Uptake of community health care provision by community health entrepreneurs for febrile illness and diarrhoea: a cross-sectional survey in rural communities in Bunyangabu district, Uganda.

OBJECTIVE: To assess the uptake of services provided by community health workers who were trained as community health entrepreneurs (CHEs) for febrile illness and diarrhoea. DESIGN: A cross-sectional survey among households combined with mapping of all providers of basic medicine and primary health services in the study area. PARTICIPANTS: 1265 randomly selected households in 15 rural villages with active CHEs. SETTING: Bunyangabu district, Uganda. OUTCOME MEASURES: We describe the occurrence and care sought for fever and diarrhoea in the last 3 months by age group in the households. Care provider options included: CHE, health centre or clinic (public or private), pharmacy, drug shop and other. Geographic Information Ssystem (GIS)-based geographical measures were used to map all care providers around the active CHEs. RESULTS: Fever and diarrhoea in the last 3 months occurred most frequently in children under 5; 68% and 41.9%, respectively. For those who sought care, CHE services were used for fever among children under 5, children 5-17 and adults over 18 years of age in 34.7%, 29.9% and 25.1%, respectively. For diarrhoea among children under 5, children 5-17 and adults over 18 years of age, CHE services were used in 22.1%, 19.5% and 7.0%, respectively. For those who did not seek care from a CHE (only), drug shops were most frequently used services for both fever and diarrhoea, followed by health centres or private clinics. Many households used a combination of services, which was possible given the high density and diversity of providers found in the study area. CONCLUSIONS: CHEs play a considerable role in providing care in rural areas where they are active. The high density of informal drug shops and private clinics highlights the need for clarity on the de facto roles played by different providers in both the public and private sector to improve primary healthcare.

Using telehealth to support community health workers in Uganda during COVID-19: a mixed-method study.

BACKGROUND: At the onset of the COVID-19 pandemic, a local consortium in Uganda set up a telehealth approach that aimed to educate 3,500 Community Health Workers (CHW) in rural areas about COVID-19, help them identify, refer and care for potential COVID-19 cases, and support them in continuing their regular community health work. The aim of this study was to assess the functioning of the telehealth approach that was set up to support CHWs during the COVID-19 pandemic. METHODS: For this mixed-method study, we combined analysis of routine consultation data from the call-center, 24 interviews with key-informants and two surveys of 150 CHWs. Data were analyzed using constant comparative method of analysis. RESULTS: Between March 2020 and June 2021, a total of 35,553 consultations took place via the call center. While the CHWs made extensive use of the call center, they rarely asked for support for potential Covid-19 cases. According to the CHWs, there were no signs that people in their communities were suffering from severe health problems due to COVID-19. People compared the lack of visible symptoms to diseases such as Ebola and were skeptical about the danger of COVID-19. At the same time, people in rural areas were afraid to report relevant symptoms and get tested for fear of being quarantined and stigmatized. The telehealth approach did prove useful for other purposes, such as supporting CHWs with their regular tasks and coordinating the supply of essential products. The health professionals at the call center supported CHWs in diagnosing, referring and treating patients and adhering to infection prevention and control practices. The CHWs felt more informed and less isolated, saying the support from the call center helped them to provide better care and improved the supply of medicine and other essential health products. CONCLUSIONS: The telehealth approach, launched at the start of the COVID-19 pandemic, provided useful support to thousands of CHWs in rural communities in Uganda. The telehealth approach could be quickly set up and scaled up and offers a low cost strategy for providing useful and flexible support to CHWs in rural communities.

Worldwide Vaccination Willingness for COVID-19: A Systematic Review and Meta-Analysis.

Countries across the globe are currently experiencing a third or fourth wave of SARS-CoV-2 infections; therefore, the need for effective vaccination campaigns is higher than ever. However, effectiveness of these campaigns in disease reduction is highly dependent on vaccination uptake and coverage in susceptible populations. Therefore, this systematic review and meta-analysis estimated the vaccination intention and identified determinants of willingness and hesitancy. This study updates the existing body of literature on vaccination willingness, and was conducted according to the PRISMA guidelines. PubMed was searched for publications, selecting only studies published between 20 October 2020 and 1 March 2021, in English, with participants aged >16 years of age. The search identified 411 articles, of which 63 surveys were included that accounted for more than 30 countries worldwide. The global COVID-19 vaccination willingness was estimated at 66.01% [95% CI: 60.76-70.89% I2 = 99.4% [99.3%; 99.4%]; τ2 = 0.83]. The vaccination willingness varied within as well as between countries. Age, gender, education, attitudes and perceptions about vaccines were most frequently observed to be significantly associated with vaccine acceptance or refusal.

Nutrient density, but not cost of diet, is associated with anemia and iron deficiency in school-age children in South Africa.

