Preventing chronic malnutrition in children under 2 years in rural Angola (MuCCUA trial): protocol for the economic evaluation of a three-arm community cluster randomised controlled trial.

INTRODUCTION: Chronic malnutrition is a serious problem in southern Angola with a prevalence of 49.9% and 37.2% in the provinces of Huila and Cunene, respectively. The MuCCUA (Mother and Child Chronic Undernutrition in Angola) trial is a community-based randomised controlled trial (c-RCT) which aims to evaluate the effectiveness of a nutrition supplementation plus standard of care intervention and a cash transfer plus standard of care intervention in preventing stunting, and to compare them with a standard of care alone intervention in southern Angola. This protocol describes the planned economic evaluation associated with the c-RCT. METHODS AND ANALYSIS: We will conduct a cost-efficiency and cost-effectiveness analysis nested within the MuCCUA trial with a societal perspective, measuring programme, provider, participant and household costs. We will collect programme costs prospectively using a combined calculation method including quantitative and qualitative data. Financial costs will be estimated by applying activity-based costing methods to accounting records using time allocation sheets. We will estimate costs not included in accounting records by the ingredients approach, and indirect costs incurred by beneficiaries through interviews, household surveys and focus group discussions. Cost-efficiency will be estimated as cost per output achieved by combining activity-specific cost data with routine data on programme outputs. Cost-effectiveness will be assessed as cost per stunting case prevented. We will calculate incremental cost-effectiveness ratios comparing the additional cost per improved outcome of the different intervention arms and the standard of care. We will perform sensitivity analyses to assess robustness of results. ETHICS AND DISSEMINATION: This economic evaluation will provide useful information to the Angolan Government and other policymakers on the most cost-effective intervention to prevent stunting in this and other comparable contexts. The protocol was approved by the República de Angola Ministério da Saúde Comité de Ética (27C.E/MINSA.INIS/2022). The findings of this study will be disseminated within academia and the wider policy sphere. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry (NCT05571280).

Do agri-food market incentives improve food security and nutrition indicators? a microsimulation evaluation for Kenya.

The sustainable development goal #2 aims at ending hunger and malnutrition by 2030. Given the numbers of food insecure and malnourished people on the rise, the heterogeneity of nutritional statuses and needs, and the even worse context of COVID-19 pandemic, this has become an urgent challenge for food-related policies. This paper provides a comprehensive microsimulation approach to evaluate economic policies on food access, sufficiency (energy) and adequacy (protein, fat, carbohydrate) at household level. The improvement in market access conditions in Kenya is simulated as an application case of this method, using original insights from households' surveys and biochemical and nutritional information by food item. Simulation's results suggest that improving market access increases food purchasing power overall the country, with a pro-poor impact in rural areas. The daily energy consumption per capita and macronutrients intakes per capita increase at the national level, being the households with at least one stunted child under 5 years old, and poor households living areas outside Mombasa and Nairobi, those which benefit the most. The developed method and its Kenya's application contribute to the discussion on how to evaluate nutrition-sensitive policies, and how to cover most households suffering food insecurity and nutrition deficiencies in any given country. Supplementary Information: The online version contains supplementary material available at 10.1007/s12571-021-01215-2.

Raw versus cooked food matching: Nutrient intake using the 2015/16 Kenya Integrated Household Budget Survey.

In many countries, statistics from household consumption and expenditure surveys are increasingly being used to inform policies and programs. In household surveys, foods are typically reported as they are acquired (the majority are raw). However, the micronutrient content of some foods diminishes during processing and cooking. Using food consumption data from the 2015/16 Kenya Integrated Household Budget Survey, this study analyzes whether mean consumption estimates of dietary energy, macronutrients, and eight micronutrients are equivalent (applying a two-side paired equivalence test) when matching foods: (1) considering the nutrient content in raw foods (as reported in the survey), and (2) considering the nutrient content in foods as typically consumed, thus applying yield and retention factors as needed. Both food matching approaches rendered statistically equivalent mean consumption estimates, at national and county levels, for dietary energy, protein, fats, available carbohydrates, total fiber, calcium and zinc. Non-equivalent means were found for iron, vitamins A, B1, B2, B12, and C. The higher differences between the means were, in percentage change, for vitamin C (47 %), B1 (34 %) and B12 (26 %).

