National norms for the obstetric nurses' and midwives' health education competence, and its influencing factors: a nationwide cross-sectional study.

BACKGROUND: Strengthening obstetric nurses' and midwives' health education competence is the investment and guarantee for the population's future health. The purpose of study is to establish national norms for their health education competence, and explore possible influencing factors for providing an uniform criterion identifying levels and weaknesses. METHODS: An online questionnaire with a standard process was used to collect data. Three normative models were constructed, and multiple linear regression analysis analyzed possible influencing factors. RESULTS: The sample respondents (n = 3027) represented obstetric nurses and midwives nationally. Three health education competency normative norms (mean, percentile and demarcation norm) were constructed separately. Locations, hospital grade, department, marital status, training times and satisfaction with health education training influenced obstetrical nurses' and midwives' health education competence (P<0.05). CONCLUSION: This study constructed the first national standard for assessing obstetric nurses' and midwives' health education competence, providing a scientific reference to evaluate the degree of health education competence directly. These known factors could help clinical and policy managers designate practice improvement measures. In future research, Grade I hospitals should be studied with larger sample sizes, and indicators need to improve to reflect health education's effect better.

Children in the Anthroposophical Education System Have Lower Rates of Obesity, and Higher Rates of Health Promoting Behaviors.

BACKGROUND: The anthroposophical philosophy is a holistic educational and lifestyle approach. Limited information exists on the health-promoting behavioral norms and obesity rates among children living anthroposophical vs. conventional lifestyles. AIMS: This study aims to compare the prevalence of childhood obesity, and parents' perceptions of their children's food environment, between anthroposophical and conventional education systems. METHODS: We performed a cross-sectional analysis of the National Anthropometric Measurement Survey for first grade students in Israel, comparing anthroposophical schools with matched conventional schools. Additionally, an online survey was distributed among parents of children in both school systems, assessing children's eating norms and dietary intake. RESULTS: Overweight and obesity rates were higher among students in conventional schools (n = 205,500) compared to anthroposophical schools (n = 2247) (11.2% vs. 9.6%, and 7.8% vs. 4.8%, respectively; Pv < 0.001). Anthroposophical schools were perceived by more parents to have health-promoting curricula, health promoting teacher behavior, and health promoting social dietary norms, while their children's dietary intake was perceived as healthier both in school and in the after-school, social, and familial environment (Pv < 0.001). CONCLUSIONS: Children in anthroposophical education exhibited lower overweight and obesity rates, and engaged in more health-promoting behaviors. Further research is needed to explore the relationship between the anthroposophical lifestyle and childhood obesity, and to identify effective anthroposophical strategies for health promotion among children.

Maternal health leaders' perceptions of barriers to midwife-led care in Ethiopia, Kenya, Malawi, Somalia, and Uganda.

OBJECTIVE: To identify and examine barriers to midwife-led care in Eastern Africa and how these barriers can be reduced DESIGN: A qualitative inductive study with online focus group discussions and semi-structured interviews using content analysis SETTING: The study examines midwife-led care in Ethiopia, Malawi, Kenya, Somalia, and Uganda -five African countries with an unmet need for midwives and a need to improve maternal and neonatal health outcomes. PARTICIPANTS: Twenty-five participants with a health care profession background and current position as a maternal and child health leader from one of the five study countries. FINDINGS: The findings demonstrate barriers to midwife-led care connected to organisational structures, traditional hierarchies, gender disparities, and inadequate leadership. Societal and gendered norms, organisational traditions, and differences in power and authority between professions are some factors explaining why the barriers persist. A focus on intra- and multisectoral collaborations, the inclusion of midwife leaders, and providing midwives with role models to leverage their empowerment are examples of how to reduce the barriers. KEY CONCLUSIONS: This study provides new knowledge on midwife-led care from the perspectives of health leaders in five African countries. Transforming outdated structures to ensure midwives are empowered to deliver midwife-led care at all healthcare system levels is crucial to moving forward. IMPLICATIONS FOR PRACTISE: This knowledge is important as enhancing the midwife-led care provision is associated with substantially improved maternal and neonatal health outcomes, higher satisfaction of care, and enhanced utilisation of health system resources. Nevertheless, the model of care is not adequately integrated into the five countries' health systems. Future studies are warranted to further explore how reducing barriers to midwife-led care can be adapted at a broader level.

The dynamic response of quorum sensing to density is robust to signal supplementation and individual signal synthase knockouts.

