Lauren S. Blum

Objective: Identifying factors that may influence aflatoxin exposure in children under 5 years of age living in farming households in western Kenya.Design: We used a mixed methods design. The quantitative component entailed serial cross-sectional interviews in 250 farming households to examine crop processing and conservation practices, household food storage and consumption and local understandings of aflatoxins. Qualitative data collection included focus group discussions (N 7) and key informant interviews (N 13) to explore explanations of harvesting and post-harvesting techniques and perceptions of crop spoilage.Setting: The study was carried out in Asembo, a rural community where high rates of child stunting exist.Participants: A total of 250 female primary caregivers of children under 5 years of age and thirteen experts in farming and food management participated.Results: Study results showed that from a young age, children routinely ate maize-based dishes. Economic constraints and changing environmental patterns guided the application of sub-optimal crop practices involving early harvest, poor drying, mixing spoiled with good cereals and storing cereals in polypropylene bags in confined quarters occupied by humans and livestock and raising risks of aflatoxin contamination. Most (80 %) smallholder farmers were unaware of aflatoxins and their harmful economic and health consequences.Conclusions: Young children living in subsistence farming households may be at risk of exposure to aflatoxins and consequent ill health and stunting. Sustained efforts to increase awareness of the risks of aflatoxins and control measures among subsistence farmers could help to mitigate practices that raise exposure.

Adequate intake of high‐quality nutritious foods during infancy and early childhood is critical to achieving optimal growth, cognitive and behavioural development, and economic productivity later in life. Integrating high‐quality and nutrient‐dense animal source foods (ASFs), a major source of protein and micronutrients, into children's diets is increasingly considered essential to reducing the global burden of malnutrition in low‐ and middle‐income countries. While eggs are an ASF that shows promise for mitigating child undernutrition, interventions promoting egg consumption among children have had mixed results in improving egg intake and child growth outcomes. As part of an evaluation of a demand creation campaign promoting egg consumption, qualitative research was carried out in September 2019 to assess sociocultural and household factors affecting egg intake among young children living in Kaduna State, Nigeria, where a thriving egg industry and childhood stunting rates of 50% exist. Methods included freelisting exercises (11), key informant interviews (11), in‐depth interviews (25) and FGDs (4). Results illuminated cultural rules that restrict egg consumption among children living in low‐income households. These rules and norms reflect social and economic valuations that foster male dominance in household decision‐making and guide food purchasing and intrahousehold food allocation that allow men to consume eggs more regularly. Study results highlight sociocultural considerations when selecting food interventions to address child malnutrition in low‐income contexts. Interventions encouraging increased consumption of ASFs, and specifically eggs in young children, should be informed by formative research to understand sociocultural norms and beliefs guiding egg consumption.

Uncertainty about the causes of death (COD) in low- and middle-income countries (LMICs) has been recognized as a constraint to global health and development. Although complete diagnostic autopsy (CDA) is the best way to assess COD, it is uncommon in LMICs because of low investment priority and assumptions about poor acceptability. Social science research was conducted from May 2016 through July 2017 to examine issues related to acceptability of CDAs in northern Tanzania where autopsy was being offered in two referral hospitals to assess COD from febrile illness. Initial formative research entailed 29 key informant interviews, seven observations of burial practices, and four group discussions. In-depth interviews were conducted with families of deceased, including nine families that accepted and 11 families that refused CDA. The formative research identified concepts related to death, understandings of CDA, and cultural practices and psychosocial considerations associated with death that informed the authorization process. Most families who accepted CDA cited the desire to get clarity regarding the COD as a primary reason for acceptance. An unexpected finding was that CDA is perceived as a means to determine witchcraft involvement, a common explanation for COD and a common reason for postmortem acceptance. Death resulting from chronic illness or conditions presumed to have a clinical diagnosis rendered CDA unnecessary. The timing, way families were approached, and content of information shared during authorization influenced acceptance and refusal of CDA. Findings show that CDAs can be acceptable in settings where traditional disease models prevail.