Barriers and Facilitators for Exclusive Breastfeeding in Women's Biopsychosocial Spheres According to Primary Care Midwives in Tenerife (Canary Islands, Spain).

(1) The objective of our study is to determine, from a primary care midwife's perspective, which biopsychosocial factors can favour or be detrimental to exclusive breast feeding. (2) The study was carried out in Tenerife (Canary Islands, Spain) and is based on qualitative methodology. Twenty in-depth interviews were carried out with midwives working in primary care centres in Tenerife, using a content analysis approach. The transcript data was then encoded following an inductive approach. (3) According to the perceptions of the primary care midwives who were interviewed, the barriers and facilitators that influence exclusive breastfeeding related to the biopsychosocial spheres of women are, at an individual level, the physical and emotional aspects during the postnatal period; at the relationship level, the presence or not of support from the close family and partner; at the community level, the environment and social networks the new mothers may have; and at the work level, characteristics of jobs and early return to work. (4) The findings of our research can help healthcare professionals to approach the promotion and encouragement of exclusive breast feeding at each of the levels studied, with the aim of increasing rates following recommendations issued by The World Health Organization.

Barriers and Facilitators for Exclusive Breastfeeding within the Health System and Public Policies from In-Depth Interviews to Primary Care Midwives in Tenerife (Canary Islands, Spain).

The aim of this study is to describe the perspectives of Primary Care midwives regarding factors that benefit or are detrimental to exclusive breastfeeding (EBF) within the health system and public policies. The study was carried out in Tenerife (Canary Islands, Spain) and is based on qualitative methodology. Twenty in-depth interviews were carried out with midwives who work in Primary Care centres in Tenerife, using a content analysis approach. The transcript data were then encoded following an inductive approach. The factors, according to midwives, that affect EBF, with regard to the healthcare system, are related to training of healthcare professionals in breastfeeding and their support to women during pregnancy, childbirth and postnatal care. Regarding public policies, midwives believe the maternity leave periods in Spain, together with a lack of laws and social policies to protect EBF are detrimental. The findings from our study show that there is a need to boost training and the role of professionals in EBF and, at the same time, promote protective policies that foster equality, favouring, among other issues, the work-life balance.

Child Dietary Diversity and Associated Factors Among Children in Somalian IDP Camps.

BACKGROUND: Malnutrition and food insecurity are major challenges in Somalia, particularly among small children living in internally displaced person (IDP) camps. Poor diet has been identified as a key driver of malnutrition in young children who depend for their diets on their household's socioeconomic standing and access to food, as well as on the family's caring and feeding practices. OBJECTIVE: To assess the dietary diversity and identify the factors associated with it among children (6-23 months) in Somalian IDP camps. METHODS: We used a cross-sectional survey conducted in 11 IDP camps in Somalia in June 2014 and in June 2015. A total of 3188 children aged 6 to 23 months were surveyed. Child diets were assessed using food frequency questionnaires, and dietary diversity was categorized using the minimum child dietary diversity (MDDC) indicator. Multivariable logistic regressions were used to identify the factors associated with the children's dietary diversity. We built and compared 2 models using alternatively the household dietary diversity score (HDDS) and the food consumption score (FCS) as food security proxies. RESULTS: Around 15% of children in IDP camps reached the minimum dietary diversity. Overall, our results confirm that not only are food security proxies the factors most associated with MDDC, but HDDS performs better than FCS. In addition, results identify that women as key decision-maker in the household, duration of household permanence in the settlement, women's physiological status, frequency of milk feeding to child, type of toilet, and measles vaccination are positively associated with MDDC. CONCLUSIONS: To improve child dietary diversity in IDP camps, food security interventions should be broadened to include female empowerment and inclusive nutrition education (encouraging male participation) programs, as well as initiatives targeting children who do not live with pregnant or lactating women and that can support families beyond the first months after their arrival.

Malnutrition and morbidity trends in Somalia between 2007 and 2016: results from 291 cross-sectional surveys.

