What works in engaging communities? Prioritising nutrition interventions in Burkina Faso, Ghana and South Africa.

BACKGROUND: "Choosing All Together" (CHAT), is a community engagement tool designed to give the public a voice in how best to allocate limited resources to improve population health. This process evaluation explored the mechanisms through which CHAT generates community engagement. METHOD: The CHAT tool was adapted and implemented for use in two rural communities (Nanoro, Burkina Faso, and Navrongo, Ghana) and one urban township (Soweto, South Africa) to prioritize maternal and child nutrition interventions. Community discussions were audio-recorded, transcribed, and translated into English. Twenty-two transcripts, including six each from Navrongo and Soweto and 10 from Nanoro, were analysed thematically to generate data driven codes and themes to explain mechanisms underlying the CHAT process. The process evaluation was based on the UK MRC process evaluation guidance. RESULTS: Seven themes describing the functions and outcomes of CHAT were identified. Themes described participants deliberating trade-offs, working together, agreeing on priorities, having a shared vision, and increasing their knowledge, also the skills of the facilitator, and a process of power sharing between participants and researchers. Participants came to an agreement of priorities when they had a shared vision. Trained facilitators are important to facilitate meaningful discussion between participants and those with lower levels of literacy to participate fully. CONCLUSION: CHAT has been shown to be adaptable and useful in prioritising maternal and child nutrition interventions in communities in Burkina Faso, Ghana, and South Africa. Conducting CHAT in communities over a longer period and involving policy-makers would increase trust, mutual respect and develop partnerships.

Men's motivations, barriers to and aspirations for their families' health in the first 1000 days in sub-Saharan Africa: a secondary qualitative analysis.

Introduction: The first 1000 days of life are a critical period of growth and development that have lasting implications for health, cognitive, educational and economic outcomes. In sub-Saharan Africa, gender and social norms are such that many men have little engagement with maternal and child health and nutrition during pregnancy and early childhood. This study explores how men perceive their role in three sites in sub-Saharan Africa. Methods: Secondary qualitative analysis of 10 focus group discussions with 76 men in Burkina Faso, Ghana and South Africa. Data were thematically analysed to explore men's perceptions of maternal and child health and nutrition. Results: Men considered themselves 'providers' and 'advisors' within their families, particularly of finances, food and medicines. They also indicated that this advice was out of care and concern for their families' health. There were similarities in how the men perceive their role. Differences between men living in rural and urban settings included health priorities, the advice and the manner in which it was provided. Across all settings, men wanted to be more involved with maternal and child health and nutrition. Challenges to doing so included stigma and proscribed social gender roles. Conclusion: Men want a greater engagement in improving maternal and child health and nutrition but felt that their ability to do so was limited by culture-specified gender roles, which are more focused on providing for and advising their families. Involving both men and women in intervention development alongside policymakers, health professionals and researchers is needed to improve maternal and child health and nutrition.

Periconceptional diet and the risk of gestational diabetes in south Indian women: findings from the BAngalore Nutrition Gestational diabetes LiFEstyle Study (BANGLES).

