Paula L. Griffiths

The burden of anemia among women in India

Objective: This research investigates the prevalence and determinants of anemia among women in Andhra Pradesh. We examined differences in anemia related to social class, urban/rural location and nutrition status body mass index (BMI). We hypothesized that rural women would have higher prevalence of anemia compared to urban women, particularly among the lower income groups, and that women with low body mass index (BMI; <18.5 kg/m2) would have a higher risk compared to normal or overweight women.Design: The National Family Health Survey 1998/99 (NFHS-2) provides nationally representative cross-sectional survey data on womens hemoglobin status, body weight, diet, social, demographic and other household and individual level factors. Ordered logit regression analyses were applied to identify socio-economic, regional and demographic determinants of anemia.Setting: Andhra Pradesh, a southern Indian state.Subjects: A total of 4032 ever-married women aged 15–49 from 3872 households.Results: Prevalence of anemia was high among all women. In all 32.4% of women had mild (100–109.99 g/l for pregnant women, 100–119.99 for non-pregnant women), 14.19% had moderate (70–99.99 g/l), and 2.2% had severe anemia (<70 g/l). Protective factors include Muslim religion, reported consumption of alcohol or pulses, and high socioeconomic status, particularly in urban areas. Poor urban women had the highest rates and odds of being anemic. Fifty-two percent of thin, 50% of normal BMI, and 41% of overweight women were anemic.Conclusion: New program strategies are needed, particularly those that improve the overall nutrition status of women of reproductive ages. This will require tailored programs across socio-economic groups and within both rural and urban areas, but particularly among the urban and rural poor.Sponsorship: Partial support for Margaret Bentley was provided by the Ford Foundation/India and the Carolina Population Center. Support for Paula Griffiths was provided by the Andrew W. Mellon Foundation.

UNDERSTANDING USERS’ PERSPECTIVES OF BARRIERS TO MATERNAL HEALTH CARE USE IN MAHARASHTRA, INDIA

This paper uses data collected using in-depth, semi-structured interviews to examine utilization of maternal health care services among two rural and urban populations of Pune and Mumbai in Maharashtra, India. The study aims to identify key social, economic and cultural factors influencing womens decisions to use maternal health care and the places used for child delivery, whilst considering the accessibility of facilities available in the local area. Socioeconomic status was not found to be a barrier to service use when women perceived the benefits of the service to outweigh the cost, and when the service was within reasonable distance of the respondents place of residence. A large number of women perceived private services to be superior to those provided by the government, although cost often meant they were unable to use them. The provision of services did not ensure that women used them; they had to first perceive them to be beneficial to their health and that of their unborn child. Respondents identified the poor quality of services offered at government institutions to be a motivating factor for delivering at home. Thus further investigation is needed into the quality of services provided by government facilities in the area. A number of respondents who had received antenatal care went on to deliver in the home environment without a trained birth attendant. Further research is needed to establish the types of care provided during an antenatal consultation to establish the feasibility of using these visits to encourage women, particularly those with high-risk pregnancies, to be linked to a trained attendant for delivery.

Cluster‐randomized trial on complementary and responsive feeding education to caregivers found improved dietary intake, growth and development among rural Indian toddlers

Inadequate feeding and care may contribute to high rates of stunting and underweight among children in rural families in India. This cluster-randomized trial tested the hypothesis that teaching caregivers appropriate complementary feeding and strategies for how to feed and play responsively through home-visits would increase childrens dietary intake, growth and development compared with home-visit-complementary feeding education alone or routine care. Sixty villages in Andhra Pradesh were randomized into three groups of 20 villages with 200 mother-infant dyads in each group. The control group (CG) received routine Integrated Child Development Services (ICDS); the complementary feeding group (CFG) received the ICDS plus the World Health Organization recommendations on breastfeeding and complementary foods; and the responsive complementary feeding and play group (RCF&PG) received the same intervention as the CFG plus skills for responsive feeding and psychosocial stimulation. Both intervention groups received bi-weekly visits by trained village women. The groups did not differ at 3 months on socioeconomic status, maternal and child nutritional indices, and maternal depression. After controlling for potential confounding factors using the mixed models approach, the 12-month intervention to the CFG and RCF&PG significantly (P < 0.05) increased median intakes of energy, protein, Vitamin A, calcium (CFG), iron and zinc, reduced stunting [0.19, confidence interval (CI): 0.0-0.4] in the CFG (but not RCF&PG) and increased (P < 0.01) Bayley Mental Development scores (mean = 3.1, CI: 0.8-5.3) in the RCF&PG (but not CFG) compared with CG. Community-based educational interventions can improve dietary intake, length (CFG) and mental development (RCF&PG) for children under 2 years in food-secure rural Indian families.

