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Resilience offers the promise of a paradigm shift in many fields of research, clinical practice, and policy. A lens on resilience shifts the focus of attention - from concerted efforts to appraise risk or vulnerability, towards concerted efforts to enhance strength or capability. It also shifts the focus of analysis - from asking relatively limited questions regarding health outcomes, such as what are the linkages between risk exposures and functional deficits, to asking more complex questions regarding wellbeing, such as when, how, why and for whom do resources truly matter. Thus we might ask when interventions are most effective, within the time frame of human development and evolutionary life history; and how do we best measure pathways of human experience, to uncover ways in which individuals and communities withstand adversity. To many, resilience is an intuitive, albeit opaque, concept - akin to fortitude in the face of adversity. We may have an intuitive grasp of what resilience means, but fall short of measuring it comprehensively and meaningfully (the same is true of risk). This Annual Research Review issue features ten articles from leaders in the field on how resilience can transform the field of child development. Each articulates important lessons on resilience some of which we editors wish to summarize at the outset. First, resilience is best understood as a process that unfolds over the course of development; consequently, we seek to understand human experience of adversity as pathways of risk and resilience. Second, research on resilience focuses attention on the biological and social trade-offs in human experience: issues of timing, process, and context to understand change or adaptability. Language: en

The impact of war on child and adolescent mental health is an issue that sits high on the global public health agenda, especially where it concerns young people living in low-income countries (Patel, Flisher, Hetrick, & McGorry, 2007) and conflict zones (Morris, van Ommeren, Belfer, Saxena, & Saraceno, 2007). One key debate in the literature on ‘conflict and child health’ focuses on the relative importance of exposure to different kinds of violence (Panter-Brick, Goodman, Tol, & Eggerman, 2011): are mental health outcomes primarily driven by war-related trauma, family-level violence and/or structural barriers taking the form of institutional, social and economic stressors? Of course, a protracted war exacerbates poverty, weakens social institutions, drives poor health and often increases social and economic inequalities. But such a macro-level view of the consequences of war does not necessarily help to understand the everyday experiences, emotional lives and social realities of children in conflict zones. It is essential for research to carefully assess the main drivers of child and adolescent mental health, in order to understand which cluster of childhood adversities has the greatest impact, to reach specific insights that have both local and global significance and to underscore which interventions might be most effective.

The rapid increase in numbers of homeless children in cities of the developed and developing world is a matter of grave concern. A multi-disciplinary study was undertaken to examine the health and lifestyles of the homeless in Nepal in comparison to other local children. Few studies have quantified the health of street-children in the developing world using anthropometric indicators, and to our knowledge this is the first to systematically compare the homeless with appropriate controls from both rural and urban areas. Heights and weights were measured for 307 six to fourteen year-old boys (111 homeless, 62 squatter, 82 privileged school and 52 village boys). Height for age (HAz), weight for age (WAz) and weight for height (WHz) z-scores relative to reference data from the National Center for Health Statistics (NCHS) were used as indicators of growth status. Stunting characterized all but the school-boys, but wasting was not observed. The homeless were less stunted than either poor squatter or village boys. On arrival on the streets, they were taller than village boys, and duration of homelessness had no effect on their growth status. Thus in terms of physical growth, and despite frequent health complaints, homeless boys in Nepal fare relatively better than control groups of poor urban and rural boys. Comparative studies which reveal some successful aspects of street-life show that urban homelessness may represent an appropriate response to circumstances of poverty.

Research on the underlying causes of population variation in levels of natural fertility has recently been given new impetus with the development of endocrinological measures able to track biological variation in human fecundity. Birth seasonality was examined for a non-contracepting population with low fertility and seasonally heavy workloads in rural Nepal. Reproductive histories were collected from 1983 to 1993, totalling 1829 live births (1532 with known month of birth) to 521 women of average parity 3.5 (SD 1.5) births. The seasonal pattern of conceptions was examined in light of previously collected data on marriage patterns, climatic seasonality, subsistence workloads, energy balance, nursing patterns, lactational amenorrhoea, and endocrinological measures of prolactin and ovarian function. Both the frequency distribution of live births and a life-table analysis of women's exposure to the risk of conception show significant seasonality. The size of seasonal variation, with peak conception rates rai...

