Trends and inequalities in the nutritional status of adolescent girls and adult women in sub-Saharan Africa since 2000: a cross-sectional series study.

INTRODUCTION: Evidence on the rate at which the double burden of malnutrition unfolds is limited. We quantified trends and inequalities in the nutritional status of adolescent girls and adult women in sub-Saharan Africa. METHODS: We analysed 102 Demographic and Health Surveys between 1993 and 2017 from 35 countries. We assessed regional trends through cross-sectional series analyses and ran multilevel linear regression models to estimate the average annual rate of change (AARC) in the prevalence of underweight, anaemia, anaemia during pregnancy, overweight and obesity among women by their age, residence, wealth and education levels. We quantified current absolute inequalities in these indicators and wealth-inequality trends. RESULTS: There was a modest decline in underweight prevalence (AARC=-0.14 percentage points (pp), 95% CI -0.17 to -0.11). Anaemia declined fastest among adult women and the richest pregnant women with an AARC of -0.67 pp (95% CI -1.06 to -0.28) and -0.97 pp (95% CI -1.60 to -0.34), respectively, although it affects all women with no marked disparities. Overweight is increasing rapidly among adult women and women with no education. Capital city residents had a threefold more rapid rise in obesity (AARC=0.47 pp, 95% CI 0.39, 0.55), compared with their rural counterparts. Absolute inequalities suggest that Ethiopia and South Africa have the largest gap in underweight (15.4 pp) and obesity (28.5 pp) respectively, between adult and adolescent women. Regional wealth inequalities in obesity are widening by 0.34 pp annually. CONCLUSION: Underweight persists, while overweight and obesity are rising among adult women, the rich and capital city residents. Adolescent girls do not present adverse nutritional outcomes except anaemia, remaining high among all women. Multifaceted responses with an equity lens are needed to ensure no woman is left behind.

Lessons learned from Evidence-Informed Decision-Making in Nutrition & Health (EVIDENT) in Africa: a project evaluation.

BACKGROUND: Evidence-informed Decision-making in Nutrition and Health (EVIDENT) is an international partnership that seeks to identify information needs in nutrition and health in Africa and build local capacity in knowledge management to help translate the best available evidence into context-appropriate recommendations aligned to the priorities of decision-makers. This study evaluates the extent to which EVIDENT achieved its intended activities, documents the lessons learned and draws on these lessons learned to inform future activities of EVIDENT, as well as in evidence-informed decision-making (EIDM) in nutrition overall. METHODS: Purposive and snowball sampling were used to identify participants that were either directly or indirectly involved with EVIDENT. An analytical framework of five key elements was developed to guide data collection from EVIDENT's documentation, in-depth interviews (n = 20), online surveys (n = 26) and a participatory discussion. Interviews were transcribed verbatim and coded in NVivo 11, using deductive thematic content analysis and a phenomenological approach. Online surveys were analysed using Stata 14. Data were triangulated to address both objectives under each element of the analytical framework. RESULTS: EVIDENT succeeded in establishing a collaborative partnership, within which it delivered four short courses in EIDM. This capacity complemented case study activities in four partner African countries where EIDM processes were implemented and assessed. Identified barriers to these processes included little experience in EIDM, difficulties in engaging stakeholders, challenging local environments (e.g. donor influence, bureaucracy, inaccessibility to scientific research, poor internet connectivity), and limited time and funding. However, EVIDENT activities were driven by a local need for EIDM, a sheer interest and commitment to the cause, and the opportunity for the Global North and South to work together and build relationships. Future activities of EVIDENT, and EIDM in nutrition overall, should focus on sustained capacity-building in EIDM processes, leadership and functional skills across the Global South, investment in stakeholder engagement, context-specific EIDM, enhanced communication and linking, and strengthening relationships with existing stakeholder organisations. CONCLUSIONS: In its first 3 years, EVIDENT developed and strengthened partnership, capacity and visibility on EIDM in Africa. Innovative and long-term capacity-building, dedicated leadership, further stakeholder engagement and sustainable financing, are needed for future activities of EVIDENT and EIDM in nutrition.

Perspective: Consideration of Values When Setting Priorities in Nutrition Research: Guidance for Transparency.

