Elizabeth G. Henry

An Urban Food Store Intervention Positively Affects Food-Related Psychosocial Variables and Food Behaviors

Obesity and other diet-related chronic diseases are more prevalent in low-income urban areas, which commonly have limited access to healthy foods. The authors implemented an intervention trial in nine food stores, including two supermarkets and seven corner stores, in a low-income, predominantly African American area of Baltimore City, with a comparison group of eight stores in another low-income area of the city. The intervention (Baltimore Healthy Stores; BHS) included an environmental component to increase stocks of more nutritious foods and provided point-of-purchase promotions including signage for healthy choices and interactive nutrition education sessions. Using pre- and postassessments, the authors evaluated the impact of the program on 84 respondents sampled from the intervention and comparison areas. Exposure to intervention materials was modest in the intervention area, and overall healthy food purchasing scores, food knowledge, and self-efficacy did not show significant improvements associated with intervention status. However, based on adjusted multivariate regression results, the BHS program had a positive impact on healthfulness of food preparation methods and showed a trend toward improved intentions to make healthy food choices. Respondents in the intervention areas were significantly more likely to report purchasing promoted foods because of the presence of a BHS shelf label. This is the first food store intervention trial in low-income urban communities to show positive impacts at the consumer level.

Prevalence of malnutrition in patients admitted to a major urban tertiary care hospital in Hanoi, Vietnam

OBJECTIVES To determine the prevalence of malnutrition using anthropometric measures among hospitalized pediatric and adult patients admitted at Bach Mai Hospital, Hanoi, Vietnam. METHODS A one-day cross-sectional survey was used in selected wards (Pediatrics, Surgery, Intensive Care Unit, Renal Diseases, Gastroenterology Diseases, Respiratory Diseases, and Endocrinology). Unavailable patients and those discharged within 24 hours were excluded. Anthropometric data included body weight, height (or length), and mid-upper arm circumference. The type, severity, and prevalence rate of malnutrition were defined based on World Health Organization (WHO) criteria. RESULTS The sample was hospitalized children and adults: 108 and 571 were children aged 6 months to 18.9 years old and adult patients, respectively. The overall rate of pediatric wasting (weight-for-height ≤ -2 SD or BMI ≤ -2 SD, kg/m²) was 19.0% (n= 19/100) and that of stunting (height-for-age ≤ -2 SD) was 13.9% (n=14/101). Using either the mid-upper arm circumference <11.5 cm or the weight-for-height and weight-for-length ≤ -3 SD, the rate of severe wasting among children aged 6-59 months old was 7.0% (n=3/43). None of the children were obese based on weight-for-length, weight-for-height, or BMI. In adults, the prevalence of under-nutrition (BMI<18.5 kg/m²) was 33.3% (n=141/423) while that of obesity (BMI ≥ 30 kg/m²) was 0.9% (n=4/423). Adults admitted to the Respiratory Diseases ward had the highest prevalence of under-nutrition, 40.9% (n=38/93). CONCLUSIONS The prevalence of malnutrition was high in this cohort of hospitalized patients, particularly in adults, but comparable to other published reports. Obesity was nearly nonexistent in both children and adults.

Addressing unmet need for long-acting family planning in Ethiopia: Uptake of single-rod progestogen contraceptive implants (Implanon) and characteristics of users

To describe women who accept single‐rod progestogen contraceptive implants (Implanon; N.V. Organon, Oss, Netherlands) from community health workers in Ethiopia and to assess whether community‐based provision addresses unmet need for contraception.

The influence of quality maternity waiting homes on utilization of facilities for delivery in rural Zambia

BackgroundResidential accommodation for expectant mothers adjacent to health facilities, known as maternity waiting homes (MWH), is an intervention designed to improve access to skilled deliveries in low-income countries like Zambia where the maternal mortality ratio is estimated at 398 deaths per 100,000 live births. Our study aimed to assess the relationship between MWH quality and the likelihood of facility delivery in Kalomo and Choma Districts in Southern Province, Zambia.MethodsWe systematically assessed and inventoried the functional capacity of all existing MWH using a quantitative facility survey and photographs of the structures. We calculated a composite score and used multivariate regression to quantify MWH quality and its association with the likelihood of facility delivery using household survey data collected on delivery location in Kalomo and Choma Districts from 2011–2013.ResultsMWH were generally in poor condition and composite scores varied widely, with a median score of 28.0 and ranging from 12 to 66 out of a possible 75 points. Of the 17,200 total deliveries captured from 2011–2013 in 40 study catchment area facilities, a higher proportion occurred in facilities where there was either a MWH or the health facility provided space for pregnant waiting mothers compared to those with no accommodations (60.7% versus 55.9%, p <0.001). After controlling for confounders including implementation of Saving Mothers Giving Life, a large-scale maternal health systems strengthening program, among women whose catchment area facilities had an MWH, those women with MWHs in their catchment area that were rated medium or high quality had a 95% increase in the odds of facility delivery than those whose catchment area MWHs were of poor quality (OR: 1.95, 95% CI 1.76, 2.16).ConclusionsImproving both the availability and the quality of MWH represents a potentially useful strategy to increasing facility delivery in rural Zambia.Trial registrationThe Zambia Chlorhexidine Application Trial is registered at Clinical Trials.gov (identifier: NCT01241318)