The article presents a description and critique of a large range of anthropological methods used in research with children in Nepal. It highlights the importance of a comparative, multidisciplinary and emic perspective. The value of empirical biological research methods, their potential for triangulation with social methods and validity for policy and programming are discussed. Data collected on physical and psychological well-being of children facilitate a comparison of homeless street children with other rural and urban control groups. The nature of researcher-informant relationships is crucial to the quality of information gleaned from traditional methods of demographic survey and observation.

Continuous HR monitoring, in conjunction with self-reports and direct observation of physical activity, was undertaken in three samples of 10-13-year-old Nepali boys living in different physical and socioeconomic environments. A total of 134 daytime HR profiles were recorded from 67 boys (76 from 31 villagers, 39 from 20 urban middle-class schoolboys, and 19 from 16 homeless street boys). Habitual levels of physical activity were compared using mean daytime HR (bpm) and the following indicators: percentage time during which boys are active (HR> flex, defined as an individual's average between resting and exercising HR), moderately active (HR> flex + 20%, also HR> 119 bpm), and vigorously active (HR> 139 bpm) over 10 hours of daylight. Mean daytime HR (102 bpm) and percentage time spent vigorously active (4%) did not differ between samples, despite obvious differences in lifestyles; thus better indicators are needed to characterize levels of physical activity. Percentage time spent active (HR> flex) was significantly higher (P < 0.0001) for villagers participating in subsistence activities, as a result of low flex HR values, indicating a higher level of physical fitness. Evaluation of moderate physical activity was sensitive to the choice of indicator, either an individual calibrated (above flex) or an absolute threshold of HR elevation. The former may be more appropriate than the latter to compare physical activity levels in populations with different lifestyles and levels of physical fitness. © 1996 Wiley-Liss, Inc.

OBJECTIVES: Biocultural research remains a challenge in the field of global mental health. We sought to test associations between blood pressure and idioms of distress in a population survey. METHODS: We drew on a randomly selected sample of 991 adults (498 men, 493 women) in Afghanistan, for whom physiological and psychosocial data were systematically collected. Assessment of mental health (Self-Reported Questionnaire, Afghan Symptom Checklist) included conceptualizations of distress related to pressure (fishar), anxiety, and dysphoria, as well as dimensions of negative affect and aggression. We used principal component analysis to map survey responses to fishar, and multiple regressions to examine associations with systolic/diastolic blood pressure, controlling for age, body mass index, and wealth, and differentiating by gender, mental health, and medication. RESULTS: The Afghan sample averaged 129/80 mmHg, with 27.14% of hypertensive individuals. SBP showed inverse associations with reports of low fishar (β = -4.58, P CONCLUSIONS: Subjective reports of fishar map onto physiological blood pressure more robustly than other conceptualizations of mental distress related to anxiety, dysphoria, negative affect, or aggression. Our results point to the utility of mapping biological and cultural measures of stress and distress, advancing biopsychosocial understandings of wellbeing in global mental health surveys.© 2016 Wiley Periodicals, Inc. Language: en

Early childhood experiences are known to influence key biological systems such as brain development, cell growth, hormonal, and immune development, a process known as “biological embedding” that reflects close associations between the social and the developmental gradients of health. Little is known about the full range of physical, socioeconomic, and sociopolitical experiences that matters for children outside Western contexts, and how these experiences differentially affect biological responses and developmental outcomes. The purpose of this chapter is to provide a global health perspective on child development and poverty. We review the literature on child health and global adversity and outline a conceptual framework to discuss both the research and applied aspects of the social ecology of child development. In addition, we evaluate the existing evidence base for children in global adversity: young people who face significant economic poverty, life disruption, violence, and social inequality within larger-scale processes of sociopolitical crises or rapid socioeconomic transformation demanding intervention. We conclude by discussing the ways in which governments can promote optimal development by supporting early, low-cost interventions as well as providing support for more research.

