Mental health literacy: Perspectives from Northern Kenya Turkana adolescents.

Mental illness accounts for high levels of morbidity, mortality and poor quality of life among young people. Depression, anxiety, conduct issues and hyperactive disorder account for 13% of the global burden of disease that affects one in seven adolescents. In Kenya, not much is documented about the mental health of non-school-going adolescents, and yet they make up about 1.8 million of the country's population. An ethnographic study by Focus Group Discussions with 32 rural northern Kenya Turkana-based adolescents divided into school and nonschool groups was conducted. We read out vignettes in which the main character exhibited symptoms of depression, schizophrenia or anxiety and explored their knowledge of causes and management options for the same, and then analyzed the data thematically. Participants described the conditions without referring to the local names we had collected earlier: depression (Akiyalolong), schizophrenia (waarit/Ngikerep) and anxiety (Ngatameta naaronok). They assigned curses, guilt, hunger pangs, and evil spells as causes, and believed friends and age-mates, parents, teachers, and the local chief, among others, could help, but rarely medical intervention. Interventions to improve the adolescent's knowledge of mental illness are a much-needed support for the health of young people.

Socioeconomic inequalities in food purchasing practices and expenditure patterns: Results from a cross-sectional household survey in western Kenya.

Introduction: Socioeconomic inequalities contribute to poor health. Inequitable access to diverse and healthy foods can be a risk factor for non-communicable diseases, especially in individuals of low socioeconomic status. We examined the extent of socioeconomic inequalities in food purchasing practices, expenditure, and consumption in a resource-poor setting in Kenya. Methods: We conducted a secondary analysis of baseline cross-sectional data from a natural experimental study with a sample size of 512 individuals from 376 households in western Kenya. Data were collected on household food sources, expenditure and food consumption. Household socioeconomic status (SES) was assessed using the multiple correspondence analysis (MCA) model. Concentration indices (Ci) and multivariable linear regression models were used to establish socioeconomic inequalities. Results: About half (47.9%) of individuals achieved a minimum level of dietary diversity with the majority coming from wealthier households. The two most consumed food groups were grains and roots (97.5%, n = 499) and dark green leafy vegetables (73.8%, n = 378), but these did not vary by SES. The consumption of dark green leafy vegetables was similar across wealth quantiles (Ci = 0.014, p = 0.314). Overall, the wealthier households spent significantly more money on food purchases with a median of USD 50 (IQR = 60) in a month compared to the poorest who spent a median of USD 40 (IQR = 40). Of all the sources of food, the highest amount was spent at open-air markets median of USD 20 (IQR = 30) and the expenditure did not vary significantly by SES (Ci = 0.4, p = 0.684). The higher the socioeconomic status the higher the total amount spent on food purchases. In multivariable regression analysis, household SES was a significant determinant of food expenditure [Adjusted coefficient = 6.09 (95%confidence interval CI = 2.19, 9.99)]. Conclusion: Wealthier households spent more money on food compared to the poorest households, especially on buying food at supermarkets. Individuals from the poorest households were dominant in eating grains and roots and less likely to consume a variety of food groups, including pulses, dairy, eggs and fruits, and vegetables. Individuals from the poorest households were also less likely to achieve adequate dietary diversity. Deliberate policies on diet and nutrition are required to address socioeconomic inequalities in food purchasing practices.

Foodscapes, finance, and faith: Multi-sectoral stakeholder perspectives on the local population health and wellbeing in an urbanizing area in Kenya.

Introduction: Rapid urbanization (growth of cities) can upset the local population's health and wellbeing by creating obesogenic environments which increase the burden of non-communicable diseases (NCDs). It is important to understand how stakeholders perceive the impact of urbanizing interventions (such as the construction of a new hypermarket) on the health and wellbeing of local populations. Because low- and middle-income countries (LMICs) lack the reliable infrastructure to mitigate the effects of obesogenic environments, so engaging stakeholders who influence dietary habits is one population-level strategy for reducing the burden of NCDs caused by newly built developments. Methods: We conducted key informant interviews with 36 stakeholders (25 regulatory and 11 local community stakeholders) from Kisumu and Homa Bay Counties of Western Kenya in June 2019. We collected stakeholders' perspectives on the impacts of a new Mall and supermarket in Kisumu, and existing supermarkets in Homa Bay on the health and wellbeing of local populations. Results: Through thematic discourse analysis, we noted that some stakeholders thought supermarkets enabled access to unhealthy food items despite these outlets being also reliable food sources for discerning shoppers. Others linked the changing physical environment to both an increase in pollution and different types of diseases. Stakeholders were unsure if the pricing and convenience of supermarkets would stop local populations from buying from their usual small-scale food vendors. The key finding of this study was that engaging relevant stakeholders as part of population health impact assessments of new developments in cities are important as it directs focus on health equity and prevention in instances of resource constraints. The findings highlight, also, that community members have a strong awareness of the potential for interventions that would improve the health and wellbeing of local populations.