BACKGROUND: More than two decades of conflict and natural disasters in Somalia have resulted in one of the longest running humanitarian crises in the world. Nutrition data have been collected over the years despite challenges to inform programmatic action. This paper explores malnutrition and morbidity trends in Somalia during the last decade, disaggregated by geographical zone and livelihood system. METHODS: We used data from 291 cross-sectional surveys conducted in children aged 6-59 months between 2007 and 2016 in Somalia. Wasting, morbidity and stunting prevalences over time were analysed by geographic area, livelihood system and season. Logistic regressions were used to test trends. RESULTS: The wasting trends show a striking peak in 2011, more marked in southern and central Somalia and coinciding with the famine declaration. The trend declines slightly thereafter although not consistently across all zones and livelihoods, and it raises again in 2016 especially among internally displaced persons (IDPs). Stunting declined for all groups and in all zones but with more consistent patterns in northern Somalia.Morbidity also showed a declining trend, although with multiple peaks depicting disease outbreaks.Pastoralist showed the lowest stunting estimates overall, while agrarian populations showed the lowest prevalence of wasting and morbidity. IDPs were the most affected by all outcomes. Seasonality affected the three outcomes differently by livelihood system. Stunting rates increased after the 2011 famine for all age groups within children under 5 years. CONCLUSIONS: Despite the continuous complex situation in Somalia, there has been a sustained decline in stunting and morbidity in the last decade. Wasting trends have remained at very high levels especially in north-east and the south zones of Somalia. The findings support the importance of performing trend analyses disaggregated by zone and livelihood groups within countries to better identify priorities for programme intervention.

Minimum dietary diversity among women of reproductive age in urban Burkina Faso.

Micronutrient malnutrition is a challenge for women of reproductive age, who are particularly vulnerable due to greater micronutrient needs. The minimum dietary diversity for women (MDD-W) indicator is a micronutrient adequacy's proxy for those women, but little is known about its relation to other dimensions. We assessed MDD-W and its association with other socioeconomic, food security and purchasing practices in urban Burkina Faso. We conducted multi-stage cluster sampling in two main cities of Burkina Faso, stratified by type of district, and interviewed 12 754 women in the 2009-2011 period. We obtained food consumption data through unquantified 24 hour recalls and computed MDD-W as consuming at least five out of ten predefined food groups. We constructed multivariable regression models with sociodemographic and food security covariates. MDD-W in urban Burkina Faso was 31%, higher in Ouagadougou (33%) than in Bobo-Dioulasso (29%), and lower in unstructured districts. The most frequently consumed food groups were 'all starchy', 'vitamin A rich dark green leafy vegetables' and 'other vegetables'. Household's expenses were associated with higher likelihood of MDD-W, while the association with household food security indicators varied by year and type of district. Purchasing foods in markets and choosing the place of purchase based on large choice rather than proximity showed a positive association with the MDD-W. Only one in three women in urban Burkina Faso reached the minimum dietary diversity, and although socioeconomic and food security variables had the greatest effect on MDD-W, purchasing practices, like going to the market, also showed a positive effect.

Children's dietary diversity and related factors in Rwanda and Burundi: A multilevel analysis using 2010 Demographic and Health Surveys.

BACKGROUND: One of the reported causes of high malnutrition rates in Burundi and Rwanda is children's inadequate dietary habits. The diet of children may be affected by individual characteristics and by the characteristics of the households and the communities in which they live. We used the minimum dietary diversity of children (MDD-C) indicator as a proxy of diet quality aiming at: 1) assess how much of the observed variation in MDD-C was attributed to community clustering, and 2) to identify the MDD-C associated factors. METHODS: Data was obtained from the 2010 Demographic and Health Surveys of Burundi and Rwanda, from which only children 6 to 23 months from rural areas were analysed. The MDD-C was calculated according to the 2007 WHO/UNICEF guidelines. We computed the intra-class coefficient to assess the percentage of variation attributed to the clustering effect of living in the same community. And then we applied two-level logit regressions to investigate the association between MDD-C and potential risk factors following the hierarchical survey structure of DHS. RESULTS: The MDD-C was 23% in rural Rwanda and 16% in rural Burundi, and a 29% of its variation in Rwanda and 17% in Burundi was attributable to community clustering. Increasing age and living standards were associated with higher MDD-C in both countries, and only in Burundi also increasing level of education of the mother's partner. In Rwanda alone, the increasing ages of the head of the household and of the mother at first birth were also positively associated with it. Despite the identification of an important proportion of the MDD-C variation due to clustering, we couldn't identify any community variable significantly associated with it. CONCLUSIONS: We recommend further research using hierarchical models, and to integrate dietary diversity in holistic interventions which take into account both the household's and the community's characteristics the children live in.

