Anemia Etiology in Ethiopia: Assessment of Nutritional, Infectious Disease, and Other Risk Factors in a Population-Based Cross-Sectional Survey of Women, Men, and Children.

BACKGROUND: While the causes of anemia at an individual level (such as certain nutritional deficiencies, infections, and genetic disorders) are well defined, there is limited understanding of the relative burden of anemia attributable to each cause within populations. OBJECTIVES: We sought to estimate the proportion of anemia cases attributable to nutrition, infectious diseases, and other risk factors among women, men, and children in 6 regions of Ethiopia. METHODS: A population-based cross-sectional study was conducted. Data were obtained from 2520 women of reproductive age (15-49 y), 1044 adult men (15-49 y), and 1528 children (6-59 mo). Participants provided venous blood samples for assessment of their hemoglobin concentration; ferritin, folate, vitamin B12, and C-reactive protein levels; and the presence of malaria infection. Stool samples were collected to ascertain the helminth infection status. Sociodemographic questionnaires and a 24-h diet recall were administered. Population-weighted prevalences of anemia and risk factors were calculated. Multivariable-adjusted associations of risk factors with anemia and partial population attributable risk percentages were estimated using generalized linear models. RESULTS: The anemia prevalences were 17% (95% CI: 13%-21%) among women, 8% (95% CI: 6%-12%) among men, and 22% (95% CI: 19%-26%) among children. Low serum ferritin contributed to 11% (95% CI: -1% to 23%) of anemia cases among women, 9% (95% CI: 0%-17%) among men, and 21% (95% CI: 4%-34%) among children. The proportions of anemia attributable to low serum folate were estimated at 25% (95% CI: 5%-41%) among women and 29% (95% CI: 11%-43%) among men. Dietary iron intake was adequate for nearly all participants, while inadequacy was common for folate and vitamin B12. Inflammation and malaria were responsible for less than 1 in 10 anemia cases. CONCLUSIONS: Folate deficiency, iron deficiency, and inflammation appear to be important contributors to anemia in Ethiopia. Folic acid food fortification, targeted iron interventions, and strategies to reduce infections may be considered as potential public health interventions to reduce anemia in Ethiopia.

Associations of percentage energy intake from total, animal and plant protein with overweight/obesity and underweight among adults in Addis Ababa, Ethiopia.

OBJECTIVE: This study investigated associations between types and food sources of protein with overweight/obesity and underweight in Ethiopia. DESIGN: We conducted a cross-sectional dietary survey using a non-quantitative FFQ. Linear regression models were used to assess associations between percentage energy intake from total, animal and plant protein and BMI. Logistic regression models were used to examine the associations of percentage energy intake from total, animal and plant protein and specific protein food sources with underweight and overweight/obesity. SETTING: Addis Ababa, Ethiopia. PARTICIPANTS: 1624 Ethiopian adults (992 women and 632 men) aged 18-49 years in selected households sampled using multi-stage random sampling from five sub-cities of Addis Ababa. RESULTS: Of the surveyed adults, 31 % were overweight or obese. The majority of energy intake was from carbohydrate with only 3 % from animal protein. In multivariable-adjusted linear models, BMI was not associated with percentage energy from total, plant or animal protein. Total and animal protein intake were both associated with lower odds of overweight/obesity (OR per 1 % energy increment of total protein 0·92; 95 % CI: 0·86, 0·99; P = 0·02; OR per 1 % energy increment of animal protein 0·89; 95 % CI: 0·82, 0·96; P = 0·004) when substituted for carbohydrate and adjusted for socio-demographic covariates. CONCLUSION: Increasing proportion of energy intake from total protein or animal protein in place of carbohydrate could be a strategy to address overweight and obesity in Addis Ababa; longitudinal studies are needed to further examine this potential association.

The Global Diet Quality Score is Associated with Higher Nutrient Adequacy, Midupper Arm Circumference, Venous Hemoglobin, and Serum Folate Among Urban and Rural Ethiopian Adults.