The Role of Mealtimes in Fostering Language Development and Aligning Home and School Learning: Protocol for a Multi-Method Study of Preschool Children in Rural Kenya and Zambia.

BACKGROUND: The association between school and home is fundamental to sustainable education: parents' understanding of the school's priorities and teachers' understanding of their pupils' home environment are both vital for children to remain in school and succeed academically. The relationship between parents and teachers is closest in preschool settings, providing a valuable opportunity to build bridges between home and school. In this protocol paper, we outline our planned methods for identifying beneficial home and school behaviors. OBJECTIVE: Our project aims to identify culture-specific structures and behaviors in home and school settings, which influence the quantity and quality of child-directed speech and identify positive experiences that can help improve children's linguistic development and nutrition. METHODS: Using a mixed methods approach and focusing on early language learning, nutrition, and responsive caregiving, we will video-record and analyze mealtime language and eating behaviors at home and in school, targeting 80 preschool children and their families in rural Kenya and Zambia. In addition, we will assess children's language skills through audio recordings and use questionnaire-based interviews to collect extensive sociodemographic and dietary data. RESULTS: Between the start of our project in January 2020 and the end of December 2021, we had collected complete sets of sociodemographic, observational, and food recall data for 40 children in Kenya and 16 children in Zambia. By the end of May 2022, we had started data collection for an additional 24 children in Zambia and transcribed and coded approximately 85% of the data. By the end of September, 2022, we plan to complete data collection, transcription, and coding for the entire sample of 80 children across both countries. From September 2022 onwards, we will focus on analyzing our language data, and we hope to have results ready for publication in early 2023. By relating children's language outcomes and nutritional intake to the observed mealtime behaviors, we hope to identify practices that increase the quantity and quality of child-directed speech and improve children's nutritional intake. CONCLUSIONS: Good nutrition and the promotion of language learning are key issues in early childhood development. By using a cross-cultural approach, combining a variety of methods, and working closely with stakeholders and policy makers throughout the project, we hope to find and share best practices for improving children's linguistic outcomes and nutrition and lay the foundation for the development of practitioner networks and parent outreach programs. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/36925.

Navigating the local foodscape: qualitative investigation of food retail and dietary preferences in Kisumu and Homa Bay Counties, western Kenya.

INTRODUCTION: Non-communicable diseases have risen markedly over the last decade. A phenomenon that was mainly endemic in high-income countries has now visibly encroached on low and middle-income settings. A major contributor to this is a shift towards unhealthy dietary behavior. This study aimed to examine the complex interplay between people's characteristics and the environment to understand how these influenced food choices and practices in Western Kenya. METHODS: This study used semi-structured guides to conduct in-depth interviews and focus group discussions with both male and female members of the community, across various socioeconomic groups, from Kisumu and Homa Bay Counties to further understand their perspectives on the influences of dietary behavior. Voice data was captured using digital voice recorders, transcribed verbatim, and translated to English. Data analysis adopted an exploratory and inductive analysis approach. Coded responses were analyzed using NVIVO 12 PRO software. RESULTS: Intrapersonal levels of influence included: Age, the nutritional value of food, occupation, perceived satiety of some foods as opposed to others, religion, and medical reasons. The majority of the participants mentioned location as the main source of influence at the community level reflected by the regional staple foodscape. Others include seasonality of produce, social pressure, and availability of food in the market. Pricing of food and distance to food markets was mentioned as the major macro-level influence. This was followed by an increase in population and road infrastructure. CONCLUSION: This study demonstrated that understanding dietary preferences are complex. Future interventions should not only consider intrapersonal and interpersonal influences when aiming to promote healthy eating among communities but also need to target the community and macro environments. This means that nutrition promotion strategies should focus on multiple levels of influence that broaden options for interventions. However, government interventions in addressing food access, affordability, and marketing remain essential to any significant change.

