Development and validation of a Context-sensitive Positive Health Questionnaire (CPHQ): A factor analysis and multivariate regression study.

BACKGROUND: The concept of Positive Health (PH) has gained increasing attention as a way of measuring individuals' ability to adapt in the face of contextual challenges. However, a suitable measurement instrument for PH that encompasses contextual factors has not yet been developed. This paper responds to this need by developing a Context-specific Positive Health (CPH) measurement instrument that aligns with the Capability Approach (CA). METHODS: The measurement instrument was developed and tested among a representative sample of 1002 Dutch internet survey panel members with diverse sociodemographic backgrounds. The instrument was developed in two stages: a preparation phase consisting of focus groups and expert consultations, and a validation among a representative panel of Dutch citizens. The goal of the preparation phase, was to pilot test and refine previously proposed Positive Health questionnaires into an initial version of the CPHQ. The validation phase aimed to examine the initial CPHQ's factorial validity using Factor Analysis, and its concurrent validity using Multivariate Regression Analysis. RESULTS: The developed questionnaire demonstrated adequate factorial and concurrent validity. Furthermore, it explicitly includes an assessment of resilience, this being a key component of PH. CONCLUSIONS: The introduced measurement tool, the CPHQ, comprises 11 dimensions that we have labeled as follows: relaxation, autonomy, fitness, perceived environmental safety, exclusion, social support, financial resources, political representation, health literacy, resilience, and enjoyment. In this article, we present four major contributions. Firstly, we embedded the measurement in a theoretical framework. Secondly, we focused the questionnaire on a key concept of Positive Health - the "ability to adapt." Thirdly, we addressed issues of health inequality by considering contextual factors. Finally, we facilitated the development of more understandable measurement items.

Greater male variability in daily energy expenditure develops through puberty.

There is considerably greater variation in metabolic rates between men than between women, in terms of basal, activity and total (daily) energy expenditure (EE). One possible explanation is that EE is associated with male sexual characteristics (which are known to vary more than other traits) such as musculature and athletic capacity. Such traits might be predicted to be most prominent during periods of adolescence and young adulthood, when sexual behaviour develops and peaks. We tested this hypothesis on a large dataset by comparing the amount of male variation and female variation in total EE, activity EE and basal EE, at different life stages, along with several morphological traits: height, fat free mass and fat mass. Total EE, and to some degree also activity EE, exhibit considerable greater male variation (GMV) in young adults, and then a decreasing GMV in progressively older individuals. Arguably, basal EE, and also morphometrics, do not exhibit this pattern. These findings suggest that single male sexual characteristics may not exhibit peak GMV in young adulthood, however total and perhaps also activity EE, associated with many morphological and physiological traits combined, do exhibit GMV most prominently during the reproductive life stages.

Total daily energy expenditure has declined over the past three decades due to declining basal expenditure, not reduced activity expenditure.

Obesity is caused by a prolonged positive energy balance1,2. Whether reduced energy expenditure stemming from reduced activity levels contributes is debated3,4. Here we show that in both sexes, total energy expenditure (TEE) adjusted for body composition and age declined since the late 1980s, while adjusted activity energy expenditure increased over time. We use the International Atomic Energy Agency Doubly Labelled Water database on energy expenditure of adults in the United States and Europe (n = 4,799) to explore patterns in total (TEE: n = 4,799), basal (BEE: n = 1,432) and physical activity energy expenditure (n = 1,432) over time. In males, adjusted BEE decreased significantly, but in females this did not reach significance. A larger dataset of basal metabolic rate (equivalent to BEE) measurements of 9,912 adults across 163 studies spanning 100 years replicates the decline in BEE in both sexes. We conclude that increasing obesity in the United States/Europe has probably not been fuelled by reduced physical activity leading to lowered TEE. We identify here a decline in adjusted BEE as a previously unrecognized factor.

The future of human malnutrition: rebalancing agency for better nutritional health.

