Decolonizing study-abroad programs in nursing in low- and middle-income countries.

Study abroad programs expose scholars, including nursing faculty and students, to different settings and cultures. However, the world of global health is rooted in colonial practices that have the potential to cause harm to communities. In this reflection, we provide lessons we have learned through study abroad that guide strategies for decolonizing our practice while working toward cultural safety and humility. We utilized a qualitative case study method. Authors discussed and reviewed study abroad programs through a series of virtual discussions. Discussions showed that study abroad programs present opportunities for students and faculty to grow and learn. However, unacknowledged privileges among visiting students and faculty, and lack of understanding of the impacts of colonialism, may lead to harm in communities and inequitable relationships with local providers. Understanding the privileges that we hold is important in advancing positive and equitable experiences in study abroad programs.

Developing a framework for interprofessional collaborative practice, cultural fluency, and ecological approaches to health.

This paper describes the development of a framework for reducing health disparities inclusive of interprofessional collaborative practice, cultural humility, and ecological approaches to health; the identification of common core competencies for students from various disciplines; and relevant assessment instruments to measure attainment of those competencies. The framework, associated logic model and initiatives, and core competencies were created through an iterative process involving multiple stakeholders. Using the framework as the outcome, a logic model was created to identify short, medium, and long-term activities and outcomes. Faculty were involved in the identification of core competencies and relevant validated assessment instruments. Future work will include mapping competencies across the curricula in a school of health at a liberal arts university and longitudinal assessment of students to evaluate attainment of competencies.

Development and evaluation of an interprofessional community health course in Zambia.

Persistent global health inequities and workforce shortage require innovative strategies to prepare professionals for teamwork in a global context. Over two years, students (n = 33) from education, nursing, occupational therapy, public health, and physical therapy participated in a course in Zambia that emphasized interprofessional collaborative practice (IPP), cultural fluency, and understanding ecological approaches to health. Faculty measured the learning outcomes of the course using the Interprofessional Education Collaborative (IPEC) Competency Self-Assessment Tool (pre and posttest), and a focus group to gain a deeper understanding of the student experience and course effectiveness. The Beliefs, Events and Values Inventory (BEVI) was used post trip to determine feasibility of distribution and response of the tool via e-mail. These preliminary results suggested that students developed skills and knowledge related to IPP, cultural fluency, and ecological approaches to health. Specifically, students acknowledged growth in their ability to communicate more effectively with other health professions, and ability to evaluate personal assumptions and biases toward health, healthcare, and cultural practices. The method of developing this course could be a model for other institutions wanting to grow IPP experiences for their students.

Using community-based interventions to reduce public stigma of children with disabilities: A feasibility study.

BACKGROUND: Public stigma, or negative community-held beliefs, about children with disabilities (CWDs) often leads to negative outcomes for CWD and their families. This study considers the effectiveness of four community-level interventions to reduce public stigma in two Lusaka, Zambia communities. METHODS: This feasibility study describes four community-based interventions to provide education to consider whether perceptions of attitudes and stigma towards CWD changed after implementing four educational interventions. RESULTS: Results revealed that these interventions were achievable. Preliminary multiple regression analyses indicated a significant impact of attending an event on the attitude scale, while no effect on the stigma scale. Presence at multiple anti-stigma events exhibited no effect for the stigma scale, while the attitude scale showed significance. DISCUSSION: This study builds on the limited research available in low-income countries to reduce public stigma towards CWD, with the hope of enhance quality of life for CWD and their families.

Evaluating the cross-cultural validity of three family quality of life sub-scales.

BACKGROUND: Families of children with disabilities often face unique challenges. Developed in a U.S. context, the Beach Center Family Quality of Life measure assesses the effectiveness of supports and services that families receive. This study examines whether items from three sub-scales of the Beach Center instrument perform similarly for two samples, one from Lusaka, Zambia, and the second from a Midwestern U.S. state. METHODS: This cross-sectional research used secondary data and completed hierarchical ordinal regression analyses on item-level performance within the sub-scales. RESULTS: Only one item flagged for potential item bias with remaining items performing similarly when controlling for overall sub-scale scores. CONCLUSIONS: This study extends existing research on the cultural and linguistic appropriateness of the Beach Center measure, providing additional validity evidence about the internal structure of the scales. Findings indicate that these items are acceptable outcome measures for policy and programme evaluations in Zambia.

Description of the home food environment in Black, White, Hmong, Latino, Native American and Somali homes with 5-7-year-old children.