Infectious diseases are a leading cause of mortality in low- and middle-income countries (LMICs) despite effective treatments. To study the sociocultural and health system barriers to care, we conducted a qualitative social autopsy study of patients who died from febrile illness in northern Tanzania. From December 2016 through July 2017, we conducted in-depth interviews in Arusha and Kilimanjaro regions with a purposive sample of 20 family members of patients who had died at two regional referral hospitals. Of the deceased patients included in this study, 14 (70%) were adults and 10 (50%) were female. Patients identified their religion as Catholic (12, 60%), Lutheran (six, 30%), and Muslim (two, 10%), and their ethnicity as Chagga (14, 70%) and Sambaa (two, 10%), among others. Family members reported both barriers to and facilitators of receiving health care. Barriers included a perceived lack of capacity of local health facilities, transportation barriers, and a lack of formal referrals to higher levels of care. Family members also reported the cost of health care as a barrier. However, one facilitator of care was access to financial resources via families’ social networks—a phenomenon we refer to as social capital. Another facilitator of care was families’ proactive engagement with the health system. Our results suggest that further investment in lower level health facilities may improve care-seeking and referral patterns and that future research into the role of social capital is needed to fully understand the effect of socioeconomic factors on healthcare utilization in LMICs.

Background: Diarrhea and acute respiratory infections (ARI) account for 30% of deaths among children displaced due to humanitarian emergencies. A wealth of evidence demonstrates that handwashing with soap prevents both diarrhea and ARI. While socially- and emotionally-driven factors are proven motivators to handwashing in non-emergency situations, little is known about determinants of handwashing behavior in emergency settings. Methods: We conducted a qualitative investigation from June to August 2015 in a camp for internally displaced persons with a population of 6360 in the war-torn eastern region of the Democratic Republic of Congo. We held key informant interviews with 9 non-governmental organizations and camp officials, in-depth interviews and rating exercises with 18 mothers of children < 5 years, and discussions with 4 groups of camp residents and hygiene promoters to identify motivators and barriers to handwashing. Results: At the time of the study, hygiene promotion activities lacked adequate resources, cultural acceptability, innovation, and adaptation for sustained behavioral change. Lack of ongoing provision of hygiene materials was a major barrier to handwashing behavior. When hygiene materials were available, camp residents reported that the primary motivator to handwashing was to prevent illness, particularly diarrheal disease, with many mentioning an increased need to wash hands during diarrhea outbreaks. Emotionally- and socially-related motivators such as “maintaining a good image” and social pressure to follow recommended camp hygiene practices were also reported to motivate handwashing with soap. Residents who engaged in day labor outside the camp had limited exposure to hygiene messages and handwashing facilities. Interviewees indicated that the harsh living conditions forced residents to prioritize obtaining basic survival needs over good hygiene. Conclusions: Hygiene promotion in camp settings must involve preparedness of adequate resources and supplies and ongoing provision of hygiene materials so that vulnerable populations affected by emergencies can apply good hygiene behaviors for the duration of the camp’s existence. Compared to non-emergency contexts, illness-based messages may be more effective in emergency settings where disease poses a current and ongoing threat. However, failure to use emotive and social drivers that motivate handwashing may present missed opportunities to improve handwashing in camps.

Adolescence is a critical period characterized by rapid physical, psychological, and social development and growth. In Bangladesh, high rates of undernutrition persist among adolescent females living in low‐income households. Prevalence of adolescent marriage and pregnancy is extremely high, with almost half of Bangladeshi women giving birth by 18 years of age. Qualitative research was carried out from April to June 2017 to examine individual, social, and environmental factors influencing eating behaviours of female adolescents between 15 and 19 years of age living in low‐income families in urban and rural settings in Bangladesh. Methods included freelisting exercises (33), key informant interviews (11), in‐depth interviews (24), direct observations (16), and focus group discussions (12). Findings show that household food insecurity necessitates adjustments in meal food quality and frequency. Gender norms prescribe that females receive small meal portions and make sacrifices in food consumption so that male family members can eat more. Work and school schedules cause long breaks between meal consumption, restricting food intake of adolescent females for extended periods. Gender discrimination and its manifestations likely amplify susceptibility to psychological stresses in adolescent females. An inferior social position makes adolescent females living in food insecure households vulnerable to undernutrition, with factors affecting food deprivation increasing as they approach childbearing. Policies to increase age of marriage and reduce adolescent pregnancy must continue. Programmes must ensure that school‐going adolescents eat adequately during the school day. Prolonging school education and strengthening the economic viability of women should alter cultural expectations regarding marriage age and normative female roles.

