Quantity and quality of physical activity during adolescence: Evidence from a mixed-method study in rural Telangana, India.

Adolescence is a unique transitional stage of physical and psychological development. As preferences and behavioural choices adopted in adolescence influence lifelong physical activity habits and health outcomes in adulthood, rural transformation in low- and middle-income countries has the potential to significantly change traditional roles and shape the next generation. By using a mixed-method approach that integrates energy expenditure estimates from accelerometer devices with 24-hour recall time-use data from adolescent boys and girls and qualitative interviews with adolescents and their caregivers, this study sheds light on the patterns of quantity and quality of physical activity of 395 adolescents in Khammam and Mahbubnagar districts of rural Telangana, India. The study shows that energy expenditure and time use are highest for educational-related activities followed by leisure in both adolescent boys and girls. However, notwithstanding the process of rural transformation and the educational infrastructure and economic opportunities provided to adolescent boys and girls, social and cultural norms allow boys, especially in late adolescence to spend more time and energy in activities outside the home such as pursuing economic work, sports and socialising, while girls spend more time and energy at home doing domestic work. The quantitative and qualitative exploration of physical activity and time use among adolescents, as expounded in this study cutting across age groups and gender, highlights the need for changes in gendered norms and renewed government strategies and investments in that direction.

Oil palm and gendered time use: A mixed-methods case study from West Kalimantan, Indonesia.

Measuring the social impact of oil palm requires the use of multiple metrics which capture different dimensions of well-being. To date, most studies have examined welfare outcomes at the household level, relying on a relatively narrow range of indicators. There is a need for a more diverse range of metrics to measure the social impacts of oil palm as well as more explicit accounting for study context and gendered effects. Here we demonstrate the utility of specialised time use methods used in combination with qualitative research to understand intra-household labour dynamics associated with oil palm adoption. We use a mixed-methods approach to investigate the role of smallholder oil palm plasma schemes on men and women's time use in Kapuas Hulu District, West Kalimantan. Time allocation is an important determinant of well-being as well as maternal and child nutrition and an indicator of women's empowerment and gender equality. We integrate the results from a fractional multinomial logistic regression of data from 603 individuals with qualitative findings on the subjective experience of time allocation, as well as, the causes, consequences and coping strategies to manage trade-offs in time allocation. We find that relative to non-oil-palm adopting swidden farmers, participation in oil palm plasma schemes is associated with more time spent in productive labour for both men and women, driven by off-farm labour on oil palm plantations. For women, increased time comes at the cost of reduced time spent in rest, leisure and sleep. Increased time spent in off-farm labour drives households to adapt agricultural production methods, changing cash crop production as well as accelerating swidden transitions. These changes alter gender dynamics and responsibilities within the household. Our results suggest that changes in time allocation may have significant consequences for women's well-being and gender equity. Women in the oil palm site experienced greater stress over time scarcity and employed coping strategies more frequently. Our findings indicate that time allocation could be used as an indicator of the effects of oil palm expansion and adoption on well-being and that potential effects of time scarcity on well-being, gender equity, and maternal and child nutrition should be considered by policy makers when making land use decisions.

Compounding crises of social reproduction: Microfinance, over-indebtedness and the COVID-19 pandemic.

The COVID-19 pandemic has hit at a time when microfinance is at its historical peak, with an estimated 139 million microfinance customers globally. Cambodia's microfinance sector is one of the fastest growing, and like others in the Global South has moved from offering entrepreneurial capital to everyday liquidity, and even disaster relief. In this Viewpoint, however, we argue that the promotion of microfinance as market-based relief and recovery from the pandemic should be a source of concern, not comfort. We firstly suggest that as a result of the health and economic impacts associated with COVID-19, credit-taking is likely to escalate further in terms of the number of borrowers and loan amounts. Second, we contend that a growing reliance on MFIs will leave households undernourished, and further vulnerable to its disciplining and extractive impulses. Third, we argue that the interplay between over-indebtedness, pre-existing malnutrition challenges, and the global public health crisis of COVID-19 represents a major challenge to gender equality and sustainable development. Coordination between the Cambodian government, microfinance lenders, international investors, and development partners is vital to offer debt relief. Furthermore, to reverse the reliance of so many households on the microfinance industry for survival, inclusive socio-economic policies and public welfare services must be prioritised.