The major threat to human societies posed by undernutrition has been recognised for millennia. Despite substantial economic development and scientific innovation, however, progress in addressing this global challenge has been inadequate. Paradoxically, the last half-century also saw the rapid emergence of obesity, first in high-income countries but now also in low- and middle-income countries. Traditionally, these problems were approached separately, but there is increasing recognition that they have common drivers and need integrated responses. The new nutrition reality comprises a global 'double burden' of malnutrition, where the challenges of food insecurity, nutritional deficiencies and undernutrition coexist and interact with obesity, sedentary behaviour, unhealthy diets and environments that foster unhealthy behaviour. Beyond immediate efforts to prevent and treat malnutrition, what must change in order to reduce the future burden? Here, we present a conceptual framework that focuses on the deeper structural drivers of malnutrition embedded in society, and their interaction with biological mechanisms of appetite regulation and physiological homeostasis. Building on a review of malnutrition in past societies, our framework brings to the fore the power dynamics that characterise contemporary human food systems at many levels. We focus on the concept of agency, the ability of individuals or organisations to pursue their goals. In globalized food systems, the agency of individuals is directly confronted by the agency of several other types of actor, including corporations, governments and supranational institutions. The intakes of energy and nutrients by individuals are powerfully shaped by this 'competition of agency', and we therefore argue that the greatest opportunities to reduce malnutrition lie in rebalancing agency across the competing actors. The effect of the COVID-19 pandemic on food systems and individuals illustrates our conceptual framework. Efforts to improve agency must both drive and respond to complementary efforts to promote and maintain equitable societies and planetary health.

Variation in contraceptive prevalence rates in Tanzania: A multilevel analysis of individual and regional determinants.

OBJECTIVE: The aim of this study was to answer two key questions: (1) what are the individual and regional determinants of contraceptive use; and (2) what are the effect(s) of individual and regional variables on regional differences in contraceptive use? DATA AND METHOD: Multilevel logistic regression was applied on data from the Tanzania Demographic and Health Survey (TDHS) 2010 that allowed us to investigate simultaneously the individual and the regional determinants of contraceptive use and its regional variation. RESULTS: There was significant variation in contraceptive use, both between population groups as well as between regions. A higher number of children ever born, urban residence, and a non-manual occupation are characteristics associated with higher odds of a woman using contraceptives. Women who talk about family planning with community-based distribution workers and clinic staff also have higher odds of using contraceptives. The regional differences in the shares of women with a secondary education or above explain a significant portion of the regional variance in contraceptive use. Having secondary education and above is related to lower contraceptive use. CONCLUSION: This study constitutes a first step towards gaining a better understanding of the macro-level effects on decision-making processes regarding contraceptive use. The regional educational level explains a significant portion of the regional variance in contraceptive use. IMPLICATION STATEMENT: An advantage of our study over other studies in Tanzania is that we extended the determinants of contraceptive use to include not only individual-level factors, but also regional-level factors.

'He usually has what we call normal fevers': Cultural perspectives on healthy child growth in rural Southeastern Tanzania: An ethnographic enquiry.

INTRODUCTION: While parents' construction of and actions around child growth are embedded in their cultural framework, the discourse on child growth monitoring (CGM) has been using indicators grounded in the biomedical model. We believe that for CGM to be effective, it should also incorporate other relevant socio-cultural constructs. To contribute to the further development of CGM to ensure that it reflects the local context, we report on the cultural conceptualization of healthy child growth in rural Tanzania. Specifically, we examine how caregivers describe and recognize healthy growth in young children, and the meanings they attach to these cultural markers of healthy growth. METHODS: Caregivers of under-five children, including mothers, fathers, elderly women, and community health workers, were recruited from a rural community in Kilosa District, Southeastern Tanzania. Using an ethnographic approach and the cultural schemas theory, data for the study were collected through 19 focus group discussions, 30 in-depth interviews, and five key informant interviews. Both inductive and deductive approaches were used in the data analysis. RESULTS: Participants reported using multiple markers for ascertaining healthy growth. These include 'being bonge' (chubby), 'being free of illness', 'eating well', 'growing in height', as well as 'having good kilos' (weight). Despite the integration of some biomedical concepts into the local conceptualization of growth, the meanings attached to these concepts are largely rooted in the participants' cultural framework. For instance, a child's weight is ascribed to the parents' adherence to postpartum sex taboos and to the nature of a child's bones. The study noted conceptual differences between the meanings attached to height from a biomedical and a local perspective. Whereas from a biomedical perspective the height increment is considered an outcome of growth, the participants did not see height as linked to nutrition, and did not believe that they have control over their child's height. CONCLUSIONS: To provide context-sensitive advice to mothers during CGM appointments, health workers should use a tool that takes into account the mothers' constructs derived from their cultural framework of healthy growth. The use of this approach should facilitate communication between health professionals and caregivers during CGM activities, increase the uptake and utilization of CGM services, and, eventually, contribute to reduced levels of childhood malnutrition in the community.

Illness experiences of diabetes in the context of malaria in settings experiencing double burden of disease in southeastern Tanzania.

