Social Determinants of Health and Multimorbidity Among Adults 50 Years and Older in the United States.

BACKGROUND: Living with two or more chronic conditions simultaneously-known as multimorbidity-has become increasingly prevalent as the aging population continues to grow. However, the factors that influence the development of multimorbidity are still not fully understood. OBJECTIVES: The purpose of this study was to investigate the prevalence of multimorbidity among U.S. adults 50 years and older and identify associated factors with multimorbidity. METHODS: We used data from four cycles from the National Health and Nutrition Examination Survey (2011-2018) to examine the associations between social determinants of health and multimorbidity among American adults aged 50 years and older. A set of variables on socioeconomic status and health behaviors was chosen based on the social determinants of health conceptual framework developed by the World Health Organization. In our study, 4,552 participants were included. All analyses were accounted for a complex survey design and the use of survey weights. Multiple logistic regression analyses were performed to examine the associated factors with multimorbidity. RESULTS: The average age was 63.1 years, and 52.9% were female. The average number of chronic conditions was 2.27. The prevalence of multimorbidity was 63.8%, with high cholesterol and hypertension being the most prevalent conditions. In the adjusted model, age, gender, household income, citizenship status, health insurance, healthcare access, body mass index, and smoking status were found to be associated with living with multimorbidity. DISCUSSION: Our results indicate that continued efforts aimed at promoting smoking cessation and maintaining a healthy weight will be beneficial in preventing the onset of chronic conditions. Additional research is warranted to gain a deeper understanding of the interrelationships between gender, race/ethnicity, household income, citizenship status, health insurance, and healthcare access as social determinants of health in the context of multimorbidity. Further research will help us develop targeted interventions and policies to address disparities and improve health outcomes for individuals with multimorbidity.

The Impact of Nutrition-Based Interventions on Nutritional Status and Metabolic Health in Small Island Developing States: A Systematic Review and Narrative Synthesis.

Small island developing states (SIDS) have a high burden of nutrition-related disease associated with nutrient-poor, energy-dense diets. In response to these issues, we assessed the effectiveness of nutrition-based interventions on nutritional status (under-nutrition) and metabolic health (over-nutrition) among persons in SIDS. We included SIDS-based nutrition studies with change in nutrition status (e.g., markers of anaemia) or metabolic status (e.g., markers of glycaemia) as outcomes. The PRISMA framework was applied and MEDLINE, Embase, CINAHL, OARE library, Web of Science, Scopus, ASSIA, EconLit, AGORA, AGRICOLA, AGRIS, WHO-EMRO, and LILACS were searched (2000−2020). Cochrane risk of bias (ROB) and Cochrane ROBINS-I tools assessed ROB for randomised and non-randomised studies, respectively. PROSPERO registration (CRD42021236396) was undertaken. We included 50 eligible interventions, involving 37,591 participants: 14 trials reported on nutritional status, 36 on metabolic health. Effective interventions, evaluated at the individual level, took a multifaceted approach for metabolic outcomes; while nutrition outcomes utilised supplements. Most intervention types were suitable for issues related to 'over' nutrition versus 'under' nutrition. Twenty-six studies (nutrition status (six); metabolic health (twenty)) were effective (p < 0.05). With the current rise of nutrition-related public health challenges, there is a need for further development and evaluation of these and related interventions at the population level.

Dietary Patterns, Food Insecurity, and Their Relationships with Food Sources and Social Determinants in Two Small Island Developing States.

Small Island Developing States (SIDS) have high burdens of nutrition-related chronic diseases. This has been associated with lack of access to adequate and affordable nutritious foods and increasing reliance on imported foods. Our aim in this study was to investigate dietary patterns and food insecurity and assess their associations with socio-demographic characteristics and food sources. We recruited individuals aged 15 years and above from rural and urban areas in Fiji (n = 186) and St. Vincent and the Grenadines (SVG) (n = 147). Data collection included a 24 h diet recall, food source questionnaire and the Food Insecurity Experience Scale. We conducted latent class analysis to identify dietary patterns, and multivariable regression to investigate independent associations with dietary patterns. Three dietary patterns were identified: (1) low pulses, and milk and milk products, (2) intermediate pulses, and milk and milk products and (3) most diverse. In both SIDS, dietary pattern 3 was associated with older age, regularly sourcing food from supermarkets and borrowing, exchanging, bartering or gifting (BEB). Prevalence of food insecurity was not statistically different across dietary patterns. In both SIDS, food insecurity was higher in those regularly sourcing food from small shops, and in SVG, lower in those regularly using BEB. These results complement previous findings and provide a basis for further investigation into the determinants of dietary patterns, dietary diversity and food insecurity in these settings.

