The Development Impacts of COVID-19 at Home and Abroad: Politics and Implications of Government Action.

What is COVID-19's impact on development? What lessons can be drawn from development studies regarding the effects of and recovery from COVID-19? The unprecedented scale and scope of government interventions carry implications at all levels: global, national, and local. In this introduction, our team of Editors underline the importance of systematic substantive study to further knowledge acquisition, and rigorous global-, national-, or context-specific evaluation to inform evidence-based policymaking. The 12 articles summarised here capture these values and sense of "high quality". In particular, despite early considerations in the first year of the pandemic, they illuminate the need for diverse responses beyond business-as-usual, attention to the multiplicity of impact of policies formulated, and progressive strategies to counteract the impacts of this disaster around the world. The path of future research is clear: studies need to consider and give voice to marginalised groups to counteract the short- and long-term impacts of the pandemic.

Quel est l'impact de la COVID-19 sur le développement international ? Quelles leçons pouvons-nous tirer des études de développement concernant les effets de la COVID-19, et du redressement après son passage ? L'ampleur et la portée sans precedent des interventions gouvernementales comportent des conséquences à tous niveaux: mondial, national, et local. Dans cette introduction, notre équipe éditoriale souligne l'importance des études à la fois systématiques et substantielles, afin d'élargir l'acquisition de connaissances; ainsi que des évaluations rigoureuses au niveau mondial, national, ou spécifiques au contexte, ayant pour but d'informer une politique des décisions basée sur l'évidence. Les 12 articles résumés ici présentent ces valeurs et ce sentiment de « haute qualité¼. En particulier, malgré des considérations précoces pendant la première année de cette pandémie, les articles soulèvent la nécessité de réponses diversifiées, bien au-delà des démarches jusqu' ici habituelles (en anglais, « business as usual¼), l'importance de prêter attention à la multiplicité d'impacts des politiques formulées, et le besoin de stratégies progressistes, pour faire face aux impacts de cette catastrophe partout dans le monde. Le chemin à prendre pour les recherches futures est clair: les études doivent considérer et donner une voix aux groupes marginalisés, pour faire face aux impacts à court et longue terme de la pandémie.

A research vision for food systems in the 2020s: Defying the status quo.

•Research and science should not only inform food and environmental policy but should be adopted and mainstreamed into actions at all levels.•Food systems are faced with grander and interconnected challenges and constraints that bring about new research questions.•Research has a vital role in charting a positive and sustainable direction for global food security, nutrition, and health.•The status quo must be challenged to shape food systems transformation to deliver sustainable, healthier diets.• Global Food Security provides a platform where evidence is shared in an accessible manner for those who need to act on it.

Are Low-Income Consumers Willing to Pay for Fortification of a Commercially Produced Yogurt in Bangladesh.

BACKGROUND: There is an active debate over the potential for market-based strategies to address micronutrient deficiencies in low- and middle-income countries. However, there are questions over the viability of market-based strategies, reflecting limited evidence on the value that low-income households attach to the nutritional attributes of processed foods. OBJECTIVE: The objective of this article is to investigate the willingness to pay of primary food purchasers in low-income households in rural Bangladesh for Shokti+, a nutritionally fortified yogurt produced and distributed by Grameen Danone Foods Limited. METHODS: A real choice experiment with economic incentives was conducted with 1000 rural food purchasers sampled from the distribution area of Shokti+ in rural Bangladesh. The choices of respondents revealed attribute nonattendance, favoring the fortification attribute over price. RESULTS: Results from a random parameter logit model found that respondents were willing to pay an average of 18 BDT (US$0.22) for fortification and 6 BDT (US$0.073) for brand name. The market price for Shokti+ at the time of the study was 10 BDT (US$0.12). The results from a random effects model suggest the magnitude of willingness to pay for fortification was primarily driven by the nutritional awareness of respondents but offset by household food insecurity. CONCLUSIONS: The article concludes that, while there is a viable market for fortified yogurt in rural Bangladesh, efforts to promote this product as a strategy to address micronutrient deficiency are best targeted at low-income households with some capacity to pay for low priced commercially produced foods.

Restaurant menu labelling: Is it worth adding sodium to the label?