Quorum sensing (QS) is a widespread mechanism of environment sensing and behavioural coordination in bacteria. At its core, QS is based on the production, sensing and response to small signalling molecules. Previous work with Pseudomonas aeruginosa shows that QS can be used to achieve quantitative resolution and deliver a dosed response to the bacteria's density environment, implying a sophisticated mechanism of control. To shed light on how the mechanistic signal components contribute to graded responses to density, we assess the impact of genetic (AHL signal synthase deletion) and/or signal supplementation (exogenous AHL addition) perturbations on lasB reaction-norms to changes in density. Our approach condenses data from 2000 timeseries (over 74 000 individual observations) into a comprehensive view of QS-controlled gene expression across variation in genetic, environmental and signal determinants of lasB expression. We first confirm that deleting either (∆lasI, ∆rhlI) or both (∆lasIrhlI) AHL signal synthase gene attenuates QS response to density. In the ∆rhlI background we show persistent yet attenuated density-dependent lasB expression due to native 3-oxo-C12-HSL signalling. We then test if density-independent quantities of AHL signal (3-oxo-C12-HSL, C4-HSL) added to the WT either flatten or increase responsiveness to density and find that the WT response is robust to all tested concentrations of signal, alone or in combination. We then move to progressively supplementing the genetic knockouts and find that cognate signal supplementation of a single AHL signal (∆lasI +3-oxo-C12-HSL, ∆rhlI +C4HSL) is sufficient to restore the ability to respond in a density-dependent manner to increasing density. We also find that dual signal supplementation of the double AHL synthase knockout restores the ability to produce a graded response to increasing density, despite adding a density-independent amount of signal. Only the addition of high concentrations of both AHLs and PQS can force maximal lasB expression and ablate responsiveness to density. Our results show that density-dependent control of lasB expression is robust to multiple combinations of QS gene deletion and density-independent signal supplementation. Our work develops a modular approach to query the robustness and mechanistic bases of the central environmental sensing phenotype of quorum sensing.

Stimuli in 3 Acts: A normative study on action-statements, action videos and object photos.

The study of action observation and imagery, separately and combined, is expanding in diverse research areas (e.g., sports psychology, neurosciences), making clear the need for action-related stimuli (i.e., action statements, videos, and pictures). Although several databases of object and action pictures are available, norms on action videos are scarce. In this study, we validated a set of 60 object-related everyday actions in three different formats: action-statements, and corresponding dynamic (action videos) and static (object photos) stimuli. In Study 1, ratings of imageability, image agreement, action familiarity, action frequency, and action valence were collected from 161 participants. In Study 2, a different sample of 115 participants rated object familiarity, object valence, and object-action prototypicality. Most actions were rated as easy to imagine, familiar, and neutral or positive in valence. However, there was variation in the frequency with which participants perform these actions on a daily basis. High agreement between participants' mental image and action videos was also found, showing that the videos depict a conventional way of performing the actions. Objects were considered familiar and positive in valence. High ratings on object-action prototypicality indicate that the actions correspond to prototypical actions for most objects. 3ActStimuli is a comprehensive set of stimuli that can be useful in several research areas, allowing the combined study of action observation and imagery.

When Social and Personal Norms Collide: Narratives of South African Women Navigating Transactional Sexual Relationships with Blessers.

Due to the negative implications of transactional sexual relationships (TSRs) for women's sexual and reproductive health, studies of social norms in sub-Saharan and South Africa have sought to inform HIV-related risk and interventions in this key population. To date, however, little research has investigated the normative conflicts facing women in African settings when initiating, continuing or abstaining from participation in TSRs. In 2017-2018, we investigated conflicts black South African women in KwaZulu-Natal expressed between adhering to social versus personal norms in TSRs with "blessers"-wealthy men who gift women financially or materially-typically in exchange for sex. Participants expressed conflicts between social norms of blesser engagement to satisfy aspirations for money/material items vs. personal norms of retaining virginity and fidelity to partners. Women largely ignored adverse sexual health risks of HIV and unintended pregnancy. Participants highlighted internal conflicts, prompting reflection on their desires, choices and normative behaviors, also informing women's self-concept, self-efficacy and desires for relationship satisfaction. Greater reflection from women about personal norms and values-and attention to their self-efficacy in relationships-may assist in understanding and advancing women's holistic health and wellbeing in research and interventions among this population and potentially women in other settings.