BACKGROUND: Nutritionally inadequate diets in Ethiopia contribute to a persisting national burden of adult undernutrition, while the prevalence of noncommunicable diseases (NCDs) is rising. OBJECTIVES: To evaluate performance of a novel Global Diet Quality Score (GDQS) in capturing diet quality outcomes among Ethiopian adults. METHODS: We scored the GDQS and a suite of comparison metrics in secondary analyses of FFQ and 24-hour recall (24HR) data from a population-based cross-sectional survey of nonpregnant, nonlactating women of reproductive age and men (15-49 years) in Addis Ababa and 5 predominately rural regions. We evaluated Spearman correlations between metrics and energy-adjusted nutrient adequacy, and associations between metrics and anthropometric/biomarker outcomes in covariate-adjusted regression models. RESULTS: In the FFQ analysis, correlations between the GDQS and an energy-adjusted aggregate measure of dietary protein, fiber, calcium, iron, zinc, vitamin A, folate, and vitamin B12 adequacy were 0.32 in men and 0.26 in women. GDQS scores were inversely associated with folate deficiency in men and women (GDQS Quintile 5 compared with Quintile 1 OR in women, 0.50; 95% CI: 0.31-0.79); inversely associated with underweight (OR, 0.63; 95% CI: 0.44-0.90), low midupper arm circumference (OR, 0.61; 95% CI: 0.45-0.84), and anemia (OR, 0.59; 95% CI: 0.38-0.91) in women; and positively associated with hypertension in men (OR: 1.77, 95% CI: 1.12-2.80). For comparison, the Minimum Dietary Diversity-Women (MDD-W) was associated more positively (P < 0.05) with overall nutrient adequacy in men and women, but also associated with low ferritin in men, overweight/obesity in women, and hypertension in men and women. In the 24HR analysis (restricted to women), the MDD-W was associated more positively (P < 0.05) with nutrient adequacy than the GDQS, but also associated with low ferritin, while the GDQS was associated inversely with anemia. CONCLUSIONS: The GDQS performed capably in capturing nutrient adequacy-related outcomes in Ethiopian adults. Prospective studies are warranted to assess the GDQS' performance in capturing NCD outcomes in sub-Saharan Africa.

Household-level double burden of malnutrition in Ethiopia: a comparison of Addis Ababa and the rural district of Kersa.

OBJECTIVE: To examine the prevalence of and factors associated with different forms of household-level double burden of malnutrition (DBM) in Ethiopia. DESIGN: We defined DBM using anthropometric measures for adult overweight (BMI ≥ 25 kg/m2), child stunting (height-for-age Z-score <-2 sd) and overweight (weight-for-height Z-score ≥2 sd). We considered sixteen biological, environmental, behavioural and socio-demographic factors. Their association with DBM forms was assessed using generalised linear models. SETTING: We used data from two cross-sectional studies in an urban (Addis Ababa, January-February 2018), and rural setting (Kersa District, June-September 2019). PARTICIPANTS: Five hundred ninety-two urban and 862 rural households with an adult man, adult woman and child <5 years. RESULTS: In Addis Ababa, overweight adult and stunted child was the most prevalent DBM form (9 % (95 % CI 7, 12)). Duration of residence in Addis Ababa (adjusted OR (aOR) 1·03 (95 % CI 1·00, 1·06)), Orthodox Christianity (aOR 1·97 (95 % CI 1·01, 3·85)) and household size (aOR 1·24 (95 % CI 1·01, 1·54)) were associated factors. In Kersa, concurrent child overweight and stunting was the most prevalent DBM form (11 % (95 % CI 9, 14)). Housing quality (aOR 0·33 (95 % CI 0·20, 0·53)), household wealth (aOR 1·92 (95 % CI 1·18, 3·11) and sanitation (aOR 2·08 (95 % CI 1·07, 4·04)) were associated factors. After adjusting for multiple comparisons, only housing quality remained a significant factor. CONCLUSIONS: DBM prevalence was low among urban and rural Ethiopian households. Environmental, socio-economic and demographic factors emerged as potential associated factors. However, we observed no common associated factors among urban and rural households.

Plant-Based Diets for Cardiovascular Disease Prevention: All Plant Foods Are Not Created Equal.

PURPOSE OF REVIEW: Plant-based diets have been widely promoted for cardiovascular disease (CVD) risk reduction. This review discusses the various definitions of plant-based diets and summarizes their associations with CVD risk, specifically distinguishing between healthy and unhealthy plant-based diets. RECENT FINDINGS: Despite wide variation in definition, most studies suggest that plant-based diets are generally beneficial for cardiovascular health. Many previous studies have defined plant-based diets by the complete exclusion of meat or animal products, while others have accounted for plant-based diets including moderate amounts of animal-source foods. Only a few studies have considered the healthfulness of the specific plant foods included in these dietary patterns. In these studies, plant-based diets containing higher amounts of healthy foods such as whole grains, fruits, vegetables, nuts, legumes, oils, tea, and coffee are associated with lower CVD risk. However, plant-based diets including higher amounts of less healthy plant foods, such as refined grains, potatoes/fries, and foods and beverages high in added sugar, are linked to increased risk. A wide spectrum of plant-based diets can be nutritionally adequate and confer cardiovascular benefits, as long as they are planned appropriately and include high-quality foods. Contrary to popular belief, plant-based diets do not have to be vegan or vegetarian. For most people, complete elimination of meat or animal products is unrealistic and not necessary for cardiovascular health. Quality of the specific components of plant-based diets is also important to consider, as not all plant-source foods have beneficial cardiovascular effects. Healthy plant-based diets can be customized to fit individual and cultural preferences and, with large-scale adoption, could concurrently mitigate threats to both human and environmental health.

