Cinemeducation: A mixed methods study on learning through reflective thinking, perspective taking and emotional narratives.

INTRODUCTION: Cinemeducation describes the use of film in medical education. The M23 Cinema (M23C) comprises a film screening and subsequent discussion with experts, affected persons and the audience. Previous research suggests that participating in cinemeducation may affect emotions and attitudes. This study aimed to establish a conceptual framework and explore when learning takes place, how learning occurs and what participants learn during the M23C. METHODS: Informed by focused literature searches, discussions of the authors and the research results, a conceptual framework of the M23C was developed, comprising three dimensions (five distinct phases, learning methodology and potential impact). A mixed method study was undertaken, employing an exploratory sequential design. Initially, the qualitative component was conducted by interviewing everyone involved, comprising focus groups, expert interviews, a group interview and one narrative interview. All qualitative data were analysed using qualitative content analysis. The qualitative findings were used to inform the development of a survey among the participants of M23C evenings. The survey results were analysed descriptively. The findings generated by both data sets were integrated using the "following a thread" protocol and visualised by joint displays. RESULTS: In total, 15 participants in M23C courses, six members of the current and two of the former organising committee, two experts, two affected persons and the initiator of the M23C were included in the qualitative component (n = 28). A total of 503 participants responded to the survey. The qualitative data confirmed the relevance of the five phases and participants described reflective thinking, perspective taking and emotional narratives as the three dimensions of how they learned during the M23C. Participants reported a change in attitudes, enriching their knowledge, experiencing empathy and learning about other health professions. DISCUSSION: Our findings suggest that the M23C as a cinemeducation course provides a unique learning environment in the training of health professionals.

Assessing the impact of an evidence- and consensus-based guideline for controlling SARS-CoV-2 transmission in German schools on decision-making processes: a multi-component qualitative analysis.

INTRODUCTION: During the COVID-19 pandemic, decision-making on measures to reduce or prevent transmission of SARS-CoV-2 in schools was rendered difficult by a rapidly evolving and uncertain evidence base regarding their effectiveness and unintended consequences. To support decision-makers, an interdisciplinary panel of scientific experts, public health and school authorities as well as those directly affected by school measures, was convened in an unprecedented effort to develop an evidence- and consensus-based public health guideline for German schools. This study sought to assess whether and how this guideline impacted decision-making processes. METHODS: This study comprised three components: (1) we sent inquiries according to the Freedom of Information Acts of each Federal State to ministries of education, family, and health. (2) We conducted semi-structured interviews with individuals involved in decision-making regarding school measures in two Federal States, and (3) we undertook semi-structured interviews with members of the guideline panel. The content of response letters in component 1 was analysed descriptively; data for components 2 and 3 were analysed using deductive-inductive thematic qualitative content analysis according to Kuckartz. RESULTS: Responses to the Freedom of Information Act inquiries showed that the guideline was recognised as a relevant source of information by ministries of education in nine out of 16 Federal States and used as a reference to check existing directives for school measures in five Federal States. All participants (20 interviews) emphasised the value of the guideline given its evidence- and consensus-based development process but also noted limitations in its usability and usefulness, e.g., lack of context-specificity. It was consulted by participants who advised policy-makers (5 interviews) alongside other sources of evidence. Overall, perceptions regarding the guideline's impact were mixed. CONCLUSIONS: Our findings suggest that the guideline was relatively well-known in Federal States' decision-making bodies and that it was considered alongside other forms of evidence in some of these. We suggest that further research to evaluate the impact of public health guidelines on (political) decision-making is warranted. Guideline development processes may need to be adapted to account for the realities of decision-making during public health emergencies and beyond.

Developing, implementing, and monitoring tailored strategies for integrated knowledge translation in five sub-Saharan African countries.