OBJECTIVE: To categorize the home food environment and dietary intake of young children (5-7 years old) from racially/ethnically diverse households using objectively collected data. DESIGN: Cross-sectional study. SETTING: In-home observations in Minneapolis/Saint Paul, Minnesota, USA. SUBJECTS: Families with 5-7-year-old children who identified as Black, White, Hmong, Latino, Native American or Somali. RESULTS: There were many significant differences by race/ethnicity for child dietary intake and for the home food environment, with specific patterns emerging by race/ethnicity. For example, Somali children had high Healthy Eating Index-2010 (HEI-2010) scores, but low daily intakes of fruits and vegetables. Black children had low HEI-2010 scores and a pattern of low intake of healthful foods and high intake of unhealthful foods. White and Latino families had high levels of both healthful and unhealthful home food availability and children with high HEI-2010 scores. CONCLUSIONS: Results indicate that the home food environment of young children varies across racial/ethnic group. Study findings also provide new information regarding the home food environment of young children in previously understudied racial/ethnic groups and indicate that interventions working to improve the home food environment and dietary intake of children may want to consider race/ethnicity.

Increasing Social Support for Breakfast: Project BreakFAST.

High school students in the United States are known to be frequent skippers of breakfast. Social support is one key element needed to encourage adolescents to consume school breakfast. This article presents an analysis of the influence of a school policy and environment change intervention on the social support of adolescents to eat breakfast. METHOD: The intervention included school policy changes in 16 schools randomized to intervention and delayed-intervention conditions, in order to allow quick and easy access to breakfast as well as to allow breakfast consumption in classrooms and hallways; a School Breakfast Program marketing campaign to address normative and attitudinal beliefs; and increasing social support and role modeling to encourage breakfast eating. The participants in the study completed an online survey at baseline and again postintervention. RESULTS: The final analysis included only students who completed the relevant survey (n = 904) items on both the baseline and follow-up surveys. The students in the intervention group showed a higher level of social support post intervention than the control group with a significant adjusted p of .02. Most of the overall social support change was explained by a change in the "other kids at my school" and "other school staff" categories. CONCLUSIONS: The BreakFAST study shows the benefits of school staff and kids other than friends supporting a behavior change to include breakfast consumption in adolescents.

How we eat what we eat: identifying meal routines and practices most strongly associated with healthy and unhealthy dietary factors among young adults.

OBJECTIVE: (i) To examine associations between young adults' meal routines and practices (e.g. food preparation, meal skipping, eating on the run) and key dietary indicators (fruit/vegetable, fast-food and sugar-sweetened beverage intakes) and (ii) to develop indices of protective and risky meal practices most strongly associated with diet. DESIGN: Cross-sectional survey. SETTING: Minneapolis/St. Paul metropolitan area, Minnesota (USA). SUBJECTS: A diverse sample of community college and public university students (n 1013). RESULTS: Meal routines and practices most strongly associated with healthy dietary patterns were related to home food preparation (i.e. preparing meals at home, preparing meals with vegetables) and meal regularity (i.e. routine consumption of evening meals and breakfast). In contrast, factors most strongly associated with poor dietary patterns included eating on the run, using media while eating and purchasing foods/beverages on campus. A Protective Factors Index, summing selected protective meal routines and practices, was positively associated with fruit/vegetable consumption and negatively associated with fast-food and sugar-sweetened beverage consumption (P<0·001). A Risky Factors Index yielded significant, positive associations with fast-food and sugar-sweetened beverage consumption (P<0·001). The probability test for the association between the Risky Factors Index and fruit/vegetable intake was P=0·05. CONCLUSIONS: Meal routines and practices were significantly associated with young adults' dietary patterns, suggesting that ways in which individuals structure mealtimes and contextual characteristics of eating likely influence food choice. Thus, in addition to considering specific food choices, it also may be important to consider the context of mealtimes in developing dietary messaging and guidelines.

Predictors of developmental status in young children living in institutional care in Kazakhstan.

The main objective of this study was to assess the developmental status of children living in the severely adverse environment of institutional care and the examination of risk factors with regard to developmental status, including degree of stunting and emotional-behavioral and anemia status. The Bayley Scales of Infant Development were used to assess development status in 103 children aged 14.9 months (SD = 6.8) in six Kazakh institutions. The Behavioral Rating Scales were used to assess emotional-behavioral regulation. Physical growth measures were converted to z scores using World Health Organization growth charts. Venous blood was collected for assessment of anemia. Our findings indicated that young children in institutions were developmentally compromised, with duration of institutional care correlated with the severity of delay. Negative predictors of developmental status included: Poor emotional-behavioral regulation, degree of stunting and age at assessment. A particularly large percentage of children were found to be anemic. Additionally, low birth weight was found to be a significant negative predictor of development. Our findings indicate that institutional care has a detrimental impact on the development and emotional regulation of young children. Time in institutional care is a negative predictor for cognitive status for children placed at birth. Moreover stunting was found to be a useful indicator of the degree of impact of early adversity on cognitive development. Particular attention is needed for special-needs children such as those with low birth weight, since their development was found to be more sensitive to early adversity than that of normal birth weight children.