Anemia prevalence and etiology among women, men, and children in Ethiopia: a study protocol for a national population-based survey.

BACKGROUND: Anemia remains a public health challenge in Ethiopia, affecting an estimated 56% of children under age 5 years, 23% of women of reproductive age and 18% of adult men. However, anemia etiology and the relative contribution of underlying risk factors for anemia remains unclear and has hindered implementation of anemia control programs. METHODS/DESIGN: Anemia Etiology in Ethiopia (AnemEE) is a population-based cross-sectional survey of six regions of Ethiopia that includes children, women of reproductive age, and men from regionally representative households. The survey will include detailed assessment of anemia, iron, inflammatory and nutritional biomarkers, diet, comorbidities, and other factors. The objectives of AnemEE are 1) to generate evidence for decision-making on the etiology of anemia in Ethiopia among men, women and children and 2) to simulate the potential effect of iron fortification and other interventions on the prevalence of anemia and risk of iron overload. DISCUSSION: AnemEE will provide the most comprehensive evaluation of anemia etiology in Ethiopia to date due to its detailed assessment of diet, biomarkers, infections and other risk factors in a population-based sample. By generating evidence and simulating potential interventions, AnemEE will inform the development of high-impact anemia control programs and policies. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04002466 . Registered on 28 June 2019. Retrospectively registered.

Research priorities for nutrition of school-aged children and adolescents in low- and middle-income countries.

PURPOSE: A lack of data, intervention studies, policies, and targets for nutrition in school-age children (SAC) and adolescents (5-19 years) is hampering progress towards tackling malnutrition. To stimulate and guide further research, this study generated a list of research priorities. METHODS: Using the Child Health and Nutrition Research Initiative (CHNRI) method, a list of 48 research questions was compiled and questions were scored against defined criteria using a stakeholder survey. Questions covered all forms of malnutrition, including micronutrient deficiencies, thinness, stunting, overweight/obesity, and suboptimal dietary quality. The context was defined as research focused on SAC and adolescents, 5 to 19 years old, in low-and middle-income countries, that could achieve measurable results in reducing the prevalence of malnutrition in the next 10 years. RESULTS: Between 85 and 101 stakeholders responded per question. Respondents covered a broad geographical distribution across 38 countries, with the largest proportion focusing on work in East and Southern Africa. Of the research questions ranked in the top ten, half focused on delivery strategies for reaching adolescents and half on improving existing interventions. There were few differences in the ranked order of questions between age groups but those related to in-school children and adolescents had higher expert agreement than those for out-of-school adolescents. The top ranked research question focused on tailoring antenatal and postnatal care for pregnant adolescent girls. CONCLUSION: Nutrition programmes should incorporate implementation research to inform delivery of effective interventions to this age group, starting in schools. Academic research on the development and tailoring of existing nutrition interventions is also needed; specifically, on how to package multisectoral programmes and how to better reach vulnerable and underserved sub- groups, including those out of school.

Vitamin D and Zinc Supplementation to Improve Treatment Outcomes among COVID-19 Patients in India: Results from a Double-Blind Randomized Placebo-Controlled Trial.

Background: There remains a need to identify low-cost interventions to improve coronavirus disease 2019 (COVID-19) outcomes. Vitamin D and zinc play a role in respiratory infections and could hold value as part of therapeutic regimens. Objectives: To determine the effect of vitamin D or zinc supplementation on recovery from COVID-19. Methods: We conducted a double-blind, randomly assigned 2 x 2 factorial placebo-controlled trial with 1:1:1:1 allocation ratio, enrolling nonpregnant adults with COVID-19 from hospitals in Mumbai and Pune, India (NCT04641195). Participants (N = 181) were randomly assigned to vitamin D3 (180,000 IU bolus, then 2000 IU daily), zinc (40 mg daily), vitamin D3 and zinc, or placebo, for 8 wk. Participants were followed until 8 wk. The primary outcome was time to resolution of fever, cough, and shortness of breath. Secondary outcomes were duration of individual symptoms; need for assisted ventilation; duration of hospital stay; all-cause mortality; and blood biomarkers, including nutritional, inflammatory, and immunological markers. Results: We observed no effect of vitamin D or zinc supplementation on time to resolution of all 3 symptoms [vitamin D hazard ratio (HR): 0.92; 95% confidence interval (95% CI): 0.66, 1.30; P = 0.650; zinc HR: 0.94; 95% CI: 0.67, 1.33; P = 0.745)]. Neither vitamin D nor zinc supplementation was associated with secondary outcomes, except for increased endline serum vitamin D with vitamin D supplementation [median (interquartile range) difference between endline and baseline for vitamin D: 5.3 ng/mL (-2.3 to 13.7); for no vitamin D: -1.4 ng/mL (-5.6 to 3.9); P = 0.003]. We observed nonsignificant increases in serum zinc at endline following zinc supplementation. There was no evidence of interaction between vitamin D and zinc supplementation, no effect of either on hypercalcemia, and no adverse events. Conclusions: Results suggest that neither vitamin D nor zinc supplementation improves COVID-19 treatment outcomes in this population. However, much larger-scale evidence, particularly from populations with vitamin D or zinc deficiency and severe infection, is required to corroborate our findings. This trial was registered at ClinicalTrials.gov and the Clinical Trials Registry of India as NCT04641195 and CTRI/2021/04/032593 respectively.