Children and adolescents who are forcibly displaced represent almost half the world's internally displaced and refugee populations. We undertook a two-part systematic search and review of the evidence-base for individual, family, community, and societal risk and protective factors for the mental health outcomes of children and adolescents. Here we review data for displacement to low-income and middle-income settings. We draw together the main findings from reports to identify important issues and establish recommendations for future work. We draw attention to exposure to violence as a well established risk factor for poor mental health. We note the paucity of research into predictor variables other than those in the individual domain and the neglect of other variables for the assessment of causal associations, including potential mediators and moderators identifiable in longitudinal work. We conclude with research and policy recommendations to guide the development and assessment of effective interventions. © 2012 Elsevier Ltd.

BACKGROUND: Age-related declines in free and bioavailable testosterone are frequently reported for Western populations, but interpopulation variation in this pattern has not previously been investigated. METHODS: Salivary testosterone was measured using a consistently applied protocol on morning samples collected from men in four populations (USA, Congo, Nepal, and Paraguay) representing different geographical, ecological, and cultural settings. RESULTS: Mean testosterone levels varied significantly between the four populations. The mean testosterone differences between populations were greatest for young men (aged 15–30 years) and insignificant for older men (aged 45–60 years). The slope of age-related decline in testosterone was significant in the USA and Congolese participants, but not in the Nepalese or Paraguayan participants. CONCLUSIONS: Age patterns of testosterone decline vary between populations primarily as a result of variation in the peak levels attained in young adulthood. The potential consequences of this variation for other aspects of male health deserve investigation.

The authors report on their multidisciplinary and longitudinal studies of Afghan families that included paired interviews with adolescents and adult caregivers. The authors argue that cultural values are the “bedrock” of resilience: they underpin the meaning attributed to great suffering, hope for the future, and a sense of emotional, social, and moral order to ordinary and extraordinary aspects of life. Remarkably, they show that war-related trauma is not the principal driver of poor mental health: traumatic experiences are linked to fractured family relationships and a failure to achieve personal, social, and cultural milestones. Resilience, meanwhile, rests upon a demonstration of family unity. In the context of structural disadvantage that includes poverty, crowded living conditions, and exposure to violence, the authors also show that cultural dictates come to entrap Afghans in the pursuit of honor and respectability, a core facet of psychosocial resilience. The chapter highlights linkages between psychosocial and structural resilience, cautioning against a simplistic view of culture as a set of protective resources. The authors discuss the ramifications of social policies that raise not just hope, but undue expectations without sufficient resource provision.

Afghanistan leads global opium and cannabis production, amidst concerted efforts to improve the country's infrastructure. In this commentary, the evidence base for drivers of increased drug use in the context of deteriorating security is presented, government, donor, and civil society responses to date are described, and key areas for health policy response are summarized. Opiate use in Afghanistan shows disturbing trends: multiple substances are accessible at low cost and frequently used in combination, and injecting use has become more common. Pressures from both donor and governmental sectors have compromised innovations in programming. Further, civil unrest and resultant displacement have created challenges for programme implementation. Afghanistan urgently needs a well-funded, sustainable, comprehensive, and inclusive programme of drug dependency treatment, aftercare, and harm reduction services, as well as realistic, effective, and culturally salient primary prevention programmes. To date, drug dependence is not a prioritised issue, current programmes are under-resourced, and the continuum of care has a narrow scope generally limited to treatment. Unless this issue is addressed, the next generation of Afghans is poised to become a casualty of the opiate industry.

Energy intake, energy expenditure and time‐allocation data for 25 child‐bearing rural Nepali women were examined for seasonal and caste differences, and food allocation compared for the mother and child. Food portions were weighed individually, activities recorded minute‐by‐minute, and mother‐child pairs observed continuously throughout the day, over three consecutive days per season at two different times of the year (repeated measures in both spring and monsoon seasons were available for 12 women). Mothers showed no seasonality in energy intake (46 kcal/kg/day), subsistence workload, or body mass. There were caste differences in subsistence activities and energy expenditure (2245 versus 1984 kcal/day, or 1.9 versus 1.7 times predicted basal metabolic rate) for agro‐pastoralist and blacksmith women, but no significant differences in energy intakes (2139 versus 2166 kcal/day), indicating a more precarious energy balance for the agro‐pastoralists. In contrast, 1–4 year olds showed a significant increase in...