Interventions in Small Island Developing States to improve diet, with a focus on the consumption of local, nutritious foods: a systematic review.

Introduction: Food security in Small Island Developing States (SIDS) is an international policy priority. SIDS have high rates of nutrition-related non-communicable diseases, including obesity and type 2 diabetes, micronutrient deficiencies and, in many, persistent childhood stunting. This is associated with an increasing reliance on imported processed food of poor nutritional quality. Calls have been made for strengthening local food systems, resilient to climate change, to increase the consumption of nutritious locally produced food. We aimed to systematically review interventions intended to improve diet in SIDS, and specifically explore whether these interventions applied a local food approach. Methods: The search strategy was applied to 11 databases, including in health, social science and agriculture. Screening of titles, abstracts and data extraction was undertaken in duplicate. Risk of bias was assessed using Cochrane tools. Narrative synthesis of the results was undertaken. The study protocol was registered (PROSPERO registration number: 2020CRD42020201274). Results: From 26 062 records, 154 full texts were reviewed and 24 were eligible. Included studies were from the Caribbean, Pacific, Mauritius and Singapore. Five were a randomised study design, one an interrupted time series analysis, eight controlled and ten uncontrolled pre-test and post-test. Nine studies included some aspect of a local food approach. Most interventions (n=15) included nutrition education, with evidence of effectiveness largely limited to those that also included practical skills training, such as vegetable gardening or food preparation. Three studies were considered low risk of bias, with the majority (n=13) of moderate risk. Conclusion: There is a lack of robust evidence on interventions to improve diet in SIDS. The evidence suggests that multifaceted approaches are likely to be the most effective, and local food approaches may promote effectiveness, through mechanisms of cultural and contextual relevance. Further development and evaluation of interventions is urgently required to increase the comparability of these studies, to help guide policy on improving nutrition in SIDS.

Impacts of COVID-19 on agriculture and food systems in Pacific Island countries (PICs): Evidence from communities in Fiji and Solomon Islands.

CONTEXT: COVID-19 mitigation measures including border lockdowns, social distancing, de-urbanization and restricted movements have been enforced to reduce the risks of COVID-19 arriving and spreading across PICs. To reduce the negative impacts of COVID-19 mitigation measures, governments have put in place a number of interventions to sustain food and income security. Both mitigation measures and interventions have had a number of impacts on agricultural production, food systems and dietary diversity at the national and household levels. OBJECTIVE: Our paper conducted an exploratory analysis of immediate impacts of both COVID-19 mitigation measures and interventions on households and communities in PICs. Our aim is to better understand the implications of COVID-19 for PICs and identify knowledge gaps requiring further research and policy attention. METHODS: To understand the impacts of COVID-19 mitigation measures and interventions on food systems and diets in PICs, 13 communities were studied in Fiji and Solomon Islands in July-August 2020. In these communities, 46 focus group discussions were carried out and 425 households were interviewed. Insights were also derived from a series of online discussion sessions with local experts of Pacific Island food and agricultural systems in August and September 2020. To complement these discussions, an online search was conducted for available literature. RESULTS AND CONCLUSIONS: Identified impacts include: 1) Reduced agricultural production, food availability and incomes due to a decline in local markets and loss of access to international markets; 2) Increased social conflict such as land disputes, theft of high-value crops and livestock, and environmental degradation resulting from urban-rural migration; 3) Reduced availability of seedlings, planting materials, equipment and labour in urban areas; 4) Reinvigoration of traditional food systems and local food production; and 5) Re-emergence of cultural safety networks and values, such as barter systems. Households in rural and urban communities appear to have responded positively to COVID-19 by increasing food production from home gardens, particularly root crops, vegetables and fruits. However, the limited diversity of agricultural production and decreased household incomes are reducing the already low dietary diversity score that existed pre-COVID-19 for households. SIGNIFICANCE: These findings have a number of implications for future policy and practice. Future interventions would benefit from being more inclusive of diverse partners, focusing on strengthening cultural and communal values, and taking a systemic and long-term perspective. COVID-19 has provided an opportunity to strengthen traditional food systems and re-evaluate, re-imagine and re-localize agricultural production strategies and approaches in PICs.