Sociodemographic determinants of diet quality of the EU elderly: a comparative analysis in four countries.

OBJECTIVE: To investigate the sociodemographic determinants of diet quality of the elderly in four EU countries. DESIGN: Cross-sectional study. For each country, a regression was performed of a multidimensional index of dietary quality v. sociodemographic variables. SETTING: In Finland, Finnish Household Budget Survey (1998 and 2006); in Sweden, SNAC-K (2001-2004); in the UK, Expenditure & Food Survey (2006-07); in Italy, Multi-purpose Survey of Daily Life (2009). SUBJECTS: One- and two-person households of over-50s (Finland, n 2994; UK, n 4749); over-50 s living alone or in two-person households (Italy, n 7564); over-60 s (Sweden, n 2023). RESULTS: Diet quality among the EU elderly is both low on average and heterogeneous across individuals. The regression models explained a small but significant part of the observed heterogeneity in diet quality. Resource availability was associated with diet quality either negatively (Finland and UK) or in a non-linear or non-statistically significant manner (Italy and Sweden), as was the preference for food parameter. Education, not living alone and female gender were characteristics positively associated with diet quality with consistency across the four countries, unlike socio-professional status, age and seasonality. Regional differences within countries persisted even after controlling for the other sociodemographic variables. CONCLUSIONS: Poor dietary choices among the EU elderly were not caused by insufficient resources and informational measures could be successful in promoting healthy eating for healthy ageing. On the other hand, food habits appeared largely set in the latter part of life, with age and retirement having little influence on the healthiness of dietary choices.

Rural-urban disparities in child nutrition in Bangladesh and Nepal.

BACKGROUND: The persistence of rural-urban disparities in child nutrition outcomes in developing countries alongside rapid urbanisation and increasing incidence of child malnutrition in urban areas raises an important health policy question - whether fundamentally different nutrition policies and interventions are required in rural and urban areas. Addressing this question requires an enhanced understanding of the main drivers of rural-urban disparities in child nutrition outcomes especially for the vulnerable segments of the population. This study applies recently developed statistical methods to quantify the contribution of different socio-economic determinants to rural-urban differences in child nutrition outcomes in two South Asian countries - Bangladesh and Nepal. METHODS: Using DHS data sets for Bangladesh and Nepal, we apply quantile regression-based counterfactual decomposition methods to quantify the contribution of (1) the differences in levels of socio-economic determinants (covariate effects) and (2) the differences in the strength of association between socio-economic determinants and child nutrition outcomes (co-efficient effects) to the observed rural-urban disparities in child HAZ scores. The methodology employed in the study allows the covariate and coefficient effects to vary across entire distribution of child nutrition outcomes. This is particularly useful in providing specific insights into factors influencing rural-urban disparities at the lower tails of child HAZ score distributions. It also helps assess the importance of individual determinants and how they vary across the distribution of HAZ scores. RESULTS: There are no fundamental differences in the characteristics that determine child nutrition outcomes in urban and rural areas. Differences in the levels of a limited number of socio-economic characteristics - maternal education, spouse's education and the wealth index (incorporating household asset ownership and access to drinking water and sanitation) contribute a major share of rural-urban disparities in the lowest quantiles of child nutrition outcomes. Differences in the strength of association between socio-economic characteristics and child nutrition outcomes account for less than a quarter of rural-urban disparities at the lower end of the HAZ score distribution. CONCLUSIONS: Public health interventions aimed at overcoming rural-urban disparities in child nutrition outcomes need to focus principally on bridging gaps in socio-economic endowments of rural and urban households and improving the quality of rural infrastructure. Improving child nutrition outcomes in developing countries does not call for fundamentally different approaches to public health interventions in rural and urban areas.

Stressor or succour? Examining the association between conflict, livestock assets, and farmers' mental health in Nigeria.