Objective: We conducted a longitudinal study to assess the impact of a hand-washing intervention on growth and biomarkers of child health in Nepali slums. This is the first study to evaluate the impact of hand-washing on markers of subclinical, asymptomatic infections associated with childhood growth faltering. Methods: We recruited a total sample of infants in the target age-range (3–12 months) living in the eight largest Kathmandu slums, allocating them to intervention (n = 45) and control (n = 43) groups. In intervention areas, a small-scale community-based hand-washing program was implemented for six months; in control areas, mothers continued their normal practices. Time series linear regression was used to assess the impact of the intervention on levels of morbidity, mucosal damage, immune stimulation and growth. Results: As expected, children with higher levels of mucosal damage exhibited worse growth over the period of the intervention (P = 0.01

Saudi parents who have received genetic counseling following the birth of a child affected by a neurometabolic disorder were interviewed during their visits to a specialist hospital. As is common in the West, understanding of heredity was often incompletely assimilated, and this was related to parental education level. Coping behaviors, however, were substantially different from those in the West. The wide range of attitudes recorded toward consanguineous marriage and future births was a reflection of the position of Saudi families in a society undergoing rapid change. (J Child Neurol 1992;7(Suppl):S69-S72.)

The impact of low hemoglobin levels on the work performance of 74 rural Nepali villagers was examined with a 3 minute exercise step test. Work output was standardized at 75 watts for men and 55 watts for women. Hemoglobin values ranged from 4.2-15.7 g/dl, and averaged 12.0 ± 2.7 g/dl for 35 men and 10.9 ± 1.72 g/dl for 39 women. Low hemoglobin levels significantly elevated the heart rates and recovery times of the men, but not of the women. A positive relationship with oxygen uptake and a negative one with net mechanical efficiency was found for men but not for women (anemic men appeared more efficient as they used up marginally less oxygen during exercise). Values are in good agreement with those recently published for Gurkha soldiers, but are at variance with those examining the step test performance of Nepali women. In the light of behavioral data on work patterns, mild anemia may have little impact on the performance of moderate self-paced physical activity. Nepali villagers pause frequently during the course of subsistence activities, a behavior which allows time for recovery from an elevated pulse rate. © 1992 Wiley-Liss, Inc.

The nursing behaviour of rural Nepali women, from two castes inhabiting the same village, is quantified on the basis of 2202 hr of continuous and direct day-time observation over 1 year. Feed duration, interval, total time and daily frequency are examined in relation to women's work, particularly the type of subsistence activity and seasonality. 'Opportunity' feeds are governed both by infant demands and maternal activity. Caste differences in birth intervals are also discussed.From 1982-1983, researchers observed working women from 2 castes (16 Tamang and 8 Kami) in Salme, Nepal for 11-13 hours/day to determine if breast feeding and working behaviors explain fertility differences between them. Work loads greatly increased for the agropastoralist Tamang women during the monsoon (p.0007), but not so for the low caste Kami women who worked mainly at home. Intervals between feeds and agricultural activities averaged 98 minutes while they averaged 47 minutes for husbandry activities (p.05). Neither affected feed duration. If Tamang women worked in a labor group rather than alone, they tended to provide shorter breast feeds only during the monsoon (p.05). Infant age greatly affected duration of breast feeds (p.0005), interval between feeds (p.004), and total frequency and nursing time (p.0001) among the Tamang. Seasonality did not affect these relationships, except for 3 year olds in which seasonality was significantly reduced during the monsoon. On the other hand, it did have a strong effect on interval (p.05), total frequency (p.01), and total time (p.001) for the Kami. Tamang women provided longer feeds for their infants than did the Kami women during the winter (p.0002), but differences between the 2 castes were minor during spring. Yet Tamang women breast feed their 2 year olds for shorter times than Kami women during the spring (p.01). Among the Kami, infant age did not affect duration, interval, total frequency, and total time. Therefore the 2 castes were not alike in how they planned feeds from day to day. In fact, the Kami women fed their children at very irregular intervals regardless of the child's age. As for Tamang women, intervals grew more irregular with increasing age of the child. Supplementary foods most likely accounted for the high variability between the 2 castes. No 3 year old Kami children were breast fed. The interval between feeds rose consistently with infant age for the Tamang but not for the Kami.