Comparison of household socioeconomic status classification methods and effects on risk estimation: lessons from a natural experimental study, Kisumu, Western Kenya.

INTRODUCTION: Low household socioeconomic status is associated with unhealthy behaviours including poor diet and adverse health outcomes. Different methods leading to variations in SES classification has the potential to generate spurious research findings or misinform policy. In low and middle-income countries, there are additional complexities in defining household SES, a need for fieldwork to be conducted efficiently, and a dearth of information on how classification could impact estimation of disease risk. METHODS: Using cross-sectional data from 200 households in Kisumu County, Western Kenya, we compared three approaches of classifying households into low, middle, or high SES: fieldworkers (FWs), Community Health Volunteers (CHVs), and a Multiple Correspondence Analysis econometric model (MCA). We estimated the sensitivity, specificity, inter-rater reliability and misclassification of the three methods using MCA as a comparator. We applied an unadjusted generalized linear model to determine prevalence ratios to assess the association of household SES status with a self-reported diagnosis of diabetes or hypertension for one household member. RESULTS: Compared with MCA, FWs successfully classified 21.7% (95%CI = 14.4%-31.4%) of low SES households, 32.8% (95%CI = 23.2-44.3) of middle SES households, and no high SES households. CHVs successfully classified 22.5% (95%CI = 14.5%-33.1%) of low SES households, 32.8% (95%CI = 23.2%-44.3%) of middle SES households, and no high SES households. The level of agreement in SES classification was similar between FWs and CHVs but poor compared to MCA, particularly for high SES. None of the three methods differed in estimating the risk of hypertension or diabetes. CONCLUSIONS: FW and CHV assessments are community-driven methods for SES classification. Compared to MCA, these approaches appeared biased towards low or middle SES households and not sensitive to high household SES. The three methods did not differ in risk estimation for diabetes and hypertension. A mix of approaches and further evaluation to refine SES classification methodology is recommended.

Qualitative Accounts of School-Aged Children's Diets during the COVID-19 Pandemic in Rural, Central, Kenya.

The COVID-19 pandemic has caused disruption to food security in many countries, including Kenya. However, the impact of this on food provision to children at an individual level is unknown. This small study aimed to provide a qualitative snapshot of the diets of children during the COVID-19 pandemic. During completion of 24-h food recalls, with 15 families with children aged 5-8 years, caregivers were asked about changes they had made to foods given to their children due to the pandemic. Food recalls were analysed to assess nutrient intakes. Qualitative comments were thematically analysed. Most of the families reported making some changes to foods they provided to their children due to COVID-19. Reasons for these changes fell into three themes, inability to access foods (both due to formal restriction of movements and fear of leaving the house), poorer availability of foods, and financial constraints (both decreases in income and increases in food prices). The COVID-19 pandemic has affected some foods parents in rural Kenya can provide to their children.

Adolescent Levers for a Diet and Physical Activity Intervention Across Socioecological Levels in Kenya, South Africa, Cameroon, and Jamaica: Mixed Methods Study Protocol.

BACKGROUND: The increasing burden of noncommunicable diseases that are prevalent in low- and middle-income countries (LMICs) is largely attributed to modifiable behavioral risk factors such as unhealthy diets and insufficient physical activity (PA). The adolescent stage, defined as 10 to 24 years of age, is an important formative phase of life and offers an opportunity to reduce the risk of noncommunicable diseases across the life course and for future generations. OBJECTIVE: The aim of this paper is to describe a protocol for a study using a convergent mixed methods design to explore exposures in the household, neighborhood, school, and the journey from home to school that may influence diet and PA behaviors in adolescents from LMICs. METHODS: Male and female adolescents (n≥150) aged between 13 and 24 years will be recruited from selected high schools or households in project site countries to ensure the socioeconomic diversity of perspectives and experiences at the individual, home, and neighborhood levels. The project will be conducted at 5 sites in 4 countries: Kenya, Cameroon, Jamaica, and South Africa (Cape Town and Johannesburg). Data on anthropometric measures, food intake, and PA knowledge and behavior will be collected using self-report questionnaires. In addition, a small number of learners (n=30-45) from each site will be selected as citizen scientists to capture data (photographs, audio notes, text, and geolocations) on their lived experiences in relation to food and PA in their homes, the journey to and from school, and the school and neighborhood environments using a mobile app, and for objective PA measurements. In-depth interviews will be conducted with the citizen scientists and their caregivers to explore household experiences and determinants of food intake and foodways, as well as the PA of household members. RESULTS: The study described in this protocol paper was primarily funded through a UK National Institute for Health Research grant in 2017 and approved by the relevant institutional ethics review boards in the country sites (South Africa, Cameroun, and Jamaica in 2019, and Kenya in 2020). As of December 23, 2020, we had completed data collection from adolescents (n≥150) in all the country sites, except Kenya, and data collection for the subgroup (n=30-45) is ongoing. Data analysis is ongoing and the output of findings from the study described in this protocol is expected to be published by 2022. CONCLUSIONS: This project protocol contributes to research that focuses on adolescents and the socioecological determinants of food intake and PA in LMIC settings. It includes innovative methodologies to interrogate and map the contexts of these determinants and will generate much-needed data to understand the multilevel system of factors that can be leveraged through upstream and downstream strategies and interventions to improve health outcomes. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/26739.