COVID-19 Preventive Practices, Psychological Distress, and Reported Barriers to Healthcare Access during the Pandemic among Adult Community Members in Sub-Saharan Africa: A Phone Survey.

The COVID-19 pandemic has had serious negative health and economic impacts in sub-Saharan Africa. Continuous monitoring of these impacts is crucial to formulate interventions to minimize the consequences of COVID-19. This study surveyed 2,829 adults in urban and rural sites among five sub-Saharan African countries: Burkina Faso, Ethiopia, Nigeria, Tanzania, and Ghana. Participants completed a mobile phone survey that assessed self-reported sociodemographics, COVID-19 preventive practices, psychological distress, and barriers to healthcare access. A modified Poisson regression model was used to estimate adjusted prevalence ratios (aPRs) and 95% CIs to investigate potential factors related to psychological distress and barriers to reduced healthcare access. At least 15.6% of adults reported experiencing any psychological distress in the previous 2 weeks, and 10.5% reported that at least one essential healthcare service was difficult to access 2 years into the pandemic. The majority of participants reported using several COVID-19 preventive methods, with varying proportions across the sites. Participants in the urban site of Ouagadougou, Burkina Faso (aPR: 2.29; 95% CI: 1.74-3.03) and in the rural site of Kintampo, Ghana (aPR: 1.68; 95% CI: 1.21-2.34) had a higher likelihood of experiencing any psychological distress compared with those in the rural area of Nouna, Burkina Faso. Loss of employment due to COVID-19 (aPR: 1.77; 95% CI: 1.47-2.11) was also associated with an increased prevalence of psychological distress. The number of children under 5 years in the household (aPR: 1.23; 95% CI: 1.14-1.33) and participant self-reported psychological distress (aPR: 1.83; 95% CI: 1.48-2.27) were associated with an increased prevalence of reporting barriers to accessing health services, whereas wage employment (aPR: 0.67; 95% CI: 0.49-0.90) was associated with decreased prevalence of reporting barriers to accessing health services. Overall, we found a high prevalence of psychological distress and interruptions in access to healthcare services 2 years into the pandemic across five sub-Saharan African countries. Increased effort and attention should be given to addressing the negative impacts of COVID-19 on psychological distress. An equitable and collaborative approach to new and existing preventive measures for COVID-19 is crucial to limit the consequences of COVID-19 on the health of adults in sub-Saharan Africa.

Determinants of COVID-19 vaccine readiness and hesitancy among adults in sub-Saharan Africa.

There is very limited data on the extent and determinants of COVID-19 vaccine hesitancy among adults living in sub-Saharan Africa since the global roll-out of vaccines began in 2021. This multi-country survey sought to investigate COVID-19 vaccine hesitancy and other predictors of readiness to get vaccinated. We conducted surveys among adults residing in nine urban and rural areas in Burkina Faso, Ethiopia, Ghana, Nigeria, and Tanzania in late 2021. Log binomial regression models were used to identify prevalence and factors associated with vaccine hesitancy and beliefs around COVID-19 misinformation. We completed a total of 2,833 interviews. Among all respondents, 9% had never heard of a COVID-19 vaccine, 12% had been vaccinated, and 20% knew someone else who had been vaccinated. The prevalence of vaccine hesitancy varied by country (Ethiopia 29%, Burkina Faso 33%, Nigeria 34%, Ghana 42%, Tanzania 65%), but not by rural or urban context. People who did not think the vaccine was safe or effective, or who were unsure about it, were more likely to be vaccine hesitant. Those who reported they did not have a trusted source of information about the vaccine (aPR: 1.25, 95% CI: 1.18,1.31) and those who thought the vaccine would not be made available to them within the year were more likely to be vaccine hesitant. Women were more likely to be vaccine hesitant (aPR: 1.31, 95% CI: 1.19,1.43) and believe COVID-19 falsehoods (aPR: 1.05, 95% CI: 1.02,1.08). The most commonly believed falsehoods were that the vaccine was developed too fast and that there was not enough information about whether the vaccine was effective or not. Educational campaigns targeted at misinformation and tailored to suit each country are recommended to build trust in COVID-19 vaccines and reduce hesitancy.