BACKGROUND: Tanzania is doubly burdened with both non-communicable and infectious diseases, but information on how Tanzanians experience the co-existence of these conditions is limited. Using Kleinman's eight prompting questions the study synthesizes explanatory models from patients to describe common illness experiences of diabetes in a rural setting where malaria is the predominant health threat. METHODS: We conducted 17 focus group discussions with adult members of the general community, diabetes patients, neighbours and relatives of diabetes patients to gain insight into shared experiences. To gain in-depth understanding of the individual illness experiences, we conducted 41 in-depth interviews with malaria or diabetes patients and family members of diabetes patients. The analysis followed grounded theory principles and the illness experiences were derived from the emerging themes. RESULTS: The illness experiences showed that malaria and diabetes are both perceived to be severe and fatal conditions, but over the years people have learned to live with malaria and the condition is relatively manageable compared with diabetes. In contrast, diabetes was perceived as a relatively new disease, with serious life-long consequences. Uncertainty, fear of those consequences, and the increased risk for severe malaria and other illnesses impacted diabetes patients and their families' illness experiences. Unpredictable ailments and loss of consciousness, memory, libido, and functional incapability were common problems reported by diabetes patients. These problems had an effect on their psychological and emotional health and limited their social life. Direct and indirect costs of illness pushed individuals and their families further into poverty and were more pronounced for diabetes patients. CONCLUSION: The illness experiences revealed both malaria and diabetes as distressing conditions, however, diabetes showed a higher level of stress because of its chronicity. Strategies for supporting social, emotional, and psychological well-being that build on the patient accounts are likely to improve illness experiences and quality of life for the chronically ill patient.

"It is the medicines that keep us alive": lived experiences of diabetes medication use and continuity among adults in Southeastern Tanzania.

BACKGROUND: Diabetes is a chronic condition which requires many patients to use medications for the remainder of their lives. While this regimen is demanding, little research has been done on the experiences individuals have with diabetes medication use and the continuity of use, especially patients from rural areas of Tanzania. This study explores the lived experiences of diabetes medication use and the continuity of use among adult diabetes patients from rural communities with limited access to diabetes medicines. METHODS: We conducted 19 in-depth interviews to explore patients' experiences with diabetes medication use and the continuity of use. We employed the 5As of access to care to situate the behavioral practices surrounding diabetes medication use in the study settings. The data analysis followed grounded theory principles, and was conducted with the help of NVivo 9. RESULTS: Study participants expressed positive attitudes toward the use of diabetes medicines, but also concerns about affordability. The patients employed two main strategies for dealing with the cost. The first was to increase their available funds by spending less money on family needs, selling household property, asking family and friends for money, or borrowing cash. They also reported sourcing medicines from pharmacies to save on consultation and laboratory costs. Second, participants reported using less than the recommended dosage or skipping doses, and sharing medicines. The geographic accessibility of diabetes service providers, the availability of medication, and the organization of the diabetes services were also cited as barriers to taking medications and to using them continuously. CONCLUSIONS: The strategies employed by the people in this study illustrate their resilience in the face of poverty and failing health care systems. More comprehensive strategies are therefore needed to encourage consistent medication use among people with chronic conditions. These strategies could include the reduction of prices by pharmaceuticals, the strengthening of community risk-pooling mechanisms and sustained health campaigns aimed at patients and the community.

It takes a mother to practise breastfeeding: Women's perceptions of breastfeeding during the period of intention.

BACKGROUND: In the Netherlands, 81% of mothers initiate breastfeeding. After one month the percentage of mothers still breastfeeding drops, despite positive intentions. Little is known about women's perceptions of breastfeeding during the period of intention. AIM: This qualitative study aimed to gain insight into these perceptions among first-time mothers from middle and high socioeconomic backgrounds in the northern part of the Netherlands. METHODS: We used the theory of planned behaviour as the deductive model. In 2008, 16 in-depth interviews were conducted with 8 mothers who intended to breastfeed. The interviews were conducted at two time points (prepartum and postpartum) and covered the same period (that is, from the time when the intention was formed until after childbirth). The interviews were transcribed verbatim and analysed using grounded theory. FINDINGS: Five inductive themes were identified: combining breastfeeding with work, learning about breastfeeding, making arrangements for childbirth, reflecting on the intention, and becoming a mother. During the extended period of intention, the women anticipated breastfeeding, but were cautious in expressing their intentions. They felt that the experience of becoming a mother would be critical to their breastfeeding outcomes. CONCLUSION: The theory of planned behaviour has been widely used in breastfeeding research. However, the period of intention is relatively long for breastfeeding. Rather than recommending an intensification of antenatal breastfeeding education, recommendations must incorporate the awareness that practising breastfeeding should not be considered the continuous outcome of the intention to do so - it takes a mother to practise breastfeeding.

Public policy, health system, and community actions against illness as platforms for response to NCDs in Tanzania: a narrative review.