BACKGROUND: Integrated knowledge translation (IKT) through strategic, continuous engagement with decision-makers represents an approach to bridge research, policy and practice. The Collaboration for Evidence-based Healthcare and Public Health in Africa (CEBHA +), comprising research institutions in Ethiopia, Malawi, Rwanda, South Africa, Uganda and Germany, developed and implemented tailored IKT strategies as part of its multifaceted research on prevention and care of non-communicable diseases and road traffic injuries. The objective of this article is to describe the CEBHA + IKT approach and report on the development, implementation and monitoring of site-specific IKT strategies. METHODS: We draw on findings derived from the mixed method IKT evaluation (conducted in 2020-2021), and undertook document analyses and a reflective survey among IKT implementers. Quantitative data were analysed descriptively and qualitative data were analysed using content analysis. The authors used the TIDieR checklist to report results in a structured manner. RESULTS: Preliminary IKT evaluation data (33 interviews with researchers and stakeholders from policy and practice, and 31 survey responses), 49 documents, and eight responses to the reflective survey informed this article. In each of the five African CEBHA + countries, a site-specific IKT strategy guided IKT implementation, tailored to the respective national context, engagement aims, research tasks, and individuals involved. IKT implementers undertook a variety of IKT activities at varying levels of engagement that targeted a broad range of decision-makers and other stakeholders, particularly during project planning, data interpretation, and output dissemination. Throughout the project, the IKT teams continued to tailor IKT strategies informally and modified the IKT approach by responding to ad hoc engagements and involving non-governmental organisations, universities, and communities. Challenges to using systematic, formalised IKT strategies arose in particular with respect to the demand on time and resources, leading to the modification of monitoring processes. CONCLUSION: Tailoring of the CEBHA + IKT approach led to the inclusion of some atypical IKT partners and to greater responsiveness to unexpected opportunities for decision-maker engagement. Benefits of using systematic IKT strategies included clarity on engagement aims, balancing of existing and new strategic partnerships, and an enhanced understanding of research context, including site-specific structures for evidence-informed decision-making.

Using GRADE Evidence to Decision frameworks to support the process of health policy-making: an example application regarding taxation of sugar-sweetened beverages.

BACKGROUND: Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Evidence to Decision (EtD) frameworks are well-known tools that enable guideline panels to structure the process of developing recommendations and making decisions in healthcare and public health. To date, they have not regularly been used for health policy-making. This article aims to illustrate the application of the GRADE EtD frameworks in the process of nutrition-related policy-making for a European country. METHODS: Based on methodological guidance by the GRADE Working Group and the findings of our recently published scoping review, we illustrate the process of moving from evidence to recommendations, by applying the EtD frameworks to a fictitious example. Sugar-sweetened beverage (SSB) taxation based on energy density was chosen as an example application. RESULTS: A fictitious guideline panel was convened by a national nutrition association to develop a population-level recommendation on SSB taxation aiming to reduce the burden of overweight and obesity. Exemplary evidence was summarized for each EtD criterion and conclusions were drawn based on all judgements made in relation to each criterion. As a result of the high priority to reduce the burden of obesity and because of the moderate desirable effects on health outcomes, but considering scarce or varying research evidence for other EtD criteria, the panel made a conditional recommendation for SSB taxation. Decision-makers may opt for conducting a pilot study prior to implementing the policy on a national level. CONCLUSIONS: GRADE EtD frameworks can be used by guideline panels to make the process of developing recommendations in the field of health policy more systematic, transparent and comprehensible.

Cinemeducation in medicine: a mixed methods study on students' motivations and benefits.

BACKGROUND: Cinemeducation courses are used to supplement more standard teaching formats at medical schools and tend to emphasise biopsychosocial aspects of health. The purpose of this paper is to explore why medical students attend the cinemeducation course M23 Cinema (M23C) at LMU Munich and whether a film screening with a subsequent expert and peer discussion benefits their studies and their future careers as medical doctors. METHODS: An exploratory sequential mixed methods study design was used. Qualitative research, i.e. three focus groups, four expert interviews, one group interview and one narrative interview, was conducted to inform a subsequent quantitative survey. Qualitative data was analysed using qualitative content analysis and quantitative data was analysed descriptively. The findings were integrated using the "following a thread" protocol. RESULTS: In total, 28 people were interviewed and 503 participants responded to the survey distributed at seven M23C screenings. Participants perceive the M23C as informal teaching where they learn about perspectives on certain health topics through the combination of film and discussion while spending time with peers. The reasons for and reported benefits of participation varied with educational background, participation frequency and gender. On average, participants gave 5.7 reasons for attending the M23C. The main reasons for participating were the film, the topic and the ability to discuss these afterwards as well as to spend an evening with peers. Attending the M23C was reported to support the students' memory with regards to certain topics addressed in the M23C when the issues resurface at a later stage, such as during university courses, in the hospital, or in their private life. CONCLUSIONS: The M23C is characterised by its unique combination of film and discussion that encourages participants to reflect upon their opinions, perspectives and experiences. Participating in the M23C amplified the understanding of biopsychosocial aspects of health and illness in students. Thus, cinemeducative approaches such as the M23C may contribute to enabling health professionals to develop and apply humane, empathetic and relational skills.

Mixed method evaluation of the CEBHA+ integrated knowledge translation approach: a protocol.