Maternal autonomy is inversely related to child stunting in Andhra Pradesh India.

Child stunting, an outcome of chronic undernutrition, contributes to poor quality of life, morbidity and mortality. In South Asia, the low status of women is thought to be one of the primary determinants of undernutrition across the lifespan. Low female status can result in compromised health outcomes for women, which in turn are related to lower infant birthweight and may affect the quality of infant care and nutrition. Maternal autonomy (defined as a womans personal power in the household and her ability to influence and change her environment) is likely an important factor influencing child care and ultimately infant and child health outcomes. To examine the relationship between maternal autonomy and child stunting in Andhra Pradesh, India, we analysed data from National Family Health Survey (NFHS)-2. We used cross-sectional demographic, health and anthropometric information for mothers and their oldest child <36 months (n = 821) from NFHS-2. The main explanatory variables of autonomy are presented by four dimensions - decision making, permission to travel, attitude towards domestic violence and financial autonomy - constructed using seven binary variables. Logistic regression models were used to test associations between indicators of female autonomy and the risk of having a stunted child. Women with higher autonomy {indicated by access to money [odds ratio (OR) = 0.731; 95% confidence interval (CI) 0.546, 0.981] and freedom to choose to go to the market [OR = 0.593; 95% CI 0.376, 0.933]} were significantly less likely to have a stunted child, after controlling for household socio-economic status and mothers education. In this south Indian state, two dimensions of female autonomy have an independent effect on child growth, suggesting the need for interventions that increase womens financial and physical autonomy.

Does maternal autonomy influence feeding practices and infant growth in rural India

The high prevalence of child under-nutrition remains a profound challenge in the developing world. Maternal autonomy was examined as a determinant of breast feeding and infant growth in children 3-5 months of age. Cross-sectional baseline data on 600 mother-infant pairs were collected in 60 villages in rural Andhra Pradesh, India. The mothers were enrolled in a longitudinal randomized behavioral intervention trial. In addition to anthropometric and demographic measures, an autonomy questionnaire was administered to measure different dimensions of autonomy (e.g. decision-making, freedom of movement, financial autonomy, and acceptance of domestic violence). We conducted confirmatory factor analysis on maternal autonomy items and regression analyses on infant breast feeding and growth after adjusting for socioeconomic and demographic variables, and accounting for infant birth weight, infant morbidity, and maternal nutritional status. Results indicated that mothers with higher financial autonomy were more likely to breastfeed 3-5 month old infants. Mothers with higher participation in decision-making in households had infants that were less underweight and less wasted. These results suggest that improving maternal financial and decision-making autonomy could have a positive impact on infant feeding and growth outcomes.

Gender, family, and the nutritional status of children in three culturally contrasting states of India

This paper has three main aims: to measure the clustering of children with low weight for age z-scores within families, to establish whether significant differences exist by gender in weight for age z-scores, and to demonstrate whether the presence of a mother-in-law in the household has any significant impact on the nutritional status of young children. Regression modelling is used to examine the weight for age z-scores of children under the age of four years in Maharashtra, Tamil Nadu and Uttar Pradesh using the 1992-93 Indian National Family Health Survey data. Random effects models measure the clustering of children with low weight for age z-scores in families, controlling for a number of other family factors. Our findings do not reveal significant gender differences in weight for age z-scores. Although little variation was found between family structures in the nutritional status of children, there were significant differences between families after controlling for family type. This suggests that there are differences between families that cannot be explained by a cross-sectional demographic survey. The evidence from this work suggests that nutrition programs need to adopt community nutrition interventions that aim resources at young children from families where children with low weight for age z-scores are found to cluster. However, there is a need for further inter-disciplinary research to collect data from families on behavioural factors and resource allocation in order that we might better understand why some families are more prone to having children with low weight for age z-scores. The diversity in the significant covariates between the three states in the models has shown the need for Indian nutrition programs to adopt state-specific approaches to tackling malnutrition.

Age at menarche and the evidence for a positive secular trend in urban South Africa.

Menarcheal age was estimated for 287 (188 Black; 99 White) urban South African girls born in Soweto‐Johannesburg in 1990. The median menarcheal age for Blacks was 12.4 years (95% confidence interval (CI) 12.2, 12.6) and 12.5 years (95% CI 11.7, 13.3) for Whites. Data from six studies of menarcheal age, including the current study, were analyzed to examine the evidence for a secular trend between 1956 and 2004 in urban South African girls. There was evidence of a statistically significant secular trend for Blacks, but not Whites. Average menarcheal age for Blacks decreased from 14.9 years (95% CI 14.8, 15.0) in 1956 to 12.4 years (95% CI 12.2, 12.6) in the current study, an average decline of 0.50 years per decade. Fewer data were available for Whites, but average menarcheal age decreased from 13.1 years (95% CI 13.0, 13.2) in 1977 to 12.5 years (95% CI 11.7, 13.3) in the current study, an average decline of 0.22 years per decade. The diminishing age at menarche and the current lack of difference between Blacks and Whites is probably reflective of the continuing nutritional and socio‐economic transition occurring within South Africa. Am. J. Hum. Biol., 2009.