Growth, nutritional, and developmental status of young children living in orphanages in Kazakhstan.

This article describes the nutritional and developmental status of young children living in Baby Houses (orphanages for children ages 0-3 years) in Kazakhstan. In 2009/2010, 308 children under age 3 years living in 10 Baby Houses were measured for height/length and weight. The Bayley Scales of Infant Development (N. Bayley, 2006) were used to assess mental and motor development. Blood was collected on a subsample to assess key nutritional factors. The World Health Organization growth charts were used to calculate Z-scores. Cut points for wasting (moderate to severe low weight for length/height growth), underweight (low weight for age), stunting (low length/height for age), development, and biomarkers used established guidelines. Most (n = 286) children had complete data on z-scores. Of these, 22.1% were experiencing wasting, 31.5% were underweight, and 36.7% had stunting. The nutritional status of the children, based on blood biomarkers, revealed that 37.1% of the children were anemic, 21.4% had low albumin, 38.1% had low vitamin D, 5.5% were iodine-deficient, and 2% had low serum zinc. One half had mild to significant mental and motor delays. Children living at these Baby Houses in Kazakhstan have substantial nutritional deficits and developmental delays. Focused attention is needed to provide a nutritionally enhanced diet and improved developmental opportunities to improve the long-term outcomes for these children.

Validation of a home food inventory among low-income Spanish- and Somali-speaking families.

OBJECTIVE: To refine and validate an existing home food inventory (HFI) for low-income Somali- and Spanish-speaking families. DESIGN: Formative assessment was conducted using two focus groups, followed by revisions of the HFI, translation of written materials and instrument validation in participants' homes. SETTING: Twin Cities Metropolitan Area, Minnesota, USA. SUBJECTS: Thirty low-income families with children of pre-school age (fifteen Spanish-speaking; fifteen Somali-speaking) completed the HFI simultaneously with, but independently of, a trained staff member. Analysis consisted of calculation of both item-specific and average food group kappa coefficients, specificity, sensitivity and Spearman's correlation between participants' and staff scores as a means of assessing criterion validity of individual items, food categories and the obesogenic score. RESULTS: The formative assessment revealed the need for few changes/additions for food items typically found in Spanish-speaking households. Somali-speaking participants requested few additions, but many deletions, including frozen processed food items, non-perishable produce and many sweets as they were not typical food items kept in the home. Generally, all validity indices were within an acceptable range, with the exception of values associated with items such as 'whole wheat bread' (k = 0.16). The obesogenic score (presence of high-fat, high-energy foods) had high criterion validity with k = 0.57, sensitivity = 91.8%, specificity = 70.6% and Spearman correlation = 0.78. CONCLUSIONS: The revised HFI is a valid assessment tool for use among Spanish and Somali households. This instrument refinement and validation process can be replicated with other population groups.

The relationship of area-level sociodemographic characteristics, household composition and individual-level socioeconomic status on walking behavior among adults.

Understanding the contextual factors associated with why adults walk is important for those interested in increasing walking as a mode of transportation and leisure. This paper investigates the relationships between neighborhood-level sociodemographic context, individual level sociodemographic characteristics and walking for leisure and transport. Data from two community-based studies of adults (n=550) were used to determine the association between the area-sociodemographic environment (ASDE), calculated from U.S. Census variables, and individual-level SES as potential correlates of walking behavior. Descriptive statistics, mean comparisons and Pearson's correlations coefficients were used to assess bivariate relationships. Generalized estimating equations were used to model the relationship between ASDE, as quartiles, and walking behavior. Adjusted models suggest adults engage in more minutes of walking for transportation and less walking for leisure in the most disadvantaged compared to the least disadvantaged neighborhoods but adding individual level demographics and SES eliminated the significant results. However, when models were stratified for free or reduced cost lunch, of those with children who qualified for free or reduced lunch, those who lived in the wealthiest neighborhoods engaged in 10.7 minutes less of total walking per day compared to those living in the most challenged neighborhoods (p<0.001). Strategies to increase walking for transportation or leisure need to take account of individual level socioeconomic factors in addition to area-level measures.