BACKGROUND: The Collaboration for Evidence-based Healthcare and Public Health in Africa (CEBHA+) is a research consortium concerned with the prevention, diagnosis and treatment of non-communicable diseases. CEBHA+ seeks to engage policymakers and practitioners throughout the research process in order to build lasting relationships, enhance evidence uptake, and create long-term capacity among partner institutions in Ethiopia, Malawi, Rwanda, South Africa and Uganda in collaboration with two German universities. This integrated knowledge translation (IKT) approach includes the formal development, implementation and evaluation of country specific IKT strategies. METHODS: We have conceptualised the CEBHA+ IKT approach as a complex intervention in a complex system. We will employ a comparative case study (CCS) design and mixed methods to facilitate an in-depth evaluation. We will use quantitative surveys, qualitative interviews, quarterly updates, and a policy document analysis to capture the process and outcomes of IKT across the African CEBHA+ partner sites. We will conduct an early stage (early 2020) and a late-stage evaluation (early 2022), triangulate the data collected with various methods at each site and subsequently compare our findings across the five sites. DISCUSSION: Evaluating a complex intervention such as the CEBHA+ IKT approach is complicated, even more so when undertaken across five diverse countries. Despite conceptual, methodological and practical challenges, our comparative case study addresses important evidence gaps: While involving decision-makers in the research process is gaining traction worldwide, we still know very little regarding (i) whether this approach really makes a difference to evidence uptake, (ii) the mechanisms that make IKT successful, and (iii) relevant differences across socio-cultural contexts. The evaluation described here is intended to provide relevant insights on all of these aspects, notably in countries in Sub-Saharan Africa, and is expected to contribute to the science of IKT overall.

[Evidence-based public health: perspectives and specific implementation factors]. / Evidenzbasierte Public Health: Perspektiven und spezifische Umsetzungsfaktoren.

An evidence-based approach is considered a central requirement in the public health system. Five general principles apply in evidence-based medicine as well as in evidence-based public health (EBPH). These comprise a systematic approach, transparency in relation to uncertainty, integration and participation, management of conflicts of interest, and a structured, reflective process. This article aims to promote a common understanding of what taking an evidence-based approach entails in the field of public health.We explored the international understanding of EBPH through systematic literature searches of definitions, concepts, and models regarding an evidence-based approach in public health. In this manner, 20 English sources and one German source were identified and examined using content analysis. Beyond the above-described general principles, characteristics of these perspectives are concerned with a population orientation, the underlying concept of evidence, disciplines, and stakeholder groups to be involved in the process, as well as relevant criteria and necessary competencies for implementing an evidence-based approach.Based on this, and taking into account methodological developments to address complexity, four specific implementation factors of EBPH can be derived. These include theory, interdisciplinarity, context-sensitivity, and complexity as well as general societal aspects.The practical implementation of EBPH requires human and financial resources as well as competencies - among others, for conducting systematic reviews of the effectiveness of measures, examining other relevant questions in a scientific manner, and establishing transparent processes to formulate recommendations.

Barriers and facilitators to institutional delivery in rural areas of Chitwan district, Nepal: a qualitative study.

BACKGROUND: Giving birth assisted by skilled care in a health facility plays a vital role in preventing maternal deaths. In Nepal, delivery services are free and a cash incentive is provided to women giving birth at a health facility. Nevertheless, about half of women still deliver at home. This study explores socio-cultural and health service-related barriers to and facilitators of institutional delivery. METHODS: Six village development committees in hill and plain areas were selected in Chitwan district. We conducted a total of 10 focus group discussions and 12 in-depth-interviews with relevant stakeholder groups, including mothers, husbands, mothers-in-law, traditional birth attendants, female community health volunteers, health service providers and district health managers. Data were analyzed inductively using thematic analysis. RESULTS: Three main themes played a role in deciding the place of delivery, i.e. socio-cultural norms and values; access to birthing facilities; and perceptions regarding the quality of health services. Factors encouraging an institutional delivery included complications during labour, supportive husbands and mothers-in-law, the availability of an ambulance, having birthing centres nearby, locally sufficient financial incentives and/or material incentives, the 24-h availability of midwives and friendly health service providers. Socio-cultural barriers to institutional deliveries were deeply held beliefs about childbirth being a normal life event, the wish to be cared for by family members, greater freedom of movement at home, a warm environment, the possibility to obtain appropriate "hot" foods, and shyness of young women and their position in the family hierarchy. Accessibility and quality of health services also presented barriers, including lack of road and transportation, insufficient financial incentives, poor infrastructure and equipment at birthing centres and the young age and perceived incompetence of midwives. CONCLUSION: Despite much progress in recent years, this study revealed some important barriers to the utilization of health services. It suggests that a combination of upgrading birthing centres and strengthening the competencies of health personnel while embracing and addressing deeply rooted family values and traditions can improve existing programmes and further increase institutional delivery rates.