Nutrition research can guide interventions to tackle the burden of diet-related diseases. Setting priorities in nutrition research, however, requires the engagement of various stakeholders with diverse insights. Consideration of what matters most in research from a scientific, social, and ethical perspective is therefore not an automatic process. Systematic ways to explicitly define and consider relevant values are largely lacking. Here, we review existing nutrition research priority-setting exercises, analyze how values are reported, and provide guidance for transparent consideration of values while setting priorities in nutrition research. Of the 27 (n = 22 peer-reviewed manuscripts and 5 grey literature documents) studies reviewed, 40.7% used a combination of different methods, 59.3% described the represented stakeholders, and 49.1% reported on follow-up activities. All priority-setting exercises were led by research groups based in high-income countries. Via an iterative qualitative content analysis, reported values were identified (n = 22 manuscripts). Three clusters of values (i.e., those related to impact, feasibility, and accountability) were identified. These values were organized in a tool to help those involved in setting research priorities systematically consider and report values. The tool was finalized through an online consultation with 7 international stakeholders. The value-oriented tool for priority setting in nutrition research identifies and presents values that are already implicitly and explicitly represented in priority-setting exercises. It provides guidance to enable explicit deliberation on research priorities from an ethical perspective. In addition, it can serve as a reporting tool to document how value-laden choices are made during priority setting and help foster the accountability of stakeholders involved.

A school-based intervention improved dietary intake outcomes and reduced waist circumference in adolescents: a cluster randomized controlled trial.

BACKGROUND: In Ecuador, adolescents' food intake does not comply with guidelines for a healthy diet. Together with abdominal obesity adolescent's inadequate diets are risk factors for non-communicable diseases. We report the effectiveness of a school-based intervention on the dietary intake and waist circumference among Ecuadorian adolescents. METHODS: A pair-matched cluster randomized controlled trial including 1430 adolescents (12-14 years old) was conducted. The program aimed at improving the nutritional value of dietary intake, physical activity (primary outcomes), body mass index, waist circumference and blood pressure (secondary outcomes). This paper reports: (i) the effect on fruit and vegetable intake, added sugar intake, unhealthy snacking (consumption of unhealthy food items that are not in line with the dietary guidelines eaten during snack time; i.e. table sugar, sweets, salty snacks, fast food, soft drinks and packaged food), breakfast intake and waist circumference; and, (ii) dose and reach of the intervention. Dietary outcomes were estimated by means of two 24-h recall at baseline, after the first 17-months (stage one) and after the last 11-months (stage two) of implementation. Dose and reach were evaluated using field notes and attendance forms. Educational toolkits and healthy eating workshops with parents and food kiosks staff in the schools were implemented in two different stages. The overall effect was assessed using linear mixed models and regression spline mixed effect models were applied to evaluate the effect after each stage. RESULTS: Data from 1046 adolescents in 20 schools were analyzed. Participants from the intervention group consumed lower quantities of unhealthy snacks (-23.32 g; 95% CI: -45.25,-1.37) and less added sugar (-5.66 g; 95% CI: -9.63,-1.65) at the end of the trial. Daily fruit and vegetable intake decreased in both the intervention and control groups compared to baseline, albeit this decrease was 23.88 g (95% CI: 7.36, 40.40) lower in the intervention group. Waist circumference (-0.84 cm; 95% CI: -1.68, 0.28) was lower in the intervention group at the end of the program; the effect was mainly observed at stage one. Dose and reach were also higher at stage one. CONCLUSIONS: The trial had positive effects on risk factors for non-communicable diseases, i.e. decreased consumption of unhealthy snacks. The program strategies must be implemented at the national level through collaboration between the academia and policy makers to assure impact at larger scale. TRIAL REGISTRATION: ClinicalTrial.gov-NCT01004367 .

Household dietary diversity and Animal Source Food consumption in Ethiopia: evidence from the 2011 Welfare Monitoring Survey.