BACKGROUND: Gestational diabetes can predispose two generations-a mother and her child-to a higher risk of obesity and type 2 diabetes. Culture-specific strategies to prevent gestational diabetes are required. BANGLES investigated the associations between women's periconceptional diet and gestational diabetes risk. METHODS: BANGLES was a prospective observational study (n=785), in which women of various socioeconomic status were recruited at 5-16 weeks' gestation in Bangalore, India. Periconceptional diet was recalled at recruitment, using a validated 224-item food frequency questionnaire, that was reduced to 21 food groups for the food group-gestational diabetes analysis, and 68 food groups for the principal component analysis for a diet pattern-gestational diabetes analysis. Diet-gestational diabetes associations were examined using multivariate logistic regression, adjusting for a priori confounders determined from the literature. Gestational diabetes was assessed by a 75 g oral glucose tolerance test at 24-28 weeks' gestation, applying 2013 WHO criteria. FINDINGS: Women who consumed whole-grain cereals (adjusted odds ratio [OR] 0·58, 95% CI 0·34-0·97, p=0·03); had moderate egg consumption (>1-3 times per week) compared with less than once per week (adjusted OR 0·54, 95% CI 0·34-0·86, p=0·01); and a higher weekly intake of pulses and legumes (adjusted OR 0·81, 95% CI 0·66-0·98, p=0·03), nuts and seeds (adjusted OR 0·77, 95% CI 0·63-0·94, p=0·01), and fried and fast food (adjusted OR 0·72, 95% CI 0·59-0·89, p=0·002) had a lower gestational diabetes. None of these associations was significant after correction for multiple testing. A high-diversity, urban diet pattern characterised by diverse home-cooked and processed foods and associated with older, affluent, educated, urban women was associated with a lower risk (adjusted OR 0·80, 95% CI 0·64-0·99, p=0·04). BMI was the strongest risk factor for gestational diabetes and possibly mediated the diet pattern-gestational diabetes associations. INTERPRETATION: The same food groups that were associated with a lower gestational diabetes risk were components of the high-diversity, urban diet pattern. One healthy diet pattern might not be relevant to India. Findings support global recommendations to encourage women to attain a healthy pre-pregnancy BMI, increase diet diversity to prevent gestational diabetes, and have policies to increase food affordability. FUNDING: Schlumberger Foundation.

Behaviour change interventions improve maternal and child nutrition in sub-Saharan Africa: A systematic review.

Evidence that nutrition-specific and nutrition-sensitive interventions can improve maternal and child nutrition status in sub-Saharan Africa is inconclusive. Using behaviour change theory and techniques in intervention design may increase effectiveness and make outcomes more predictable. This systematic review aimed to determine whether interventions that included behaviour change functions were effective. Six databases were searched systematically, using MeSH and free-text terms, for articles describing nutrition-specific and nutrition-sensitive behaviour change interventions published in English until January 2022. Titles, abstracts and full-text papers were double-screened. Data extraction and quality assessments followed Centre for Reviews and Dissemination guidelines. Behaviour change functions of interventions were mapped onto the COM-B model and Behaviour Change Wheel. PROSPERO registered (135054). The search yielded 1193 articles: 79 articles met inclusion criteria, ranging from low (n = 30) to high (n = 11) risk of bias. Many that applied behaviour change theory, communication or counselling resulted in significant improvements in infant stunting and wasting, household dietary intake and maternal psychosocial measures. Interventions with >2 behaviour change functions (including persuasion, incentivisation, environmental restructuring) were the most effective. We recommend incorporating behaviour change functions in nutrition interventions to improve maternal and child outcomes, specifically drawing on the Behaviour Change Wheel, COM-B model (SORT B recommendation). To enhance the designs of these interventions, and ultimately improve the nutritional and psychosocial outcomes for mothers and infants in sub-Saharan Africa, collaborations are recommended between behaviour change and nutrition experts, intervention designers, policy makers and commissioners to fund and roll-out multicomponent behaviour change interventions.

Monocyte anisocytosis increases during multisystem inflammatory syndrome in children with cardiovascular complications.