Facilitating evidence uptake: development and user testing of a systematic review summary format to inform public health decision-making in German-speaking countries.

BACKGROUND: Systematic reviews are an important source of evidence for public health decision-making, but length and technical jargon tend to hinder their use. In non-English speaking countries, inaccessibility of information in the native language often represents an additional barrier. In line with our vision to strengthen evidence-based public health in the German-speaking world, we developed a German language summary format for systematic reviews of public health interventions and undertook user-testing with public health decision-makers in Germany, Austria and Switzerland. METHODS: We used several guiding principles and core elements identified from the literature to produce a prototype summary format and applied it to a Cochrane review on the impacts of changing portion and package sizes on selection and consumption of food, alcohol and tobacco. Following a pre-test in each of the three countries, we carried out 18 user tests with public health decision-makers in Germany, Austria and Switzerland using the 'think-aloud' method. We analysed participants' comments according to the facets credibility, usability, understandability, usefulness, desirability, findability, identification and accessibility. We also identified elements that hindered the facile and satisfying use of the summary format, and revised it based on participants' feedback. RESULTS: The summary format was well-received; participants particularly appreciated receiving information in their own language. They generally found the summary format useful and a credible source of information, but also signalled several barriers to a positive user experience such as an information-dense structure and difficulties with understanding statistical terms. Many of the identified challenges were addressed through modifications of the summary format, in particular by allowing for flexible length, placing more emphasis on key messages and relevance for public health practice, expanding the interpretation aid for statistical findings, providing a glossary of technical terms, and only including graphical GRADE ratings. Some barriers to uptake, notably the participants' wish for actionable recommendations and contextual information, could not be addressed. CONCLUSIONS: Participants welcomed the initiative, but user tests also revealed their problems with understanding and interpreting the findings summarised in our prototype format. The revised summary format will be used to communicate the results of Cochrane reviews of public health interventions.

Assessing the complexity of interventions within systematic reviews: development, content and use of a new tool (iCAT_SR).

BACKGROUND: Health interventions fall along a spectrum from simple to more complex. There is wide interest in methods for reviewing 'complex interventions', but few transparent approaches for assessing intervention complexity in systematic reviews. Such assessments may assist review authors in, for example, systematically describing interventions and developing logic models. This paper describes the development and application of the intervention Complexity Assessment Tool for Systematic Reviews (iCAT_SR), a new tool to assess and categorise levels of intervention complexity in systematic reviews. METHODS: We developed the iCAT_SR by adapting and extending an existing complexity assessment tool for randomized trials. We undertook this adaptation using a consensus approach in which possible complexity dimensions were circulated for feedback to a panel of methodologists with expertise in complex interventions and systematic reviews. Based on these inputs, we developed a draft version of the tool. We then invited a second round of feedback from the panel and a wider group of systematic reviewers. This informed further refinement of the tool. RESULTS: The tool comprises ten dimensions: (1) the number of active components in the intervention; (2) the number of behaviours of recipients to which the intervention is directed; (3) the range and number of organizational levels targeted by the intervention; (4) the degree of tailoring intended or flexibility permitted across sites or individuals in applying or implementing the intervention; (5) the level of skill required by those delivering the intervention; (6) the level of skill required by those receiving the intervention; (7) the degree of interaction between intervention components; (8) the degree to which the effects of the intervention are context dependent; (9) the degree to which the effects of the interventions are changed by recipient or provider factors; (10) and the nature of the causal pathway between intervention and outcome. Dimensions 1-6 are considered 'core' dimensions. Dimensions 7-10 are optional and may not be useful for all interventions. CONCLUSIONS: The iCAT_SR tool facilitates more in-depth, systematic assessment of the complexity of interventions in systematic reviews and can assist in undertaking reviews and interpreting review findings. Further testing of the tool is now needed.

An approach for setting evidence-based and stakeholder-informed research priorities in low- and middle-income countries.