Adolescence is a critical period characterized by physical, social, and developmental changes that impact on health and eating behaviour. Indonesia is experiencing dramatic economic and infrastructural changes, causing greater access to the global food industry and media. This transition is influencing food intake trends, leading to new nutritional challenges in adolescent girls. Qualitative research was conducted between November 2016 and January 2017 in five urban sites in Java, Indonesia, to examine individual, social, environmental, and macrosystem factors affecting snacking behaviours in unmarried adolescent girls 16–19 years of age. Methods entailed 30 freelisting exercises, nine key informant interviews, and 16 in‐depth interviews. Freelisting results identified over 200 snack foods, with the most salient processed convenience foods such as chips and cookies. Respondents typically snacked multiple times daily. Widespread availability of affordable and “tasty” snacks makes snack foods appealing meal substitutes. Snacks provide a distraction to boredom and loneliness and an enhancement to social gatherings. Girls exhibited limited understanding or concern about potential negative effects of snacking. Parents facilitate acquisition of nutrient‐poor snacks, whereas friends exert pressure for routine consumption of snack foods. Social media infiltrated with promotions of eateries and snack foods is likely contributing to the preponderance of snack food consumption. Routine consumption of snack foods high in sugar, salt, and fat and skipping meals will likely have long‐term consequences on the nutritional status and health of Indonesian adolescent girls. Findings underline the urgent need to develop contextually relevant, targeted behavioural change strategies to modify the potentially harmful eating and activity patterns of adolescent girls identified in this study and to curb the trajectory of overweight in urban Indonesia.

Refugees are at high risk for communicable diseases due to overcrowding and poor water, sanitation, and hygiene conditions. Handwashing with soap removes pathogens from hands and reduces disease risk. A hepatitis E outbreak in the refugee camps of Maban County, South Sudan in 2012 prompted increased hygiene promotion and improved provision of soap, handwashing stations, and latrines. We conducted a study 1 year after the outbreak to assess the knowledge, attitudes, and practices of the refugees in Maban County. We conducted a cross sectional survey of female heads of households in three refugee camps in Maban County. We performed structured observations on a subset of households to directly observe their handwashing practices at times of possible pathogen transmission. Of the 600 households interviewed, nearly all had soap available and 91 % reported water was available “always” or “sometimes”. Exposure to handwashing promotion was reported by 85 % of the respondents. Rinsing hands with water alone was more commonly observed than handwashing with soap at critical handwashing times including “before eating” (80 % rinsing vs. 7 % washing with soap) and “before preparing/cooking food” (72.3 % vs 23 %). After toilet use, 46 % were observed to wash hands with soap and an additional 38 % rinsed with water alone. Despite intensive messaging regarding handwashing with soap and access to soap and water, rinsing hands with water alone rather than washing hands with soap remains more common among the refugees in Maban County. This practice puts them at continued risk for communicable disease transmission. Qualitative research into local beliefs and more effective messaging may help future programs tailor handwashing interventions.

Typhoid fever affects an estimated 22 million people annually and causes 216,000 deaths worldwide. We conducted an investigation in August and September 2010 to examine the acceptability of typhoid vaccine in Neno District, Malawi where a typhoid outbreak was ongoing. We used qualitative methods, including freelisting exercises, key informant and in-depth interviews, and group discussions. Respondents associated illness with exposure to “bad wind,” and transmission was believed to be airborne. Typhoid was considered extremely dangerous because of its rapid spread, the debilitating conditions it produced, the number of related fatalities, and the perception that it was highly contagious. Respondents were skeptical about the effectiveness of water, sanitation, and hygiene (WaSH) interventions. The perceived severity of typhoid and fear of exposure, uncertainty about the effectiveness of WaSH measures, and widespread belief in the efficacy of vaccines in preventing disease resulted in an overwhelming interest in receiving typhoid vaccine during an outbreak.