BACKGROUND: It is imperative to track dietary quality and progress in nutritional outcomes in a population to develop timely interventions. Dietary diversity is a commonly used proxy to assess dietary quality in low-income countries. This study identified predictors of household dietary diversity in Ethiopia and pattern of consumption of animal source food (ASF) among households. METHODS: Secondary data were analyzed from the 2011 Ethiopian Welfare Monitoring Survey (WMS). This survey used a structured questionnaire to collect socio-demographic and economic data. Dietary data were collected using a dietary diversity questionnaire measuring dietary diversity over the past 1 week. A Household Dietary Diversity Score (HDDS) was constructed according to the Food and Agricultural Organization (FAO) guidelines. Consumption of ASFs is described by its distribution among the regions and by HDDS. Multiple logistic regression analysis was fitted to identify independent predictors for HDDS. RESULTS: A total of 27,995 households were included in the analyses. A little over half of the study households (52.2%) had more than four household members, and 75% of households were male headed. The mean HHDS was five food groups. Cereals were the most commonly (96%) consumed food groups. Fish, egg and fruits, on the other hand, were the least consumed food groups. ASFs were consumed in greater proportion among households with higher HDDS. Being part of the higher and middle socio economic strata (P < 0.001), literacy (P < 0.01), urban residence (P < 0.01), male headed household (P < 0.01), larger family size (P <0.01) and owning livestock (P < 0.01) were positively associated with higher HDDS. CONCLUSIONS: Considering these findings, nutrition sensitive interventions which address the problem through economic and educational empowerment and modern technologies supporting agricultural practices need to be designed to increase both local production and increased consumption.

Individual and Environmental Factors Influencing Adolescents' Dietary Behavior in Low- and Middle-Income Settings.

OBJECTIVE: Given the public health importance of improving dietary behavior in chronic disease prevention in low- and middle-income countries it is crucial to understand the factors influencing dietary behavior in these settings. This study tested the validity of a conceptual framework linking individual and environmental factors to dietary behavior among Ecuadorian adolescents aged 10-16 years. METHODS: A cross-sectional survey was conducted in 784 school-going Ecuadorian adolescents in urban and rural Southern Ecuador. Participants provided data on socio-economic status, anthropometry, dietary behavior and its determining factors. The relationships between individual (perceived benefits and barriers, self-efficacy, habit strength, and a better understanding of healthy food) and environmental factors (physical environment: accessibility to healthy food; social environment: parental permissiveness and school support), and their association with key components of dietary behavior (fruit and vegetables, sugary drinks, breakfast, and unhealthy snack intake) were assessed using structural equation modeling. RESULTS: The conceptual model performed well for each component of eating behavior, indicating acceptable goodness-of-fit for both the measurement and structural models. Models for vegetable intake and unhealthy snacking showed significant and direct effects of individual factors (perceived benefits). For breakfast and sugary drink consumption, there was a direct and positive association with socio-environmental factors (school support and parental permissiveness). Access to healthy food was associated indirectly with all eating behaviors (except for sugary drink intake) and this effect operated through socio-environmental (parental permissiveness and school support) and individual factors (perceived benefits). CONCLUSION: Our study demonstrated that key components of adolescents' dietary behaviors are influenced by a complex interplay of individual and environmental factors. The findings indicate that the influence of these factors varied by type of dietary behavior.

Two years of school-based intervention program could improve the physical fitness among Ecuadorian adolescents at health risk: subgroups analysis from a cluster-randomized trial.

BACKGROUND: Adolescents with overweight and poor physical fitness have an increased likelihood of developing cardiovascular diseases during adulthood. In Ecuador, a health promotion program improved the muscular strength and speed-agility, and reduced the decline of the moderate-to-vigorous physical activity of adolescents after 28 months. We performed a sub-group analysis to assess the differential effect of this intervention in overweight and low-fit adolescents. METHODS: We performed a cluster-randomized pair matched trial in schools located in Cuenca-Ecuador. In total 20 schools (clusters) were pair matched, and 1440 adolescents of grade 8 and 9 (mean age of 12.3 and 13.3 years respectively) participated in the trial. For the purposes of the subgroup analysis, the adolescents were classified into groups according to their weight status (body mass index) and aerobic capacity (scores in the 20 m shuttle run and FITNESSGRAM standards) at baseline. Primary outcomes included physical fitness (vertical jump, speed shuttle run) and physical activity (proportion of students achieving over 60 min of moderate-to-vigorous physical activity/day). For these primary outcomes, we stratified analysis by weight (underweight, normal BMI and overweight/obese) and fitness (fit and low fitness) groups. Mixed linear regression models were used to assess the intervention effect. RESULTS: The prevalence of overweight/obesity, underweight and poor physical fitness was 20.3 %, 5.8 % and 84.8 % respectively. A higher intervention effect was observed for speed shuttle run in overweight (ß = -1.85 s, P = 0.04) adolescents compared to underweight (ß = -1.66 s, P = 0.5) or normal weight (ß = -0.35 s, P = 0.6) peers. The intervention effect on vertical jump was higher in adolescents with poor physical fitness (ß = 3.71 cm, P = 0.005) compared to their fit peers (ß = 1.28 cm, P = 0.4). The proportion of students achieving over 60 min of moderate-to-vigorous physical activity/day was not significantly different according to weight or fitness status. CONCLUSION: Comprehensive school-based interventions that aim to improve diet and physical activity could improve speed and strength aspects of physical fitness in low-fit and overweight/obese adolescents. TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT01004367 . Registered October 28, 2009.