Dietary patterns and nutritional status of HIV-infected children and adolescents in El Salvador: A cross-sectional study.

INTRODUCTION: The present study aimed to assess the nutritional status, the dietary patterns and its associated factors in the HIV-infected population of children and adolescents on antiretroviral treatment at the El Salvador reference center for pediatric HIV care (CENID). METHODS: A cross-sectional survey was carried out between December 2010 and December 2011. Socio-demographic and clinical characteristics were collected from 307 children and adolescents aged 2-18 years and receiving antiretroviral therapy. Nutritional status was assessed by height-for-age, weight-for-height and body mass index-for-age. Dietary data was collected through a 24 hour recall, and through a weekly food frequency questionnaire. Dietary patterns were identified by principal component analysis. Bivariate and multivariable statistical methods were used to assess the factors associated with "high adherence" to the "healthy diet" pattern. RESULTS: More than a third of the study group (33.2%) were stunted, 3.3% were identified as being wasted, and 10% were overweight or obese. Their diets were predominantly based on a high consumption of cereals, beans, eggs and processed foods and a low consumption of fruits, vegetables and dairy products. Three dietary patterns were identified: "healthy diet", "high fat/sugar diet" and "low diversity diet". Being female (OR: 1.63; 95%CI: 0.97-2.75), younger (OR: 2.37; 95%CI: 1.28-4.36) and institutionalized (OR: 14.5; 95%CI: 5.35-39.50) increased the odds to adhere to the "healthy diet" pattern. CONCLUSION: Our findings reveal a high prevalence of stunting and overweight in HIV-infected children in El Salvador. Institutionalized children were more likely to adhere to a healthy dietary pattern whereas children in poverty were more likely to have less varied and healthy diets. These results highlight the need to assess the dietary patterns of HIV-infected children and adolescents in order to guide public policies to design healthy life style interventions for this population at risk.

Nutritional supplements for patients being treated for active visceral leishmaniasis.

BACKGROUND: Visceral leishmaniasis (VL) is a disease caused by a parasite, which can lead to death if untreated. Poor nutritional status hastens the progression of VL infection, and VL worsens malnutrition status. Malnutrition is one of the poor prognostic factors identified for leishmaniasis. However, the effects of nutritional supplementation in people treated for VL are not known. OBJECTIVES: To assess the effects of oral nutritional supplements in people being treated with anti-leishmanial drug therapy for VL. SEARCH METHODS: We searched the Cochrane Infectious Diseases Group (CIDG) Specialized Register, CENTRAL, MEDLINE, Embase, LILACS, and two trial registers up to 12 September 2017. We checked conference proceedings and WHO consultative meeting reports, the reference lists of key documents and existing reviews, and contacted experts and nutritional supplement companies. SELECTION CRITERIA: Randomized controlled trials (RCTs), quasi-randomized controlled trials (quasi-RCTs), and non-randomized controlled trials (NRCTs) of any oral nutritional supplement, compared to no nutritional intervention, placebo, or dietary advice alone, in people being treated for VL. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the literature search results for studies that met the inclusion criteria. We had planned for two review authors to independently extract data and assess the risk of bias of the included studies. We planned to follow the Cochrane standard methodological procedures for assessing risk of bias and analysing the data. MAIN RESULTS: We identified no eligible studies for this review, either completed or ongoing. AUTHORS' CONCLUSIONS: We found no studies, either completed or ongoing, that assessed the effects of oral nutritional supplements in people with VL who were being treated with anti-leishmanial drug therapy. Thus, we could not draw any conclusions on the impact of these interventions on primary cure of VL, definitive cure of VL, treatment completion, self-reported recovery from illness or resolution of symptoms, weight gain, increased skinfold thickness, other measures of lean or total mass, or growth in children.This absence of evidence should not be interpreted as evidence of no effect for nutritional supplements in people under VL treatment. It means that we did not identify research that fulfilled our review inclusion criteria.The effects of oral nutritional supplements in people with VL who are being treated with anti-leishmanial drug therapy have yet to be determined by rigorous experimental studies, such as cluster-randomized trials, that focus on outcomes relevant for patients.