Monitor to innovate with feedback loops: process evaluation protocol for an anemia prevention intervention.

Background: Digital process monitoring and evaluation tools designed to capture near-to-real-time intervention data paired with feedback loops have the potential to innovate intervention delivery. Objective: To describe how a multilevel social norms field trial (RANI) is using feedback loops to enhance intervention delivery. Methods: We use a mixed-methods process evaluation design to monitor the Reduction of Anemia through Normative Innovations (RANI) project; a three-year randomized control trial which aims to lower rates of anemia among women in Odisha, India. Surveys and structured observation monitor fidelity to implementation and acceptability of implementation activities among study participants. Quantitative data evaluates implementation dose, coverage, exposure, and reach of intervention activities, and qualitative data will delve more deeply into reasons for high or low functioning. Iron folic acid supplement supply and demand are also monitored for stock-outs. Data collected from 130 intervention villages is processed, visualized, and triangulated in near to real-time via Real-time Monitoring for Knowledge Generation (RPM4K), a locally developed software application. Data visualization products facilitate the examination of monitoring data to mitigate bottlenecks and identify and implement tweaks to our intervention delivery strategy on an ongoing basis. Discussion: Feedback loops facilitate timely course corrections. Feedback loops can also engender a shared understanding of ground realities for a geographically dispersed and culturally diverse team. Leveraging feedback loops, we identify opportunities to provide on-going supportive supervision for our community facilitators promoting joint problem-solving, and communication. Monthly media and hemoglobin level demonstration strategies are informed by participant engagement and acceptability. Stock-outs of iron folic acid tablets activate contingency plans to mobilize local stakeholders and advocate for timely resolutions. Unintended effects are monitored based on ongoing feedback from community facilitators. Conclusions: Documenting our processes can inform the future implementation or scale up of similar projects embracing feedback loops to iterate and innovate their intervention delivery.

Building sustainable and scalable peer-based programming: promising approaches from TESFA in Ethiopia.

BACKGROUND: Girls in Ethiopia's Amhara region experience high rates of child marriage and are less able to negotiate sex or use family planning. Seeking to improve their lives, CARE's TESFA programme delivered reproductive health and financial savings curricula to married girls via reflective dialogues in peer-based solidarity groups. From 2010 to 2013, 5,000 adolescent girls participated via three intervention arms: sexual and reproductive health, economic empowerment, and a combination of both. At end-line, participants reported improvements across health and empowerment outcomes. Four years post-TESFA, 88% of groups reported meeting without continued assistance from CARE. Some original participants had created new groups based on the TESFA model, and some girls not recruited for TESFA spontaneously replicated it to create their own groups. However, questions remained about what had contributed to this organic sustainment and scale-up of groups. METHODS: This 2018 study investigated factors affecting sustainability and scale-up of peer solidarity groups through a systematic mapping of TESFA groups across five woredas (districts) and interviews with key stakeholders. Data were collected from 39 focus groups with active and dissolved Girl Groups, Social Analysis and Action groups, and girls' husbands and from 29 in-depth interviews with group facilitators and community health workers across three districts. Data were coded and analyzed per grounded theory principles. RESULTS: Changes in reproductive health knowledge and specific behaviours, such as contraceptive use and institutional delivery, were maintained 5 years after the intervention ended. Group connectedness, spousal support, integration of holistic community platforms, and opportunities for financial independence were found to be important for group sustainability. Observed changes in TESFA girls' confidence to negotiate and assert their rights, hopes of improved mobility, and the promise of economic opportunity commonly inspired spontaneous replication of groups. Recommendations for future peer-based programmes include creating environments of solidarity and holistically engaging intervention communities. CONCLUSION: By increasing knowledge of and access to reproductive health services, TESFA mitigates some of the harmful effects of child marriage. The maintenance and organic replication of groups suggest that TESFA provides a successful, scalable and sustainable tested model for reproductive health program delivery through peer-based solidarity groups.