Insulin Pump Therapy Improves Quality of Life of Young Patients With Type 1 Diabetes Enrolled in a Government-Funded Insulin Pump Program: A Qualitative Study.

BACKGROUND: The Nova Scotia Insulin Pump Program (NSIPP) subsidizes the cost of insulin pump therapy for young patients (≤25 years) with type 1 diabetes. The first NSIPP evaluation focused on clinical outcomes rather than quality of life. Existing research on insulin pumps and quality of life is mostly survey based, with limited first-voice experiences. In this qualitative study, we examined patient and parent perspectives on how insulin pumps affect quality of life in the context of a government-funded program. METHODS: In this investigation, we used a phenomenological approach, guided by a conceptual model. In-depth semistructured telephone interviews (median, 37 minutes) were completed with NSIPP enrollees and/or their parents. Saturation was reached after 23 interviews. Verbatim transcripts were coded independently by 2 researchers. Coding discrepancies were discussed and resolved using concept mapping to clarify relationships between codes and to identify main themes. RESULTS: There were 2 main themes: 1) NSIPP financial support was necessary for those without private insurance and 2) control over life and diabetes with subthemes of social experiences and worry. Participants expressed this theme differently depending on their stage of life. For example, some children experienced shame and even hid their pump, whereas teens were more self-confident with the discreetness of pumps and young adults wore their pump with pride. CONCLUSIONS: Insulin pump therapy, subsidized through the NSIPP, led to improved quality of life, which was experienced differently depending on stage of life.

Food Sources and Dietary Quality in Small Island Developing States: Development of Methods and Policy Relevant Novel Survey Data from the Pacific and Caribbean.

Small Island Developing States (SIDS) have high and increasing rates of diet-related diseases. This situation is associated with a loss of food sovereignty and an increasing reliance on nutritionally poor food imports. A policy goal, therefore, is to improve local diets through improved local production of nutritious foods. Our aim in this study was to develop methods and collect preliminary data on the relationships between where people source their food, their socio-demographic characteristics and dietary quality in Fiji and Saint Vincent and the Grenadines (SVG) in order to inform further work towards this policy goal. We developed a toolkit of methods to collect individual-level data, including measures of dietary intake, food sources, socio-demographic and health indicators. Individuals aged ≥15 years were eligible to participate. From purposively sampled urban and rural areas, we recruited 186 individuals from 95 households in Fiji, and 147 individuals from 86 households in SVG. Descriptive statistics and multiple linear regression were used to investigate associations. The mean dietary diversity score, out of 10, was 3.7 (SD1.4) in Fiji and 3.8 (SD1.5) in SVG. In both settings, purchasing was the most common way of sourcing food. However, 68% (Fiji) and 45% (SVG) of participants regularly (>weekly) consumed their own produce, and 5% (Fiji) and 33% (SVG) regularly consumed borrowed/exchanged/bartered food. In regression models, independent positive associations with dietary diversity (DD) were: borrowing/exchanging/bartering food (ß = 0.73 (0.21, 1.25)); age (0.01 (0.00, 0.03)); and greater than primary education (0.44 (0.06, 0.82)). DD was negatively associated with small shop purchasing (-0.52 (95% CIs -0.91, -0.12)) and rural residence (-0.46 (-0.92, 0.00)). The findings highlight associations between dietary diversity and food sources and indicate avenues for further research to inform policy actions aimed at improving local food production and diet.

Gender and active travel: a qualitative data synthesis informed by machine learning.

BACKGROUND: Innovative approaches are required to move beyond individual approaches to behaviour change and develop more appropriate insights for the complex challenge of increasing population levels of activity. Recent research has drawn on social practice theory to describe the recursive and relational character of active living but to date most evidence is limited to small-scale qualitative research studies. To 'upscale' insights from individual contexts, we pooled data from five qualitative studies and used machine learning software to explore gendered patterns in the context of active travel. METHODS: We drew on 280 transcripts from five research projects conducted in the UK, including studies of a range of populations, travel modes and settings, to conduct unsupervised 'topic modelling analysis'. Text analytics software, Leximancer, was used in the first phase of the analysis to produce inter-topic distance maps to illustrate inter-related 'concepts'. The outputs from this first phase guided a second researcher-led interpretive analysis of text excerpts to infer meaning from the computer-generated outputs. RESULTS: Guided by social practice theory, we identified 'interrelated' and 'relating' practices across the pooled datasets. For this study we particularly focused on respondents' commutes, travelling to and from work, and on differentiated experiences by gender. Women largely described their commute as multifunctional journeys that included the school run or shopping, whereas men described relatively linear journeys from A to B but highlighted 'relating' practices resulting from or due to their choice of commute mode or journey such as showering or relaxing. Secondly, we identify a difference in discourses about practices across the included datasets. Women spoke more about 'subjective', internal feelings of safety ('I feel unsafe'), whereas men spoke more about external conditions ('it is a dangerous road'). CONCLUSION: This rare application of machine learning to qualitative social science research has helped to identify potentially important differences in co-occurrence of practices and discourses about practice between men's and women's accounts of travel across diverse contexts. These findings can inform future research and policy decisions for promoting travel-related social practices associated with increased physical activity that are appropriate across genders.