BACKGROUND: Most low- and middle- income countries are facing a rise of the burden of non-communicable diseases (NCDs) alongside the persistent burden of infectious diseases. This narrative review aims to provide an inventory of how the existing policy environment, health system, and communities are addressing the NCDs situation in Tanzania and identify gaps for advancing the NCD research and policy agenda. METHODOLOGY: A literature search was performed on PubMed and Google scholar with full text retrieval from HINARI of English language articles published between 2000 and 2012. Documents were read to extract information on what Tanzanian actors were doing that contributed to NCDs prevention, treatment, and control, and a narration was written out of these. Reference lists of all retrieved articles were searched for additional relevant articles. Websites of organizations active in the field of NCDs including the Government of Tanzania and WHO were searched for reports and grey literature. RESULTS: Lack of a specific and overarching NCD policy has slowed and fragmented the implementation of existing strategies to prevent and control NCDs and their determinants. The health system is not prepared to deal with the rising NCD burden although there are random initiatives to improve this situation. How the community is responding to these emerging conditions is still unknown, and the current health-seeking behavior and perceptions on the risk factors may not favor control of NCDs and their risk factors. CONCLUSION AND RECOMMENDATION: There is limited information on the burden and determinants of NCDs to inform the design of an integrative and multisectorial policy. Evidence on effective interventions for NCD services in primary care levels and on community perceptions on NCDs and their care seeking is virtually absent. Research and public health interventions must be anchored in the policy, health system, and community platforms for a holistic response.

Breast milk and complementary food intake in Brazilian infants according to socio-economic position.

OBJECTIVE: (a) To compare breast milk and complementary food intake between breast-fed infants from high and low socio-economic status (SES) aged 8 months of age; (b) To compare these intakes with PAHO/WHO recommendations. METHODS: Cross-sectional, community-based study in Pelotas, Brazil. Breast milk and complementary food intake were compared between 8-month-old infants from high (n=35) and low SES (n=30). Breast milk intake was measured using the 'dose-to-the mother' deuterium-oxide turnover method; complementary food intake was assessed using a questionnaire and by 24 hours food weighing. RESULTS: Energy intake from breast milk (51.1 ± 26.4 kcal/kg/d) was not different between social groups, being in line with current recommendations. However, energy intake from complementary foods (34.5 ± 22.7 kcal/kg/d) and from milk, including breast milk, cow's milk and formula (60.1 ± 19.6 kcal/kg/d), were significantly higher than recommendations. Total energy intake was 20% higher than recommended (93.3 ± 24.4 versus 77.3 kcal/kg/day, p<0.001). This was mainly due to a high intake of complementary foods and addition of cow's milk to breast milk. Introduction of complementary foods before 6 months was common. In the high SES group, more infants consumed vegetables (p=0.005) and fruit (p=0.020), whereas fats and sugar tended to be consumed less frequently (p=0.05 and p=0.17, respectively). CONCLUSIONS: Feeding habits deviate from PAHO/WHO recommendations, especially for infants of lower SES. Of main concern are the high-energy intake and early introduction of cow's milk and complementary foods. This may be important in view of metabolic programming and the development of obesity and associated diseases later in life.

Socio-economic and environmental factors influence energy utilization in Brazilian breast-fed infants.

Energy intake recommendations for infants are based on data from industrialized countries. FAO/WHO/UNU expressed the need for studies on total energy expenditure (TEE) and basal metabolic rate from developing countries covering current and changing lifestyles. For this observational study, 65 infants of differing socioeconomic status (SES) (n = 32 middle SES, n = 33 low SES) were selected in Pelotas, southern Brazil, aiming to: 1) compare TEE, minimum observable energy expenditure (MOEE), activity energy expenditure (AEE) between breast-fed infants 8.7 mo of age from middle and low SES; and 2) investigate the effect of potential mediating factors on TEE and AEE. TEE and total body water were measured with doubly labeled water, MOEE with respiration calorimetry, breast milk intake using the dose-to-the-mother deuterium-oxide turnover method, food intake using 1-d food weighing, and prevalence of overweight using BMI Z-scores. TEE adjusted for ethnicity was 257 (95% CI 232-281) kJ/(kg . d) in middle SES infants vs. 318 (95%CI 294-342) kJ/(kg . d) in low SES infants (P = 0.001). MOEE did not differ between groups and the difference in TEE was therefore attributed to AEE (P = 0.008). The effect of SES on AEE was mediated by the number of persons per bedroom (crowding). Prevalence of overweight tended to be higher in middle SES infants (P = 0.054) than in low SES infants. The difference in TEE and AEE between SES groups emphasizes the importance of an accurate description of the SES of any population in which TEE is studied and questions the extent to which TEE data from middle-class infants in transitional countries should be considered normative.