MUAC-for-age more useful than absolute MUAC for nutritional surveillance in Somalia: results from nineteen cross-sectional surveys (2007-2016).

BACKGROUND: Somalia is affected by a civil war and a protracted humanitarian crisis for more than two decades. The international community has put in place nutrition surveillance systems to monitor the situation and inform decisions. However, the indicators commonly used to identify acute malnutrition, weight-for-height Z-score (WHZ) and mid upper arm circumference (MUAC), do not always converge in their estimations of acute malnutrition, creating challenges for decision making. Furthermore, the divergences are not consistent across livelihood populations within the country. We explored the MUAC-for-age Z-score (MUACAZ) as an alternative indicator in Somalia to minimize the discrepancy. METHODS: We analyzed data from nineteen cross-sectional surveys conducted in Somalia between 2007 and 2016. We compared the acute malnutrition prevalence estimates by each of the indicators and the degree of overlap in the individual diagnosis of acute malnutrition between the WHZ and the MUAC-based indicators. We performed multivariate regression analysis with sex, age and stunting as independent variables and acute malnutrition as the dependent outcome, defined by WHZ, MUAC or MUACAZ. We performed all the analysis in the population overall and in each of the livelihood populations separately. RESULTS: A total 255,623 measurements of children 6-59 months of age were analyzed. The overall prevalence of global acute malnutrition by MUACAZ (15.8%) was similar to the one obtained using WHZ (16%), whereas prevalence based on MUAC was much lower (7.8%). These patterns of divergence were sustained throughout the nineteen surveys and the livelihoods studied, with only few exceptions. However, the proportion of overlap in the individual diagnosis of children as acutely malnourished was low between WHZ and absolute MUAC diagnosis (18.1%) and also between WHZ and MUACAZ (28.3%). Results show that age, sex and stunting status of the child affected the likelihood of being diagnosed as acutely malnourished to varying degrees, depending on the indicator used. CONCLUSIONS: The MUAC-for-age (MUACZ) indicator yielded acute malnutrition prevalence estimates convergent with those obtained by WHZ indicator. However, the degree of overlap between these two indicators for individual diagnosis of acute malnutrition is low. Further studies of MUACAZ as an alternative indicator for nutrition surveillance are needed.

Dyslipidemia, Diet and Physical Exercise in Children on Treatment With Antiretroviral Medication in El Salvador: A Cross-sectional Study.

BACKGROUND: Dyslipidemias are common in HIV-infected children, especially if treated with protease inhibitors, but there are few data on how to treat dyslipidemias in this population. We estimated the dyslipidemia prevalence and its association with treatment, diet and physical exercise in children on antiretroviral treatment at the El Salvador reference center for pediatric HIV care (CENID). METHODS: Information was gathered regarding socio-demographic characteristics, treatment, diet and physical activity of 173 children aged 5-18 years and receiving antiretroviral therapy. Triglycerides, total cholesterol, low-density lipoprotein (LDL-C), high-density lipoprotein (HDL-C), viral load and CD4 T-lymphocytes were measured. Abnormal concentrations were defined as triglycerides ≥130 mg/dL in 10- to 18-year olds and ≥100 mg/dL in <10-year olds; total cholesterol ≥200 mg/dL; LDL-C ≥130 mg/dL and HDL-C ≤35 mg/dL. We adjusted 4 different multivariate models to assess the independent association of each type of dyslipidemia with protease inhibitors, diet and physical exercise. RESULTS: Of the 173 children, 83 (48%) had hypertriglyceridemia and 25 (14.5%) hypercholesterolemia. High LDL-C concentrations were observed in 17 children (9.8%) and low HDL-C in 38 (22%). Treatment with protease inhibitors was significantly associated with hypertriglyceridemia [prevalence ratio (PR) 2.8; 95% confidence interval (CI): 2.0-3.8] and hypercholesterolemia (PR 9.0; 95% CI: 3.6-22.2). Higher adherence to a "high fat/sugar diet" was associated with hypercholesterolemia (PR 1.6; 95% CI: 1.1-2.3) and high LDL-C (PR 1.7; 95% CI: 1.0-2.9). Compared with those exercising <3 times/week, children exercising ≥7 times were less likely to have low HDL-C (PR = 0.4; 95% CI: 0.2-0.7). CONCLUSIONS: These results suggest that a healthy diet and exercise habits can contribute to controlling some aspects of the lipid profile in this population.