The Continued Impacts of the COVID-19 Pandemic on Education and Mental Health Among Sub-Saharan African Adolescents.

PURPOSE: This multicountry survey assessed the levels and the determinants of the impacts of the pandemic on education and mental health among adolescents in sub-Saharan Africa and the potential factors that may exacerbate these adverse impacts. METHODS: A phone survey was conducted among adolescents in nine diverse areas in Burkina Faso, Ethiopia, Ghana, Nigeria, and Tanzania between July and December 2021. Approximately 300 adolescents per area and 2,803 adolescents in total were included. The survey collected information on adolescents' sociodemographic characteristics, current COVID-19 preventive measures, and the impacts of the pandemic on daily activities, education, and mental health. Log-binomial models were used to calculate the adjusted prevalence ratios (aPRs) for determinants of education and mental health outcomes. RESULTS: Overall, 17% of the adolescents were not receiving any education. Compared to boys, girls were 15% more likely than boys to lack fully in-person education (aPR: 1.15; 95% confidence interval [CI]: 1.02, 1.30). Rural residence was associated with 2.7 times the prevalence of not currently receiving any education (aPR: 2.68; 95% CI: 2.23, 3.22). Self-reported experience of the current impacts of the pandemic on daily activities was associated with a higher prevalence of possible psychological distress (aPR: 1.86; 95% CI: 1.55, 2.24), high anxiety level (aPR: 3.37; 95% CI: 2.25, 5.06), and high depression level (aPR: 3.01; 95% CI: 2.05, 4.41). DISCUSSION: The COVID-19 pandemic presents continued challenges to adolescents' education and mental health. Multisectoral efforts are needed to ensure that adolescents in sub-Saharan Africa do not fall further behind due to the pandemic.

Positive attitudes toward legumes are associated with legume intake among adults in Puerto Rico.

Legumes are a traditional healthy staple food in Latin America, with great potential for use in diet-related chronic disease prevention interventions. This study aimed to investigate attitudes about legume consumption and associations with dietary intake. Adult participants from the Puerto Rico Assessment of Diet, Lifestyle, and Diseases, who completed a validated food frequency questionnaire and a legumes questionnaire (n = 229) were included. A 25-item Likert scale was used to assess agreement with stated attitudes regarding legumes consumption. Exploratory factor analysis produced 3 factors: (1) taste and perceived benefits; (2) barriers and negative attitudes; and (3) social support and cultural beliefs. A combined attitudes scale was computed, with higher scores indicating more positive attitudes toward legumes. Adjusted linear regression models examined associations between each factor and the combined scale with legumes intake, rice intake, and ratio of legumes to rice intake. Significant positive associations were observed for the taste and perceived benefits factor (ß = 0.14; 95% confidence interval [CI], 0.07-0.21) and the social support and cultural beliefs factor (ß = 0.14; 95% CI, 0.07-0.22) with legume intake. The social support and cultural beliefs factor was also associated with a higher ratio of legumes to rice intake (ß = 1.59; 95% CI, 0.04-3.14). A 3-unit increase in the combined attitudes scale (corresponding to 1 additional positive attitude) was associated with a 0.03 (95% CI, 0.01-0.05) higher servings/day legume intake. The barriers and negative attitudes factor was inversely associated with rice intake (ß = -0.10; 95% CI, -0.02 to -0.17) and positively associated with ratio of legumes to rice intake (ß = 1.55; 95% CI, 0.03-3.07). Nutritional programs to increase legume intake as a healthy staple food among Puerto Ricans and Hispanic/Latino populations should emphasize building positive attitudes, especially those related to taste, perceived benefits, social support, and cultural beliefs, while diminishing barriers and negative attitudes.

Randomised trial to determine the effect of vitamin D and zinc supplementation for improving treatment outcomes among patients with COVID-19 in India: trial protocol.