In-depth interviews of 36 Saudi families whose children suffered from neuro-metabolic disorders were conducted at a specialist hospital in Riyadh in order to examine parental understanding of disease and attitudes towards future births and consanguineous marriages. Parents had difficulty accepting a genetic explanation for diseases that did not affect all children at the time of birth; they also expressed religious or folk beliefs to account for illness. Coping behaviours included denial and resignation to the situation, divorce and remarriage. Some families adopted a cautious approach to cousin marriages and future births; this was significantly related to their education level, but not to previous infant deaths. Awareness of medical facts brought little emotional comfort to parents but allowed for preventive measures through screening adult carriers and identifying affected infants. This study presents new material from Saudi Arabia to strengthen current awareness that the range of religious beliefs, social attitudes and reproductive behaviours adopted by families in a society undergoing rapid change is of direct relevance to health care.

Afghanistan provides a unique setting in which to appraise psychosocial stress, given the context of persistent insecurity and widening economic inequality. In Kabul, people experience widespread frustrations, hinging on restricted opportunities for social advancement, education, and employment. We appraised social aspirations, every-day stressors, psychosocial distress, and mental health problems for a random sample of 161 male and female students at Kabul University. The survey featured both existing and newly-developed instruments (Self-Reported Questionnaire SRQ-20; Afghan Symptom Checklist; Afghan Daily Stressor Scale; and Social Aspirations and Frustrations), implementing both internationally-used and culturally-grounded measures of mental health assessment. We also included indicators of physical health (blood pressure, immune responses to Epstein-Barr virus (EBV), C-reactive protein, and body mass index), to map physiological function with reported psychosocial distress. This young, urban elite expressed major feelings of frustrations, related to physical, economic, social, and political stressors of day-to-day life in Kabul. There were striking gender differences for psychosocial and physiological markers of wellbeing; specifically, women showed poorer mental health (SRQ-20, P = 0.01) and elevated EBV antibody titers (P = 0.003). Both diastolic blood pressure (P = 0.018) and EBV (P = 0.038) were associated with a subscale of family stressors among women, but not among men, consistent with women's social vulnerabilities to stressful family dynamics. This is the first study to integrate approaches from anthropology, cross-cultural psychiatry, and human biology to document social stressors, psychosocial distress, and physiological wellbeing in the challenging setting of present-day Afghanistan.

Early childhood growth retardation persists in developing countries despite decades of nutritional interventions. Adequate food is necessary, but not sufficient, to ensure normal growth where there is ubiquitous exposure to infection. Pathways associated with infection, small intestinal mucosal damage and chronic immunostimulation remain largely undemonstrated in countries other than The Gambia. We conducted a longitudinal study of one squatter and one middle-class group (n 86, 3–18 month olds) to assess these relationships in Nepal. Growth, mucosal damage index (MDI; urinary lactose:creatinine ratio adjusted for body weight), morbidity reports, and blood concentrations of albumin, α-1-acid glycoprotein, IgG and Hb, were recorded monthly. Growth status worsened dramatically from 6 to 18 months, with squatters more stunted (height-for-age Z-score (HAZ), P Z-score (WAZ), P = 0·009) than middle class. IgG increased with age, was elevated in squatter children, and negatively related to WAZ (P = 0·034). MDI showed significant negative associations with growth performance, explaining 9 and 19 % of height and weight deficits (ΔHAZ, P = 0·004; ΔWAZ, P P

In 2004-05, Niger suffered a food crisis during which global attention focused on high levels of acute malnutrition among children. In response, decentralised emergency nutrition programmes were introduced into much of southern Niger. Child malnutrition, however, is a chronic problem and its links with food production and household food security are complex. This qualitative, anthropological study investigates pathways by which children are rendered vulnerable in the context of a nutritional 'emergency'. It focuses on household-level decisions that determine resource allocation and childcare practices in order to explain why practices apparently detrimental to children's health persist. Risk aversion, the need to maintain self-identity and status, and constrained decision making result in a failure to invest extra necessary resources in growth-faltering children. Understanding and responding to the social context of child malnutrition will help humanitarian workers to integrate their efforts more effectively with longer-term development programmes aimed at improving livelihood security.