Psychometric properties of the Hospital Survey on Patient Safety Culture: findings from the UK

Background Patient safety culture is measured using a range of survey tools. Many provide limited data on psychometric properties and few report findings outside of the US healthcare context. This study reports an assessment of the psychometric properties and suitability of the American Hospital Survey on Patient Safety Culture for use within the UK. Methods A questionnaire survey of three hospitals within a large UK Acute NHS Trust. 1437 questionnaires were completed (37% response rate). Exploratory factor analysis, confirmatory factor analysis and reliability analyses were carried out to assess the psychometric performance of this survey instrument and to explore potential improvements. Results Reliability analysis of the items within each proposed scale showed that more than half failed to achieve satisfactory internal consistency (Cronbachs α<0.7). Furthermore, a confirmatory factor analysis carried out on the UK data set achieved a poor fit when compared with the original American model. An optimal measurement model was then constructed via exploratory and confirmatory factor analyses with split-half sample validation and consisted of nine dimensions compared with the original 12 in the American model. Conclusion This is one of the few studies to provide an evaluation of an American patient safety culture survey using data from the UK. The results indicate that there is need for caution in using the Hospital Survey on Patient Safety Culture survey in the UK and underline the importance of appropriate validation of safety culture surveys before extending their usage to populations outside of the specific geographical and healthcare contexts in which they were developed.

Individual differences in food-cue reactivity. The role of BMI and everyday portion-size selections.

This study sought to explore the association between sensitivity to food cues (sight and smell of food) and (i) body weight (overweight or non-overweight), (ii) typical everyday portion sizes, and (iii) the DEBQ-restraint scale. One hundred and twenty female participants (aged between 18 and 30) were exposed to the sight and smell of pizza for three minutes. Both before and after this period, three measures of food-cue reactivity were taken (ratings of desire to eat, craving, and a measure of desired portion size of the cued food). Separate regression analyses were used to explore the associations between the change in measures of cue reactivity from pre- to post-cue exposure, and (i) an overweight/non-overweight classification, (ii) a measure of participants everyday portion-size selection, and (iii) scores on the DEBQ-restraint scale. This analysis revealed that scores on the DEBQ-restraint scale were not significantly associated with changes in food-cue reactivity. However, individuals identified as overweight, and participants who reported consuming the largest everyday portion sizes, experienced a significantly greater change in their desired portion size of the cued food. The findings suggest that heightened food-cue reactivity might present an under-explored risk factor for overeating, and becoming overweight, and/or maintaining an overweight body shape.

UK adults exhibit higher step counts in summer compared to winter months

Background: Seasonal differences in step counts have been observed in a limited number of studies conducted on US adults. Due to the diverse global climate, assessment and interpretation of seasonal patterns in ambulatory activity may vary between countries, and regionally specific studies are necessary to understand global patterns. Currently, no studies have assessed whether a seasonal trend is present when ambulatory activity is measured objectively in adults living in the UK. Aim: The present study investigated whether pedometer-determined step counts of adults living in the UK vary between summer and winter. Subjects and methods: Ninety-six adults (52% male, age = 41.0 ± 12.3 years, BMI = 26.1 ± 5.1 kg m–2) completed a within-subject bi-seasonal pedometer study. All participants completed two 4-week monitoring periods; one during the summer and one the following winter. The same Yamax SW-200 pedometer was worn throughout waking hours during both seasons, and daily step counts were recorded in an activity log. Intra-individual seasonal changes in mean daily steps were analysed using a paired samples t-test. Results: Summer mean daily step counts (10 417 ± 3055 steps day–1) were significantly higher than those reported during the winter (9132 ± 2841 steps day–1) (p < 0.001). A follow-up study conducted the subsequent summer in a sub-sample (n = 28) reinforced this trend. Summer step counts were significantly higher than winter step counts on all days of the week (p ≤ 0.001). A significant day of the week effect was present in both seasons, with step counts reported on a Sunday being on average 1500 steps day–1 lower than those reported Monday through to Saturday. Conclusion: Step counts in the sample of UK adults surveyed decreased significantly in the winter compared to the summer, suggesting future pedometer surveillance studies should capture step counts throughout the year for a non-biased reflection of habitual ambulatory activity. Public health initiatives should target these seasonal differences, and opportunities should be provided that encourage individuals to increase their activity levels during the colder, darker months of the year.