Household Dietary Diversity among Households with and without Children with Disabilities in Three Low-Income Communities in Lusaka, Zambia.

The purpose of this manuscript is to describe household dietary diversity (HDDS) in Lusaka, Zambia between households with and without a child with a disability living in the same communities. Cross-sectional data were collected in three low-income compounds in September 2021. Participants included households with a child with a disability enrolled in Kusamala+, a community-based program, (n = 444) and a convenience sample of adults living in the same area without a child with a disability (n = 1027). The HDDS tool asked about food groups consumed in the past 24 h by people in the household. The responses were summed (yes = 1, no = 0), range 0-12. Individual dietary diversity scores (IDDSs) were calculated for children (0-8 items). Analysis included descriptive statistics and linear regression. Mean HDDS for the households with a child with a disability was 4.8 (SD 2.1) vs. 6.1 (SD = 2.2) among households without a child with a disability (p < 0.001). The individual score for children (IDDS) for households with children with disabilities was 2.6 (SD = 1.4) vs. 3.7 (SD = 1.6) for households without a child with a disability. Households with a child with a disability had a significantly lower HDDS and IDDS in unadjusted and adjusted models (p < 0.001). National policy must assure the most vulnerable populations, and often hidden, receive focused financial and food support.

The role of the arts on community mental health and cultural understanding in Addis Ababa, Ethiopia.

Background: In low-and middle-income countries, there are rising rates of depression and anxiety. In Ethiopia, depression and anxiety rates were rising before the COVID-19 pandemic, and the country faces ethnic discord and armed conflict. Novel community-based strategies are needed to improve mental health and cultural unity. The purpose of this research was to describe the role of a cultural center's art programming in mental health and cultural unity. Methods: This qualitative study conducted interviews and focus groups with audience members, artists, and staff at Fendika Cultural Center, Addis Ababa, in January 2023. Participants were recruited via word of mouth and purposive sampling. Focus groups and interviews led in English or Amharic were recorded, transcribed, and translated as needed. Questions included participant experiences with Fendika Cultural Center and how experiencing the arts at Fendika influences wellbeing. We used deductive analysis, guided by the Arts and Culture in Public Health Framework. Results: Two focus groups (n = 11 participants, five females and six males) and five key informant interviews (three females and two males) were completed. Findings suggested that the activities at Fendika were important for addressing individual depression and anxiety through the social and physical environments as well as the inherent cultural support and unity expressed through the arts. The themes were consistent with the Arts and Culture in Public Health Framework. Conclusion: The arts play an important role in positive mental health and cultural unity. Further research is needed to establish the generalizability, reach, and persistence of the impact of cultural centers on mental health cultural understanding.

A campus-based community clinic and food-shelf join efforts to reduce food insecurity using a One Health approach toward building a vibrant living system.

This report describes a One Health approach to address food insecurity among two distinct campus populations-college students and patients at a campus-based community health clinic serving Latine adults. The multidisciplinary collaboration includes college staff, faculty, and students, and the founders, both women-centered institutions. Organic community gardens located on and near campus property, pollinated by campus-based beehives, contribute local organic produce to a campus-based food shelf increasing food security and nutritional health for both populations. The One Health system modeled in this report is a step toward building a vibrant community and demonstrates how others can be a part of the larger One Health movement.

Multilevel predictors of adolescent physical activity: a longitudinal analysis.

BACKGROUND: To examine how factors from a social ecologic model predict physical activity (PA) among adolescents using a longitudinal analysis. METHODS: Participants in this longitudinal study were adolescents (ages 10-16 at baseline) and one parent enrolled in the Transdisciplinary Research on Energetics and Cancer-Identifying Determinants of Eating and Activity (TREC-IDEA) and the Etiology of Childhood Obesity (ECHO). Both studies were designed to assess a socio-ecologic model of adolescent obesity risk. PA was collected using ActiGraph activity monitors at two time points 24 months apart. Other measures included objective height and weight, adolescent and parent questionnaires on multilevel psychological, behavioral and social determinants of PA, and a home PA equipment inventory. Analysis was conducted using SAS, including descriptive characteristics, bivariate and stepped multivariate mixed models, using baseline adjustment. Models were stratified by gender. RESULTS: There were 578 adolescents with complete data. Results suggest few statistically significant longitudinal associations with physical activity measured as minutes of MVPA or total counts from accelerometers. For boys, greater self-efficacy (B = 0.75, p = 0.01) and baseline MVPA (B = 0.55, p < 0.01) remained significantly associated with MVPA at follow-up. A similar pattern was observed for total counts. For girls, baseline MVPA (B = 0.58, p = 0.01) and barriers (B = -0.32, p = 0.05) significantly predicted MVPA at follow-up in the full model. The full multilevel model explained 30% of the variance in PA among boys and 24% among girls. CONCLUSIONS: PA change in adolescents is a complex issue that is not easily understood. Our findings suggest early PA habits are the most important predictor of PA levels in adolescence. Intervention may be necessary prior to middle school to maintain PA through adolescence.