BACKGROUND: Multisystem inflammatory syndrome in children (MIS-C) is a life-threatening complication that can develop weeks to months after an initial SARS-CoV-2 infection. A complex, time-consuming laboratory evaluation is currently required to distinguish MIS-C from other illnesses. New assays are urgently needed early in the evaluation process to expedite MIS-C workup and initiate treatment when appropriate. This study aimed to measure the performance of a monocyte anisocytosis index, obtained on routine complete blood count (CBC), to rapidly identify subjects with MIS-C at risk for cardiac complications. METHODS: We measured monocyte anisocytosis, quantified by monocyte distribution width (MDW), in blood samples collected from children who sought medical care in a single medical center from April 2020 to October 2020 (discovery cohort). After identifying an effective MDW threshold associated with MIS-C, we tested the utility of MDW as a tier 1 assay for MIS-C at multiple institutions from October 2020 to October 2021 (validation cohort). The main outcome was the early screening of MIS-C, with a focus on children with MIS-C who displayed cardiac complications. The screening accuracy of MDW was compared to tier 1 routine laboratory tests recommended for evaluating a child for MIS-C. RESULTS: We enrolled 765 children and collected 846 blood samples for analysis. In the discovery cohort, monocyte anisocytosis, quantified as an MDW threshold of 24.0, had 100% sensitivity (95% CI 78-100%) and 80% specificity (95% CI 69-88%) for identifying MIS-C. In the validation cohort, an initial MDW greater than 24.0 maintained a 100% sensitivity (95% CI 80-100%) and monocyte anisocytosis displayed a diagnostic accuracy greater that other clinically available hematologic parameters. Monocyte anisocytosis decreased with disease resolution to values equivalent to those of healthy controls. CONCLUSIONS: Monocyte anisocytosis detected by CBC early in the clinical workup improves the identification of children with MIS-C with cardiac complications, thereby creating opportunities for improving current practice guidelines.

Peri-conceptional diet patterns and the risk of Gestational diabetes mellitus in South Indian women.

OBJECTIVE: To identify peri-conceptional diet patterns among women in Bangalore, and examine their associations with risk of gestational diabetes mellitus. DESIGN: BANGLES, started in June 2016, was a prospective observational study, in which women were recruited at 5-16 weeks' gestation. Peri-conceptional diet was recalled at recruitment, using a validated 224-item food frequency questionnaire. GDM was assessed by a 75-gram oral glucose tolerance test at 24-28 weeks' gestation, applying WHO 2013 criteria. Diet patterns were identified using principal component analysis and diet pattern-GDM associations were examined using multivariate logistic regression, adjusting for 'a priori' confounders. SETTING: Antenatal clinics of two hospitals, Bangalore, South India. PARTICIPANTS: 785 pregnant women of varied socio-economic status. RESULTS: GDM prevalence was 22%. Three diet patterns were identified: a) High-diversity, urban (HDU) characterised by diverse, home-cooked and processed foods was associated with older, more affluent, better-educated and urban women; b) Rice-fried snacks-chicken-sweets (RFCS), characterised by low diet-diversity, was associated with younger, less-educated, and lower income, rural and joint families; c) Healthy, traditional vegetarian (HTV), characterised by home-cooked-vegetarian and non-processed foods was associated with less-educated, more affluent, and rural and joint families. The HDU pattern was associated with a lower GDM risk (aOR: 0.80 per SD, 95% CI: 0.64, 0.99, p=0.04) after adjusting for confounders. BMI was strongly related to GDM risk and possibly mediated diet-GDM associations. CONCLUSIONS: The findings support global recommendations to encourage women to attain a healthy pre-pregnancy BMI and increase diet-diversity. Both healthy and unhealthy foods in the patterns indicate low-awareness about healthy foods and a need for public-education.

Body Composition and Cardiometabolic Risk Markers in Children of Women who Took Part in a Randomized Controlled Trial of a Preconceptional Nutritional Intervention in Mumbai, India.