OBJECTIVES: This study aimed to investigate the relationship of nutrient density and diet cost with anemia and iron deficiency (ID) in children. METHODS: Dietary intake data of 5- to 12-y-old children (n = 578) from three independent studies in low-income communities were pooled. Nutrient densities were calculated using the Nutrient Rich Foods index and Nutrient Rich Diet index, with higher scores indicating more nutrient-dense foods and diets. Food prices and food intake data were used to calculate ratios of nutrient density to price for foods and diets. Descriptive and correlation analyses examined associations of nutrient density and diet cost with anemia and ID. RESULTS: Most children (>50%) consumed starchy staples (100%), vegetables that are not vitamin A rich (63.9%), and legumes (58.1%), with mean NRF9.3 scores ranging from 31.9 to 56.3. Cheese, eggs, organ meat, fish, dark-green leafy vegetables, and vitamin A-rich vegetables and fruits had mean NRF9.3 scores ranging from 112.6 to 184.7, but each was consumed by less than a third of the children. Children with anemia or ID had lower NRD9.3 scores than children without (P < 0.001 and P = 0.039, respectively). Diet cost did not differ according to anemia and iron status, but nutrient-density-to-price ratio was lower in children with anemia than without (P = 0.001). CONCLUSIONS: Careful selection of nutrient-dense foods as substitutes for foods with lower nutrient density could make it possible for children to consume a diet richer in specific nutrients and help prevent anemia and ID without affecting diet cost.

Associations of dietary diversity with anaemia and iron status among 5- to 12-year-old schoolchildren in South Africa.

OBJECTIVE: To examine the associations of dietary diversity with anaemia and iron status among primary school-aged children in South Africa. DESIGN: An analysis was conducted with pooled individual data from the baseline surveys from three previously conducted independent intervention studies. Two different dietary diversity scores (DDS) were calculated based on data from 1-day (1-d) and 3-day (3-d) dietary recall periods, respectively. Logistic regression analysis was performed to examine the associations of dietary diversity with anaemia and iron status. SETTING: KwaZulu-Natal and North West provinces, South Africa. PARTICIPANTS: Children (n 578) 5- to 12-year-old. RESULTS: A DDS ≤ 4 was associated with higher odds of being anaemic (1-d P = 0·001; 3-d P = 0·006) and being iron deficient (ID) (3-d P < 0·001). For both recall periods, consumption of 'vegetables and fruits other than vitamin A-rich' and 'animal-source foods (ASF)' was associated with lower odds of being anaemic (both P = 0·002), and 'organ meats' with lower odds of being ID (1-d P = 0·045; 3-d P < 0·001). Consumption of 'meat, chicken and fish' was associated with lower odds of being anaemic (P = 0·045), and 'vegetables and fruits other than vitamin A-rich', 'legumes, nuts and seeds' and 'ASF' with lower odds of being ID for the 3-d recall period only (P = 0·038, P = 0·020 and P = 0·003, respectively). CONCLUSION: In order to improve anaemia and iron status among primary school-aged children, dietary diversification, with emphasis on consumption of vegetables, fruits and ASF (including organ meats), should be promoted.

Adherence to Child Feeding Practices and Child Growth: A Retrospective Cohort Analysis in Cambodia.

Appropriate feeding in the first 1000 days of a child's life is critical for their health and growth. We determined associations between adherence to age-appropriate feeding practices and child growth in Cambodia. Children (n = 1079) were included in the first follow-up (FU) data analyses and followed for 30 months (six FUs). Data were analyzed by generalized linear mixed-effect models. Children who adhered to feeding practices on at least three FUs, with an adequate minimal dietary diversity (MDD), a minimal acceptable diet (MAD), and age-appropriate daily feeding (ADF) were less stunted (14.8%, 12.3%, and 6.4%, respectively) than children who never adhered to these indicators (25.2%, 30.1%, and 24.8%, respectively). A higher adherence to MDD and ADF was associated with a higher height-for-age Z-score (HAZ) (ß: 0.13, 95% CI: 0.01-0.25 and ß: 0.36, 95% CI: 0.22-0.50), while a higher adherence to the MDD and MAD was associated with a higher weight-for-height Z-score (WHZ) (ß: 0.19, 95% CI: 0.08-0.30; and ß: 0.16, 95% CI: 0.05-0.27). A higher adherence to a minimum meal frequency (MMF) was associated with a lower HAZ (ß: -0.99, 95% CI: -1.28--0.70). Our findings showed that to reduce wasting and stunting in Cambodia, interventions should focus on improving both the quality and quantity of food intake of children under two while targeting the whole complementary feeding period.

Nutrient patterns and their relation to anemia and iron status in 5- to 12-y-old children in South Africa.