In Ethiopia, married girls are a particularly vulnerable adolescent population because of the many health risks associated with early marriage. Peer-based approaches are a common strategy to improve sexual and reproductive health knowledge and behaviours for marginalized groups. Critiques of these approaches are that they lack sustainability without ongoing investment and have no lasting impact on health behaviours. CARE's TESFA programme, a peer-based approach with married adolescent girls in South Gondar, was found to be effective in creating long-term behavior change related to uptake of family planning and rates of institutional delivery. Some 88% of groups who received the TESFA curriculum were still meeting 4 years after the programme had concluded. Some participants even created groups of their own, scaling TESFA beyond the original audience, suggesting a potential approach to wider scale-up. To explore lessons learned around scale and sustainability, this study interviewed TESFA participants and stakeholders.Improvements in behaviours related to contraceptive use, institutional delivery, and girls' agency in reproductive decision-making were sustained over time regardless of group status. Factors that affected the sustainability and scale-up of groups included solidarity among group members, support from husbands and community members, ongoing savings and loan structures, flexibility of group processes, and availability of relevant curriculum topics. Through an analysis of these findings, this paper discusses recommendations for sustainable and scalable peer-based programme design via existing Ethiopian community structures. Using TESFA principles as a model, practitioners could design and implement scalable and sustainable peer-based programming for adolescents sexual and reproductive health.

A Matter of Trust: Online Proctored Exams and the Integration of Technologies of Assessment in Medical Education.

ISSUE:  Technology is pervasive in medicine, but we too rarely examine how it shapes assessment, learning, knowledge, and performance. Cultures of assessment also shape identities, social relations, and the knowledge and behavior recognized as legitimate by a profession. Therefore, the combination of technology and assessment within medical education is worthy of review. Online proctoring services have become more prevalent during the Covid-19 pandemic, as a means of continuing high-stakes invigilated examinations online. With criticisms about increased surveillance, discrimination, and the outsourcing of control to commercial vendors, is this simply "moving exams online", or are there more serious implications? What can this extreme example tell us about how our technologies of assessment influence relationships between trainees and medical education institutions? EVIDENCE:  We combine postdigital and postphenomenology approaches to analyze the written component of the 2020 online proctored United Kingdom Royal College of Physicians (MRCP) membership exam. We examine the scripts, norms, and trust relations produced through this example of online proctoring, and then locate them in historical and economic contexts. We find that the proctoring service projects a false objectivity that is undermined by the tight script with which examinees must comply in an intensified norm of surveillance, and by the interpretation of digital data by unseen human proctors. Nonetheless, such proctoring services are promoted by an image of data-driven innovation, a rhetoric of necessity in response to a growing problem of online cheating, and an aversion, within medical education institutions, to changing assessment formats (and thus the need to accept different forms of knowledge as legitimate). IMPLICATIONS:  The use of online proctoring technology by medical education institutions intensifies established norms, already present within examinations, of surveillance and distrust. Moreover, it exacerbates tensions between conflicting agendas of commercialization, accountability, and the education of trustworthy professionals. Our analysis provides an example of why it is important to stop and consider the holistic implications of introducing technological "solutions", and to interrogate the intersection of technology and assessment practices in relation to the wider goals of medical education.

Mental imagery interventions to promote face covering use among UK university students and employees during the COVID-19 pandemic: study protocol for a randomized controlled trial.

BACKGROUND: The 2020 COVID-19 pandemic has witnessed wide-ranging efforts to minimize the spread of the virus and to protect those most vulnerable to becoming unwell following viral infection. Core COVID-19 preventive measures include social distancing, regular hand washing, and wearing face coverings in public places. Understanding links between social cognitive factors relating to beliefs/skills is important in the context of the COVID-19 pandemic, as this can suggest which factors might be targeted via behaviour change interventions to promote adherence to COVID-19 preventative behaviours. In this context, mental imagery exercises-self-directed imagining of an anticipated outcome or processes linked to a defined behaviour/activity-offer a well-evidenced, relatively simple behaviour change intervention. In the mental imagery invention reported in this protocol, individuals will be randomly assigned to one of four separate conditions (outcome imagery, process imagery, outcome and process imagery, control). METHODS: The primary objective of this randomized controlled study is to assess the effectiveness of a mental imagery intervention on wearing face coverings, as a defined core COVID-19 preventative behaviour. Participants will consist of UK university students and university employees of any age. Participants will be randomized to complete an 'outcome imagery' or a 'process imagery' exercise, both exercises (i.e. a combined condition) or neither exercise (i.e. a control condition). A total of 260 individuals will be recruited into the study. Outcomes for all study condition arms will be assessed at baseline (Time 1), immediately post-intervention (Time 2), and at 1-month follow-up (Time 3). The primary outcome is frequency of wearing face covering, as reported at T2 and T3. Secondary outcomes include intervention effects on face covering attitudes, social norms, perceived behavioural control and barrier self-efficacy at T2 and T3. Putative moderators of intervention effects are conscientiousness, narcissism and 'light triad' personality traits. DISCUSSION: This trial will contribute toward the currently sparse evidence base concerning behaviour change techniques designed to promote COVID-19 preventative behaviours among UK university students and university employees. TRIAL REGISTRATION: ClinicalTrials.gov (U.S. National Library of Medicine) NCT04583449 . Retrospectively registered on 20 October 2020.