BACKGROUND: Maternal nutrition influences fetal development and may permanently alter ("program") offspring body composition and metabolism, thereby influencing later risk of diabetes and cardiovascular (cardiometabolic) disease. The prevalence of cardiometabolic disease is rising rapidly in India. OBJECTIVES: To test the hypothesis that supplementing low-income Indian women with micronutrient-rich foods preconceptionally and during pregnancy has a beneficial impact on the children's body composition and cardiometabolic risk marker profiles. METHODS: Follow-up of 1255 children aged 5-10 y whose mothers took part in the Mumbai Maternal Nutrition Project [Project "SARAS"; International Standard Randomised Controlled Trial Number (ISRCTN)62811278]. Mothers were randomly assigned to receive a daily micronutrient-rich snack or a control snack of lower micronutrient content, both made from local foods, in addition to normal diet, from before pregnancy until delivery. Children's body composition was assessed using anthropometry and DXA. Their blood pressure, plasma glucose, insulin, and lipid concentrations were measured. Outcomes were compared between allocation groups with and without adjustment for confounding factors. RESULTS: Overall, 15% of children were stunted, 34% were wasted, and 3% were overweight. In the intention-to-treat analysis, there were no differences in body composition or risk markers between children in the intervention and control groups. Among children whose mothers started supplementation ≥3 mo before conception (the "per protocol" sample) the intervention increased adiposity among girls, but not boys. BMI in girls was increased relative to controls by 2% (95% CI: 1, 4; P = 0.01); fat mass index by 10% (95% CI: 3, 18; P = 0.004); and percent fat by 7% (95% CI: 1, 13; P = 0.01) unadjusted, with similar results in adjusted models. CONCLUSIONS: Overall, supplementing women with micronutrient-rich foods from before pregnancy until delivery did not alter body composition or cardiometabolic risk markers in the children. Subgroup analyses showed that, if started ≥3 mo before conception, supplementation may increase adiposity among female children.

Children born during the hunger season are at a higher risk of severe acute malnutrition: Findings from a Guinea Sahelian ecological zone in Northern Ghana.

Heightened food insecurity in the hunger season increases the risk of severe acute malnutrition (SAM) in childhood. This study examined the association of season of birth with SAM in a Guinean Sahelian ecological zone. We analyzed routine health and sociodemographic surveillance data from the Navrongo Health and Socio-demographic Surveillance System collected between 2011 and 2018. January-June, the period of highest food insecurity, was defined as the hunger season. We defined moderate acute malnutrition as child mid-upper arm circumference (MUAC) between 115 mm and 135 mm and SAM as MAUC ≤ 115 mm. We used adjusted logistic regression to quantify the association between the season of birth and SAM in children aged 6-35 months. From the 29,452 children studied, 24% had moderate acute malnutrition. Overall, 1.4% had SAM, with a higher prevalence (1.8%) in the hunger season of birth. Compared with those born October-December, adjusted odds ratios (aOR) and 95% confidence interval (95% CI) for SAM were increased for children born in the hunger season: January-March (1.77 [1.31-2.39]) and April-June (1.92 [1.44-2.56]). Low birth weight, age at an assessment of nutritional status, and ethno-linguistic group were also significantly associated with SAM in adjusted analyses. Our study established that being born in the hunger season is associated with a higher risk of severe acute malnutrition. The result implies improvement in the food supply to pregnant and lactating mothers through sustainable agriculture or food system change targeting the hunger season may reduce the burden of severe acute malnutrition.

Engaging community members in setting priorities for nutrition interventions in rural northern Ghana.

This study used "Choosing All Together" (CHAT), a deliberative engagement tool to prioritise nutrition interventions and to understand reasons for intervention choices of a rural community in northern Ghana. The study took an exploratory cross-sectional design and used a mixed method approach to collect data between December 2020 and February 2021. Eleven nutrition interventions were identified through policy reviews, interaction with different stakeholders and focus group discussions with community members. These interventions were costed for a modified CHAT tool-a board-like game with interventions represented by colour coded pies and the cost of the interventions represented by sticker holes. Supported by trained facilitators, six community groups used the tool to prioritise interventions. Discussions were audio-recoded, transcribed and thematically analysed. The participants prioritised both nutrition-sensitive and nutrition-specific interventions, reflecting the extent of poverty in the study districts and the direct and immediate benefits derived from nutrition-specific interventions. The prioritised interventions involved livelihood empowerment, because they would create an enabling environment for all-year-round agricultural output, leading to improved food security and income for farmers. Another nutrition-sensitive, education-related priority intervention was male involvement in food and nutrition practices; as heads of household and main decision makers, men were believed to be in a position to optimise maternal and child nutrition. The prioritised nutrition-specific intervention was micronutrient supplementation. Despite low literacy, participants were able to use CHAT materials and work collectively to prioritize interventions. In conclusion, it is feasible to modify and use the CHAT tool in public deliberations to prioritize nutrition interventions in rural settings with low levels of literacy. These communities prioritised both nutrition-sensitive and nutrition-specific interventions. Attending to community derived nutrition priorities may improve the relevance and effectiveness of nutrition health policy, since these priorities reflect the context in which such policy is implemented.