Low Dietary Diversity and Intake of Animal Source Foods among School Aged Children in Libo Kemkem and Fogera Districts, Ethiopia.

BACKGROUND: A low dietary diversity score (DDS) and low consumption of food from animal sources (ASF) are among the factors related to malnutrition in school-aged children living in Libo Kemkem and Fogera (Ethiopia). OBJECTIVES: This study aimed to identify associated determinants for low dietary diversity and lack of consumption of ASF. METHODS: In 2009, a cross-sectional survey was carried out in May, at the end of the lean season. Socio-demographic characteristics and diet habits were collected from 886 school-aged children. Additionally, 516 children from rural sites were followed up in the post-harvest season, in December of the same year. Bivariate and multivariable statistical methods were employed to assess low DDS and ASF intake and their association with different factors. RESULTS: Up to 80% and 60% of school-aged children living in rural and urban sites, respectively, ate ≤ 3 food groups the day before the survey. The percentage of children consuming ASF was significantly higher in urban settings (64% vs 18%). In the rural areas, if the head of the household was male (OR: 1.91; 95%CI: 1.00-3.65) and older than 40 years (OR: 1.56; 95%CI: 1.02-2.38) the child had a lower DDS in the lean season, while differences by socioeconomic indexes were observed in the post-harvest season. Males took more ASF than females in rural settings (OR: 1.73; 95%CI: 1.14-2.62) and differences by socioeconomic indexes were observed in both settings in the lean season, though not in post-harvest survey. CONCLUSIONS: The findings of this study revealed that the diet among school-aged children in Libo Kemkem and Fogera districts lacked diversity, and that the intake of foods from animal sources was low, especially among rural girls. To effectively tackle malnutrition, dietary diversification strategies oriented to the local needs are recommended.

Micronutrient deficiencies and related factors in school-aged children in Ethiopia: a cross-sectional study in Libo Kemkem and Fogera districts, Amhara Regional State.

INTRODUCTION: The present study describes the distribution of selected micronutrients and anaemia among school-aged children living in Libo Kemkem and Fogera (Amhara State, Ethiopia), assessing differences by socio-demographic characteristics, health status and dietary habits. METHODS: A cross-sectional survey was carried out during May-December 2009. Socio-demographic characteristics, health status and dietary habits were collected. Biomarkers were determined for 764 children. Bivariate and multivariable statistical methods were employed to assess micronutrient deficiencies (MD), anaemia, and their association with different factors. RESULTS: More than two thirds of the school-aged children (79.5%) had at least one MD and 40.5% had two or more coexisting micronutrient deficiencies. The most prevalent deficiencies were of zinc (12.5%), folate (13.9%), vit A (29.3%) and vit D (49%). Anaemia occurred in 30.9% of the children. Children living in rural areas were more likely to have vit D insufficiency [OR: 5.9 (3.7-9.5)] but less likely to have folate deficiency [OR: 0.2 (0.1-0.4)] and anaemia [OR: 0.58 (0.35-0.97)]. Splenomegaly was positively associated with folate deficiency and anaemia [OR: 2.77 (1.19-6.48) and 4.91 (2.47-9.75)]. Meat and fish consumption were inversely correlated with zinc and ferritin deficiencies [OR: 0.2 (0.1-0.8) and 0.2 (0.1-0.9)], while oil consumption showed a negative association with anaemia and deficiencies of folate and vitamin A [0.58 (0.3-0.9), OR: 0.5 (0.3-0.9) and 0.6 (0.4-0.9)]. Serum ferritin levels were inversely correlated to the presence of anaemia (p<0.005). CONCLUSION: There is a high prevalence of vitamin A deficiency and vitamin D insufficiency and a moderate prevalence of zinc and folate deficiencies in school-aged children in this area. The inverse association of anaemia and serum ferritin levels may be due to the presence of infectious diseases in the area. To effectively tackle malnutrition, strategies should target not only isolated micronutrient supplementation but also diet diversification.