To what extent do site-based training, mentoring, and operational research improve district health system management and leadership in low- and middle-income countries: a systematic review protocol.

BACKGROUND: District health managers play a key role in the effectiveness of decentralized health systems in low- and middle-income countries. Inadequate management and leadership skills often hamper their ability to improve quality of care and effectiveness of health service delivery. Nevertheless, significant investments have been made in capacity-building programmes based on site-based training, mentoring, and operational research. This systematic review aims to review the effectiveness of site-based training, mentoring, and operational research (or action research) on the improvement of district health system management and leadership. Our secondary objectives are to assess whether variations in composition or intensity of the intervention influence its effectiveness and to identify enabling and constraining contexts and underlying mechanisms. METHODS: We will search the following databases: MEDLINE, PsycInfo, Cochrane Library, CRD database (DARE), Cochrane Effective Practice and Organisation of Care (EPOC) group, ISI Web of Science, Health Evidence.org, PDQ-Evidence, ERIC, EMBASE, and TRIP. Complementary search will be performed (hand-searching journals and citation and reference tracking). Studies that meet the following PICO (Population, Intervention, Comparison, Outcome) criteria will be included: P: professionals working at district health management level; I: site-based training with or without mentoring, or operational research; C: normal institutional arrangements; and O: district health management functions. We will include cluster randomized controlled trials, controlled before-and-after studies, interrupted time series analysis, quasi-experimental designs, and cohort and longitudinal studies. Qualitative research will be included to contextualize findings and identify barriers and facilitators. Primary outcomes that will be reported are district health management and leadership functions. We will assess risk of bias with the Cochrane Collaboration's tools for randomized controlled trials (RCT) and non RCT studies and Critical Appraisal Skills Programme checklists for qualitative studies. We will assess strength of recommendations with the GRADE tool for quantitative studies, and the CERQual approach for qualitative studies. Synthesis of quantitative studies will be performed through meta-analysis when appropriate. Best fit framework synthesis will be used to synthesize qualitative studies. DISCUSSION: This protocol paper describes a systematic review assessing the effectiveness of site-based training (with or without mentoring programmes or operational research) on the improvement of district health system management and leadership. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015032351.

School-based intervention on healthy behaviour among Ecuadorian adolescents: effect of a cluster-randomized controlled trial on screen-time.

BACKGROUND: Effective interventions on screen-time behaviours (television, video games and computer time) are needed to prevent non-communicable diseases in low- and middle-income countries. The present manuscript investigates the effect of a school-based health promotion intervention on screen-time behaviour among 12- to 15-year-old adolescents. We report the effect of the trial on screen-time after two stages of implementation. METHODS: We performed a cluster-randomised pair matched trial in urban schools in Cuenca-Ecuador. Participants were adolescents of grade eight and nine (mean age 12.8 ± 0.8 years, n = 1370, control group n = 684) from 20 schools (control group n = 10). The intervention included an individual and environmental component tailored to the local context and resources. The first intervention stage focused on diet, physical activity and screen-time behaviour, while the second stage focused only on diet and physical activity. Screen-time behaviours, primary outcome, were assessed at baseline, after the first (18 months) and second stage (28 months). Mixed linear models were used to analyse the data. RESULTS: After the first stage (data from n = 1224 adolescents; control group n = 608), the intervention group had a lower increase in TV-time on a week day (ß = -15.7 min; P = 0.003) and weekend day (ß = -18.9 min; P = 0.005), in total screen-time on a weekday (ß = -25.9 min; P = 0.03) and in the proportion of adolescents that did not meet the screen-time recommendation (ß = -4 percentage point; P = 0.01), compared to the control group. After the second stage (data from n = 1078 adolescents; control group n = 531), the TV-time on a weekday (ß = 13.1 min; P = 0.02), and total screen-time on a weekday (ß = 21.4 min; P = 0.03) increased more in adolescents from the intervention group. No adverse effects were reported. DISCUSSION AND CONCLUSION: A multicomponent school-based intervention was only able to mitigate the increase in adolescents' television time and total screen-time after the first stage of the intervention or in other words, when the intervention included specific components or activities that focused on reducing screen-time. After the second stage of the intervention, which only included components and activities related to improve healthy diet and physical activity and not to decrease the screen-time, the adolescents increased their screen-time again. Our findings might imply that reducing screen-time is only possible when the intervention focuses specifically on reducing screen-time. TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT01004367.