INTRODUCTION: Presently, there are few population-level strategies to address SARS-CoV-2 infection except preventive measures such as vaccination. Micronutrient deficiency, particularly vitamin D and zinc deficiency, has been associated with dysregulated host responses, and may play an important role in COVID-19. METHODS AND ANALYSIS: We have designed a 2×2 factorial, randomised, double-blind, multi-centre placebo-controlled trial to evaluate the effect of vitamin D and zinc on COVID-19 outcomes in Maharashtra, India. COVID-19 positive individuals are recruited from hospitals in Mumbai and Pune. Participants are provided (1) vitamin D3 bolus (180 000 IU) maintained by daily dose of 2000 IU and/or (2) zinc gluconate (40 mg daily), versus placebo for 8 weeks. Participants undergo a detailed assessment at baseline and at 8 weeks, and are monitored daily in hospital or every 3 days after leaving the hospital to assess symptoms and other clinical measures. A final follow-up telephone call occurs 12 weeks post-enrolment to assess long-term outcomes. The primary outcome of the study is to time to recovery, defined as time to resolution of all of fever, cough and shortness of breath. Secondary outcomes include: duration of hospital stay, all-cause mortality, necessity of assisted ventilation, change in blood biomarker levels and individual symptoms duration. Participant recruitment commenced on April 2021. ETHICS AND DISSEMINATION: Ethical approval was obtained from institutional ethical committees of all participating institutions. The study findings will be presented in peer-reviewed medical journals. TRIAL REGISTRATION NUMBERS: NCT04641195, CTRI/2021/04/032593, HMSC (GOI)-2021-0060.

COVID-19 vaccine hesitancy and its determinants among sub-Saharan African adolescents.

COVID-19 vaccine hesitancy among adolescents poses a challenge to the global effort to control the pandemic. This multi-country survey aimed to assess the prevalence and determinants of COVID-19 vaccine hesitancy among adolescents in sub-Saharan Africa between July and December 2021. The survey was conducted using computer-assisted telephone interviewing among adolescents in five sub-Saharan African countries, Burkina Faso, Ethiopia, Ghana, Nigeria, and Tanzania. A rural area and an urban area were included in each country (except Ghana, which only had a rural area), with approximately 300 adolescents in each area and 2662 in total. Sociodemographic characteristics and perceptions and attitudes on COVID-19 vaccines were measured. Vaccine hesitancy was defined as definitely not getting vaccinated or being undecided on whether to get vaccinated if a COVID-19 vaccine were available. Log-binomial models were used to calculate the adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) for associations between potential determinants and COVID-19 vaccine hesitancy. The percentage of COVID-19 vaccine hesitancy was 14% in rural Kersa, 23% in rural Ibadan, 31% in rural Nouna, 32% in urban Ouagadougou, 37% in urban Addis Ababa, 48% in rural Kintampo, 65% in urban Lagos, 76% in urban Dar es Salaam, and 88% in rural Dodoma. Perceived low necessity, concerns about vaccine safety, and concerns about vaccine effectiveness were the leading reasons for hesitancy. Healthcare workers, parents or family members, and schoolteachers had the greatest impacts on vaccine willingness. Perceived lack of safety (aPR: 3.52; 95% CI: 3.00, 4.13) and lack of effectiveness (aPR: 3.46; 95% CI: 2.97, 4.03) were associated with greater vaccine hesitancy. The prevalence of COVID-19 vaccine hesitancy among adolescents is alarmingly high across the five sub-Saharan African countries, especially in Tanzania. COVID-19 vaccination campaigns among sub-Saharan African adolescents should address their concerns and misconceptions about vaccine safety and effectiveness.

Analysis of Changes in Weight, Waist Circumference, or Both, and All-Cause Mortality in Chinese Adults.

Importance: Although numerous studies have separately investigated the associations of changes in weight or waist circumference with mortality risk, few studies have examined the associations of concurrent changes in these 2 anthropometric parameters with all-cause mortality. Objective: To assess the associations of changes in body weight, waist circumference, or both, combined with all-cause mortality. Design, Setting, and Participants: This cohort study used data from 2 longitudinal cohort studies in Dongfeng-Tongji and Kailuan, China. Participants included 58 132 adults (aged 40 years and older) with measures of weight and waist circumference at baseline and follow-up visit. Statistical analysis was performed from June 2020 to September 2021. Exposures: Changes in weight and waist circumference between 2 visits (2008-2010 to 2013 in the Dongfeng-Tongji cohort, and 2006-2007 to 2010-2011 in the Kailuan study). Stable weight was defined as change in weight within 2.5 kg between the 2 visits and stable waist circumference was defined as changes within 3.0 cm. Changes were categorized as loss, stable, or gain for weight and waist circumference separately, and created a 9-category variable to represent the joint changes. Main Outcomes and Measures: All-cause mortality from follow-up visit (2013 in Dongfeng-Tongji cohort and 2010-2011 in Kailuan study) until December 31, 2018. Cox proportional hazard regression models were used to estimate the associations with adjustment for potential confounders. Results were obtained in the 2 cohorts separately and pooled via fixed-effect meta-analysis. Results: A total of 10 951 participants in the Dongfeng-Tongji cohort (median [IQR] age, 62 [56-66] years; 4203 [38.4%] men) and 47 181 participants in the Kailuan study (median [IQR] age, 51 [46-58] years; 36 663 [77.7%] men) were included in the analysis. During 426 072 person-years of follow-up, 4028 deaths (523 in the Dongfeng-Tongji cohort and 3505 in the Kailuan study) were documented. When changes in weight and waist circumference were examined separately, U-shape associations were found: both gain and loss in weight (weight loss: pooled hazard ratio [HR], 1.33; 95% CI, 1.23-1.43; weight gain: HR, 1.10; 95% CI, 1.02-1.19) or waist circumference (waist circumference loss: HR, 1.14; 95% CI, 1.05-1.24; waist circumference gain: HR, 1.11; 95% CI, 1.03-1.21) were associated with higher mortality risk compared with stable weight or waist group. When changes in weight and waist circumference were jointly assessed, compared with participants with stable weight and waist circumference (16.9% of the total population [9828 of 58 132] with 508 deaths), participants with different combinations of weight and waist circumference change all had higher mortality risks except for those with stable weight but significant loss in waist. Notably, those who lost weight but gained waist circumference (6.4% of the total population [3698 of 58 132] with 308 deaths) had the highest risk of all-cause mortality (HR, 1.69; 95% CI, 1.46-1.96; absolute rate difference per 100 000 person-years in the Dongfeng-Tongji cohort: 414; 95% CI, 116-819; and in the Kailuan study: 333; 95% CI, 195-492) among the joint subgroups. Conclusions and Relevance: In this cohort study, weight loss with concurrent waist circumference gain was associated with a higher mortality risk in middle-aged and older Chinese adults. This study's findings suggest the importance of evaluating the changes in both body weight and waist circumference when assessing their associations with mortality.

