The DQQ is a Valid Tool to Collect Population-Level Food Group Consumption Data: A Study Among Women in Ethiopia, Vietnam, and Solomon Islands.

BACKGROUND: The Diet Quality Questionnaire (DQQ) is a rapid dietary assessment tool designed to enable feasible measuring and monitoring of diet quality at population level in the general public. OBJECTIVES: To evaluate validity of the DQQ for collecting population-level food group consumption data required for calculating diet quality indicators by comparing them with a multipass 24-h dietary recall (24hR) as the reference. METHODS: Cross-sectional data were collected among female participants aged 15-49 y in Ethiopia (n = 488), 18-49 y in Vietnam (n = 200), and 19-69 y in Solomon Islands (n = 65) to compare DQQ and 24hR data in proportional differences in food group consumption prevalence, percentage of participants achieving Minimum Dietary Diversity for Women (MDD-W), percent agreement, percentage misreporting food group consumption, and diet quality scores of Food Group Diversity Score (FGDS), noncommunicable disease (NCD)-Protect, NCD-Risk, and the Global Dietary Recommendation (GDR) score using a nonparametric analysis. RESULTS: The mean (standard deviation) percentage point difference between DQQ and 24hR in population prevalence of food group consumption was 0.6 (0.7), 2.4 (2.0), and 2.5 (2.7) in Ethiopia, Vietnam, and Solomon Islands, respectively. Percent agreement of food group consumption data ranged from 88.6% (10.1) in Solomon Islands to 96.3% (4.9) in Ethiopia. There was no significant difference between DQQ and 24hR in population prevalence of achieving MDD-W except for Ethiopia (DQQ 6.1 percentage points higher, P < 0.01). Median (25th-75th percentiles) scores of FGDS, NCD-Protect, NCD-Risk, and GDR score were comparable between the tools. CONCLUSIONS: The DQQ is a suitable tool for collecting population-level food group consumption data for estimating diet quality with food group-based indicators such as the MDD-W, FGDS, NCD-Protect, NCD-Risk, and GDR score.

Association between Biomarkers of Inflammation and Total Liver Vitamin A Reserves Estimated by 13C-Retinol Isotope Dilution among Preschool Children in 5 African Countries.

BACKGROUND: Vitamin A (VA) assessment is important for targeting public health programs. Retinol isotope dilution (RID) is a sensitive method to estimate total body VA stores (TBSs) and total liver reserves (TLRs), but the impact of subclinical inflammation on RID is unclear. OBJECTIVE: We determined the association between TBSs and TLRs, estimated by RID, and inflammation among preschool children without clinical infection in Burkina Faso, Cameroon, Ethiopia, South Africa, and Tanzania. METHODS: Five studies (n = 532; 47.9 ± 8.3 mo; 49.0% male) included 13C-RID and measurement of inflammation markers, CRP, and α1-acid glycoprotein (AGP). Spearman correlations were used to evaluate TBSs and TLRs with inflammation biomarkers. Wilcoxon and Kruskal-Wallis tests were used to compare TBSs and TLRs by inflammation categories [normal vs. elevated CRP (>5 mg/L) or AGP (>1 g/L)] and inflammation stage [reference, incubation (elevated CRP), early convalescence (elevated CRP and AGP), and late convalescence (elevated AGP)]. RESULTS: Complete data were available for 439 children. Median (Q1, Q3) TLRs ranged from 0.12 (0.07, 0.18) µmol/g in Ethiopia to 1.10 (0.88, 1.38) µmol/g in South Africa. Elevated CRP ranged from 4% in Burkina Faso to 42% in Cameroon, and elevated AGP from 20% in Tanzania to 58% in Cameroon. Pooled analysis (excluding Cameroon) showed a negative correlation between TBSs and AGP (ρ = -0.131, P = 0.01). Children with elevated AGP had higher probability of having lower TBSs (probability = 0.61, P = 0.002). TBSs differed among infection stages (P = 0.020). Correlations between TLRs and CRP or AGP were not significant. CONCLUSIONS: No indication of systematic bias in RID-estimated TLRs was found due to subclinical inflammation among preschool children. The inverse relationship between TBSs and AGP may reflect decreased stores after infection or an effect of inflammation on isotope partitioning. Further research should investigate potential confounding variables to improve TBS-estimate validity.