Factors affecting physical activity in Ecuadorian adolescents: a focus group study.

BACKGROUND: Physical inactivity levels are increasingly prevalent among Ecuadorian adolescents. School-based interventions can be potentially effective in promoting physical activity but must be informed by cultural-specific factors. METHODS: Twelve focus groups were carried out with adolescents (n = 80) in rural and urban Ecuador to identify factors influencing physical activity. In addition, 4 focus group discussions with parents (n = 32) and 4 with school staff (n = 32) were conducted. Individual and environmental factors were questioned using the 'Attitude, Social influences and Self-efficacy' model and the socioecological model as theoretical frameworks. RESULTS: Factors influencing physical activity varied between groups. In the rural area farming and norms for girls impeded leisure-time physical activity, whereas urban groups emphasized traffic and crime concerns. Groups from a low socioeconomic status more frequently mentioned a fear of injuries and financial constraints. Several factors were common for all groups including preferences for sedentary activities, poor knowledge, time constraints and laziness, as well as a lack of opportunities at home and school, unsupportive parental rules and lack of role models. CONCLUSION: A conceptual framework including the identified factors emerged to inform the design of a cultural-sensitive school-based intervention to improve physical activity among Ecuadorian adolescents. Future interventions should be tailored to each setting.

A school-based intervention improves physical fitness in Ecuadorian adolescents: a cluster-randomized controlled trial.

BACKGROUND: Effective lifestyle interventions are needed to prevent noncommunicable diseases in low- and middle-income countries. We analyzed the effects of a school-based health promotion intervention on physical fitness after 28 months and explored if the effect varied with important school characteristics. We also assessed effects on screen time, physical activity and BMI. METHODS AND RESULTS: We performed a cluster-randomized pair matched trial in schools in urban Ecuador. The intervention included an individual and environmental component tailored to the local context and resources. Primary outcomes were physical fitness (EUROFIT battery), screen time (questionnaires) and physical activity (accelerometers). Change in BMI was a secondary outcome. A total of 1440 grade 8 and 9 adolescents (intervention: n = 700, 48.6%) and 20 schools (intervention: n = 10, 50%) participated. Data of 1083 adolescents (intervention: n = 550, 50.8%) from 20 schools were analyzed. CONCLUSIONS: A school-based intervention with an individual and environment component can improve physical fitness and can minimize the decline in physical activity levels from childhood into adolescence in urban Ecuador. TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT01004367.

Effectiveness of a nutrition education package in improving feeding practices, dietary adequacy and growth of infants and young children in rural Tanzania: rationale, design and methods of a cluster randomised trial.

BACKGROUND: Strategies to improve infant and young child nutrition in low- and middle- income countries need to be implemented at scale. We contextualised and packaged successful strategies into a feasible intervention for implementation in rural Tanzania. Opportunities that can optimise delivery of the intervention and encourage behaviour change include mothers willingness to modifying practices; support of family members; seasonal availability and accessibility of foods; established set-up of village peers and functioning health system. The primary objective of the study is to evaluate the effectiveness of a nutrition education package in improving feeding practices, dietary adequacy and growth as compared to routine health education. METHODS/DESIGN: A parallel cluster randomised controlled trial will be conducted in rural central Tanzania in 9 intervention and 9 control villages. The control group will receive routine health education offered monthly by health staff at health facilities. The intervention group will receive a nutrition education package in addition to the routine health education. The education package is comprised of four components: 1) education and counselling of mothers, 2) training community-based nutrition counsellors and monthly home visits, 3) sensitisation meetings with health staff and family members, and 4) supervision of community-based nutrition counsellors. The duration of the intervention is 9 months and infants will be recruited at 6 months of age. Primary outcome (linear growth as length-for-age Z-scores) and secondary outcomes (changes in weight-for-length Z-scores; mean intake of energy, fat, iron and zinc from complementary foods; proportion of children consuming 4 or more food groups and recommended number of semi-solid/soft meals and snacks per day; maternal level of knowledge and performance of recommended practices) will be assessed at baseline and ages 9, 12 and 15 months. Process evaluation will document reach, dose and fidelity of the intervention and context at 8 and 15 months. DISCUSSION: Results of the trial will provide evidence of the effectiveness of the nutrition education package in community settings of rural Tanzania. They will provide recommendations for strengthening the nutrition component of health education in child health services. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02249754, September 25, 2014.