A Systematic Scoping Review of the Impacts of Community Food Production Initiatives in Kenya, Cameroon, and South Africa.

BACKGROUND: Even before the COVID-19 pandemic, one in two people in Africa were food insecure. The burden of malnutrition remains high (e.g. childhood stunting, anaemia in women of reproductive age) or are increasing (e.g. overweight and obesity). A range of coordinated actions are required to improve this situation, including increasing local food production and consumption. The aim of this review was to provide a systematic and comprehensive overview of recently published research into the health, social, economic, and environmental impacts of community food production initiatives (CFPIs) in Kenya, Cameroon and South Africa. METHODS: We searched eight electronic databases covering health, social, environmental, economic and agricultural sciences. Primary research studies published from 1 January 2014 to 31 December 2018 were considered. Data on geographic location, study design, type of CFPI and the impacts assessed were abstracted from eligible articles. FINDINGS: We identified 4828 articles, 260 of which required full-text review and 118 met our eligibility criteria. Most research was conducted in Kenya (53.4%) and South Africa (38.1%). The categories of CFPIs studied were (in order of decreasing frequency): crop farming, livestock farming, unspecified farming, fisheries, home / school gardens, urban agriculture, and agroforestry. The largest number of studies were on the economic and environmental impacts of CFPIs, followed by their health and social impacts. The health impacts investigated included food security, nutrition status and dietary intake. One study investigated the potential impact of CFPIs on non-communicable diseases. Over 60% of studies investigated a single category of impact. Not one of the studies explicitly used a theoretical framework to guide its design or interpretation. CONCLUSIONS: Our findings on research studies of CFPIs suggest the need for a greater focus on interdisciplinary research in order to improve understanding of the relationships between their health, environmental, economic, and social impacts. Greater use of explicit theoretical frameworks could assist in research design and interpretation, helping to ensure its relevance to informing coordinated intersectoral interventions and policy initiatives.

Cross-Sectional Association of Food Source with Food Insecurity, Dietary Diversity and Body Mass Index in Western Kenya.

The triple burden of malnutrition in many low- and middle-income countries (LMICs) is partly a result of changing food environments and a shift from traditional diets to high-calorie Western-style diets. Exploring the relationship between food sources and food- and nutrition-related outcomes is important to understanding how changes in food environments may affect nutrition in LMICs. This study examined associations of household food source with household food insecurity, individual dietary diversity and individual body mass index in Western Kenya. Interview-administered questionnaire and anthropometric data from 493 adults living in 376 randomly-selected households were collected in 2019. Adjusted regression analyses were used to assess the association of food source with measures of food insecurity, dietary diversity and body mass index. Notably, participants that reported rearing domesticated animals for consumption ('own livestock') had lower odds of moderate or severe household food insecurity (odds ratio (OR) = 0.29 (95% CI: 0.09, 0.96)) and those that reported buying food from supermarkets had lower odds of moderate or severe household food insecurity (borderline significant, OR = 0.37 (95% CI: 0.14, 1.00)), increased dietary diversity scores (Poisson coefficient = 0.17 (95% CI: 0.10, 0.24)) and higher odds of achieving minimum dietary diversity (OR = 2.84 (95% CI: 1.79, 4.49)). Our findings provide insight into the relationship between food environments, dietary patterns and nutrition in Kenya, and suggest that interventions that influence household food source may impact the malnutrition burden in this context.

Impacts of a New Supermarket on Dietary Behavior and the Local Foodscape in Kisumu, Kenya: Protocol for a Mixed Methods, Natural Experimental Study.