Comparison of Total Body Vitamin A Stores Using Individual versus Population 13C-Natural Abundance of Serum Retinol in Preschool Children and Women Residing in 6 Diverse African Countries.

BACKGROUND: Stable isotope techniques using 13C to assess vitamin A (VA) dietary sources, absorption, and total body VA stores (TBSs) require determination of baseline 13C abundance. 13C-natural abundance is approximately 1.1% total carbon, but varies with foods consumed, supplements taken, and food fortification with synthetic retinyl palmitate. OBJECTIVES: We determined 13C variation from purified serum retinol and the resulting impact on TBSs using pooled data from preschool children in Burkina Faso, Cameroon, Ethiopia, South Africa, Tanzania, and Zambia and Zambian women. METHODS: Seven studies included children (n = 639; 56 ± 25 mo; 48% female) and one in women (n = 138; 29 ± 8.5 y). Serum retinol 13C-natural abundance was determined using GC-C-IRMS. TBSs were available in 7 studies that employed retinol isotope dilution (RID). Serum CRP and α1-acid-glycoprotein (AGP) were available from 6 studies in children. Multivariate mixed models assessed the impact of covariates on retinol 13C. Spearman correlations and Bland-Altman analysis compared serum and milk retinol 13C and evaluated the impact of using study- or global-retinol 13C estimates on calculated TBSs. RESULTS: 13C-natural abundance (%, median [Q1, Q3]) differed among countries (low: Zambia, 1.0744 [1.0736, 1.0753]; high: South Africa, 1.0773 [1.0769, 1.0779]) and was associated with TBSs, CRP, and AGP in children and with TBSs in women. 13C-enrichment from serum and milk retinol were correlated (r = 0.52; P = 0.0001). RID in children and women using study and global estimates had low mean bias (range, -3.7% to 2.2%), but larger 95% limits of agreement (range, -23% to 37%). CONCLUSIONS: 13C-natural abundance is different among human cohorts in Africa. Collecting this information in subgroups is recommended for surveys using RID. When TBSs are needed on individuals in clinical applications, baseline 13C measures are important and should be measured in all enrolled subjects.

Developing feasible healthy diets for Ethiopian women of reproductive age: a linear goal programming approach.

OBJECTIVE: To develop a healthy diet for Ethiopian women closely resembling their current diet and taking fasting periods into account while tracking the cost difference. DESIGN: Linear goal programming models were built for three scenarios (non-fasting, continuous fasting and intermittent fasting). Each model minimised a function of deviations from nutrient reference values for eleven nutrients (protein, Ca, Fe, Zn, folate, and the vitamins A, B1, B2, B3, B6, and B12). The energy intake in optimised diets could only deviate 5 % from the current diet. SETTINGS: Five regions are included in the urban and rural areas of Ethiopia. PARTICIPANTS: Two non-consecutive 24-h dietary recalls (24HDR) were collected from 494 Ethiopian women of reproductive age from November to December 2019. RESULTS: Women's mean energy intake was well above 2000 kcal across all socio-demographic subgroups. Compared to the current diet, the estimated intake of several food groups was considerably higher in the optimised modelled diets, that is, milk and dairy foods (396 v. 30 g/d), nuts and seeds (20 v. 1 g/d) and fruits (200 v. 7 g/d). Except for Ca and vitamin B12 intake in the continuous fasting diet, the proposed diets provide an adequate intake of the targeted micronutrients. The proposed diets had a maximum cost of 120 Ethiopian birrs ($3·5) per d, twice the current diet's cost. CONCLUSION: The modelled diets may be feasible for women of reproductive age as they are close to their current diets and fulfil their energy and nutrient demands. However, the costs may be a barrier to implementation.

Burden of disease attributable to suboptimal diet, metabolic risks and low physical activity in Ethiopia and comparison with Eastern sub-Saharan African countries, 1990-2015: findings from the Global Burden of Disease Study 2015.