Farmers are disproportionately vulnerable to violent attacks in the conflict situation in Nigeria, with potential traumatising effects due to the destruction of agricultural livelihoods. In this study, we conceptualise the links between conflict exposure, livestock assets, and depression, using a cross-sectional nationally representative survey of 3021 Nigerian farmers to quantify the relationships. We highlight three main findings. First, conflict exposure is significantly associated with farmers exhibiting depressive symptoms. Second, holding higher herds of livestock, more cattle, and more sheep and goats while exposed to conflict is associated with higher risk of depression. Third, keeping more poultry is negatively associated with depressive symptoms. Finally, this study accentuates the significance of psychosocial support for farmers in conflict situations. The relationships between different livestock species and farmers' mental health may interest further research in strengthening the evidence.

The impact of gender equity in agriculture on nutritional status, diets, and household food security: a mixed-methods systematic review.

Introduction: Undernutrition rates remain high in rural, low-income settings, where large, gender-based inequities persist. We hypothesised that increasing gender equity in agriculture could improve nutrition. Methods: We conducted a systematic review to assess the associations between gender-based inequities (in income, land, livestock, and workloads) and nutrition, diets and food security outcomes in agricultural contexts of low-income and middle-income countries. Between 9 March and 7 August 2018, we searched 18 databases and 14 journals, and contacted 27 experts. We included quantitative and qualitative literature from agricultural contexts in low-income and middle-income countries, with no date restriction. Outcomes were women's and children's anthropometric status, dietary quality and household food security. We conducted meta-analyses using random-effects models. Results: We identified 19 820 records, of which 34 studies (42 809 households) met the inclusion criteria. Most (22/25) quantitative studies had a high risk of bias, and qualitative evidence was of mixed quality. Income, land and livestock equity had heterogeneous associations with household food security and child anthropometric outcomes. Meta-analyses showed women's share of household income earned (0.32, 95% CI -4.22 to 4.86; six results) and women's share of land owned (2.72, 95% CI -0.52 to 5.96; three results) did not increase the percentage of household budget spent on food. Higher-quality studies showed more consistently positive associations between income equity and food security. Evidence is limited on other exposure-outcome pairings. Conclusions: We find heterogeneous associations between gender equity and household-level food security. High-quality research is needed to establish the impact of gender equity on nutrition outcomes across contexts. PROSPERO registration number: CRD42018093987.

Physical activity, time use, and food intakes of rural households in Ghana, India, and Nepal.

With more than 820 million undernourished people living in rural areas of low- and middle-income countries (LMICs), ending hunger and ensuring access to food by all is a global priority. In the past few decades, the adoption of technological innovations in the agricultural sector and related crop yield improvements have not led to expected improvements in the nutritional status of rural households in many LMICs. The increased energy expenditure associated with the adoption of productivity-enhancing innovations may provide an important explanation of the disconnect between agricultural productivity enhancements and improved nutritional outcomes. We develop a methodology for generating reliable livelihood energy/calorie expenditure profiles for rural agricultural households using research-grade accelerometer devices. We integrate the data on physical activity and energy expenditure in rural households with data on time-use and food intakes to generate a data set that provides a unique window into rural livelihoods. This can be a valuable resource to analyse agriculture-nutrition impact pathways and improve the welfare of rural and agricultural households.

Drudgery reduction, physical activity and energy requirements in rural livelihoods.