To derive evidence-based and stakeholder-informed research priorities for implementation in African settings, the international research consortium Collaboration for Evidence-Based Healthcare and Public Health in Africa (CEBHA+) developed and applied a pragmatic approach. First, an online survey and face-to-face consultation between CEBHA+ partners and policy-makers generated priority research areas. Second, evidence maps for these priority research areas identified gaps and related priority research questions. Finally, study protocols were developed for inclusion within a grant proposal. Policy and practice representatives were involved throughout the process. Tuberculosis, diabetes, hypertension and road traffic injuries were selected as priority research areas. Evidence maps covered screening and models of care for diabetes and hypertension, population-level prevention of diabetes and hypertension and their risk factors, and prevention and management of road traffic injuries. Analysis of these maps yielded three priority research questions on hypertension and diabetes and one on road traffic injuries. The four resulting study protocols employ a broad range of primary and secondary research methods; a fifth promotes an integrated methodological approach across all research activities. The CEBHA+ approach, in particular evidence mapping, helped to formulate research questions and study protocols that would be owned by African partners, fill gaps in the evidence base, address policy and practice needs and be feasible given the existing research infrastructure and expertise. The consortium believes that the continuous involvement of decision-makers throughout the research process is an important means of ensuring that studies are relevant to the African context and that findings are rapidly implemented.

Afin de déterminer, à partir d'éléments factuels et avec l'apport des parties prenantes, les priorités de recherche pouvant être mises en œuvre dans les pays d'Afrique, le consortium de recherche international Collaboration for Evidence-Based Health Care and Public Health in Africa (CEBHA+) a élaboré et appliqué une démarche pragmatique. Tout d'abord, une enquête en ligne et une consultation en face à face entre les partenaires du CEBHA+ et les responsables politiques ont permis de mettre en lumière les domaines de recherche prioritaires. Ensuite, des listes documentaires relatives à ces domaines de recherche prioritaires ont permis d'identifier les lacunes ainsi que des questions connexes prioritaires en matière de recherche. Enfin, des protocoles d'étude ont été mis au point en vue d'être intégrés à une proposition de subvention. Des représentants de la mise en œuvre des politiques ont participé à l'ensemble du processus. La tuberculose, le diabète, l'hypertension et les blessures de la route ont été sélectionnés comme domaines de recherche prioritaires. Les listes documentaires portaient sur le dépistage et les modèles de soins du diabète et de l'hypertension, sur la prévention de ces maladies ainsi que sur leurs facteurs de risque au niveau de la population, et sur la prévention et la prise en charge des blessures de la route. L'analyse de ces listes a permis de dégager trois questions de recherche prioritaires portant sur l'hypertension et le diabète et une sur les blessures de la route. Les quatre protocoles d'étude en découlant utilisent toute une série de méthodes de recherche primaire et secondaire; un cinquième favorise une démarche méthodologique intégrée sur l'ensemble des activités de recherche. La démarche du CEBHA+, en particulier la constitution de listes documentaires, a permis de formuler les questions de recherche et les protocoles d'étude qui reviendront aux partenaires africains, de combler les lacunes des bases de données et de répondre aux besoins en matière de politiques et de pratiques; elle s'est également révélée applicable compte tenu de l'expertise et de l'infrastructure de recherche existantes. Pour le consortium, l'implication continue des décisionnaires dans le processus de recherche est un important moyen de garantir que les études soient pertinentes pour les pays africains et que leurs résultats soient rapidement mis en œuvre.

Para obtener las prioridades de investigación documentadas y comunicadas a las partes interesadas para su implementación en África, el consorcio de investigación internacional Asociación de Asistencia Médica Basada en Evidencia en África (CEBHA+, por sus siglas en inglés), desarrolló y aplicó un enfoque pragmático. En primer lugar, una encuesta en línea y una consulta presencial entre socios de la CEBHA+ y responsables políticos originó los sectores de investigación prioritarios. En segundo lugar, unos mapas documentados para estos sectores de investigación prioritarios identificaron disparidades y asuntos relativos a la investigación prioritaria. Por último, se desarrollaron protocolos de estudio para incluirlos dentro de una propuesta de subvención. Los representantes políticos y prácticos participaron durante todo el proceso. Los sectores de investigación prioritarios seleccionados fueron la tuberculosis, la diabetes, la hipertensión y los traumatismos provocados por accidentes de tráfico. Los mapas documentados abordaron el examen y los modelos de asistencia de la diabetes y la hipertensión, la prevención de la diabetes y la hipertensión a nivel de población, sus factores de riesgo y la prevención y gestión de traumatismos provocados por accidentes de tráfico. Los análisis de estos mapas generaron tres asuntos de investigación de prioridades sobre hipertensión y diabetes y uno sobre traumatismos provocados por accidentes de tráfico. Los cuatro protocolos de estudio resultantes emplean una amplia gama de métodos de investigación primarios y secundarios; un quinto presenta un enfoque metodológico integrado a través de todas las actividades de investigación. El enfoque de la CEBHA+, concretamente los mapas documentados, contribuyó a formular cuestiones y protocolos de estudio sobre la investigación que pertenecerían a socios africanos, subsanarían diferencias en la base de pruebas, abordarían las necesidades sobre políticas y prácticas y serían viables gracias a la infraestructura y experiencia de investigación existentes. El consorcio considera que la constante implicación de los responsables de la toma de decisiones a lo largo del proceso de investigación es un medio importante para garantizar que los estudios se correspondan al contexto africano y que los resultados se implementen con rapidez.