Consumption of dietary folate estimates and its implication for reproductive outcome among women of reproductive age in Kersa: cross-sectional survey.

BACKGROUND: Dietary folate inadequacy is one the most common micronutrient deficiencies that cause neural tube defect (NTD) among infants in Sub-Saharan African countries. This study aims to determine the dietary intake of folate among women of reproductive age (WRA) of Kersa, Eastern Ethiopia. METHODS: A cross-sectional study took place among voluntary women that were selected from 1140 random households. Using a validated Food Frequency Questionnaire, participant's weekly dietary intake history of Ethiopian foods and dietary folate intake was worked out. Statistical analysis was done at a 95% confidence interval. Modified Poisson regression was used to identify factors associated with dietary folate consumption. RESULT: The estimated median usual intake of folate was 170 µg/d (IQR: 118.3; 252.2) and about 33% of WRA had low folate intake and 73.9% were at risk for folate inadequacy. From the reported food groups, Beans and Peas, Starchy staples, and Vitamin-A rich dark-green leafy vegetables were the top three ranked foods that contributed much of the dietary folate. The following conditions were statistically related to dietary folate inadequacy; women's age, being in poor wealth index, low dietary diversity, having seasonal employment, and reliance on market food sources. CONCLUSIONS: We found that women's dietary intake of folate in Kersa is very low and cannot protect their offspring from the risk of having NTD. They could also potentially be predisposed to poor health outcomes. Diversifying and fortification of Ethiopian wheats and salts could decrease the burden of folate deficiency in the country.

Reported Barriers to Healthcare Access and Service Disruptions Caused by COVID-19 in Burkina Faso, Ethiopia, and Nigeria: A Telephone Survey.

The coronavirus disease 2019 (COVID-19) pandemic may have short-term and long-term impacts on health services across sub-Saharan African countries. A telephone survey in Burkina Faso, Ethiopia, and Nigeria was conducted to assess the effects of the pandemic on healthcare services from the perspectives of healthcare providers (HCPs) and community members. A total of 900 HCPs (300 from each country) and 1,797 adult community members (approximately 600 from each country) participated in the study. Adjusted risk ratios (ARRs) and 95% confidence intervals (CIs) were computed using modified Poisson regression. According to the HCPs, more than half (56%) of essential health services were affected. Child health services and HIV/surgical/other services had a slightly higher percentage of interruption (33%) compared with maternal health services (31%). A total of 21.8%, 19.3%, and 7.7% of the community members reported that their family members and themselves had difficulty accessing childcare services, maternal health, and other health services, respectively. Nurses had a lower risk of reporting high service interruptions than physicians (ARR, 0.85; 95% CI, 0.56-0.95). HCPs at private facilities (ARR, 0.71; 95% CI, 0.59-0.84) had a lower risk of reporting high service interruptions than those at governmental facilities. Health services in Nigeria were more likely to be interrupted than those in Burkina Faso (ARR, 1.38; 95% CI, 1.19-1.59). Health authorities should work with multiple stakeholders to ensure routine health services and identify novel and adaptive approaches to recover referral services, medical care, maternal and child health, family planning, immunization and health promotion, and prevention during the COVID-19 era.