Low and middle-income countries in Asia and Africa have been witnessing a process of rural transformation, characterised by rising agricultural productivity, commercialisation of agriculture, improved infrastructure and access to services, over several decades. However, there is little empirical evidence on how this transformation process has affected the patterns and intensity of physical activity and time use in rural livelihoods. The lack of empirical evidence can be attributed to the constraints in accurate measurement of physical activity and energy expenditure in the context of free-living populations. Using wearable accelerometry devices, we develop robust energy expenditure profiles for men and women in rural households for two case studies in India and Ghana. An innovative feature of this study is the integration of data on energy expenditure (derived from accelerometers) with data on time-use, which has hitherto not been feasible in observational studies of rural populations. Using the data on physical activity, energy expenditure and time use from the case studies, we examine the impact of drudgery reduction- the substitution of less intense for more intense activities - on energy requirements for men and women in rural households. Our results show that drudgery reduction can have large effects on human energy (calorie) requirements, with an hour of drudgery reduction reducing energy requirements by 11-22 % for men and 13-17 % for women in Ghana and India. There are significant gender differences in energy expenditure patterns and drudgery reduction effects vary by socio-demographic characteristics and endowments of households. Our results suggest that drudgery reduction can offer rural households an important route to improved nutritional status. At the same time, drudgery reduction can lead to increased incidence of overweight and obesity for some segments of the population. The design of development interventions needs to explicitly consider the effects on nutrition and well-being through the energy expenditure dimension.

Antibiotic knowledge, attitudes and practices: new insights from cross-sectional rural health behaviour surveys in low-income and middle-income South-East Asia.

INTRODUCTION: Low-income and middle-income countries (LMICs) are crucial in the global response to antimicrobial resistance (AMR), but diverse health systems, healthcare practices and cultural conceptions of medicine can complicate global education and awareness-raising campaigns. Social research can help understand LMIC contexts but remains under-represented in AMR research. OBJECTIVE: To (1) Describe antibiotic-related knowledge, attitudes and practices of the general population in two LMICs. (2) Assess the role of antibiotic-related knowledge and attitudes on antibiotic access from different types of healthcare providers. DESIGN: Observational study: cross-sectional rural health behaviour survey, representative of the population level. SETTING: General rural population in Chiang Rai (Thailand) and Salavan (Lao PDR), surveyed between November 2017 and May 2018. PARTICIPANTS: 2141 adult members (≥18 years) of the general rural population, representing 712 000 villagers. OUTCOME MEASURES: Antibiotic-related knowledge, attitudes and practices across sites and healthcare access channels. FINDINGS: Villagers were aware of antibiotics (Chiang Rai: 95.7%; Salavan: 86.4%; p<0.001) and drug resistance (Chiang Rai: 74.8%; Salavan: 62.5%; p<0.001), but the usage of technical concepts for antibiotics was dwarfed by local expressions like 'anti-inflammatory medicine' in Chiang Rai (87.6%; 95% CI 84.9% to 90.0%) and 'ampi' in Salavan (75.6%; 95% CI 71.4% to 79.4%). Multivariate linear regression suggested that attitudes against over-the-counter antibiotics were linked to 0.12 additional antibiotic use episodes from public healthcare providers in Chiang Rai (95% CI 0.01 to 0.23) and 0.53 in Salavan (95% CI 0.16 to 0.90). CONCLUSIONS: Locally specific conceptions and counterintuitive practices around antimicrobials can complicate AMR communication efforts and entail unforeseen consequences. Overcoming 'knowledge deficits' alone will therefore be insufficient for global AMR behaviour change. We call for an expansion of behavioural AMR strategies towards 'AMR-sensitive interventions' that address context-specific upstream drivers of antimicrobial use (eg, unemployment insurance) and complement education and awareness campaigns. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov identifier NCT03241316.

Antibiotics and activity spaces: protocol of an exploratory study of behaviour, marginalisation and knowledge diffusion.

BACKGROUND: Antimicrobial resistance (AMR) is a global health priority. Leading UK and global strategy papers to fight AMR recognise its social and behavioural dimensions, but current policy responses to improve the popular use of antimicrobials (eg, antibiotics) are limited to education and awareness-raising campaigns. In response to conceptual, methodological and empirical weaknesses of this approach, we study people's antibiotic-related health behaviour through three research questions.RQ1: What are the manifestations and determinants of problematic antibiotic use in patients' healthcare-seeking pathways?RQ2: Will people's exposure to antibiotic awareness activities entail changed behaviours that diffuse or dissipate within a network of competing healthcare practices?RQ3: Which proxy indicators facilitate the detection of problematic antibiotic behaviours across and within communities? METHODS: We apply an interdisciplinary analytical framework that draws on the public health, medical anthropology, sociology and development economics literature. Our research involves social surveys of treatment-seeking behaviour among rural dwellers in northern Thailand (Chiang Rai) and southern Lao PDR (Salavan). We sample approximately 4800 adults to produce district-level representative and social network data. Additional 60 cognitive interviews facilitate survey instrument development and data interpretation. Our survey data analysis techniques include event sequence analysis (RQ1), multilevel regression (RQ1-3), social network analysis (RQ2) and latent class analysis (RQ3). DISCUSSION: Social research in AMR is nascent, but our unprecedentedly detailed data on microlevel treatment-seeking behaviour can contribute an understanding of behaviour beyond awareness and free choice, highlighting, for example, decision-making constraints, problems of marginalisation and lacking access to healthcare and competing ideas about desirable behaviour. TRIAL REGISTRATION NUMBER: NCT03241316; Pre-results.

