpose laundry bleach, the taste of treated water, and reinforcement. This analysis suggests that a focus on these determinants and the household domain may help to improve the sustainability of future intervention efforts.

Patient navigation to increase mammography screening among inner city women.

BACKGROUND: Lower mammography screening rates among minority and low income women contribute to increased morbidity and mortality from breast cancer. OBJECTIVE: To evaluate the effect of a patient navigation intervention on adherence rates to biennial screening mammography among women engaged in primary care at an inner-city academic medical center. DESIGN: Quality improvement intervention with a concurrent control group, conducted from February to November of 2008. STUDY SUBJECTS: All women in a hospital-based primary care practice aged 51-70 years. Subjects were randomized at the level of their primary care provider, such that half of the patients in the practice received the intervention, while the other half received usual care. INTERVENTIONS: Intervention subjects whose last mammogram was >18 months prior received a combination of telephone calls and reminder letters from patient navigators trained to identify barriers to care. Navigators were integrated into primary care teams and interacted directly with patients, providers, and radiology to coordinate care. Navigators utilized an electronic report to track subjects. Adherence rates to biennial mammography were assessed in intervention and control groups at baseline and post-intervention. KEY RESULTS: A total of 3,895 women were randomized to intervention (n = 1,817) and control (n = 2,078) groups. Mean age was 60, 71% were racial/ethnic minorities, 23% were non-English speaking, and 63% had public or no health insurance. At baseline, there was no difference in mammography adherence between the control and intervention groups (78%, respectively, p = 0.55). After the 9-month intervention, mammogram adherence was higher in the intervention group compared with the control group (87% vs. 76%, respectively, p < 0.001). Except among Hispanic women who demonstrated high rates in both the intervention and control groups (85% and 83%, respectively), all racial/ethnic and insurance groups demonstrated higher adherence in the intervention group. CONCLUSIONS: Patient navigation improves biennial mammography rates for inner city, low income, minority populations.