Body Composition and Cardiometabolic Risk Markers in Children of Women who Took Part in a Randomized Controlled Trial of a Preconceptional Nutritional Intervention in Mumbai, India.

BACKGROUND: Maternal nutrition influences fetal development and may permanently alter ("program") offspring body composition and metabolism, thereby influencing later risk of diabetes and cardiovascular (cardiometabolic) disease. The prevalence of cardiometabolic disease is rising rapidly in India. OBJECTIVES: To test the hypothesis that supplementing low-income Indian women with micronutrient-rich foods preconceptionally and during pregnancy has a beneficial impact on the children's body composition and cardiometabolic risk marker profiles. METHODS: Follow-up of 1255 children aged 5-10 y whose mothers took part in the Mumbai Maternal Nutrition Project [Project "SARAS"; International Standard Randomised Controlled Trial Number (ISRCTN)62811278]. Mothers were randomly assigned to receive a daily micronutrient-rich snack or a control snack of lower micronutrient content, both made from local foods, in addition to normal diet, from before pregnancy until delivery. Children's body composition was assessed using anthropometry and DXA. Their blood pressure, plasma glucose, insulin, and lipid concentrations were measured. Outcomes were compared between allocation groups with and without adjustment for confounding factors. RESULTS: Overall, 15% of children were stunted, 34% were wasted, and 3% were overweight. In the intention-to-treat analysis, there were no differences in body composition or risk markers between children in the intervention and control groups. Among children whose mothers started supplementation ≥3 mo before conception (the "per protocol" sample) the intervention increased adiposity among girls, but not boys. BMI in girls was increased relative to controls by 2% (95% CI: 1, 4; P = 0.01); fat mass index by 10% (95% CI: 3, 18; P = 0.004); and percent fat by 7% (95% CI: 1, 13; P = 0.01) unadjusted, with similar results in adjusted models. CONCLUSIONS: Overall, supplementing women with micronutrient-rich foods from before pregnancy until delivery did not alter body composition or cardiometabolic risk markers in the children. Subgroup analyses showed that, if started ≥3 mo before conception, supplementation may increase adiposity among female children.

Food insecurity, diet quality and body composition: data from the Healthy Life Trajectories Initiative (HeLTI) pilot survey in urban Soweto, South Africa.

OBJECTIVE: To determine whether food security, diet diversity and diet quality are associated with anthropometric measurements and body composition among women of reproductive age. The association between food security and anaemia prevalence was also tested. DESIGN: Secondary analysis of cross-sectional data from the Healthy Life Trajectories Initiative (HeLTI) study. Food security and dietary data were collected by an interviewer-administered questionnaire. Hb levels were measured using a HemoCue, and anaemia was classified as an altitude-adjusted haemoglobin level < 12·5 g/dl. Body size and composition were assessed using anthropometry and dual-energy x-ray absorptiometry. SETTING: The urban township of Soweto, Johannesburg, South Africa. PARTICIPANTS: Non-pregnant women aged 18-25 years (n 1534). RESULTS: Almost half of the women were overweight or obese (44 %), and 9 % were underweight. Almost a third of women were anaemic (30 %). The prevalence rates of anaemia and food insecurity were similar across BMI categories. Food insecure women had the least diverse diets, and food security was negatively associated with diet quality (food security category v. diet quality score: B = -0·35, 95 % CI -0·70, -0·01, P = 0·049). Significant univariate associations were observed between food security and total lean mass. However, there were no associations between food security and body size or composition variables in multivariate models. CONCLUSIONS: Our data indicate that food security is an important determinant of diet quality in this urban-poor, highly transitioned setting. Interventions to improve maternal and child nutrition should recognise both food security and the food environment as critical elements within their developmental phases.