Dietary intake practices associated with cardiovascular risk in urban and rural Ecuadorian adolescents: a cross-sectional study.

BACKGROUND: Cardiovascular diseases (CVD) are amongst the leading causes of death worldwide. Risk factors of CVD develop during childhood and adolescence, and dietary quality has been linked to the development of CVD itself. This study examines the association between dietary patterns and cardiovascular risk in a group of urban and rural Ecuadorian adolescents from different socioeconomic backgrounds. METHODS: A cross-sectional study was conducted from January 2008 to April 2009 among 606 adolescents from the 8th, 9th and 10th grade in an urban area (Cuenca), and 173 adolescents from a rural area (Nabón) in Ecuador. Data collection involved measuring anthropometric data (weight, height and waist circumference), blood pressure, dietary intake (2-day 24 h recall) and socio-demographic characteristics. Fasting blood lipids and glucose were measured in a subsample of 334 adolescents. Factor analysis was used to identify dietary patterns and linear regression models were used to (i) identify differences in food intake practices according to socioeconomic status and place of residence and (ii) establish relationships between dietary patterns and cardiovascular risk factors. RESULTS: Median energy intake was 1851 kcal/day. Overall, fiber, fish and fruit and vegetables were scarcely consumed, while added sugar, refined cereals and processed food were important constituents of the diet. Two dietary patterns emerged, one labelled as "rice-rich non-animal fat pattern" and the other one as "wheat-dense animal-fat pattern". The first pattern was correlated with a moderate increase in glucose in urban participants, while the second pattern was associated with higher LDL and cholesterol blood levels in rural participants. CONCLUSIONS: This group of adolescents presented various dietary practices conducive to CVD development. Effective strategies are needed to prevent CVD in the Ecuadorian population by encouraging a balanced diet, which contains less refined cereals, added sugar, and processed food, but has more fruits, vegetables and whole grain cereals.

Physical fitness among urban and rural Ecuadorian adolescents and its association with blood lipids: a cross sectional study.

BACKGROUND: Physical fitness has been proposed as a marker for health during adolescence. Currently, little is known about physical fitness and its association with blood lipid profile in adolescents from low and middle-income countries. The aim of this study is therefore to assess physical fitness among urban and rural adolescents and its associations with blood lipid profile in a middle-income country. METHODS: A cross-sectional study was conducted between January 2008 and April 2009 in 648 Ecuadorian adolescents (52.3% boys), aged 11 to 15 years, attending secondary schools in Cuenca (urban n = 490) and Nabón (rural n = 158). Data collection included anthropometric measures, application of the EUROFIT battery, dietary intake (2-day 24 h recall), socio-demographic characteristics, and blood samples from a subsample (n = 301). The FITNESGRAM standards were used to evaluate fitness. The associations of fitness and residential location with blood lipid profile were assessed by linear and logistic regression after adjusting for confounding factors. RESULTS: The majority (59%) of the adolescents exhibited low levels of aerobic capacity as defined by the FITNESSGRAM standards. Urban adolescents had significantly higher mean scores in five EUROFIT tests (20 m shuttle, speed shuttle run, plate tapping, sit-up and vertical jump) and significantly most favorable improved plasma lipid profile (triglycerides and HDL) as compared to rural adolescents. There was a weak association between blood lipid profile and physical fitness in both urban and rural adolescents, even after adjustment for confounding factors. CONCLUSIONS: Physical fitness, in our sample of Ecuadorian adolescents, was generally poor. Urban adolescents had better physical fitness and blood lipid profiles than rural adolescents. The differences in fitness did not explain those in blood lipid profile between urban and rural adolescents.

A conceptual framework for healthy eating behavior in ecuadorian adolescents: a qualitative study.