BACKGROUND: Twelve of the 17 Sustainable Development Goals (SDGs) are related to malnutrition (both under- and overnutrition), other behavioral, and metabolic risk factors. However, comparative evidence on the impact of behavioral and metabolic risk factors on disease burden is limited in sub-Saharan Africa (SSA), including Ethiopia. Using data from the Global Burden of Disease (GBD) Study, we assessed mortality and disability-adjusted life years (DALYs) attributable to child and maternal undernutrition (CMU), dietary risks, metabolic risks and low physical activity for Ethiopia. The results were compared with 14 other Eastern SSA countries. METHODS: Databases from GBD 2015, that consist of data from 1990 to 2015, were used. A comparative risk assessment approach was utilized to estimate the burden of disease attributable to CMU, dietary risks, metabolic risks and low physical activity. Exposure levels of the risk factors were estimated using spatiotemporal Gaussian process regression (ST-GPR) and Bayesian meta-regression models. RESULTS: In 2015, there were 58,783 [95% uncertainty interval (UI): 43,653-76,020] or 8.9% [95% UI: 6.1-12.5] estimated all-cause deaths attributable to CMU, 66,269 [95% UI: 39,367-106,512] or 9.7% [95% UI: 7.4-12.3] to dietary risks, 105,057 [95% UI: 66,167-157,071] or 15.4% [95% UI: 12.8-17.6] to metabolic risks and 5808 [95% UI: 3449-9359] or 0.9% [95% UI: 0.6-1.1] to low physical activity in Ethiopia. While the age-adjusted proportion of all-cause mortality attributable to CMU decreased significantly between 1990 and 2015, it increased from 10.8% [95% UI: 8.8-13.3] to 14.5% [95% UI: 11.7-18.0] for dietary risks and from 17.0% [95% UI: 15.4-18.7] to 24.2% [95% UI: 22.2-26.1] for metabolic risks. In 2015, Ethiopia ranked among the top four countries (of 15 Eastern SSA countries) in terms of mortality and DALYs based on the age-standardized proportion of disease attributable to dietary and metabolic risks. CONCLUSIONS: In Ethiopia, while there was a decline in mortality and DALYs attributable to CMU over the last two and half decades, the burden attributable to dietary and metabolic risks have increased during the same period. Lifestyle and metabolic risks of NCDs require more attention by the primary health care system of the country.

Alkylene-bridged viologen dendrimers: versatile cell delivery tools with biosensing properties.

The synthesis of two types of viologen dendrimers with peripheral carboxyl groups is described. Their interaction with plasmid DNA and CT-DNA and the influence of time evolution and electrolyte on dendriplex formation have been electrochemically investigated. A negative potential shift appearing in the cyclic voltammograms of the dendrimers indicates dendriplex formation on the time scale of 15 to 19 minutes, i.e. similar to those determined empirically for other dendrimer types. The presence or absence of the negative potential shift can be used to check the stability towards sodium chloride and different cell growth media directing to sucrose for cell incubation experiments. The electrolyte content of commercially available cell growth media inhibits the dendriplex formation in solution prior to plasmid addition. Furthermore, a low salt stability of 20 mM sodium chloride for viologen dendriplexes has been confirmed, also recommending the use of lysosomotropic sucrose. The two types of viologen dendrimers have been combined with two plasmids differing in the number of base pairs. Four immortal cell lines have been tested to check the suitability of viologen dendriplexes as gene delivery systems. Probably due to the absence of terminal amino groups and endosomolytic substances only a small transfection efficiency of dendriplexes was achieved at low pH, generally excluding in vivo applications. With the larger pHSV-eGFP plasmid (5743 bp) no transfected cells were observed indicating a preference for shorter plasmids.

Factors influencing the low utilization of curative child health services in Shebedino District, Sidama Zone, Ethiopia.

BACKGROUND: Use and coverage of curative interventions for childhood pneumonia, diarrhea, and malaria were low in Ethiopia before integrated community-based case management (iCCM). OBJECTIVES: To examine factors accounting for low use of iCCMin Shebedino District applying a "Pathway to Sur- vival" approach to assess illness recognition; home care; labeling and decision-making; patterns of care-seeking; access, availability and quality of care; and referral. METHODS: Shortly after introduction of iCCM, we conducted five studies in Shebedino District in May 2011: a population-based household survey; focus group discussions of mothers of recently ill children; key informant in- terviews, including knowledge assessment, with Health Extension Workers at health posts and with health workers at health centers; and an inventory of drugs, supplies, and job aids at health posts and health centers. RESULTS: The many barriers to use of evidence-based treatment included: (1) home remedies of uncertain effect and safety that delay care-seeking; (2) absent decision-maker; (3) fear of stigma; (4) expectation of non-availability of service or medicine; (5) geographic and financial barriers; (6) perception of (or actual) poor quality of care; and (7) accessible, available, affordable, reliable, non-standard, alternative sources of care. CONCLUSION: Only a system-strengthening approach can overcome such manifold barriers to use of curative care that has not increased much after ICCM introduction.