COVID-19 Knowledge, Perception, Preventive Measures, Stigma, and Mental Health Among Healthcare Workers in Three Sub-Saharan African Countries: A Phone Survey.

The coronavirus disease 2019 (COVID-19) pandemic is an unprecedented public health crisis globally. Understanding healthcare providers' (HCPs') knowledge and perceptions of COVID-19 is crucial to identifying effective strategies to improve their ability to respond to the pandemic in sub-Saharan Africa. A phone-based survey of 900 HCPs in Burkina Faso, Ethiopia, and Nigeria (300 per country) was conducted to assess knowledge, perceptions, COVID-19 prevention measures, stigma, and mental health of HCPs. Modified Poisson regression models were used to evaluate predictors of knowledge, perceptions, and prevention measures; adjusted risk ratios (ARRs) and 95% confidence intervals (CIs) were calculated. Three-fourths of the HCPs had adequate knowledge, and over half had correct perceptions of risk and high levels of self-reported prevention measures. The majority of the HCPs (73.7%) reported self-perceived social stigma. There was relatively low prevalence of depression (6.6%), anxiety (6.6%), or psychological distress (18%). Compared with doctors, being a nurse was associated with lower levels of knowledge (ARR: 0.83; 95% CI: 0.77-0.90) and was also negatively associated with having correct perceptions toward COVID-19 (AOR: 0.82; 95% CI: 0.73-0.92). HCPs treating COVID-19 patients had higher likelihood of having high levels of prevention measures (AOR: 1.37; 95% CI: 1.23-1.53). Despite high levels of knowledge among HCPs in sub-Saharan Africa, there is a need to improve COVID-19 perceptions and compliance with prevention measures as well as address social stigma toward HCPs to better ensure their safety and prepare them to deliver health services.

Knowledge and Practice Related to COVID-19 and Mental Health among Adults in Sub-Saharan Africa.

Coronavirus disease 2019 (COVID-19) is a public health emergency affecting the lives of millions of people globally. Different measures and extraordinary steps are being taken to contain the transmission of the virus. The levels of knowledge and implementation of preventive practices related to COVID-19 in sub-Saharan African countries are unclear. Additionally, there is a lack of evidence regarding the impacts of the pandemic on mental health. This study aimed to describe knowledge and practices related to COVID-19 and to assess mental health status among adults in three sub-Saharan African countries: Burkina Faso, Ethiopia, and Nigeria. A total of 1,797 adults were included in the survey, and data were collected using computer-assisted telephone interviews. The proportions of adults who identified more than 80% of COVID-19 symptoms, transmission methods, and prevention mechanisms were 69.9%, 79.2%, and 90.7%, respectively. The practice of preventive measures was relatively lower for avoiding social gatherings and disinfecting contaminated surfaces. Better education, urban residence, and believing the pandemic is real were factors associated with good knowledge on COVID-19 symptoms, transmission methods, and preventive actions. Additionally, being male was associated with good knowledge on symptoms and transmission methods, whereas being in an older age group was associated with knowledge of transmission methods. Mild, moderate, and severe psychological distress was reported by 20.6%, 5.9%, and 1.1% of the participants, respectively. Although this study found high levels of knowledge regarding COVID-19, interventions are needed to increase the uptake of recommended preventive practices among adults in sub-Saharan Africa.

School-Based Nutrition Programs for Adolescents in Dodoma, Tanzania: A Situation Analysis.

BACKGROUND: Tanzania has a double burden of malnutrition, including a high prevalence of undernutrition and an increasing prevalence of overweight and obesity among adolescents. Schools present a valuable opportunity to reach a large section of the country's adolescent population with nutrition-oriented interventions. OBJECTIVE: The objective of this study was to assess the current state of adolescent school nutrition interventions in Dodoma, Tanzania, with emphasis on 3 potential school-based nutrition interventions, school vegetable gardens, school meals, and education (on nutrition, agriculture, and water, sanitation, and hygiene). METHODS: Focus group discussions were conducted with several regional and district-level governmental stakeholders, including health, education, and agricultural officers. Ten public secondary schools were visited, and interviews with school administrators, teachers, students, and parents were conducted. RESULTS: All stakeholders interviewed supported interventions to improve school-based nutrition, including school gardens, school feeding, and nutrition education. All 10 schools visited had some experience providing school meals, but parents' contributions were essential for the program's sustainability. Most schools visited had land available for a school garden program, but water availability could be challenging during certain times of the year. The teachers interviewed expressed that the curriculum on nutrition education was highly theoretical and did not allow students to practice the knowledge and skills they learned in the classroom. CONCLUSIONS: The current school-based approach to tackling the double burden of adolescent malnutrition in Dodoma is localized and ad hoc. To leverage the potential of schools as a platform for nutrition interventions, integrated and policy-mandated interventions are needed.