Listening to the community: Using formative research to strengthen maternity waiting homes in Zambia.

Background The WHO recommends maternity waiting homes (MWH) as one intervention to improve maternal and newborn health. However, persistent structural, cultural and financial barriers in their design and implementation have resulted in mixed success in both their uptake and utilization. Guidance is needed on how to design a MWH intervention that is acceptable and sustainable. Using formative research and guided by a sustainability framework for health programs, we systematically collected data from key stakeholders and potential users in order to design a MWH intervention in Zambia that could overcome multi-dimensional barriers to accessing facility delivery, be acceptable to the community and be financially and operationally sustainable. Methods and findings We used a concurrent triangulation study design and mixed methods. We used free listing to gather input from a total of 167 randomly sampled women who were pregnant or had a child under the age of two (n = 59), men with a child under the age of two (n = 53), and community elders (n = 55) living in the catchment areas of four rural health facilities in Zambia. We conducted 17 focus group discussions (n = 135) among a purposive sample of pregnant women (n = 33), mothers-in-law (n = 32), traditional birth attendants or community maternal health promoters (n = 38), and men with a child under two (n = 32). We administered 38 semi-structured interviews with key informants who were identified by free list respondents as having a stake in the condition and use of MWHs. Lastly, we projected fixed and variable recurrent costs for operating a MWH. Respondents most frequently mentioned distance, roads, transport, and the quality of MWHs and health facilities as the major problems facing pregnant women in their communities. They also cited inadequate advanced planning for delivery and the lack of access to delivery supplies and baby clothes as other problems. Respondents identified the main problems of MWHs specifically as over-crowding, poor infrastructure, lack of amenities, safety concerns, and cultural issues. To support operational sustainability, community members were willing to participate on oversight committees and contribute labor. The annual fixed recurrent cost per 10-bed MWH was estimated as USD543, though providing food and charcoal added another

Nutritional status and feeding practices in gastrointestinal surgery patients at Bach Mai Hospital, Hanoi, Vietnam

3,000USD. Respondents identified water pumps, an agriculture shop, a shop for baby clothes and general goods, and grinding mills as needs in their communities that could potentially be linked with an MWH for financial sustainability. Conclusions Findings informed the development of an intervention model for renovating existing MWH or constructing new MWH that meets community standards of safety, comfort and services offered and is aligned with government policies related to facility construction, ownership, and access to health services. The basic strategies of the new MWH model include improving community acceptability, strengthening governance and accountability, and building upon existing efforts to foster financial and operational sustainability. The proposed model addresses the problems cited by our respondents and challenges to MWHs identified by in previous studies and elicits opportunities for social enterprises that could serve the dual purpose of meeting a community need and generating revenue for the MWH.

Factors affecting home delivery among women living in remote areas of rural Zambia: a cross-sectional, mixed-methods analysis

BACKGROUND AND OBJECTIVES The nutritional status and hospital feeding practices of surgical patients in Vietnam are not well documented. Based on a cross-sectional study at Bach Mai Hospital (BMH), the prevalence of malnutrition was found to be 33% in the surgical ward using a body mass index (BMI<18.5 kg/m(2). We conducted an observational study over a three month period to evaluate the feeding practices in the gastrointestinal (GI) surgery ward at Bach Mai Hospital (BMH) in Hanoi, Vietnam. METHODS AND STUDY DESIGN Investigators from the U.S. and the Vietnamese National Institute of Nutrition (NIN) enrolled 72 subjects admitted for elective GI surgery in an observational study at BMH. Baseline anthropometrics and changes over time, body mass index (BMI), Subjective Global Assessment (SGA) and daily kcal and protein intake from oral diet, tube feeding, and parenteral nutrition (PN) from admission until discharge were documented. RESULTS A total of 50% of subjects scored a B or C on the SGA; 48% of subjects had a BMI<18.5, while mean mid upper arm circumference was in the lownormal range (24±4 cm). Nearly all patients (98%) were given PN postoperatively, with oral feeding starting on an average of postoperative day 4. Only one patient was tube fed. Mean daily total calorie intake was 15 kcal/kg/day and protein intake was 0.61 g/kg/day during hospitalization. Micronutrient supplementation was minimal in subjects receiving PN. CONCLUSIONS Hospital malnutrition in surgical patients in Vietnam is a significant problem, peri-operative feeding appears suboptimal and use of early postoperative PN was routine.