Illness recognition, home care, and care-seeking for sick infants less than two months of age in Shebedino District, Sidama Zone, Ethiopia.

BACKGROUND: The incidence of newborn and young infant health danger signs is unknown in Ethiopia. Neverthe- less, experience shows that care-seeking is far lower than conservative morbidity estimates would project. OBJECTIVES: To examine illness recognition, home care, decision-making, and care-seeking for sick infants less than two months of age in Shebedino District, Southern Nations, Nationalities and Peoples Region in 2011. METHODS: Focus group interviews of mothers (n = 60) of recently ill children. RESULTS: Mothers reported recognizing many, but not all, evidence-based newborn danger signs. Home care ranged from probably harmless to harmful and delayed definitive care-seeking. Decision-making was widespread, but patterns of care-seeking rarely led to prompt, evidence-based care. Mothers reported 10 barriers to care- seeking at health posts: lack of knowledge about availability of curative services, fear of evil eye, social stigma, perceived financial barrier, perceived young infant fragility, an elder's contrary advice, distance, husband's re- fusal, fear of injection, and belief in recovery without medicine. CONCLUSION: Young infants are more vulnerable to illness than their older counterparts, yet they are less likely to receive the care they need without a targeted, contextualized communication strategy to generate demand for case management services that are accessible, available, and of good quality.

Performance of Ethiopia's health system in delivering integrated community-based case management.

BACKGROUND: Analyzing complex health programs by their components and sub-components serves design, documentation, evaluation, research, and gap identification and prioritization. In 2012, we developed a rapid methodology to characterize integrated community case management (iCCM) programs, by assessing benchmarks for eight health system components in three program phases. OBJECTIVE. To assess iCCM benchmarks in Ethiopia three years after scale-up commenced, and to compare the benchmarks across the geographical region. METHODS. Six national iCCM experts scored each of 70 benchmarks (no, partial, or yes) and then were facilitated to reach consensus. RESULTS. Overall, iCCM benchmark achievement in Ethiopia was high (87.3%), highest for pre-introduction (93.0%), followed by introduction (87.9%) and scale-up (78.1%) phases. Achievement by system component was highest for coordination and policy (94.2%) and lowest for costing and finance (70.3%). Six regional, countries benchmark assessments, including two from Ethiopia 14 months apart, were highly correlated with program duration at scale (correlation coefficient: +0.88). CONCLUSION: Ethiopia has a mature, broad-based iCCM program. Despite limitations, the method described here rapidly, systematically, and validly characterized a complex program and highlighted areas for attention through government or partners.

Effect of performance review and clinical mentoring meetings (PRCMM) on recording of community case management by health extension workers in Ethiopia.

BACKGROUND: The Performance Review and Clinical Mentoring Meeting (PRCMM) is an approach to improve and sustain Health Extension Worker (HEW) skills and performance in integrated Community Case Management (iCCM). OBJECTIVE: To compare HEW performance in recording case management before and after they participated in PRCMM. METHODS: We conducted a historical cohort analysis of iCCM case records between September 2010 and December 2012 from 622 randomly selected health posts representing 31 intervention woredas (districts) of Amhara, Oromia and Southern Nations Nationalities and Peoples' Regions. We used longitudinal regression analysis comparing the trend in the consistency of the classification with the assessment, treatment and follow-up date as well as caseload in the periods before and after PRCMM, with 5511 and 7901 case records, respectively. RESULTS: Overall consistency improved after PRCMM for all common classifications as follows: pneumonia (54.1% [95% CI: 47.7%-60.5%] vs. 78.2% [73.9%-82.5%]), malaria (50.8% [42.9%-58.7%] vs. 78.9% [73.4%- 84.4%]), and diarrhea (33.7% [27.9%-39.5%] vs. 70.0% [64.7%-75.3%]). This improvement was consistently observed comparing the six months before and the six months after PRCMM in all the common classifications except for malaria where the improvement observed during the first three post-PRCMM months disappeared during the fifth and sixth months. Caseload increased significantly after PRCMM (6.6 [95% CI: 5.9-7.3] vs. 9.2 [8.5-9.9] cases/health post/month). CONCLUSION: PRCMM seemed to improve iCCM performance of HEWs and should be integrated within the PHC system and given about every six months, at least at first, to sustain improvement.