Quantifying Acute Fuel and Respiration Dependent pH Homeostasis in Live Cells Using the mCherryTYG Mutant as a Fluorescence Lifetime Sensor.

Intracellular pH plays a key role in physiology, and its measurement in living specimens remains a crucial task in biology. Fluorescent protein-based pH sensors have gained widespread use, but there is limited spectral diversity for multicolor detection, and it remains a challenge to measure absolute pH values. Here we demonstrate that mCherryTYG is an excellent fluorescence lifetime pH sensor that significantly expands the modalities available for pH quantification in live cells. We first report the 1.09 Å X-ray crystal structure of mCherryTYG, exhibiting a fully matured chromophore. We next determine that it has an extraordinarily large dynamic range with a 2 ns lifetime change from pH 5.5 to 9.0. Critically, we find that the sensor maintains a p Ka of 6.8 independent of environment, whether as the purified protein in solution or expressed in live cells. Furthermore, the lifetime measurements are robustly independent of total fluorescence intensity and scatter. We demonstrate that mCherryTYG is a highly effective sensor using time-resolved fluorescence spectroscopy on live-cell suspensions, which has been previously overlooked as an easily accessible approach for quantifying intracellular pH. As a red fluorescent sensor, we also demonstrate that mCherryTYG is spectrally compatible with the ATeam sensor and EGFP for simultaneous dual-color measurements of intracellular pH, ATP, and extracellular pH. In a proof-of-concept, we quantify acute respiration-dependent pH homeostasis that exhibits a stoichiometric relationship with the ATP-generating capacity of the carbon fuel choice in E. coli. Broadly speaking, our work presents a previously unemployed methodology that will greatly facilitate continuous pH quantification.

Semiautomated text analytics for qualitative data synthesis.

Approaches to synthesizing qualitative data have, to date, largely focused on integrating the findings from published reports. However, developments in text mining software offer the potential for efficient analysis of large pooled primary qualitative datasets. This case study aimed to (a) provide a step-by-step guide to using one software application, Leximancer, and (b) interrogate opportunities and limitations of the software for qualitative data synthesis. We applied Leximancer v4.5 to a pool of five qualitative, UK-based studies on transportation such as walking, cycling, and driving, and displayed the findings of the automated content analysis as intertopic distance maps. Leximancer enabled us to "zoom out" to familiarize ourselves with, and gain a broad perspective of, the pooled data. It indicated which studies clustered around dominant topics such as "people." The software also enabled us to "zoom in" to narrow the perspective to specific subgroups and lines of enquiry. For example, "people" featured in men's and women's narratives but were talked about differently, with men mentioning "kids" and "old," whereas women mentioned "things" and "stuff." The approach provided us with a fresh lens for the initial inductive step in the analysis process and could guide further exploration. The limitations of using Leximancer were the substantial data preparation time involved and the contextual knowledge required from the researcher to turn lines of inquiry into meaningful insights. In summary, Leximancer is a useful tool for contributing to qualitative data synthesis, facilitating comprehensive and transparent data coding but can only inform, not replace, researcher-led interpretive work.

With a little help from our friends: Collaborative research partnerships in three workplace-based occupational disease research projects.