OBJECTIVE: Several provincial and federal bills have recommended various forms of menu labelling that would require information beyond just calories; however, the additional benefit of including sodium information is unknown. The objective of this study was to determine whether sodium information on menus helps consumers make lower-sodium choices and to understand what other factors influence the effect of menu labelling on consumers' meal choices. METHODS: A total of 3,080 Canadian consumers completed an online survey that included a repeated measures experiment in which consumers were asked to select what they would typically order from four mock-restaurant menus. Subsequently, consumers were randomly allocated to see one of three menu-labelling treatments (calories; calories and sodium; or calories, sodium and serving size) and were given the option to change their order. RESULTS: There was a significant difference in the proportion of consumers who changed their order, varying from 17% to 30%, depending on the restaurant type. After participants had seen menu labelling, sodium levels decreased in all treatments (p<0.0001). However, in three of the four restaurant types, consumers who saw calorie and sodium information ordered meals with significantly less sodium than consumers who saw only calorie information (p<0.01). Consumers who saw sodium labelling decreased the sodium level of their meal by an average of 171-384 mg, depending on the restaurant. In the subset of consumers who saw sodium information and chose to change their order, sodium levels decreased by an average of 681-1,360 mg, depending on the restaurant. Sex, intent to lose weight and the amount of calories ordered at baseline were the most important predictors of who used menu labelling. Eighty percent of survey panelists wanted to see nutrition information when dining out. CONCLUSION: Including sodium information alongside calorie information may result in a larger decrease in the amount of sodium ordered by restaurant-goers.

Innovation in regulation of rapidly changing health markets.

The rapid evolution and spread of health markets across low and middle-income countries (LMICs) has contributed to a significant increase in the availability of health-related goods and services around the world. The support institutions needed to regulate these markets have lagged behind, with regulatory systems that are weak and under-resourced. This paper explores the key issues associated with regulation of health markets in LMICs, and the different goals of regulation, namely quality and safety of care, value for money, social agreement over fair access and financing, and accountability. Licensing, price controls, and other traditional approaches to the regulation of markets for health products and services have played an important role, but they have been of questionable effectiveness in ensuring safety and efficacy at the point of the user in LMICs. The paper proposes a health market systems conceptual framework, using the value chain for the production, distribution and retail of health goods and services, to examine regulation of health markets in the LMIC context. We conclude by exploring the changing context going forwards, laying out implications for future heath market regulation. We argue that the case for new approaches to the regulation of markets for health products and services in LMICs is compelling. Although traditional "command and control" approaches will have a place in the toolkit of regulators, a broader bundle of approaches is needed that is adapted to the national and market-level context of particular LMICs. The implication is that it is not possible to apply standard or single interventions across countries, as approaches proven to work well in one context will not necessarily work well elsewhere.

Assessment of consumers' level of engagement in following recommendations for lowering sodium intake.

Population-wide sodium reduction strategies encourage consumer participation in lowering dietary sodium. This study aims to measure and rank consumers' level of engagement in following 23 recommendations to reduce dietary sodium and to compare variation in level of consumers' engagement by sociodemographic sub-groups. The study included 869 randomly selected participants of an online food panel survey from Ontario during November and December 2010. Rasch modelling was used for the analysis. Consumers were less likely to be engaged in 9 out of the 23 recommendations, in particular those related to avoiding foods higher in sodium and implementing sodium reduction strategies while eating in restaurants. Higher level of consumers' engagement was observed in relation to food preparation practices, including use of low sodium ingredients. In comparison to the relevant reference group, men, older individuals, with lower educational level, single, and those who do not prepare food from scratch showed an overall lower level of engagement in following recommendations to lowering dietary sodium, particularly related to avoiding processed foods. These data provide novel insights and can inform public education campaigns, and highlight the need for interventions and programs targeted at the food supply that can assist consumers in lowering their sodium intake.

Canadians' perceptions of food, diet, and health--a national survey.