Urban v. suburban perceptions of the neighbourhood food environment as correlates of adolescent food purchasing.

OBJECTIVE: To assess the relationship between adolescent perception of time to walk to neighbourhood food retail outlets and purchasing of sugar-sweetened beverages (SSB), fast and convenience food items, and to test for differences by urban v. suburban environment. DESIGN: Cross-sectional observational study. SETTING: Twin Cities Metropolitan Area, Minnesota, USA. SUBJECTS: Adolescents from two studies completed survey-based measures on perceptions of time to walk to food retail outlets from home, purchasing patterns of SSB and fast and convenience store items, perceptions of personal safety and pedestrian infrastructure, and demographic characteristics. Descriptive analysis, Spearman correlations and multivariate linear regression, accounting for clustering, were conducted. RESULTS: There were 634 adolescents, approximately half male, predominantly white, with a middle-class background. Greater perceived time to food outlets was associated with less frequent purchasing of SSB, convenience store foods and fast-food items. Multivariate models showed that a perceived shorter walking time (i.e. 1-5 v. 31+ min) was significantly associated with more SSB purchasing. SSB purchases were also significantly associated with the number of food outlets within a 10 min walk (B = 0·05, P = 0·02). CONCLUSIONS: A reduction in consumption of SSB and other energy-dense snacks is an important obesity prevention approach. An approach offering alternatives or reducing exposure in addition to education to alter purchasing habits may contribute to improving dietary habits and reducing the obesity epidemic.

Community-based intervention to reduce stigma for children with disabilities in Lusaka, Zambia: a pilot.

PURPOSE: This pilot intervention aims to reduce stigma towards children with disabilities living in family-based care. MATERIALS AND METHODS: Kusamala + is a pre-post evaluation of a pilot community-based intervention in two low-income compounds in Lusaka, Zambia. Door-to-door canvassing and community referrals were used to identify and enroll children with disabilities. Parents/guardians and community members completed surveys regarding stigma and support. Health professionals supervised, trained, and provided ongoing support for 2-3 community caregivers (CCGs). CCG's provided home-based education, referrals, playgroups, and social support for 20-25 families each. Community events were held at health facilities, churches and community spaces to reduce community-level stigma towards children with disabilities. RESULTS: Staff identified 632 children with disabilities. Staff completed over 4500 home visits, 288 children joined playgroups, made 775 referrals, and over 23,000 attended community sensitization events. Longitudinal data was available for 129 families with a child with a disability. Over one year, families and community members reported less perceived rejection by family and peers but less agreement that children with disabilities should be treated the same as other children. CONCLUSION: Kusamala + was a feasible, acceptable and broad reach with limited program impact. Future work will incorporate lessons learned with a focus on sustainability and scalability.Implications for rehabilitationChildren with disability are often hidden and isolated in low- and middle-income countries (LMIC), particularly in low-resource communities.Stigma towards children with disabilities continues in LMIC and further reduces that child's ability to engage fully in social and civic life.Community- and home-based programming is a feasible and acceptable approach to engaging with community and families with a child with a disability.The identification and referral of additional children with disabilities to physiotherapy and other government services can provide additional strain on already limited resources.Once a pilot program is deemed acceptable and feasible, any further design planning must include considerations for sustainability and scalability.System strengthening is a key component of sustainability and scalability to ensure success in planning, implementation, monitoring and evaluation.

Examining the relationships between family meal practices, family stressors, and the weight of youth in the family.

BACKGROUND: Research is limited on how the social environment of the home is related to childhood obesity. PURPOSE: The purpose of this research was to examine the relationships between positive family meal practices, family stressors, and the weight of youth and to examine parental weight status as a moderator of these relationships. METHODS: The study enrolled 368 parent/child dyads from a Minnesota sample. We used mediation analysis to examine the associations RESULTS: Families represented by an overweight parent reported fewer positive family meal practices (p < 0.001), higher levels of depression (p = 0.01), and fewer family rules (p = 0.02) as compared to families represented by a healthy weight parent. For overweight parents, positive family meal practices mediated the relationship between some family stressors and child weight. CONCLUSIONS: This research suggests that the home environment may affect the weight of children in the family, and the effect is more pronounced in families with at least one overweight parent.