BACKGROUND: Research conducted in collaboration between academic and non-academic partners (known as integrated knowledge translation [iKT]) in the field of occupational health and safety needs to be evaluated. OBJECTIVE: This study examined three collaborative workplace-based intervention projects that focused on reducing exposure to occupational carcinogens. Practice, policy and advocacy intermediary organizations partnered with multidisciplinary groups of researchers. This evaluation study sought to understand the characteristics of successful and unsuccessful iKT partnerships from the perspective of the intermediaries. METHODS: Researchers conducted face-to-face interviews with 21 intermediaries and used a thematic-driven "framework analysis" method to analyze the interviews, based upon an evolving conceptual framework. RESULTS: Seven enablers and barriers of collaboration were identified. Enablers included having: adequate capacity; defined project roles; the right partners; an inclusive project leader; mutual respect; good communication; and shared values and priorities. Lacking these was considered a barrier. Seven outcomes were identified as: improved relevance and quality of the research; learning about each others' "world"; building contacts; improved use of research in practice and policy; dissemination of the research; development of trust and goodwill; and continued collaborations. CONCLUSIONS: Recommendations for future collaborative studies include: spend time defining roles, responsibilities, and expectations; ensure practitioners have the time and resources, and the commitment to the project; and choose representatives from the organizations with the necessary skills or decision-making mandate.

Health and other impacts of community food production in Small Island Developing States: a systematic scoping review

[ABSTRACT]. Objective. To explore what is known on community-based food production initiatives (CFPIs) in Small Island Developing States, particularly the health, social, economic, and environmental impacts of and on CFPIs. Methods. This was a systematic scoping review using 14 electronic databases to identify articles published from 1997 to 2016 on the topic of CFPIs in Small Island Developing States. From 8 215 articles found, 153 were eligible and abstracted. Analysis focused on geographic location, typology, methodology, study design, theoretical frameworks, and impacts. Results. Most research was conducted in the Pacific or Caribbean (49% and 43% of studies, respectively) and primarily focused on fishing and crop farming (40%, 34%). Findings indicate a predominance of research focusing on the environmental impact of marine and coastal resources on CFPIs, and very limited evidence of CFPI impact on human health, particularly nutrition and diet-related outcomes. There was a lack of explicit theoretical frameworks to explain the impacts of CFPIs. Conclusions. Evidence of impacts of CPFIs in Small Island Developing States is limited and the approaches taken are inconsistent. This review demonstrates the need and provides a basis for developing a coherent body of methods to examine the impacts of CFPIs and provide evidence to guide policy, especially as it relates to health.

[RESUMEN]. Objetivo. Explorar las iniciativas de producción de alimentos basadas en la comunidad (CFPI, por sus siglas en inglés) en los pequeños Estados insulares en desarrollo, en particular su impacto sanitario, social, económico y ambiental. Métodos. Se realizó una revisión sistemática exploratoria usando 14 bases de datos electrónicas para identificar artículos publicados entre 1997 y 2016 sobre las CFPI en los pequeños Estados insulares en desarrollo. De 8 215 artículos encontrados, 153 fueron elegibles y resumidos. El análisis se centró en la ubicación geográfica, el tipo de iniciativa, la metodología, el diseño del estudio, el marco teórico y el impacto. Resultados. La mayoría de las investigaciones se realizaron en el Pacífico o el Caribe (49% y 43% de los estudios, respectivamente) y se centraron principalmente en la pesca y el cultivo (40%, 34%). Los hallazgos indican un predominio de investigaciones centradas en el impacto ambiental de los recursos marinos y costeros en las CFPI, y una evidencia muy limitada del impacto de las CFPI en la salud humana, en particular en resultados relacionados con la nutrición y la dieta. Faltan marcos teóricos explícitos para explicar el impacto de las CFPI. Conclusiones. La evidencia del impacto de las CPFI en los pequeños Estados insulares en desarrollo es limitada y los enfoques adoptados son inconsistentes. Esta revisión demuestra la necesidad de efectuar estudios y proporciona una base para desarrollar métodos coherentes para examinar el impacto de las CFPI y proporcionar evidencia para guiar las políticas, especialmente las relacionadas con la salud.