BACKGROUND: Poor nutrition is harmful to one's health as it can lead to overweight and obesity and a number of chronic diseases. Understanding consumer perceptions toward diet and nutrition is critical to advancing nutrition-related population health interventions to address such issues. The purpose of this paper was to examine Canadians' perceived health and diet status, compared to their actual health status, and general concern about their own diet and beliefs about health. Also analyzed were some of the perceived barriers to eating "healthy" foods, with a focus on the availability of "healthy" processed foods. METHODS: Two surveys were administered online to a group of Canadian panelists from all ten provinces during May 2010 to January 2011. Thirty thousand were invited; 6,665 completed the baseline survey and 5,494 completed the second survey. Panelists were selected to be nationally representative of the Canadian adult population by age, sex, province and education level, according to 2006 census data. RESULTS: Approximately one third of Canadians perceived their health or diet to be very good while very few Canadians perceived their health or diet to be very poor. While the majority of Canadians believed food and nutrition to be very important for improving one's health, fewer Canadians were concerned about their own diets. The majority of Canadians reported difficulty finding "healthy" processed foods (low in salt and sugar and with sufficient vitamins and minerals). Many also reported difficulty finding healthy foods that are affordable. CONCLUSION: Although consumers believe that nutrition is one of the most important factors for maintaining health, there are still a number of attitudinal and perceived environmental barriers to healthy eating.

Consumer attitudes and understanding of low-sodium claims on food: an analysis of healthy and hypertensive individuals.

BACKGROUND: Sodium-related claims on food labels should facilitate lower-sodium food choices; however, consumer attitudes and understanding of such claims are unknown. OBJECTIVES: We evaluated consumer attitudes and understanding of different types of sodium claims and the effect of having hypertension on responses to such claims. DESIGN: Canadian consumers (n = 506), with and without hypertension, completed an online survey that contained a randomized mock-package experiment, which tested 4 packages that differed only by the claims they carried as follows: 3 sodium claims (disease risk reduction, function, and nutrient-content claims) and a tastes-great claim (control). Participants answered the same questions on attitudes and understanding of claims after seeing each package. RESULTS: Food packages with any sodium claim resulted in more positive attitudes toward the claim and the product healthfulness than did packages with the taste control claim, although all mock packages were identical nutritionally. Having hypertension increased ratings related to product healthfulness and purchase intentions, but there was no difference in reported understanding between hypertensives and normotensives. In general, participants attributed additional health benefits to low-sodium products beyond the well-established relation of sodium and hypertension. CONCLUSIONS: Sodium claims have the potential to facilitate lower-sodium food choices. However, we caution that consumers do not seem to differentiate between different types of claims, but the nutritional profiles of foods that carry different sodium claims can potentially differ greatly in the current labeling environment. Additional educational efforts are needed to ensure that consumers do not attribute inappropriate health benefits to foods with low-sodium claims. This trial was registered at clinicaltrials.gov as NCT01764724.

Results of a national survey examining Canadians' concern, actions, barriers, and support for dietary sodium reduction interventions.

Population-wide dietary sodium reduction is considered a priority intervention to address sodium-related chronic diseases. In 2010, the Canadian government adopted a sodium reduction strategy to lower sodium intakes of Canadians; however, there has been a lack of coordinated action in its implementation. Our objective was to evaluate Canadians' concern, actions, reported barriers, and support for government-led policy interventions aimed at lowering sodium intakes. We conducted a survey among Canadians about sodium knowledge, attitudes, and behaviours. Data were weighted to reflect the 2006 Canadian census. Among 2603 respondents, 67.0% were concerned about dietary sodium and 59.3% were currently taking action to limit sodium intake. Those aged 50-59 years (odds ratio [OR], 1.79; 95% confidence interval [CI], 1.17-2.72) and 60-69 years (OR, 1.63; 95% CI, 1.05-2.55) were more likely to be concerned about sodium vs younger individuals (20-29 years), as were hypertensive patients vs normotensive patients (OR, 4.13; 95% CI, 3.05-5.59). Older age groups and those with hypertension (OR, 3.48; 95% CI, 2.58-4.69) were also more likely to limit sodium consumption. Common barriers to sodium reduction were limited variety of lower sodium processed (55.5%) and restaurant (65.8%) foods. High support for government-led actions was observed, including interventions for lowering sodium levels in processed (86.6%) and restaurant (72.7%-74.3%) foods, and in food served in public institutions (81.8%-82.3%), and also for public education (80.4%-83.1%). There was much less support for financial incentives and disincentives. In conclusion, these concerns, barriers, and high level of support for government action provide further rationale for multi-sectoral interventions to assist Canadians in lowering their sodium intakes.

Difficulty of healthy eating: a Rasch model approach.