Conflicts between adolescents and their caregivers living in slums of Mumbai, India in relation to junk food consumption and physical activity.

OBJECTIVE: To explore influences on the diet and physical activity of adolescents living in Mumbai slums, from the perspectives of adolescents and their caregivers. DESIGN: Three investigators from Mumbai conducted six focus group discussions. SETTING: The study was conducted in suburban Mumbai slums. PARTICIPANTS: Thirty-six adolescents (aged 10-12 and 15-17 years) and twenty-three caregivers were recruited through convenience sampling. RESULTS: The findings highlighted the complex negotiations between adolescent and caregivers surrounding adolescent junk food consumption and physical activity opportunities. Caregivers learned recipes to prepare popular junk foods to encourage adolescents to eat more home-cooked, and less 'outside', food, yet adolescents still preferred to eat outside. To adolescents, the social aspect of eating junk food with friends was an important and enjoyable experience. Caregivers felt that they had no control over adolescents' food choices, whereas adolescents felt their diets were dictated by their parents. Adolescents wanted to be physically active but were encouraged to focus on their academic studies instead. Gender was also a key driver of physical activity, with girls given less priority to use outside spaces due to cultural and religious factors, and parental fears for their safety. CONCLUSIONS: These findings show that adolescents and caregivers have different agendas regarding adolescent diet. Adolescent girls have less opportunity for healthy exercise, and are more sedentary, than boys. Adolescents and caregivers need to be involved in designing effective interventions such as making space available for girls to be active, and smartphone games to encourage healthy eating or physical activity.

Supporting maternal and child nutrition: views from community members in rural Northern Ghana.

OBJECTIVE: Despite efforts to improve maternal and child nutrition, undernutrition remains a major public health challenge in Ghana. The current study explored community perceptions of undernutrition and context-specific interventions that could improve maternal and child nutrition in rural Northern Ghana. DESIGN: This exploratory qualitative study used ten focus group discussions to gather primary data. The discussions were recorded, transcribed and coded into themes using Nvivo 12 software to aid thematic analysis. SETTING: The study was conducted in rural Kassena-Nankana Districts of Northern Ghana. STUDY PARTICIPANTS: Thirty-three men and fifty-one women aged 18-50 years were randomly selected from the community. RESULTS: Most participants reported poverty, lack of irrigated agricultural land and poor harvests as the main barriers to optimal nutrition. To improve maternal and child nutrition, study participants suggested that the construction of dams at the community level would facilitate all year round farming including rearing of animals. Participants perceived that the provision of agricultural materials such as high yield seedlings, pesticides and fertiliser would help boost agricultural productivity. They also recommended community-based nutrition education by trained health volunteers, focused on types of locally produced foods and appropriate ways to prepare them to help improve maternal and child nutrition. CONCLUSION: Drawing on these findings and existing literature, we argue that supporting community initiated nutrition interventions such as improved irrigation for dry season farming, provision of agricultural inputs and community education could improve maternal and child nutrition.

Social, economic and cultural influences on adolescent nutrition and physical activity in Jimma, Ethiopia: perspectives from adolescents and their caregivers.

OBJECTIVE: To explore influences on adolescent diet and physical activity, from the perspectives of adolescents and their caregivers, in Jimma, Ethiopia. DESIGN: Qualitative design, using focus group discussions (FGD). SETTING: A low-income setting in Jimma, Ethiopia. PARTICIPANTS: Five FGD with adolescents aged 10-12 years and 15-17 years (n 41) and three FGD with parents (n 22) were conducted. RESULTS: Adolescents displayed a holistic understanding of health comprising physical, social and psychological well-being. Social and cultural factors were perceived to be the main drivers of adolescent diet and physical activity. All participants indicated that caregivers dictated adolescents' diet, as families shared food from the same plate. Meals were primarily determined by caregivers, whose choices were driven by food affordability and accessibility. Older adolescents, particularly boys, had opportunities to make independent food choices outside of the home which were driven by taste and appearance, rather than nutritional value. Many felt that adolescent physical activity was heavily influenced by gender. Girls' activities included domestic work and family responsibilities, whereas boys had more free time to participate in outdoor games. Girls' safety was reported to be a concern to caregivers, who were fearful of permitting their daughters to share overcrowded outdoor spaces with strangers. CONCLUSIONS: Adolescents and caregivers spoke a range of social, economic and cultural influences on adolescent diet and physical activity. Adolescents, parents and the wider community need to be involved in the development and delivery of effective interventions that will take into consideration these social, economic and cultural factors.