[RESUMO]. Objetivo. Explorar iniciativas de produção alimentar baseada na comunidade (CFPI) em pequenos Estados insulares em desenvolvimento, particularmente seu impacto na saúde, social, econômico e ambiental. Métodos. Uma revisão sistemática exploratória foi realizada utilizando 14 bases de dados eletrônicas para identificar artigos publicados entre 1997 e 2016 sobre CFPI em pequenos Estados insulares em desenvolvimento. Dos 8 215 artigos encontrados, 153 foram elegíveis e resumidos. A análise centrou-se na localização geográfica, no tipo de iniciativa, na metodologia, no desenho do estudo, no referencial teórico e no impacto. Resultados. A maior parte da pesquisa foi realizada no Pacífico ou no Caribe (49% e 43% dos estudos, respectivamente) e se concentrou principalmente na pesca e na agricultura (40%, 34%). Os resultados indicam uma predominância de pesquisas focadas no impacto ambiental dos recursos marinhos e costeiros na CFPI, e evidências muito limitadas do impacto das CFPI na saúde humana, particularmente nos resultados relacionados à nutrição e dieta. Não existem quadros teóricos explícitos para explicar o impacto das CFPI. Conclusões. A evidência do impacto das CPFI em pequenos Estados insulares em desenvolvimento é limitada e as abordagens adotadas são inconsistentes. Esta revisão demonstra a necessidade de estudos e fornece uma base para o desenvolvimento de métodos coerentes para examinar o impacto das CFPI e fornecer evidências para orientar políticas, especialmente aquelas relacionadas à saúde.

Imaging pH Dynamics Simultaneously in Two Cellular Compartments Using a Ratiometric pH-Sensitive Mutant of mCherry.

The regulation of pH is essential for proper organelle function, and organelle-specific changes in pH often reflect the dynamics of physiological signaling and metabolism. For example, mitochondrial energy production depends on the proton gradient maintained between the alkaline mitochondrial matrix and neutral cytosol. However, we still lack a quantitative understanding of how pH dynamics are coupled between compartments and how pH gradients are regulated at organelle boundaries. Genetically encoded pH sensors are well suited to address this problem because they can be targeted to specific subcellular locations and they facilitate live, single-cell analysis. However, most of these pH sensors are derivatives of green and yellow fluorescent proteins that are not spectrally compatible for dual-compartment imaging. Therefore, there is a need for ratiometric red fluorescent protein pH sensors that enable quantitative multicolor imaging of spatially resolved pH dynamics. In this work, we demonstrate that the I158E/Q160A mutant of the red fluorescent protein mCherry is an effective ratiometric pH sensor. It has a pKa of 7.3 and a greater than 3-fold change in ratio signal. To demonstrate its utility in cells, we measured activity and metabolism-dependent pH dynamics in cultured primary neurons and neuroblastoma cells. Furthermore, we were able to image pH changes simultaneously in the cytosol and mitochondria by using the mCherryEA mutant together with the green fluorescent pH sensor, ratiometric-pHluorin. Our results demonstrate the feasibility of studying interorganelle pH dynamics in live cells over time and the broad applicability of these sensors in studying the role of pH regulation in metabolism and signaling.

INFORMED CHOICE AND FEMALE STERILIZATION IN SOUTH ASIA AND LATIN AMERICA.

Globally, female sterilization is one of the most popular contraceptive methods despite concerns about quality of care for women who report being sterilized. In this study, informed choice among sterilized women was quantified using Demographic and Health Survey (DHS) data from 2000 to 2012 for countries in South Asia and Latin America. Three responses measured informed choice and knowledge about whether women were informed by a health worker or provider: that sterilization is permanent, the potential side-effects of sterilization and other methods of contraception. An ascending composite Method Information Index with scores ranging from 0 (women received no information) to 3 (women received information across all three indicators) was used. Using ordinal logistic regression analysis, the results indicated that women younger than 25 and older than 35 at the time of sterilization, and those at high parities, had lower odds of a high score on the index, while the opposite was true for women sterilized in the private sector in Latin America. Educated women in India had higher odds of a high score on the index, while the same was true for educated and wealthy women in Colombia. These findings indicate that not enough health care providers spend time informing women in South Asia and Latin America about different aspects of sterilization, and that there are specific groups of women that are more affected. There is an urgent need to improve quality of care within health systems providing sterilization for this very important and effective type of contraception.

Health and other impacts of community food production in Small Island Developing States: a systematic scoping review.