This study aims to measure the difficulty of healthy eating as a single latent construct and, within that, assess which dietary guidelines consumers find more or less difficult to comply with using the Rasch model approach. Participants self-reported their compliance with 12 health-promoting dietary recommendations related to cooking methods and consumption of specific food items. Data were drawn from a survey elicited using a longitudinal consumer panel established in the City of Guelph, Ontario, Canada in 2008. The panel consists of 1962 randomly-selected residents of Guelph between the age of 20 and 69 years. The response rate was equal to 68 percent. The main assumptions of the Rasch model were satisfied. However, subsequent differential item functioning analysis revealed significant scale variations by gender, education, age and household income, which reduced the validity of the Rasch scale. Conversely, these scale variations highlight the importance of socio-economic and demographic factors on the difficulty of healthy eating.

Understanding the propensity of consumers to comply with dietary guidelines directed at heart health.

The aim of this paper is to explore the difficulty faced by consumers in complying with health-related dietary guidelines, focusing on those guidelines that consumers find it more/less difficult to meet and the factors driving the ability to make associated dietary changes. Participants reported self-assessed compliance with 12 dietary recommendations predominantly directed at reducing the risk of heart disease. The difficulty of complying with each of the dietary guidelines was measured using a Rasch model, while the determinants of ability to comply with the dietary recommendations as a whole were identified using regression analysis. The more difficult dietary recommendations included limiting consumption of red meats and consuming the recommended daily intake of fruits and vegetables. Attitudinal variables associated with food, nutrition and health, perception of cholesterol risk and a range of socio-demographic variables, including age, gender and education, were significant determinants of person ability to comply with the dietary recommendations. The results show that there are significant differences in the difficulty faced by consumers in complying with particular dietary recommendations, while there is substantial variation in the ability to eat a healthy diet across participants.

A multifactorial risk prioritization framework for foodborne pathogens.

We develop a prioritization framework for foodborne risks that considers public health impact as well as three other factors (market impact, consumer risk acceptance and perception, and social sensitivity). Canadian case studies are presented for six pathogen-food combinations: Campylobacter spp. in chicken; Salmonella spp. in chicken and spinach; Escherichia coli O157 in spinach and beef; and Listeria monocytogenes in ready-to-eat meats. Public health impact is measured by disability-adjusted life years and the cost of illness. Market impact is quantified by the economic importance of the domestic market. Likert-type scales are used to capture consumer perception and acceptance of risk and social sensitivity to impacts on vulnerable consumer groups and industries. Risk ranking is facilitated through the development of a knowledge database presented in the format of info cards and the use of multicriteria decision analysis (MCDA) to aggregate the four factors. Three scenarios representing different stakeholders illustrate the use of MCDA to arrive at rankings of pathogen-food combinations that reflect different criteria weights. The framework provides a flexible instrument to support policymakers in complex risk prioritization decision making when different stakeholder groups are involved and when multiple pathogen-food combinations are compared.

Understanding the complexities of private standards in global agri-food chains as they impact developing countries.

The increasing prevalence of private standards governing food safety, food quality and environmental and social impacts of agri-food systems has raised concerns about the effects on developing countries, as well as the governance of agri-food value chains more broadly. It is argued that current debates have been 'clouded' by a failure to recognise the diversity of private standards in terms of their institutional form, who develops and adopts these standards and why. In particular, there is a need to appreciate the close inter-relationships between public regulations and private standards and the continuing ways in which private standards evolve.

Consumer valuation of functional foods and nutraceuticals in Canada. A conjoint study using probiotics.

This paper applied conjoint analysis to elicit consumer preferences over attributes of functional foods and nutraceuticals using probiotics as the functional compound of interest. Data were gathered through a mall intercept survey in Guelph, Canada. Cluster analysis and chi-square tests were used to examine the relationship between respondents' characteristics and preferences for product variants. On the basis of cluster analysis of the part-worth scores from the conjoint analysis, three clusters were identified. Clusters differed predominantly according to the preferred mode of delivery and source of health claims. The value attached to health claims related to probiotics was also explored. The results suggested that consumers place a strong premium on claims verified by government, but little value on 'non-verified' claims made by product manufacturers.

Understanding consumer attitudes toward food technologies in Canada.