Cross-sectional study of malnutrition and associated factors among school aged children in rural and urban settings of Fogera and Libo Kemkem districts, Ethiopia.

INTRODUCTION: Little information is available on malnutrition-related factors among school-aged children ≥5 years in Ethiopia. This study describes the prevalence of stunting and thinness and their related factors in Libo Kemkem and Fogera, Amhara Regional State and assesses differences between urban and rural areas. METHODS: In this cross-sectional study, anthropometrics and individual and household characteristics data were collected from 886 children. Height-for-age z-score for stunting and body-mass-index-for-age z-score for thinness were computed. Dietary data were collected through a 24-hour recall. Bivariate and backward stepwise multivariable statistical methods were employed to assess malnutrition-associated factors in rural and urban communities. RESULTS: The prevalence of stunting among school-aged children was 42.7% in rural areas and 29.2% in urban areas, while the corresponding figures for thinness were 21.6% and 20.8%. Age differences were significant in both strata. In the rural setting, fever in the previous 2 weeks (OR: 1.62; 95% CI: 1.23-2.32), consumption of food from animal sources (OR: 0.51; 95% CI: 0.29-0.91) and consumption of the family's own cattle products (OR: 0.50; 95% CI: 0.27-0.93), among others factors were significantly associated with stunting, while in the urban setting, only age (OR: 4.62; 95% CI: 2.09-10.21) and years of schooling of the person in charge of food preparation were significant (OR: 0.88; 95% CI: 0.79-0.97). Thinness was statistically associated with number of children living in the house (OR: 1.28; 95% CI: 1.03-1.60) and family rice cultivation (OR: 0.64; 95% CI: 0.41-0.99) in the rural setting, and with consumption of food from animal sources (OR: 0.26; 95% CI: 0.10-0.67) and literacy of head of household (OR: 0.24; 95% CI: 0.09-0.65) in the urban setting. CONCLUSION: The prevalence of stunting was significantly higher in rural areas, whereas no significant differences were observed for thinness. Various factors were associated with one or both types of malnutrition, and varied by type of setting. To effectively tackle malnutrition, nutritional programs should be oriented to local needs.

Knowledge, attitudes and practices related to visceral leishmaniasis in rural communities of Amhara State: a longitudinal study in northwest Ethiopia.

BACKGROUND: In the northwest of Ethiopia, at the South Gondar region, there was a visceral leishmaniasis (VL) outbreak in 2005, making the disease a public health concern for the regional health authorities ever since. The knowledge on how the population perceives the disease is essential in order to propose successful control strategies. METHODOLOGY/PRINCIPAL FINDINGS: Two surveys on VL knowledge, attitudes and practices were conducted at the beginning (May 2009) and at the end (February 2011) of a VL longitudinal study carried out in rural communities of Libo Kemkem and Fogera, two districts of the Amhara Regional State. Results showed that VL global knowledge was very low in the area, and that it improved substantially in the period studied. Specifically, from 2009 to 2011, the frequency of proper knowledge regarding VL signs and symptoms increased from 47% to 71% (p<0.0001), knowledge of VL causes increased from 8% to 25% (p<0.0001), and knowledge on VL protection measures from 16% to 55% (p<0.0001). Moreover, the improvement observed in VL knowledge was more marked among the families with no previous history of VL case. Finally, in 2011 more than 90% of the households owned at least an impregnated bed net and had been sprayed, and attitudes towards these and other protective measures were very positive (over 94% acceptance for all of them). CONCLUSIONS/SIGNIFICANCE: In 2009 the level of knowledge regarding VL was very low among the rural population of this area, although it improved substantially in the study period, probably due to the contribution of many actors in the area. VL patients and relatives should be appropriately informed and trained as they may act as successful health community agents. VL risk behavioural patterns are subject to change as attitudes towards protective measures were very positive overall.