The impact of a multi-level maternal health programme on facility delivery and capacity for emergency obstetric care in Zambia

Purpose Access to skilled care and facilities with capacity to provide emergency obstetric and newborn care is critical to reducing maternal mortality. In rural areas of Zambia, 42% of women deliver at home, suggesting persistent challenges for women in seeking, reaching, and receiving quality maternity care. This study assessed the determinants of home delivery among remote women in rural Zambia. Methods A household survey was administered to a random selection of recently delivered women living 10 km or more from their catchment area health facility in 40 sites. A subset of respondents completed an in-depth interview. Multiple regression and content analysis were used to analyze the data. Results The final sample included 2,381 women, of which 240 also completed an interview. Households were a median of 12.8 km (interquartile range 10.9, 16.2) from their catchment area health facility. Although 1% of respondents intended to deliver at home, 15.3% of respondents actually delivered at home and 3.2% delivered en route to a facility. Respondents cited shorter than expected labor, limited availability and high costs of transport, distance, and costs of required supplies as reasons for not delivering at a health facility. After adjusting for confounders, women with a first pregnancy (adjusted OR [aOR]: 0.1, 95% CI: 0.1, 0.2) and who stayed at a maternity waiting home (MWH) while awaiting delivery were associated with reduced odds of home delivery (aOR 0.1, 95% CI: 0.1, 0.2). Being over 35 (aOR 1.3, 95% CI: 0.9, 1.9), never married (aOR 2.1, 95% CI: 1.2, 3.7), not completing the recommended four or more antenatal visits (aOR 2.0, 95% CI: 1.5, 2.5), and not living in districts exposed to a large-scale maternal health program (aOR 3.2, 95% CI: 2.3, 4.5) were significant predictors of home delivery. After adjusting for confounders, living nearer to the facility (9.5–10 km) was not associated with reduced odds of home delivery, though the CIs suggest a trend toward significance (aOR 0.7, 95% CI: 0.4, 1.1). Conclusion Findings highlight persistent challenges facing women living in remote areas when it comes to realizing their intentions regarding delivery location. Interventions to reduce home deliveries should potentially target not only those residing farthest away, but multigravida women, those who attend fewer antenatal visits, and those who do not utilize MWHs.

A novel tool for assessing primary care quality at the point of care in Vietnam

ABSTRACT In 2012, Saving Mothers, Giving Life (SMGL), a multi-level health systems initiative, launched in Kalomo District, Zambia, to address persistent challenges in reducing maternal mortality. We assessed the impact of the programme from 2012 to 2013 using a quasi-experimental study with both household- and health facility-level data collected before and after implementation in both intervention and comparison areas. A total of 21,680 women and 75 non-hospital health centres were included in the study. Using the difference-in-differences method, multivariate logistic regression, and run charts, rates of facility-based birth (FBB) and delivery with a skilled birth provider were compared between intervention and comparison sites. Facility capacity to provide emergency obstetric and newborn care was also assessed before and during implementation in both study areas. There was a 45% increase in the odds of FBB after the programme was implemented in Kalomo relative to comparison districts, but there was a limited measurable change in supply-side indicators of intrapartum maternity care. Most facility-level changes related to an increase in capacity for newborn care. As SMGL and similar programmes are scaled-up and replicated, our results underscore the need to ensure that the health services supply is in balance with improved demand to achieve maximal reductions in maternal mortality.

Trends in Nutrition Screening for Hospitalized Patients in Hanoi, Vietnam During a Four-year Clinical Nutrition Demonstration Project

Abstract Background: The development of improved primary care systems around the world has received increased attention as a step towards improved health care for all. Vietnam is engaged in efforts to improve health care quality with a focus on primary care and Family Medicine training. New methods of assessment are needed to accurately measure competency in primary care practice. Methods: A behaviourally-anchored rating scale was developed focused on core primary care principles for use in direct observation at the site of primary care delivery. This assessment tool was implemented with trainees in Family Medicine and a cohort of physicians not trained in Family Medicine. Results: The tool measured statistically significant differences in selected behaviours related to communication skills and comprehensiveness among Family Medicine trained physicians. No significant differences were measured in other primary care domains. Conclusion: This behaviourally-anchored rating scale is a feasible tool for use in direct observation of primary care practice delivery in developing settings. More work is needed to refine this tool and assess its sensitivity, validity and reliability.