This article reports a study on consumer attitudes to 21 food and nonfood technologies in Canada. The study involves repertory grid interviews with 36 food consumers, the data from which are analyzed using generalized Procrustes analysis. Results highlight the role of perceived risk and perceived benefit in determining the acceptability of the technologies, with individual technologies lying along a continuum between the two. For technology as a whole and the 21 specific technologies, the perceived risk and perceived benefit constructs were the dominant determinants of consumer acceptability. While perceptions of perceived risk and perceived benefit differed between individual respondents, there were very limited consistent relations with a range of sociodemographic variables.

Who consumes functional foods and nutraceuticals in Canada? Results of cluster analysis of the 2006 survey of Canadians' demand for food products supporting health and wellness.

This research seeks to identify consumer segments related to consumption of functional food and nutraceutical products in Canada. The segments are differentiated by consumer receptivity to functional foods and nutraceuticals. In turn, receptivity is tied to attitudes, motivations and knowledge related to food/diet and connections with health. At one extreme, a segment emerges that is highly receptive to functional foods and nutraceuticals, and shows a keen interest in learning about foods that have health benefits. A second segment, conversely, has low receptivity, but demonstrates a higher degree of knowledge related to the relationship between food/diet and health. A key driver of receptivity towards functional foods and nutraceuticals appears to be perceptions of disease threat, which tend to increase with age. Pre-emptive use of messages relating to the preventative properties of these products does not seem to have a major impact on the receptivity of consumers.

Population distribution and burden of acute gastrointestinal illness in British Columbia, Canada.

BACKGROUND: In developed countries, gastrointestinal illness (GI) is typically mild and self-limiting, however, it has considerable economic impact due to high morbidity. METHODS: The magnitude and distribution of acute GI in British Columbia (BC), Canada was evaluated via a cross-sectional telephone survey of 4,612 randomly selected residents, conducted from June 2002 to June 2003. Respondents were asked if they had experienced vomiting or diarrhoea in the 28 days prior to the interview. RESULTS: A response rate of 44.3% was achieved. A monthly prevalence of 9.2% (95% CI 8.4-10.0), an incidence rate of 1.3 (95% CI 1.1-1.4) episodes of acute GI per person-year, and an average probability that an individual developed illness in the year of 71.6% (95% CI 68.0-74.8), weighted by population size were observed. The average duration of illness was 3.7 days, translating into 19.2 million days annually of acute GI in BC. CONCLUSION: The results corroborate those from previous Canadian and international studies, highlighting the substantial burden of acute GI.

Public perceptions of drinking water: a postal survey of residents with private water supplies.

BACKGROUND: In Canada, the legal responsibility for the condition of private water supplies, including private wells and cisterns, rests with their owners. However, there are reports that Canadians test these water supplies intermittently and that treatment of such water is uncommon. An estimated 45% of all waterborne outbreaks in Canada involve non-municipal systems. An understanding of the perceptions and needs of Canadians served by private water supplies is essential, as it would enable public health professionals to better target public education and drinking water policy. The purpose of this study was to investigate the public perceptions of private water supplies in the City of Hamilton, Ontario (Canada), with the intent of informing public education and outreach strategies within the population. METHODS: A cross-sectional postal survey of 246 residences with private water supplies was conducted in May 2004. Questions pertained to the perceptions of water quality and alternative water sources, water testing behaviours and the self-identified need for further information. RESULTS: Private wells, cisterns or both, were the source of household water for 71%, 16% and 13% of respondents, respectively. Although respondents rated their water quality highly, 80% also had concerns with its safety. The most common concerns pertained to bacterial and chemical contamination of their water supply and its potential negative effect on health. Approximately 56% and 61% of respondents used in-home treatment devices and bottled water within their homes, respectively, mainly due to perceived improvements in the safety and aesthetic qualities compared to regular tap water. Testing of private water supplies was performed infrequently: 8% of respondents tested at a frequency that meets current provincial guidelines. Two-thirds of respondents wanted more information on various topics related to private water supplies. Flyers and newspapers were the two media reported most likely to be used. CONCLUSION: Although respondents rated their water quality highly, the majority had concerns regarding the water from their private supply, and the use of bottled water and water treatment devices was extensive. The results of this study suggest important lines of inquiry and provide support and input for public education programs, particularly those related to private water testing, in this population.