Community perspectives on maternal and child health during nutrition and economic transition in sub-Saharan Africa.

OBJECTIVE: To explore community perceptions on maternal and child nutrition issues in Sub-Saharan Africa. DESIGN: Thirty focus groups with men and women from three communities facilitated by local researchers. SETTING: One urban (Soweto, South Africa) and two rural settings (Navrongo, Ghana and Nanoro, Burkina Faso) at different stages of economic transition. PARTICIPANTS: Two hundred thirty-seven men and women aged 18-55 years, mostly subsistence farmers in Navrongo and Nanoro and low income in Soweto. RESULTS: Differences in community concerns about maternal and child health and nutrition reflected the transitional stage of the country. Community priorities revolved around poor nutrition and hunger caused by poverty, lack of economic opportunity and traditional gender roles. Men and women felt they had limited control over food and other resources. Women wanted men to take more responsibility for domestic chores, including food provision, while men wanted more involvement in their families but felt unable to provide for them. Solutions suggested focusing on ways of increasing control over economic production, family life and domestic food supplies. Rural communities sought agricultural support, while the urban community wanted regulation of the food environment. CONCLUSIONS: To be acceptable and effective, interventions to improve maternal and child nutrition need to take account of communities' perceptions of their needs and address wider determinants of nutritional status and differences in access to food reflecting the stage of the country's economic transition. Findings suggest that education and knowledge are necessary but not sufficient to support improvements in women's and children's nutritional status.

Exploring influences on adolescent diet and physical activity in rural Gambia, West Africa: food insecurity, culture and the natural environment.

OBJECTIVE: To explore, from the perspectives of adolescents and caregivers, and using qualitative methods, influences on adolescent diet and physical activity in rural Gambia. DESIGN: Six focus group discussions (FGD) with adolescents and caregivers were conducted. Thematic analysis was employed across the data set. SETTING: Rural region of The Gambia, West Africa. PARTICIPANTS: Participants were selected using purposive sampling. Four FGD, conducted with forty adolescents, comprised: girls aged 10-12 years; boys aged 10-12 years; girls aged 15-17 years, boys aged 15-17 years. Twenty caregivers also participated in two FGD (mothers and fathers). RESULTS: All participants expressed an understanding of the association between salt and hypertension, sugary foods and diabetes, and dental health. Adolescents and caregivers suggested that adolescent nutrition and health were shaped by economic, social and cultural factors and the local environment. Adolescent diet was thought to be influenced by: affordability, seasonality and the receipt of remittances; gender norms, including differences in opportunities afforded to girls, and mother-led decision-making; cultural ceremonies and school holidays. Adolescent physical activity included walking or cycling to school, playing football and farming. Participants felt adolescent engagement in physical activity was influenced by gender, seasonality, cultural ceremonies and, to some extent, the availability of digital media. CONCLUSIONS: These novel insights into local understanding should be considered when formulating future interventions. Interventions need to address these interrelated factors, including misconceptions regarding diet and physical activity that may be harmful to health.

Double-duty solutions for optimising maternal and child nutrition in urban South Africa: a qualitative study.