Reducing Anemia Prevalence in Afghanistan: Socioeconomic Correlates and the Particular Role of Agricultural Assets.

This research aims to examine the socio-economic correlates of anemia in women, and potential sources of iron in household diets in Afghanistan. It also examines whether ownership of agricultural (particularly livestock) assets and their use in food production has a role in alleviating anaemia, especially where local markets may be inadequate. We analyse data from the 2010/11 Afghanistan Multiple Indicator Cluster Survey, estimating a logistic regression to examine how anemia status of women is associated with socio-economic covariates. A key result found is that sheep ownership has a protective effect in reducing anemia (prevalence odds ratio of sheep ownership on anemia of 0.83, 95% confidence interval (CI): 0.73-0.94) after controlling for wealth and other covariates. This association is found to be robust to alternative model specifications. Given the central role of red meat in heme iron provision and absorption of non-heme iron, we hypothesise that sheep ownership promotes mutton consumption from own-production in a setting where market-sourced provision of nutritious food is a challenge. We then use the 2011/12 National Risk and Vulnerability Assessment household data to understand the Afghan diet from the perspective of dietary iron provision, and to understand interactions between own-production, market sourcing and mutton consumption. Sheep ownership is found to increase the likelihood that a household consumed mutton (odds ratio of 1.27, 95% CI: 1.15-1.42), the number of days in the week that mutton was consumed (prevalence rate ratio of 1.24. 95% CI: 1.12-1.37) and the quantity of mutton consumed (7 grams/person/week). In the subsample of mutton consumers, households sourcing mutton mostly from own production consumed mutton 1.5 days more frequently on average than households relying on market purchase, resulting in 100 grams per person per week higher mutton intake. Thus this analysis lends support to the notion that the linkage between sheep ownership and anemia risk is at least partly due to consumption arising from own-production in the presence of market incompleteness.

What Explains Cambodia's Success in Reducing Child Stunting-2000-2014?

In many developing countries, high levels of child undernutrition persist alongside rapid economic growth. There is considerable interest in the study of countries that have made rapid progress in child nutrition to uncover the driving forces behind these improvements. Cambodia is often cited as a success case having reduced the incidence of child stunting from 51% to 34% over the period 2000 to 2014. To what extent is this success driven by improvements in the underlying determinants of nutrition, such as wealth and education, ("covariate effects") and to what extent by changes in the strengths of association between these determinants and nutrition outcomes ("coefficient effects")? Using determinants derived from the widely-applied UNICEF framework for the analysis of child nutrition and data from four Demographic and Health Surveys datasets, we apply quantile regression based decomposition methods to quantify the covariate and coefficient effect contributions to this improvement in child nutrition. The method used in the study allows the covariate and coefficient effects to vary across the entire distribution of child nutrition outcomes. There are important differences in the drivers of improvements in child nutrition between severely stunted and moderately stunted children and between rural and urban areas. The translation of improvements in household endowments, characteristics and practices into improvements in child nutrition (the coefficient effects) may be influenced by macroeconomic shocks or other events such as natural calamities or civil disturbance and may vary substantially over different time periods. Our analysis also highlights the need to explicitly examine the contribution of targeted child health and nutrition interventions to improvements in child nutrition in developing countries.