Dietary Diversity Is Positively Associated with Deviation from Expected Height in Rural Nepal.

BACKGROUND: Recent research has highlighted the need for additional studies on the nutrition input required to stabilize growth. OBJECTIVE: Our objective was to examine the association between dietary diversity and conditional growth in children aged 0-89 mo. METHODS: We analyzed cohort data from 529 mothers and children living in a remote and food-insecure region in the mountains of Nepal. Children were aged 0-59 mo at baseline and were followed up after 9 and 29 mo. Conditional growth was calculated as the deviation from the expected height-for-age difference (HAD) trajectory based on previous measures of HAD and the pattern of growth in the population. Dietary diversity was assessed with the use of a count of the foods consumed from 7 food groups in the previous 7 d. The association between dietary diversity and conditional growth during the 2 follow-up periods (of 9 and 20 mo, respectively) was estimated with the use of ordinary least-squares regressions. RESULTS: Prevalence of stunting and absolute height deficits was very high and increased over the course of the study. At the last measurement (age range 29-89 mo), 76.5% were stunted and the mean ± SD HAD was -11.7 ± 4.6 cm. Dietary diversity was associated positively with conditional growth in the later (May 2012-December 2013) but not the earlier (July 2011-May 2012) growth period. Children's ages ranged from 0 to 59 mo in July 2011, 9 to 69 mo in May 2012, and 29 to 89 mo in December 2013. After adjustment, increasing the dietary diversity by one food group was associated with a 0.09 cm (95% CI: 0.00, 0.17 cm) increase in conditional growth in the second growth period. CONCLUSIONS: Increasing dietary diversity for children reduces the risk of stunting and improves growth after growth faltering. Future efforts should be directed at enabling families in food-insecure areas to feed their children a more diverse diet.

Clean fuels for resource-poor settings: A systematic review of barriers and enablers to adoption and sustained use.

BACKGROUND: Access to, and sustained adoption of, clean household fuels at scale remains an aspirational goal to achieve sufficient reductions in household air pollution (HAP) in order to impact on the substantial global health burden caused by reliance on solid fuels. AIM AND OBJECTIVES: To systematically appraise the current evidence base to identify: (i) which factors enable or limit adoption and sustained use of clean fuels (namely liquefied petroleum gas (LPG), biogas, solar cooking and alcohol fuels) in low- and middle-income countries; (ii) lessons learnt concerning equitable scaling-up of programmes of cleaner cooking fuels in relation to poverty, urban-rural settings and gender. METHODS: A mixed-methods systematic review was conducted using established review methodology and extensive searches of published and grey literature sources. Data extraction and quality appraisal of quantitative, qualitative and case studies meeting inclusion criteria were conducted using standardised methods with reliability checking. FINDINGS: Forty-four studies from Africa, Asia and Latin America met the inclusion criteria (17 on biogas, 12 on LPG, 9 on solar, 6 on alcohol fuels). A broad range of inter-related enabling and limiting factors were identified for all four types of intervention, operating across seven pre-specified domains (i.e. fuel and technology characteristics, household and setting characteristics, knowledge and perceptions, financial, tax and subsidy aspects, market development, regulation, legislation and standards, and programme and policy mechanisms) and multiple levels (i.e. household, community, national). All domains matter and the majority of factors are common to all clean fuels interventions reviewed although some are fuel and technology-specific. All factors should therefore be taken into account and carefully assessed during planning and implementation of any small- and large-scale initiative aiming at promoting clean fuels for household cooking. CONCLUSIONS: Despite limitations in quantity and quality of the evidence this systematic review provides a useful starting point for the design, delivery and evaluation of programmes to ensure more effective adoption and use of LPG, biogas, alcohol fuels and solar cooking. FUNDING: This review was funded by the Department for International Development (DfID) of the United Kingdom. The authors would also like to thank the Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre) for their technical support.