BACKGROUND: Access to healthy food is considered a key determinant of dietary behavior, and there is mixed evidence that living near a supermarket is associated with a healthier diet. In Africa, supermarkets may contribute to the nutrition transition by offering both healthy and unhealthy foods and by replacing traditional food sellers. In Kisumu, Kenya, a planned hypermarket (ie, a supermarket combined with a department store) will form the basis for a natural experimental evaluation. OBJECTIVE: The aim of this study is to explore the impacts of a new hypermarket on food shopping practices, dietary behaviors, physical activity patterns, and body composition among local residents and to identify concurrent changes in the local foodscape. We also aim to explore how impacts and associations vary by socioeconomic status. METHODS: We employ a mixed methods, longitudinal study design. Two study areas were defined: the hypermarket intervention area (ie, Kisumu) and a comparison area with no hypermarket (ie, Homabay). The study is comprised of 4 pieces of primary data collection: a quantitative household survey with local residents, a qualitative study consisting of focus group discussions with local residents and semistructured interviews with government and private sector stakeholders, an audit of the local foodscape using on-the-ground data collection, and an intercept survey of shoppers in the hypermarket. Assessments will be undertaken at baseline and approximately 1 year after the hypermarket opens. RESULTS: Baseline assessments were conducted from March 2019 to June 2019. From a total sampling frame of 400 households, we recruited 376 of these households, giving an overall response rate of 94.0%. The household survey was completed by 516 individuals within these households. Across the two study areas, 8 focus groups and 44 stakeholder interviews were conducted, and 1920 food outlets were geocoded. CONCLUSIONS: This study aims to further the understanding of the relationship between food retail and dietary behaviors in Kenya. Baseline assessments for the study have been completed. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/17814.

The global diet and activity research (GDAR) network: a global public health partnership to address upstream NCD risk factors in urban low and middle-income contexts.

BACKGROUND: Non-communicable diseases (NCDs) are the leading cause of death globally. While upstream approaches to tackle NCD risk factors of poor quality diets and physical inactivity have been trialled in high income countries (HICs), there is little evidence from low and middle-income countries (LMICs) that bear a disproportionate NCD burden. Sub-Saharan Africa and the Caribbean are therefore the focus regions for a novel global health partnership to address upstream determinants of NCDs. PARTNERSHIP: The Global Diet and Activity research Network (GDAR Network) was formed in July 2017 with funding from the UK National Institute for Health Research (NIHR) Global Health Research Units and Groups Programme. We describe the GDAR Network as a case example and a potential model for research generation and capacity strengthening for others committed to addressing the upstream determinants of NCDs in LMICs. We highlight the dual equity targets of research generation and capacity strengthening in the description of the four work packages. The work packages focus on learning from the past through identifying evidence and policy gaps and priorities, understanding the present through adolescent lived experiences of healthy eating and physical activity, and co-designing future interventions with non-academic stakeholders. CONCLUSION: We present five lessons learned to date from the GDAR Network activities that can benefit other global health research partnerships. We close with a summary of the GDAR Network contribution to cultivating sustainable capacity strengthening and cutting-edge policy-relevant research as a beacon to exemplify the need for such collaborative groups.

Implications of COVID-19 control measures for diet and physical activity, and lessons for addressing other pandemics facing rapidly urbanising countries.

At the time of writing, it is unclear how the COVID-19 pandemic will play out in rapidly urbanising regions of the world. In these regions, the realities of large overcrowded informal settlements, a high burden of infectious and non-communicable diseases, as well as malnutrition and precarity of livelihoods, have raised added concerns about the potential impact of the COVID-19 pandemic in these contexts. COVID-19 infection control measures have been shown to have some effects in slowing down the progress of the pandemic, effectively buying time to prepare the healthcare system. However, there has been less of a focus on the indirect impacts of these measures on health behaviours and the consequent health risks, particularly in the most vulnerable. In this current debate piece, focusing on two of the four risk factors that contribute to >80% of the NCD burden, we consider the possible ways that the restrictions put in place to control the pandemic, have the potential to impact on dietary and physical activity behaviours and their determinants. By considering mitigation responses implemented by governments in several LMIC cities, we identify key lessons that highlight the potential of economic, political, food and built environment sectors, mobilised during the pandemic, to retain health as a priority beyond the context of pandemic response. Such whole-of society approaches are feasible and necessary to support equitable healthy eating and active living required to address other epidemics and to lower the baseline need for healthcare in the long term.