Factors associated with Leishmania asymptomatic infection: results from a cross-sectional survey in highland northern Ethiopia.

BACKGROUND: In northern Ethiopia the prevalence of visceral leishmaniasis is steadily rising posing an increasing public health concern. In order to develop effective control strategies on the transmission of the disease it is important to generate knowledge on the epidemiological determinants of the infection. METHODOLOGY/PRINCIPAL FINDINGS: We conducted a cross-sectional survey on children 4-15 years of age using a multi staged stratified cluster sampling on high incidence sub-districts of Amhara regional state, Ethiopia. The survey included a socio-demographic, health and dietary questionnaire, and anthropometric measurements. We performed rK39-ICT and DAT serological tests in order to detect anti-Leishmania antibodies and carried out Leishmanin Skin Test (LST) using L.major antigen. Logistic regression models were used. Of the 565 children surveyed 56 children were positive to infection (9.9%). The individual variables that showed a positive association with infection were increasing age, being male and sleeping outside [adjusted odds ratios (95% CI): 1.15 (1.03, 1.29), 2.56 (1.19, 5.48) and 2.21 (1.03, 4.71) respectively] and in relation to the household: past history of VL in the family, living in a straw roofed house and if the family owned sheep [adjusted OR (95% CI): 2.92 (1.25, 6.81), 2.71 (1.21, 6.07) and 4.16 (1.41, 12.31) respectively]. CONCLUSIONS/SIGNIFICANCE: A behavioural pattern like sleeping outside is determinant in the transmission of the infection in this area. Protective measures should be implemented against this identified risk activity. Results also suggest a geographical clustering and a household focalization of the infection. The behaviour of the vector in the area needs to be clarified in order to establish the role of domestic animals and house materials in the transmission of the infection.

Low prevalence of Leishmania infection in post-epidemic areas of Libo Kemkem, Ethiopia.

In Libo Kemkem (a district of Amhara region, Ethiopia), no cases of kala-azar had ever been reported until 2005 when an outbreak occurred. Over one-third of those cases were children under 15 years of age. The aim of the present study was to determine the prevalence of Leishmania infection in children aged 4-15 years. A cross-sectional survey was conducted in 2009. Children participating in the survey were selected using a three-stage cluster sampling method. A total of 386 children were included in the study. The overall prevalence of Leishmania infection (direct agglutination test- and/or rK39 immunochromatographic test- and/or leishmanin skin test-positive subjects) in this population was 1.02% (95% confidence interval = 0-4.54), and prevalence was higher in boys and children older than 12 years. Only one case of active disease was encountered. The results suggest that the conditions responsible for the outbreak no longer reign. However, active surveillance remains necessary.

Usefulness of the rK39-immunochromatographic test, direct agglutination test, and leishmanin skin test for detecting asymptomatic Leishmania infection in children in a new visceral leishmaniasis focus in Amhara State, Ethiopia.

In areas where visceral leishmaniasis is anthroponotic, asymptomatically infected patients may play a role in transmission. Additionally, the number of asymptomatic patients in a disease-endemic area will also provide information on transmission dynamics. Libo Kemkem and Fogera districts (Amhara State, Ethiopia) are now considered newly established areas to which visceral leishmaniasis is endemic. In selected villages in these districts, we conducted a study to assess the usefulness of different approaches to estimate the asymptomatic infection rate. Of 605 participants, the rK39 immunochromatographic test was able to detect asymptomatic infection in 1.5% (9 of 605), direct agglutination test in 5.3% (32 of 605), and leishmanin skin test in 5.6% (33 of 589); the combined use of serologic methods and leishmanin skin test enabled detecting asymptomatic infection in 10.1% (61 of 605). We conclude that the best option to detect asymptomatic infection in this new visceral leishmaniasis-endemic focus is the combined use of the direct agglutination test and the leishmanin skin test.