As challenges to child well-being through economic disadvantage, family disruption, and migration or displacement escalate world wide, the need for cross-culturally robust understanding of childhood adversity proportionately increases. Toward this end, developmental risk was assessed in four contrasting groups of 107 Nepali children ages 10–14 years that represent distinctive, common conditions in which contemporary children grow up. Relative cumulative burden (allostatic load) indexed by multiple dimensions of physical and psychosocial stress was ascertained among homeless street boys and three family-based groups, from poor urban squatter settlements, urban middle class, and a remote rural village. Biomarkers of stress and vulnerability to stress included growth status, salivary cortisol, antibodies to Epstein–Barr virus, acute phase inflammatory responses (alpha1-antichymotrypsin), and cardiovascular fitness and reactivity (flex heart rate and pressor response). Individual biomarkers of risk and allostatic load differed markedly among groups, were highest in villagers, and varied by components of allostatic load. Such data suggest a need for critical appraisal of homelessness and migration as a risk factor to youth, given prevailing local conditions such as rural poverty, and represents the only multidimensional study of childhood allostatic load and developmental risk in non-Western settings.

SummaryStroke is an emerging problem in sub-Saharan Africa, about which little is known since most research to date has been based on retrospective, hospital-based studies. This anthropological work, designed to complement a large community-based project on stroke incidence, focuses on local understandings and treatment-seeking behaviours in urban (Dar-es-Salaam) and rural (Hai) areas of Tanzania. Semi-structured interviews (n=80) were conducted with 20 stroke patients, 20 relatives of stroke patients, ten traditional healers, and 30 other local residents. In contrast to common expectations, and literature that finds witchcraft beliefs to be most common in rural areas, stroke in urban Dar was widely believed to emanate from supernatural causes (demons and witchcraft), while in rural Hai, explanations drew mostly on ‘natural’ causes (hypertension, fatty foods, stress). These different beliefs and explanatory models fed into treatment-seeking behaviours. The first option in Hai was hospital treatment, while in Dar-es-Salaam, where belief in demons led to hospital avoidance, it was traditional healers. In both sites, multiple treatment options (serially or simultaneously) were the norm. Analysis of patient and carer narratives suggested that causation beliefs outweighed other factors, such as cost and distance, in shaping effective treatment. Three policy implications are drawn. First, as other studies have also shown, it is important to engage with, rather than dismiss, local explanations and interpretations of stroke. Stroke awareness messages need to take into account the geographical and belief systems differences. Developing an understanding of explanatory models that recognizes that local beliefs arise from dynamic processes of social interaction will be critical to designing effective interventions. Second, there is a clear role for multiple healing systems with possibility of cross-reference in the case of a chronic, disabling condition like stroke, since biomedical treatment cannot offer a ‘quick fix’ while traditional healers can help people come to terms with their condition. Third, issues of communication between health services and their patients are particularly critical.

The purpose of this paper is to analyse household decision-making regarding resource allocation in the aftermath of a food crisis in rural Niger. International attention had resulted in humanitarian agencies launching emergency nutrition programmes to alleviate persistently high levels of acute child malnutrition. We conducted participant observation, 93 in-depth interviews, 15 focus groups, 44 feeding and illness histories for children under 5, and debriefing sessions with local humanitarian staff. The impetus for this study came from observations of marked intra-household differences in child growth and health status, despite the caregivers' ethos of treating children equally. Egalitarian input, however, does not always result in equal outcomes: vulnerable children become “victims of non-discrimination” through a form of benign neglect engendered by pervasive poverty. The ethos and practices of equal investment in children are rooted in a need to balance the perceived risks to children with the preservation of long-term livelihoods. We discuss the mismatch of views between external interventions, which focus on saving individual children's lives, and local priorities, aimed at spreading risk. This mismatch is rooted in the different ways in which humanitarian agencies and local communities weigh up risks and vulnerabilities in matters of child health.