OBJECTIVE: The aim of this study was to assess nutrient patterns and their relation to anemia and iron status of school children using pooled data from three study populations in South Africa. METHODS: Data from 5- to 12-y-old children (N = 578) from three independent studies conducted in two provinces in South Africa were pooled. Data used in the analysis were dietary intake, hemoglobin, and plasma ferritin concentrations. Nutrient patterns were determined using factor analysis. Logistic regression analysis was performed to determine relationships of nutrient patterns with anemia and iron deficiency. RESULTS: In the pooled group, 13.8% of the children were anemic and 27.7% were iron deficient (ID). More than half of children did not meet the Estimated Average Requirement for various nutrients, including vitamins A, C, B12, folate, and zinc, although only 17.7% of children had an iron intake below the requirements. Median intakes for vitamins A and C were lower for anemic than non-anemic children (P = 0.03 and 0.02, respectively) and for ID versus non-ID children (P = 0.03 and 0.046, respectively). Four nutrient patterns were identified: plant protein, carbohydrate, iron, and B vitamins; animal protein and saturated fat; vitamins A and B12; and calcium and fiber. The vitamin A and B12 nutrient pattern was associated with lower odds of being anemic (odds ratio, 0.63; 95% confidence interval, 0.49-0.91; P = 0.035). CONCLUSION: The present results highlighted the potential role of the combination of dietary vitamin A and B12 in the etiology of nutritional anemia in school-age children in South Africa. Nutrient pattern analysis may improve the understanding of the synergistic role of nutrients related to anemia and may assist in planning intervention strategies.

Effect of African leafy vegetables on the micronutrient status of mildly deficient farm-school children in South Africa: a randomized controlled study.

OBJECTIVE: A randomized controlled trial was conducted to assess the effect of African leafy vegetable (ALV) consumption on Fe, Zn and vitamin A status in children. DESIGN: Children were randomly allocated to receive either a 300 g cooked ALV dish and school meal starch (n 86) or the normal school meal (n 81) five times per week for three months. ALV in the dish consisted mainly of Amaranthus cruentus (at least 80 %) and the remainder of Cleome gynandra, Cucurbita maxima or Vigna unguiculata. Nutrient content and consumer acceptance of the ALV dish were also determined. SETTING: North West Province, South Africa. SUBJECTS: Grade R to grade 4 children (6-12 years old) of two farm schools. RESULTS: The ALV dish contributed 11·6-15·8 mg Fe and 1·4-3·7 mg Zn. At baseline, prevalence of deficiencies in the intervention group was 16·0 %, 16·3 %, 7·0 % and 75·6 %, respectively, for anaemia (Hb<11·5 g/dl), Fe (serum ferritin<15 µg/l), vitamin A (serum retinol<20 µg/dl) and Zn (serum Zn<65 µg/dl); and in the control group 10·5 %, 18·5 %, 2·5 % and 75·3 %, respectively. No significant estimated intervention effect was found. CONCLUSIONS: This randomized controlled trial showed that ALV were unable to improve serum retinol, serum ferritin or Hb if there are only mild deficiencies present. Furthermore, despite the low Zn status in the study population, ALV consumption did not improve serum Zn concentrations either.

Potential contribution of African green leafy vegetables and maize porridge composite meals to iron and zinc nutrition.

OBJECTIVES: The aim of this study was to determine the mineral nutritive value of different traditional African green leafy vegetable (GLV) dishes and their composite meals with fortified and unfortified maize porridge. METHODS: The mineral (iron, zinc, and calcium) and antinutrient (phytate, total phenolics, and tannins) contents and in vitro bioaccessibility of iron and zinc were analyzed. The iron and zinc contents and bioaccessibilities were used to calculate contribution these dishes and meals could make toward the recommended daily requirements and absolute requirements of vulnerable populations. RESULTS: It was found that the GLV dishes contained average amounts of zinc (2.8-3.2 mg/100 g, dry base [db]), but were high in both iron (12.5-23.4 mg/100 g, db) and antinutrients (phytate 1420-2089 mg/100 g, db; condensed tannins 105-203 mg/100 g, db). The iron bioaccessibility and amount of bioaccessible iron ranged between 6.7% and 45.2% and 0.9 and 5.11 mg/100 g, db, respectively. The zinc bioaccessibility and amount of bioaccessible zinc ranged between 6.4% and 12.7% and 0.63 and 1.63 mg/100 g, db, respectively. CONCLUSION: Importantly, although compositing the GLV dishes with fortified maize porridges decreases the iron and zinc contents, because of the low antinutrient content of the maize meal, the amount of bioaccessible iron and zinc in the meal increases.

Indigenous and traditional plants: South African parents' knowledge, perceptions and uses and their children's sensory acceptance.