Impacts of in utero and early infant taste experiences on later taste acceptance: a systematic review.

BACKGROUND: Dietary behavior exerts a critical influence on health and is the outcome of a broad range of interacting factors, including food and taste acceptance. These may be programmed in utero and during early infancy. OBJECTIVE: We examined the hypothesis that fetuses and infants exposed to sweet, salty, sour, bitter, umami, or specific tastes show greater acceptance of that same taste later in life. METHODS: We conducted a systematic review of the literature, using comprehensive searches and following established procedures for screening, data extraction, and quality appraisal. We used harvest plots to synthesize the evidence graphically. RESULTS: Twenty studies comprising 38 subgroups that differed by taste, age, medium, and duration of exposure were included. Exposure to bitter and specific tastes increased the acceptance of these tastes. Studies on sweet and salty tastes showed equivocal results. Studies on sour tastes were sparse. CONCLUSION: Our systematic review clearly shows programming of the acceptance of bitter and specific tastes. For other tastes the results were either equivocal or confined to a few number of studies that precluded us from drawing conclusions. Further research should examine the association of salty and sour taste exposures on later preferences of these tastes. Long-term studies and randomized clinical trials on each type of taste are needed.

Sustained use of biogas fuel and blood pressure among women in rural Nepal.

BACKGROUND: More than two fifths of the world's population cook with solid fuels and are exposed to household air pollution (HAP). As of now, no studies have assessed whether switching to alternative fuels like biogas could impact cardiovascular health among cooks previously exposed to solid fuel use. METHODS: We conducted a propensity score matched cross-sectional study to explore if the sustained use of biogas fuel for at least ten years impacts blood pressure among adult female cooks of rural Nepal. We recruited one primary cook ≥ 30 years of age from each biogas (219 cooks) and firewood (300 cooks) using household and measured their systolic (SBP) and diastolic blood pressure (DBP). Household characteristics, kitchen ventilation and 24-h kitchen carbon monoxide were assessed. We matched cooks by age, body mass index and socio-economic status score using propensity scores and investigated the effect of biogas use through multivariate regression models in two age groups, 30-50 years and >50 years to account for any post-menopausal changes. RESULTS: We found substantially reduced 24-h kitchen carbon monoxide levels among biogas-using households. After matching and adjustment for smoking, kitchen characteristics, ventilation status and additional fuel use, the use of biogas was associated with 9.8 mmHg lower SBP [95% confidence interval (CI), -20.4 to 0.8] and 6.5 mmHg lower DBP (95% CI, -12.2 to -0.8) compared to firewood users among women >50 years of age. In this age group, biogas use was also associated with 68% reduced odds [Odds ratio 0.32 (95% CI, 0.14 to 0.71)] of developing hypertension. These effects, however, were not identified in younger women aged 30-50 years. CONCLUSIONS: Sustained use of biogas for cooking may protect against cardiovascular disease by lowering the risk of high blood pressure, especially DBP, among older female cooks. These findings need to be confirmed in longitudinal or experimental studies.

Factors affecting institutional delivery in rural Chitwan district of Nepal: a community-based cross-sectional study.

BACKGROUND: Health facility delivery is considered a critical strategy to improve maternal health. The Government of Nepal is promoting institutional delivery through different incentive programmes and the establishment of birthing centres. This study aimed to identify the socio-demographic, socio-cultural, and health service-related factors influencing institutional delivery uptake in rural areas of Chitwan district, where high rates of institutional deliveries co-exist with a significant proportion of home deliveries. METHODS: This community-based cross-sectional study was conducted in six rural Village Development Committees of Chitwan district, which are characterised by relatively low institutional delivery rates and the availability of birthing centres. The study area represents both hilly and plain areas of Chitwan. A total of 673 mothers who had given birth during a one-year-period were interviewed using a structured questionnaire. Univariate and multivariable logistic regression analysis using stepwise backward elimination was performed to identify key factors affecting institutional delivery. RESULTS: Adjusting for all other factors in the final model, advantaged caste/ethnicity [aOR: 1.98; 95% CI: 1.15-3.42], support for institutional delivery by the husband [aOR: 19.85; 95% CI: 8.53-46.21], the decision on place of delivery taken jointly by women and family members [aOR: 5.43; 95% CI: 2.91-10.16] or by family members alone [aOR: 4.61; 95% CI: 2.56-8.28], birth preparations [aOR: 1.75; 95% CI: 1.04-2.92], complications during the most recent pregnancy/delivery [aOR: 2.88; 95% CI: 1.67-4.98], a perception that skilled health workers are always available [aOR: 2.70; 95% CI: 1.20-6.07] and a birthing facility located within one hour's travelling distance [aOR: 2.15; 95% CI: 1.26-3.69] significantly increased the likelihood of institutional delivery. On the other hand, not knowing about the adequacy of physical facilities significantly decreased the likelihood of institutional delivery [aOR: 0.14; 95% CI: 0.05-0.41]. CONCLUSION: With multiple incentives present, the decision to deliver in a health facility is affected by a complex interplay of socio-demographic, socio-cultural, and health service-related factors. Family decision-making roles and a husband's support for institutional delivery exert a particularly strong influence on the place of delivery, and this should be emphasized in the health policy as well as development and implementation of maternal health programmes in Nepal.