For Exercise, Relaxation, or Spirituality: Exploring Participation Motives and Conformity to Masculine Norms among Male and Female Yoga Participants.

Yoga is a traditional practice from India with the potential to promote physical activity and health. Participation worldwide remains low, particularly among men. To better understand yoga participation parameters, with a special focus on what influences male participation, this study examined gender differences in participation motives and conformity to masculine norms. It also explored these factors across three participant subgroups who differed in their engagement with the physical and the more psycho-spiritual aspects of yoga. A total of 546 yoga participants (138 males, 399 females, 9 others), 18-73 years old, completed an online survey that included an adapted version of the Exercise Motivation Inventory-2 and three subscales from the Conformity to Masculine Norms Inventory-46. Results showed significant gender differences in participation motives and conformity to masculine norms. Females were more motivated by positive affect, health/fitness, nimbleness, mind-body integration, and coping/stress management, whereas males were more motivated by supplementary activity and competition/social recognition. These differences should be considered in tailoring messages to promote uptake and continued participation. Furthermore, males were more likely than females to conform to emotional control and heterosexual self-presentation masculine norms. Future research may examine how differences in masculine norm adherence influences uptake, particularly among men.

A critical review on the occurrence and distribution of the uranium- and thorium-decay nuclides and their effect on the quality of groundwater.

This critical review presents the key factors that control the occurrence of natural elements from the uranium- and thorium-decay series, also known as naturally occurring radioactive materials (NORM), including uranium, radium, radon, lead, polonium, and their isotopes in groundwater resources. Given their toxicity and radiation, elevated levels of these nuclides in drinking water pose human health risks, and therefore understanding the occurrence, sources, and factors that control the mobilization of these nuclides from aquifer rocks is critical for better groundwater management and human health protection. The concentrations of these nuclides in groundwater are a function of the groundwater residence time relative to the decay rates of the nuclides, as well as the net balance between nuclides mobilization (dissolution, desorption, recoil) and retention (adsorption, precipitation). This paper explores the factors that control this balance, including the relationships between the elemental chemistry (e.g., solubility and speciation), lithological and hydrogeological factors, groundwater geochemistry (e.g., redox state, pH, ionic strength, ion-pairs availability), and their combined effects and interactions. The various chemical properties of each of the nuclides results in different likelihoods for co-occurrence. For example, the primordial 238U, 222Rn, and, in cases of high colloid concentrations also 210Po, are all more likely to be found in oxic groundwater. In contrast, in reducing aquifers, Ra nuclides, 210Pb, and in absence of high colloid concentrations, 210Po, are more mobile and frequently occur in groundwater. In highly permeable sandstone aquifers that lack sufficient adsorption sites, Ra is often enriched, even in low salinity and oxic groundwater. This paper also highlights the isotope distributions, including those of relatively long-lived nuclides (238U/235U) with abundances that depend on geochemical conditions (e.g., fractionation induced from redox processes), as well as shorter-lived nuclides (234U/238U, 228Ra/226Ra, 224Ra/228Ra, 210Pb/222Rn, 210Po/210Pb) that are strongly influenced by physical (recoil), lithological, and geochemical factors. Special attention is paid in evaluating the ability to use these isotope variations to elucidate the sources of these nuclides in groundwater, mechanisms of their mobilization from the rock matrix (e.g., recoil, ion-exchange), and retention into secondary mineral phases and ion-exchange sites.

Transforming social norms to improve girl-child health and well-being: a realist evaluation of the Girls' Holistic Development program in rural Senegal.