BACKGROUND: The dietary shift from indigenous and traditional plants (ITPs) to cash crops and exotic plant food sources increases the risk of malnutrition and other nutrition-related non-communicable diseases, especially in poor rural communities. Farm communities in South Africa have been associated with poor nutritional status and extreme poverty. ITPs have been found to be affordable sources of several micronutrients. However, knowledge of and the use of these plants are declining, and little is known about the child's acceptance of dishes prepared with ITPs. This knowledge can be used to improve the general acceptance of ITPs. This study aimed to gain insight into parents' knowledge and perceptions and their use of ITPs in a farming community in the North West Province and to assess children's acceptance of and preference for dishes made with African leafy vegetables (ALVs) and Swiss chard. METHODS: Parents (n = 29) responsible for food preparation for children in grade 2 to 4 in two schools were purposively selected for four focus group discussions. A sensory evaluation assessed the children's (n = 98) acceptance of, preference for and intended consumption of dishes made with leafy vegetables. The dishes were made of Amaranthus spp., Cleome gynandra, Cucurbita maxima, Vigna unguiculata and Beta vulgaris. RESULTS: Parents mentioned 30 edible ITPs during the focus group discussions. Parents had knowledge of available ITPs and their use as food. Location, seasonal variation and rainfall affected the availability of and access to ITPs. Sun-dried ITPs were stored in sacks for later use. ITPs were perceived as healthy, affordable and delicious, hence acceptable to the parents. The children also evaluated the dishes made with ALVs as acceptable in terms of colour, smell and taste. Swiss chard was preferred, most likely because of the children's exposure to this vegetable. Children indicated that they would like to eat these leafy vegetables twice a week. CONCLUSION: These results look promising for the promotion of ITPs as a strategy to reduce malnutrition in rural farm communities and for potential inclusion of these micronutrient-rich ALVs in school feeding programmes to improve the nutritional status of children.

Differences in health care seeking behaviour between rural and urban communities in South Africa.

OBJECTIVE: The aim of this study was to explore possible differences in health care seeking behaviour among a rural and urban African population. DESIGN: A cross sectional design was followed using the infrastructure of the PURE-SA study. Four rural and urban Setswana communities which represented different strata of urbanisation in the North West Province, South Africa, were selected. Structured interviews were held with 206 participants. Data on general demographic and socio-economic characteristics, health status, beliefs about health and (access to) health care was collected. RESULTS: The results clearly illustrated differences in socio-economic characteristics, health status, beliefs about health, and health care utilisation. In general, inhabitants of urban communities rated their health significantly better than rural participants. Although most urban and rural participants consider their access to health care as sufficient, they still experienced difficulties in receiving the requested care. The difference in employment rate between urban and rural communities in this study indicated that participants of urban communities were more likely to be employed. Consequently, participants from rural communities had a significantly lower available weekly budget, not only for health care itself, but also for transport to the health care facility. Urban participants were more than 5 times more likely to prefer a medical doctor in private practice (OR:5.29, 95% CI 2.83-988). CONCLUSION: Recommendations are formulated for infrastructure investments in rural communities, quality of health care and its perception, improvement of household socio-economical status and further research on the consequences of delay in health care seeking behaviour.

Pressure cooker ownership and food security in Aurangabad, India.

OBJECTIVE: To explore associations between household food security and home gardening, use of soya and pressure cooker ownership in low-income households affected by HIV/AIDS in Aurangabad, India. DESIGN: Cross-sectional pilot study which assessed household food security using the validated US Department of Agriculture's food security core-module questionnaire. Questions were added to explore household environment, education, occupation, home gardening, use of soya and pressure cooker ownership. Households with very low v. low food security were compared using logistic regression analysis, controlling for confounding by socio-economic status. SETTING: Aurangabad is an urban setting situated in a primarily agricultural dependent area. The study was carried out in 2008, at the peak of the global food crisis. SUBJECTS: Adult caregivers of children affiliated with the Network of People Living with HIV/AIDS in Aurangabad. RESULTS: All except for one of 133 households were identified as food insecure (99.2 %). Of these households, 35.6 % had to cut size or skip a meal in the past 30 d. Households that cut meal size due to cooking fuel shortages were more likely to have very low food security (OR = 4.67; 95 % CI 1.62, 13.44) compared with households having no cooking fuel shortages. Owning a pressure cooker was shown to be protective against very low food security after controlling for confounding by socio-economic status (OR = 0.27; 95 % CI 0.11, 0.64). CONCLUSIONS: Only pressure cooker ownership showed a protective association with low household food security. Pressure cookers save household fuel costs. Therefore, future interventions should explore pressure cookers as a sustainable means of improving household food security.