OBJECTIVE: The objective of this study was to identify factors influencing eating behavior of Ecuadorian adolescents - from the perspective of parents, school staff and adolescents - to develop a conceptual framework for adolescents' eating behavior. STUDY DESIGN: Twenty focus groups (N=144 participants) were conducted separately with adolescents aged 11-15 y (n (focus groups)=12, N (participants)=80), parents (n=4, N=32) and school staff (n=4, N=32) in rural and urban Ecuador. A semi-structured questioning route was developed based on the 'Attitude, Social influences and Self-efficacy' model and the socio-ecological model to assess the relevance of behavioral and environmental factors in low- and middle-income countries. Two researchers independently analyzed verbatim transcripts for emerging themes, using deductive thematic content analysis. Data were analyzed using NVivo 8. RESULTS: All groups recognized the importance of eating healthily and key individual factors in Ecuadorian adolescents' food choices were: financial autonomy, food safety perceptions, lack of self-control, habit strength, taste preferences and perceived peer norms. Environmental factors included the poor nutritional quality of food and its easy access at school. In their home and family environment, time and convenience completed the picture as barriers to eating healthily. Participants acknowledged the impact of the changing socio-cultural environment on adolescents' eating patterns. Availability of healthy food at home and financial constraints differed between settings and socio-economic groups. CONCLUSION: Our findings endorse the importance of investigating behavioral and environmental factors that influence and mediate healthy dietary behavior prior to intervention development. Several culture-specific factors emerged that were incorporated into a conceptual framework for developing health promotion interventions in Ecuador.

Predictors of validity and reliability of a physical activity record in adolescents.

BACKGROUND: Poor to moderate validity of self-reported physical activity instruments is commonly observed in young people in low- and middle-income countries. However, the reasons for such low validity have not been examined in detail. We tested the validity of a self-administered daily physical activity record in adolescents and assessed if personal characteristics or the convenience level of reporting physical activity modified the validity estimates. METHODS: The study comprised a total of 302 adolescents from an urban and rural area in Ecuador. Validity was evaluated by comparing the record with accelerometer recordings for seven consecutive days. Test-retest reliability was examined by comparing registrations from two records administered three weeks apart. Time spent on sedentary (SED), low (LPA), moderate (MPA) and vigorous (VPA) intensity physical activity was estimated. Bland Altman plots were used to evaluate measurement agreement. We assessed if age, sex, urban or rural setting, anthropometry and convenience of completing the record explained differences in validity estimates using a linear mixed model. RESULTS: Although the record provided higher estimates for SED and VPA and lower estimates for LPA and MPA compared to the accelerometer, it showed an overall fair measurement agreement for validity. There was modest reliability for assessing physical activity in each intensity level. Validity was associated with adolescents' personal characteristics: sex (SED: P=0.007; LPA: P=0.001; VPA: P=0.009) and setting (LPA: P=0.000; MPA: P=0.047). Reliability was associated with the convenience of completing the physical activity record for LPA (low convenience: P=0.014; high convenience: P=0.045). CONCLUSIONS: The physical activity record provided acceptable estimates for reliability and validity on a group level. Sex and setting were associated with validity estimates, whereas convenience to fill out the record was associated with better reliability estimates for LPA. This tendency of improved reliability estimates for adolescents reporting higher convenience merits further consideration.

Exploring the focus of prenatal information offered to pregnant mothers regarding newborn care in rural Uganda.

BACKGROUND: Neonatal death accounts for one fifth of all under-five mortality in Uganda. Suboptimal newborn care practices resulting from hypothermia, poor hygiene and delayed initiation of breastfeeding are leading predisposing factors. Evidence suggests focused educational prenatal care messages to mitigate these problems. However, there is a paucity of data on the interaction between the service provider and the prenatal service user. This study aims to understand the scope of educational information and current practices on newborn care from the perspectives of prenatal mothers and health workers. METHODS: A qualitative descriptive methodology was used. In-depth interviews were conducted with lactating mothers (n = 31) of babies younger than five months old across Masindi in western Uganda. Additional interviews with health workers (n = 17) and their employers or trainers (n = 5) were conducted to strengthen our findings. Data were audio-taped and transcribed verbatim. A thematic content analysis was performed using NVivo 8. RESULTS: Vertical programmes received more attention than education for newborn care during prenatal sessions. In addition, attitudinal and communication problems existed among health workers thereby largely ignoring the fundamental principles of patient autonomy and patient-centred care. The current newborn care practices were largely influenced by relatives' cultural beliefs rather than by information provided during prenatal sessions. There is a variation in the training curriculum for health workers deployed to offer recommended prenatal and immediate newborn care in the different tiers of health care. CONCLUSIONS: Findings revealed serious deficiencies in prenatal care organisations in Masindi. Pregnant mothers remain inadequately prepared for childbirth and newborn care, despite their initiative to follow prenatal sessions. These findings call for realignment of prenatal care by integrating education on newborn care practices into routine antenatal care services and be based on principles of patient-centred care.