Use of the WHO Nutrient Profile Model for Food Marketing Regulation in Germany: Feasibility and Public Health Implications.

INTRODUCTION: Exposure to marketing for foods high in sugar, salt, and fat is considered a key risk factor for childhood obesity. To support efforts to limit such marketing, the World Health Organization Regional Office for Europe has developed a nutrient profile model (WHO NPM). Germany's Federal Ministry of Food and Agriculture plans to use this model in proposed new food marketing legislation, but it has not yet been tested in Germany. The present study therefore assesses the feasibility and implications of implementing the WHO NPM in Germany. METHODS: We applied the WHO NPM to a random sample of 660 food and beverage products across 22 product categories on the German market drawn from Open Food Facts, a publicly available product database. We calculated the share of products permitted for marketing to children based on the WHO NPM, both under current market conditions and for several hypothetical reformulation scenarios. We also assessed effects of adaptations to and practical challenges in applying the WHO NPM. RESULTS: The median share of products permitted for marketing to children across the model's 22 product categories was 20% (interquartile range (IQR) 3-59%) and increased to 38% (IQR 11-73%) with model adaptations for fruit juice and milk proposed by the German government. With targeted reformulation (assuming a 30% reduction in fat, sugar, sodium, and/or energy), the share of products permitted for marketing to children increased substantially (defined as a relative increase by at least 50%) in several product categories (including bread, processed meat, yogurt and cream, ready-made and convenience foods, and savoury plant-based foods) but changed less in the remaining categories. Practical challenges included the ascertainment of the trans-fatty acid content of products, among others. CONCLUSION: The application of the WHO NPM in Germany was found to be feasible. Its use in the proposed legislation on food marketing in Germany seems likely to serve its intended public health objective of limiting marketing in a targeted manner specifically for less healthy products. It seems plausible that it may incentivise reformulation in some product categories. Practical challenges could be addressed with appropriate adaptations and procedural provisions.

Diagram-based Analysis of Causal Systems (DACS): elucidating inter-relationships between determinants of acute lower respiratory infections among children in sub-Saharan Africa.

BACKGROUND: Effective interventions require evidence on how individual causal pathways jointly determine disease. Based on the concept of systems epidemiology, this paper develops Diagram-based Analysis of Causal Systems (DACS) as an approach to analyze complex systems, and applies it by examining the contributions of proximal and distal determinants of childhood acute lower respiratory infections (ALRI) in sub-Saharan Africa. RESULTS: Diagram-based Analysis of Causal Systems combines the use of causal diagrams with multiple routinely available data sources, using a variety of statistical techniques. In a step-by-step process, the causal diagram evolves from conceptual based on a priori knowledge and assumptions, through operational informed by data availability which then undergoes empirical testing, to integrated which synthesizes information from multiple datasets. In our application, we apply different regression techniques to Demographic and Health Survey (DHS) datasets for Benin, Ethiopia, Kenya and Namibia and a pooled World Health Survey (WHS) dataset for sixteen African countries. Explicit strategies are employed to make decisions transparent about the inclusion/omission of arrows, the sign and strength of the relationships and homogeneity/heterogeneity across settings.Findings about the current state of evidence on the complex web of socio-economic, environmental, behavioral and healthcare factors influencing childhood ALRI, based on DHS and WHS data, are summarized in an integrated causal diagram. Notably, solid fuel use is structured by socio-economic factors and increases the risk of childhood ALRI mortality. CONCLUSIONS: Diagram-based Analysis of Causal Systems is a means of organizing the current state of knowledge about a specific area of research, and a framework for integrating statistical analyses across a whole system. This partly a priori approach is explicit about causal assumptions guiding the analysis and about researcher judgment, and wrong assumptions can be reversed following empirical testing. This approach is well-suited to dealing with complex systems, in particular where data are scarce.