Contested reports associating the MMR vaccine with autism have resulted in diminished confidence and uptake of the vaccine in the UK. This postal survey of parent's decisions, attitudes and use of information about MMR immunisation was constructed from questions derived from in-depth qualitative work. The setting was a Primary Care Trust in northeast England (N=996). Both MMR-accepting and refusing parents were supportive of immunisation, yet the high level of concern about the safety of the vaccine expressed even by parents who had immunised their children is worrying in its implications for public confidence and trust in health care. The findings suggest that the ability of practitioners to provide effective professional advice about MMR vaccine could be undermined if a government were to directly promote the vaccine to parents. Practitioners should continue to provide parents with accurate information, while communicating respect for parents' intentions to protect their children's health.

Behaviour change is notoriously difficult to initiate and sustain, and the reasons why efforts to promote healthy behaviours fail are coming under increasing scrutiny. To be successful, health interventions should build on existing practices, skills and priorities, recognise the constraints on human behaviour, and either feature community mobilisation or target those most receptive to change. Furthermore, interventions should strive to be culturally compelling, not merely culturally appropriate: they must engage local communities and nestle within social and ecological landscapes. In this paper, we propose a social ecology perspective to make explicit the links between intention to change, actual behaviour change, and subsequent health impact, as relating to both theory-based models and practical strategies for triggering behaviour change. A social ecology model focuses attention on the contexts of behaviour when designing, implementing or critically evaluating interventions. As a case study, we reflect on a community-directed intervention in rural Gambia designed to reduce malaria by promoting a relatively simple and low-cost behaviour: repairing holes in mosquito bednets. In phase 1, contextual information on bednet usage, transactions and repairs (the 'social lives' of nets) was documented. In phase 2 (intervention), songs were composed and posters displayed by community members to encourage repairs, creating a sense of ownership and a compelling medium for the transmission of health messages. In phase 3 (evaluation), qualitative and quantitative data showed that household responses were particularly rapid and extensive, with significant increase in bednet repairs (p

The purpose of the study was to determine whether chronic immunostimulation could explain growth faltering in disadvantaged children in the UK, as it does in developing countries such as The Gambia. In all, 216 infants, age 10-21 months, were recruited when blood samples were taken for the routine or clinical purposes of a longitudinal study tracking a larger cohort of children. Aliquots of blood were collected on Guthrie cards to determine blood concentrations of albumin (Alb), alpha(1)-antichymotrypsin (ACT), and immunoglobulin G (IgG). Haemoglobin concentrations were determined by routine hospital laboratory analysis. Heights and weights were measured and converted to z-scores; birth weights were used with recruitment weight to calculate a 'thrive index' for each child. Age-corrected plasma IgG concentration was negatively associated with both height- and weight-for-age z-scores (P = 0.042 and 0.038, respectively) but not with the thrive index or body mass index z-scores. Blood haemoglobin levels were positively related to height- and weight-for age z-scores, as well as to the thrive index (P = 0.026, 0.014, and 0.007, respectively). Although significant, these relationships could only account for a small part the observed growth variation. Although the relationships were weak, the results suggest that some of the observed variation in growth of these UK infants may be explained on the basis of persistent immunostimulation or poor iron status. In terms of markers of immunostimulation (Alb, ACT, ACT:Alb ratio, IgG), both absolute levels and relationships with height-for-age are substantially different than those previously observed in cohort studies of infants in The Gambia.

Objectives: To describe the first-week feeding patterns for breast- vs bottle-fed babies, and their association with sustained breast-feeding and infant weight gain at 6 weeks. Design: A longitudinal cohort study. Setting: Feeding diaries were completed by mothers in an urban UK community shortly after birth; follow-up weight and feeding data were collected at routine health checks. Subjects: Mothers of 923 full-term infants born during the recruiting period agreed to join the study. In all, 502 usable diaries were returned from 54% of the cohort. Results: Breast-fed infants were fed more frequently (2.71 h between feeds) than bottle-fed infants (3.25 h between feeds) and mixed-fed infants (3.14 h between feeds) (P