BACKGROUND: Early adolescence is a critical period where social norms, attitudes, and behaviors around gender equality form. Social norms influence adolescent choices and behaviors and are reinforced by caregivers and community members, affecting girls' reproductive health and educational opportunities. Understanding how to shift these often-interconnected norms to delay child marriage, pregnancy and keep girls in school requires understanding of the structure and dynamics of family and community systems. The Senegalese and American non-governmental organization, the Grandmothers Project-Change through Culture, seeks to address these intertwined factors through innovative community change strategies that build on the specific structure and values of West African collectivist cultures. METHODS: The Girls' Holistic Development approach in rural Vélingara, Senegal posits that by increasing recognition, knowledge and empowerment of elder community women and reinforcing intergenerational communication and decision-making, community members including girls will support and advocate on behalf of girls' interests and desires. We assessed the Girls Holistic Development approach using Realist Evaluation with a mixed-method, quasi-experimental design with a comparison population. We examined differences in intergenerational communication, decision-making and descriptive and injunctive norms related to early marriage, pregnancy and schooling. RESULTS: After 18 months, intergenerational communication was more likely, grandmothers felt more valued in their communities, adolescent girls felt more supported with improved agency, and norms were shifting to support delayed marriage and pregnancy and keeping girls in school. Grandmothers in intervention villages were statistically significantly more likely to be perceived as influential decision-makers by both VYA girls and caregivers for marriage and schooling decisions compared to girls and caregivers in comparison villages. CONCLUSIONS: This realist evaluation demonstrated shift in social norms, particularly for VYA girls, in intervention villages favoring delaying girls' marriage, preventing early pregnancy and keeping girls in school along with increased support for and action by grandmothers to support girls and their well-being related to these same outcomes. These shifts represent greater community social cohesion on girl-child issues. This research helps explain the linkage between social norms and girls' reproductive health and education outcomes and demonstrates that normative shifts can lead to behavior change via collective community action mechanisms.

During adolescence in Senegal, as elsewhere, decisions on whether to keep girls in school and at what age to marry girls are made by their caregivers and influenced by family and community members. Early pregnancy occurs at these ages, either before or during marriage. These social influences, called social norms, set expectations for parents and girls.The Grandmothers Project­Change through Culture developed an intervention to shift social norms and change these three outcomes­early pregnancy, early marriage and keeping girls in school. The project, called Girls Holistic Development (GHD), builds on local relationships between girls, grandmothers, parents and community leaders and local values to facilitate discussion, reflection, collaboration and advocacy.This study used realist evaluation methods, including qualitative and quantitative interview and focus group discussions, to understand whether these shifts in norms and behaviors took place. Research took place with girls, grandmothers and male and female caregivers 18 months after GHD started. Quantitative survey included 7 intervention and 7 comparison villages.Results supported GHDs' expectations and strategy. In intervention villages, grandmothers and girls reported closer relationships; parents considered grandmothers important sources of advice. Girls, grandmothers and caregivers described social expectations as favoring girl's education, marriage at older ages and development of strategies to prevent girl's pregnancy in intervention villages.This evaluation provided strong support for GHDs' ability to shift social norms to improve girls' outcomes. By working with local relationships and values, GHD created more communication between community and family members and facilitated increased social bonds within the community.

A qualitative exploration of the norms and intentions of nurses toward the clinical use of herbal medicine in Ghana.

PURPOSE: The purpose of the study was to determine the norms and intentions of nurses towards the clinical use of herbal medicine. METHOD: Information on nurses' demographics, norms and intentions was gathered through individual face-to-face interviews. Interviews were analysed using the process of content analysis. RESULTS: Beliefs of the nurses and motivational factors formed their norms. The nurses believed herbal medicine was God-given and was used by their ancestors with good outcomes. Some were self-motivated to serve herbal medicine while others counted on patient's recovery upon the use of herbal medicine to motivate them. Positive and negative intentions were discovered; thus, preparedness and unpreparedness to serve herbal medicine in the future. CONCLUSIONS: Though some nurses believe herbal medicine is God-given, used by their ancestors and motivated to serve, others were unwilling because of inadequate training. Training of professional nurses on herbal medicine may improve their negative intentions.

How gender norms affect anemia in select villages in rural Odisha, India: A qualitative study.

BACKGROUND: In India, 50% of women of reproductive age, compared with 23% of men, have iron deficiency anemia. Extant research focuses on biological, not social, determinants of this disparity. OBJECTIVES: The aim of this study was to examine how gender norms may affect anemia prevalence among women in rural India. METHODS: We conducted 16 focus group discussions (N = 124) with women of reproductive age, husbands, and mothers-in-law and 25 key informant interviews in four villages in Odisha, India. RESULTS: We identified the following themes that help explain how inequitable gender norms exacerbate anemia among women from different castes and tribes: Due to a double burden of work outside the home and completing the majority of unpaid work in the home, women lack time to visit health centers to get tested for anemia and to obtain iron supplements. Women are expected to prioritize the health of their family over their own, thus affecting their access to health care. Women's autonomy to leave the house to seek health care is limited. Men are the primary breadwinners for the family, but often spend their money on alcohol, rather than on iron-rich food for the household. Intra-household food allocation favors men, in-laws, and children, thus women serve their family first, often being left with little food. CONCLUSION: Anemia reduction interventions need to include examination of the whole social context to successfully increase iron supplement use and iron-rich food intake. Understanding how gender norms contribute to anemia could change the narrative from a biomedical to a social justice issue.