OBJECTIVE: To obtain a community perspective on key nutrition-specific problems and solutions for mothers and children. DESIGN: A qualitative study comprising nine focus group discussions (FGD) following a semi-structured interview guide. SETTING: The township of Soweto in South Africa with a rising prevalence of double burden of malnutrition. PARTICIPANTS: Men and women aged ≥18 years (n 66). Three FGD held with men, six with women. RESULTS: Despite participants perceived healthy diet to be important, they felt their ability to maintain a healthy diet was limited. Inexpensive, unhealthy food was easier to access in Soweto than healthier alternatives. Factors such as land use, hygiene and low income played a fundamental role in shaping access to foods and decisions about what to eat. Participants suggested four broad areas for change: health sector, social protection, the food system and food environment. Their solutions ranged from improved nutrition education for women at clinic visits, communal vegetable gardens and government provision of food parcels to regulatory measures to improve the healthiness of their food environment. CONCLUSIONS: South Africa's current nutrition policy environment does not adequately address community-level needs that are often linked to structural factors beyond the health sector. Our findings suggest that to successfully address the double burden of malnutrition among women and children, a multifaceted approach is needed combining action on the ground with coherent policies that address upstream factors, including poverty. Further, there is a need for public engagement and integration of community perspectives and priorities in developing and implementing double-duty actions to improve nutrition.

'Men are not playing their roles', maternal and child nutrition in Nanoro, Burkina Faso.

OBJECTIVE: To collect context-specific insights into maternal and child health and nutrition issues, and to explore potential solutions in Nanoro, Burkina Faso. DESIGN: Eleven focus groups with men and women from eleven communities, facilitated by local researchers. SETTING: The study took place in the Nanoro Health district, in the West-Central part of Burkina Faso. PARTICIPANTS: Eighty-six men (18-55 years) and women by age group: 18-25; 26-34 and 35-55 years, participated in the group discussions. RESULTS: Participants described barriers to optimal nutrition of mothers and children related to a range of community factors, with gender inequality as central. Major themes in the discussions are related to poverty and challenges generated by socially and culturally determined gender roles. Sub-themes are women lacking access to food whilst pregnant and having limited access to health care and opportunities to generate income. Although communities believe that food donations should be implemented to overcome this, they also pointed out the need for enhancing their own food production, requiring improved agricultural technologies. Given the important role that women could play in reducing malnutrition, these communities felt they needed to be empowered to do so and supported by men. They also felt that this had to be carried out in the context of an enhanced health care system. CONCLUSIONS: Findings reported here highlight the importance of nutrition-sensitive interventions and women's empowerment in improving maternal and child nutrition. There is a need to integrate a sustainable multi-sectorial approach which goes beyond food support.

Adolescent diet and physical activity in the context of economic, social and nutrition transition in rural Maharashtra, India: a qualitative study.

OBJECTIVE: To explore the perceptions of adolescents and their caregivers on drivers of diet and physical activity in rural India in the context of ongoing economic, social and nutrition transition. DESIGN: A qualitative study comprising eight focus group discussions (FGD) on factors affecting eating and physical activity patterns, perceptions of health and decision-making on food preparation. SETTING: Villages approximately 40-60 km from the city of Pune in the state of Maharashtra, India. PARTICIPANTS: Two FGD with adolescents aged 10-12 years (n 20), two with 15- to 17- year-olds (n 18) and four with their mothers (n 38). RESULTS: Dietary behaviour and physical activity of adolescents were perceived to be influenced by individual and interpersonal factors including adolescent autonomy, parental influence and negotiations between adolescents and caregivers. The home food environment, street food availability, household food security and exposure to television and digital media were described as influencing behaviour. The lack of facilities and infrastructure was regarded as barriers to physical activity as were insufficient resources for public transport, safe routes for walking and need for cycles, particularly for girls. It was suggested that schools take a lead role in providing healthy foods and that governments invest in facilities for physical activity. CONCLUSIONS: In this transitioning environment, that is representative of many parts of India and other Lower Middle Income Countries (LMIC), people perceive a need for interventions to improve adolescent diet and physical activity. Caregivers clearly felt that they had a stake in adolescent health, and so we would recommend the involvement of both adolescents and caregivers in intervention design.