OBJECTIVE: To explore what is known on community-based food production initiatives (CFPIs) in Small Island Developing States, particularly the health, social, economic, and environmental impacts of and on CFPIs. METHODS: This was a systematic scoping review using 14 electronic databases to identify articles published from 1997 to 2016 on the topic of CFPIs in Small Island Developing States. From 8 215 articles found, 153 were eligible and abstracted. Analysis focused on geographic location, typology, methodology, study design, theoretical frameworks, and impacts. RESULTS: Most research was conducted in the Pacific or Caribbean (49% and 43% of studies, respectively) and primarily focused on fishing and crop farming (40%, 34%). Findings indicate a predominance of research focusing on the environmental impact of marine and coastal resources on CFPIs, and very limited evidence of CFPI impact on human health, particularly nutrition and diet-related outcomes. There was a lack of explicit theoretical frameworks to explain the impacts of CFPIs. CONCLUSIONS: Evidence of impacts of CPFIs in Small Island Developing States is limited and the approaches taken are inconsistent. This review demonstrates the need and provides a basis for developing a coherent body of methods to examine the impacts of CFPIs and provide evidence to guide policy, especially as it relates to health.

From awareness to action: Sudbury, mining and occupational disease in a time of change.

BACKGROUND: Miners work in highly hazardous environments, but surprisingly, there are more fatalities from occupational diseases, including cancers, than from fatalities from injuries. Over the last few decades, the mining environment has become safer with fewer injuries and less exposure to the toxins that lead to occupational disease. There have been improvements in working conditions, and a reduction in the number of workers exposed, together with an overall improvement in the health of miners. OBJECTIVES: This study attempted to gain a deeper understanding of the impetus for change to reduce occupational exposures or toxins at the industry level. It focuses on one mining community in Sudbury, Ontario, with a high cancer rate, and its reduction in occupational exposures. It explored the level of awareness of occupational exposures from the perspective of industry and worker representatives in some of the deepest mines in the world. Although awareness may be necessary, it is often not a sufficient impetus for change, and it is this gap between awareness and change that this study explored. It examined the awareness of occupational disease as an impetus to reducing toxic exposures in the mining sector, and explores other forces of change at the industrial and global levels that have led to an impact on occupational exposures in mining. METHODS: From 2014 and 2016, 60 interviews were conducted with individuals who were part of, or witness to the changes in mining in Sudbury. From these, 12 labour and 10 industry interviews and four focus groups were chosen for further analysis to gain a deeper understanding of industry and labour's views on the changes in mining and the impact on miners' health from occupational exposures. The results from this subsection of the data is the focus for this paper. RESULTS: The themes that emerged told a story about Sudbury. There is awareness of occupational exposures, but this awareness is dwarfed in comparison to the attention that is given to the tragic fatal injuries from injuries and accidents. The mines are now owned by foreign multinationals with a change from an engaged, albeit paternalistic sense of responsibility for the health of the miners, to a less responsive or sympathetic workplace culture. Modernization has led to the elimination, substitution, or reduction of some of the worst toxins, and hence present-day miners are less exposed to hazards that lead to occupational disease than they were in the past. However, modernization and the drop in the price of nickel has also led to a precipitous reduction in the number of unionized miners, a decline in union power, a decline in the monitoring of present-day exposures, and an increase in non-unionized contract workers. The impact has been that miners have lost their solidarity and power to investigate, monitor or object to present-day exposures. CONCLUSIONS: Although an increase in the awareness of occupational hazards has made a contribution to the reduction in occupational exposures, the improvement in health of miners may be considered more as a "collateral benefit" of the changes in the mining sector. Multiple forces at the industrial and global level have differentially led to an improvement in the working and living environment. However, with the loss of union power, the miners have lost their major advocate for miner health.

Obesity prevention advocacy in Australia: an analysis of policy impact on autonomy.

OBJECTIVE: To explore obesity policy options recommended by stakeholders and identify their impact on individual autotomy. METHODS: Qualitative and quantitative methods were used. A content analysis of submissions to the Australian Government's Inquiry into Obesity was conducted. Each recommendation was categorised by its impact on autonomy, according to existing frameworks. Chi-square test for independence was used to explore the association between autonomy and stakeholder support defined as frequency of recommendation. RESULTS: The extent of support for a policy option was significantly associated with impact on autonomy (p<0.001). Options that reduce autonomy were least frequently recommended in every setting; but more likely in schools (27%) than other settings (<1%). Recommendations to provide incentives (9%) were more common than disincentives (2%) or restrictions (3%), and those that enhance autonomy were most widely recommended (46%). CONCLUSIONS: Stakeholders advocated policy options that enhance individual autonomy to a greater extent than those that diminish autonomy. Implications for public health: Targeting obesity policy options that enhance rather than diminish autonomy may be more politically acceptable across most settings, with the exception of schools where more restrictive policy options are appropriate. Re-framing options accordingly may improve leadership by government in obesity policy.