Influence of gender norms in relation to child's quality of care: follow-up of families of children with SCD identified through NBS in Tanzania.

Introducing newborn screening (NBS) services for sickle cell disease (SCD) in Africa has been proven to be one of the most cost-effective approach to reducing morbidity and mortality associated with this condition. In view of this evidence, efforts have been made by countries in Africa where SCD prevalence is high to pilot NBS programmes and to strengthen comprehensive care services for SCD. While it is important to reap the benefits of NBS for SCD in Africa in terms of overall quantitative measures, it is also important to understand how certain social and cultural conditions may disproportionately influence the outcomes of screening for some groups. The aim of this study was to analyse the role of gender norms before and after NBS for SCD in Tanzania, and to assess how they influence the quality of care of diagnosed children. Using qualitative methods, we did in-depth interviews with families of children with SCD identified through the NBS services and focus group sessions with nurses working in neonatal and postnatal sections of regional referral hospitals in Dar es Salaam. By analysing the experiences of both the families and nurses, we were able to provide evidence on, firstly, the gendered relations that undergird childcare and, secondly, how those relations influence the quality of care the child may potentially receive. The results emphasize the importance of studying the social implications of SCD in Africa, especially with regard to improving the quality of care for patients with SCD in the region. We propose simple interventions, including gender-conscious health education and genetic counselling, which can help to improve the community understanding of genetic diseases while also reducing gender-related inequalities related to SCD care in Africa.

[Nutriome as the direction of the "main blow": determination of physiological needs in macro- and micronutrients, minor biologically active substances].

One of the essential parts of fundamental research in Nutrition Science is the determination of the physiological requirements of humans for energy and food substances. Research that has been carried out in this area over the past 90 years, consistently develops and improves the norms of physiological requirements for energy and nutrients for various groups of the population of the Russian Federation. In the 50 years of the last century in this research field, determining the values of daily intake for macronutrients (proteins, lipids and carbohydrates), was in the first place. Then the Era of micronutrients (vitamins, minerals, trace elements) was started, and, finally, now there is the Era of minor food biologically active substances. More and more facts are accumulating about their leading role in regulating metabolism. They can be recognized as endogenous regulators, the primary vital components involved in the formation of human health. In recent years, the new definition of Nutriome is introduced into Nutrition Science. It is considered as a set of essential nutritional factors to maintain a dynamic equilibrium between human being and the environment, aimed to ensure viability, the preservation and reproduction of the species, keeping the adaptive capacity, the system of antioxidant defence, apoptosis, metabolism, and immune system function. The Nutriome is a formula for optimal nutrition, which is continually being improved and supplemented. Knowledge of this formula is the key to forming an optimal diet for a person, and, therefore, to save their health. It is evident that at the population level, the Nutriome has its characteristics, its structure for each age period of human life. The need to develop a formula for optimal nutrition and, consequently, updating nutrient-based dietary guidelines is induced by socio-economic and demographic changes in population, changes in anthropometric characteristics of children and adults, increasing prevalence of socially significant non-communicable diseases, developing studies of the significance of particular food substances and establishing the relationship between nutrition and health.

Role of norms in variation in cancer centers' end-of-life quality: qualitative case study protocol.