Effectiveness of preventive school-based obesity interventions in low- and middle-income countries: a systematic review.

BACKGROUND: The prevalence of childhood obesity is increasing rapidly in low- and middle-income countries, and informed policies to tackle the problem must be defined. OBJECTIVE: We systematically reviewed the evidence on the effectiveness of school-based interventions targeting dietary behavior and/or physical activity for the primary prevention of obesity in children and adolescents aged 6-18 y in low- and middle-income countries. DESIGN: We searched the MEDLINE, EMBASE, Web of Science, CENTRAL, ERIC, Cochrane Library, and Centre for Reviews and Dissemination databases for peer-reviewed controlled studies published in English, Spanish, French, German, or Dutch between January 1990 and July 2011. The quality of the included studies was appraised independently by 2 authors who used the Effective Public Health Practice Project tool. RESULTS: From a total of 7218 unique references, we retained 22 studies. Most of the interventions (82%) had a positive effect on dietary behavior and physical activity behavior (effect size ranged from -0.48 to 1.61). BMI decreased in 8 studies (effect size ranged from -0.7 to 0.0). Effective interventions targeted both diet and physical activity, involved multiple stakeholders, and integrated educational activities into the school curriculum. CONCLUSIONS: School-based interventions have the potential to improve dietary and physical activity behavior and to prevent unhealthy body weights in low- and middle-income countries. To reach their full potential, interventions should conduct process evaluations to document program implementation. The effect and the pathways through which interventions have this effect need to be better documented through rigorous evaluation studies.

Food safety is a key determinant of fruit and vegetable consumption in urban Beninese adolescents.

OBJECTIVE: To identify the determinants of fruit and vegetable consumption in urban Beninese adolescents and elements to develop a school-based fruit and vegetable program. DESIGN: Sixteen focus groups conducted with a key word guide. SETTING AND PARTICIPANTS: Two private and 2 public secondary schools in Cotonou, Benin. One hundred fifty-three students aged 13 to 19 years, 54% girls. ANALYSIS: The focus groups were audiotaped, transcribed, and analyzed. Three a priori categories from the Social Cognitive Theory were used for the coding: socioenvironmental, personal, and behavioral factors. Additionally, the data were checked to determine whether new categories should be created. RESULTS: Major determinants in the school were availability and accessibility of fruits and vegetables, nutrition education, and the competition of unhealthful foods. Food safety emerged as a strong barrier to the adolescents' fruit and vegetable consumption outside home and particularly at school. CONCLUSIONS AND IMPLICATIONS: Except for food safety, the determinants of fruit and vegetable intake in Beninese adolescents were similar to those in high-income countries. The food safety of fruits and vegetables outside home is a key issue to be studied in detail and integrated in any intervention in Benin and potentially other low- and middle-income countries.

Factors associated with eating out of home in Vietnamese adolescents.

Eating out of home (OH) is nutritionally important in some developing countries. This study identifies the factors associated with eating OH in Vietnamese adolescents. Data were obtained from a cross-sectional cluster survey of 502 adolescents in rural and urban areas in Vietnam. Factors associated with eating OH were recorded with a Likert scale and analysed using factor analysis. Data on eating OH was collected using a frequency questionnaire and a 1-day 24h recall. A first pattern "Convenience" incorporated preparation time, price, variety, taste, proximity and social aspects as items associated with eating OH. A second pattern "Nutritional and food safety concerned" reflected concerns with regard to hygiene, fat and salt content of the food prepared OH. Adolescents characterised by the convenience pattern were more likely (OR=1.51, P<0.001) to eat OH more frequently. The highest tertile of the Nutritional and food safety concerned pattern was less likely (OR=0.61, P=0.03) to eat OH compared to lower tertiles. Both patterns were not associated with the % energy from eating OH per day. Convenience and to a lesser extent Nutritional and food safety concerns are significant factors associated with the frequency of eating OH in Vietnamese adolescents.