Modified Policy-Delphi study for exploring obesity prevention priorities.

INTRODUCTION: Until now, industry and government stakeholders have dominated public discourse about policy options for obesity. While consumer involvement in health service delivery and research has been embraced, methods which engage consumers in health policy development are lacking. Conflicting priorities have generated ethical concern around obesity policy. The concept of 'intrusiveness' has been applied to policy decisions in the UK, whereby ethical implications are considered through level of intrusiveness to choice; however, the concept has also been used to avert government regulation to address obesity. The concept of intrusiveness has not been explored from a stakeholder's perspective. The aim is to investigate the relevance of intrusiveness and autonomy to health policy development, and to explore consensus on obesity policy priorities of under-represented stakeholders. METHODS AND ANALYSIS: The Policy-Delphi technique will be modified using the James Lind Alliance approach to collaborative priority setting. A total of 60 participants will be recruited to represent three stakeholder groups in the Australian context: consumers, public health practitioners and policymakers. A three-round online Policy-Delphi survey will be undertaken. Participants will prioritise options informed by submissions to the 2009 Australian Government Inquiry into Obesity, and rate the intrusiveness of those proposed. An additional round will use qualitative methods in a face-to-face discussion group to explore stakeholder perceptions of the intrusiveness of options. The novelty of this methodology will redress the balance by bringing the consumer voice forward to identify ethically acceptable obesity policy options. ETHICS AND DISSEMINATION: Ethical approval was granted by the Bond University Health Research Ethics Committee. The findings will inform development of a conceptual framework for analysing and prioritising obesity policy options, which will be relevant internationally and to ethical considerations of wider public health issues. The findings will be disseminated through peer-reviewed publications, conference presentations and collaborative platforms of policy and science.

Polygyny and women's health in rural Mali.

Women's social networks and social power are increasingly seen as important factors modulating their health in sub-Saharan Africa. Polygyny, a common marital structure in many societies, mediates important intra-household relationships by requiring both competition and co-operation among co-wives. Using mixed methods, semi-structured questionnaires were administered to 298 women aged 15-84 living in the Kolondiéba region of rural Mali in 1999, and supplemented by detailed interviews with 40 women. Three categories of outcome were explored: illness experience, therapeutic itinerary and social support received. Quantitative data were analysed using regression analysis and qualitative data using a grounded theory approach. In quantitative analyses, controlling for age and household wealth index, senior wives were less likely to be escorted to a healer by their husbands during illness than were junior wives or monogamous women. Polygynous women were also less likely to obtain a treatment for which there was a monetary fee. Fewer than one-third of polygynous women reported the assistance of a co-wife during illness in any given task. In qualitative analyses, women further related varied mechanisms through which polygyny impacted their health trajectories. These ranged from strongly supportive relationships, to jealousy because of unequal health or fertility, bias in emotional and material support provided by husbands, and accusations of wrong-doing and witchcraft. This study highlights the need for more prospective mixed methods analyses to further clarify the impact of polygyny on women's health-related experiences and behaviours in sub-Saharan Africa.

Women's health in urban Mali: social predictors and health itineraries.

Social and marital factors may influence women's health outcomes. This is of particular relevance in sub-Saharan Africa, where women's health indicators lag behind the rest of the world. Our study examines the impact of social mediators of women's health during key events (pregnancy and illness) in urban Mali. In this cross-sectional study, we interviewed 324 women aged 15-80, living in Bamako, the capital city, in 1999. We used mixed quantitative and qualitative methods to obtain detailed histories of pregnancy and illness during specific time periods preceding the survey. We examined the role of marital factors (polygyny, widowhood), social factors (sources of support and scales derived for social network and social power), and household wealth on women's therapeutic itineraries. We compared the sociodemographic characteristics of our sample with those of the 2001 Mali Demographic and Health Survey and used their data on contraception to enrich analyses. We found that most pregnant women delivered in a health center and most women sought medical care during an illness event. Household wealth influenced illness reporting, and financial concerns were obstacles to medical care. Polygyny was associated with lower prevalence of contraceptive use, lower social power, as well as with less support received during pregnancy from women's husbands and in-laws. Widowhood appeared to increase susceptibility to illness, while decreasing resort to biomedical care. Our social composite scores highlighted differences in healthcare utilization in an urban setting with near-uniform access to biomedical care. We validate the utility of locally-derived composite scores, which may provide a deeper understanding into the social mediation of health outcomes for women.