BACKGROUND: A critical barrier to improving the quality of end-of-life (EOL) cancer care is our lack of understanding of the mechanisms underlying variation in EOL treatment intensity. This study aims to fill this gap by identifying 1) organizational and provider practice norms at major US cancer centers, and 2) how these norms influence provider decision making heuristics and patient expectations for EOL care, particularly for minority patients with advanced cancer. METHODS: This is a multi-center, qualitative case study at six National Comprehensive Cancer Network (NCCN) and National Cancer Institute (NCI) Comprehensive Cancer Centers. We will theoretically sample centers based upon National Quality Forum (NQF) endorsed EOL quality metrics and demographics to ensure heterogeneity in EOL intensity and region. A multidisciplinary team of clinician and non-clinician researchers will conduct direct observations, semi-structured interviews, and artifact collection. Participants will include: 1) cancer center and clinical service line administrators; 2) providers from medical, surgical, and radiation oncology; palliative or supportive care; intensive care; hospital medicine; and emergency medicine who see patients with cancer and have high clinical practice volume or high local influence (provider interviews and observations); and 3) adult patients with metastatic solid tumors and whom the provider would not be surprised if they died in the next 12 months and their caregivers (patient and caregiver interviews). Leadership interviews will probe about EOL institutional norms and organization. We will observe inpatient and outpatient care for two weeks. Provider interviews will use vignettes to probe explicit and implicit motivations for treatment choices. Semi-structured interviews with patients near EOL, or their family members and caregivers will explore past, current, and future decisions related to their cancer care. We will import transcribed field notes and interviews into Dedoose software for qualitative data management and analysis, and we will develop and apply a deductive and inductive codebook to the data. DISCUSSION: This study aims to improve our understanding of organizational and provider practice norms pertinent to EOL care in U.S. cancer centers. This research will ultimately be used to inform a provider-oriented intervention to improve EOL care for racial and ethnic minority patients with advanced cancer. TRIAL REGISTRATION: Clinicaltrials.gov ; NCT03780816 ; December 19, 2018.

Social norms as possible causes of stillbirths.

OBJECTIVE: High stillborn rates are a concern in developing countries. Hence, this article aims to describe the sociocultural norms contributing to the high number of stillbirths as perceived by mothers, significant others, midwives and records of the Pregnancy Problem Identification Programme (PPIP). DESIGN & SETTING: A multimethod qualitative descriptive study was conducted in a district in the Free State, South Africa. Each of the five sub-districts has a district hospital where most pregnant women give birth. Eighty per cent of the community is black of which about a quarter live in poor conditions below the poverty line. PARTICIPANTS: The first author conducted unstructured in-depth interviews with 36 mothers and their significant other who gave birth to a stillborn. She also extracted relevant data from the PPIP record of each mother. A skilled moderator conducted three focus group interviews with a convenience sample of midwives. The data were inductively analysed to identify subthemes under the central theme of social norms. KEY CONCLUSIONS: The authors concluded that traditional practices, traditional role players (traditional healer, mother-in-law, partner), abuse, and prescriptive social norms might contribute to stillbirths. Pregnant women are oppressed as they adhere to traditional social norms and are unable to make independent, informed healthcare decisions. The midwives, who are mostly female, may find it difficult to empower pregnant women because they are under the same social oppression as their clients. IMPLICATIONS FOR PRACTICE: It is imperative that healthcare providers consider social determinants of health, including social norms, when providing healthcare, especially to pregnant women as some social practices may have detrimental outcomes for the mother and/or baby.

Engaging African American Parents to Develop a Mobile Health Technology for Breastfeeding: KULEA-NET.

BACKGROUND: African Americans breastfeed less than other groups, which has implications for health throughout the life course. Little is known about mobile health technologies to support breastfeeding. RESEARCH AIMS: This study proceeded in two phases. The aim of Phase 1 was to identify ideal technological components and content of a mobile health intervention. The aim of Phase 2 was to determine the usability of a prototype, KULEA-NET, based on the Phase 1 findings. METHODS: For this mixed-methods study, we used community-based participatory research methods and user-centered technology design methods. We used open coding in NVivo 11 to organize data from focus groups and in-depth interviews, then we analyzed the data. We then developed a prototype and tested the prototype's usability with the System Usability Scale. Fifty pregnant and postpartum African Americans from the District of Columbia participated. RESULTS: Participants preferred an app with text messaging technology and identified areas for intervention: self-efficacy, parent-child attachment beliefs, social support, public breastfeeding and social desirability, and returning to work. Desired features included local resources, support person access, baby care logs, identification of public breastfeeding venues, and peer discussions. The System Usability Scale score was 73.8, which indicates above average usability. CONCLUSIONS: A mobile health technology like KULEA-NET can be used to meet the breastfeeding needs of African Americans, build social desirability, and complement traditional health care. The appeal of an African American-specific intervention is unclear. Responding to mixed feeding practices is challenging. KULEA-NET is a mobile breastfeeding intervention guided by the preferences of African American parents and offers promising usability metrics.