This article raises issues about work intensity, pace, and sustainability during physical activity, focusing attention on the nature of work in labor-intensive societies, the management of exertion in habitual tasks, and the health and broad socioeconomic correlates of alternative ways to regulate work patterns. At the heart of this review are concerns to document human adaptability (in terms of the physical and behavioral management of heavy work) and to renew debate regarding the conceptualization and measurement of work intensity (variously evaluated in absolute or relative terms, as indexed by oxygen consumption, energy expenditure, percentage maximal work capacity, heart rate elevation, time and motion indicators, or physiological cost). Three questions are examined: Is heavy work primarily a matter of time or energy intensity? How is heavy work habitually sustained? What is the bigger picture relating work performance to work context and to nutritional or health status? It is argued that many arduous activities, such as carrying loads, demand endurance over time rather than intensive effort per unit time, and that work pace management lies in regulating both the rate of work and the time in rest during physical activity. Furthermore, strategies that maximize long-term endurance (adopted by "tortoises") and those that maximize short-term productivity (adopted by "hares") are appropriate to different work contexts (e.g., a subsistence or wage-labor economy) and suit individuals with different health status and ability. Thus, work intensity is an important aspect of the links between physical activity, health, productivity, and society, as noted in literature reviewing objectives for sustainable development and public health messages for disease risk management. These areas of scholarship are underresearched, partly because consensus has been slow in agreeing on which are the best measures of work pace and work intensity for use in field situations, and which are the most meaningful thresholds for evaluating absolute or relative effort across a range of populations.

This study examined the associations between severity of stunting, plasma protein concentrations and morbidity of 104 Nepali boys, aged 10-14 years, living in contrasting environments. Boys from a remote village were compared with three similarly aged urban groups: poor squatters, homeless street children, and middle-class schoolchildren. All but the middle-class group were stunted, particularly village boys whose mean height-for-age z-score (-2.97, SD 0.82) indicates severe growth retardation. Stunting was significantly associated with increased plasma levels of the acute-phase protein alpha1-antichymotrypsin itself inversely related to plasma levels of albumin. Plasma ACT levels of village children (mean 1.52 g/l, SD 0.43) were three to four times higher than those of squatters and homeless street children, and five times higher than those of middle-class boys. Despite being the most severely stunted and having the most abnormal plasma protein values, village children reported the lowest burden of disease, a contradiction which may reflect exposure to sub-clinical infections or habituation to illness and low expectation of treatment. This study draws attention to the strikingly high levels of ACT and of stunting in the rural sample, and cautions on the use of uncorroborated morbidity reports across different epidemiological and socio-ecological environments. Possible mechanisms to explain the impact of illness and inflammation on growth faltering are discussed.

The definition of street children—those for whom the street has become their home, with no protection, supervision, or direction from responsible adults—includes several problematic terms. Attempts to categorize their working and living circumstances have also been difficult. In both Western and non-Western countries, agencies issue controversial estimates of their overall number, reflecting the nebulous definition of targeted groups and the creation of homelessness as a social issue. Representations of street children hinge upon the constructs of home, family, and a proper childhood, while explanations of rising homelessness emphasize either broad structural factors or personal dysfunction. Popular views of street children—as victims or villains, foresaken, or deviant—are actually unhelpful. Child-centered perspectives now emphasize the capabilities of children (agency and social competence) rather than their helplessness or dependency, while methods of participatory research seek to listen to children in planning welfare interventions in their ‘best interest.’ There is, particularly with respect to health, little comparative and longitudinal information on the outcomes of street life. Current research is focused on the subjective and cultural interpretations of homelessness, the context of poverty and social exclusion, and appropriate interventions which respect the coping strategies and rights of street children.

As widespread social transformations have been paralleled by gains in health and life expectancy through public health and other improvements, a variety of other challenges to health have emerged, particularly in lifestyle related, behaviourally mediated changes in rates of chronic disease. Hormones, Health and Behavior looks at the relationship of human biology and human society at the intersection of behavior, hormones and health. There is both scientific interest and practical urgency behind the ideas and findings presented here, as the need for a socio-ecological view of function and well-being has become more apparent. This book documents an emerging understanding of how hormones create linkage between behavior or social life and health. It will inform graduate students and researchers interested in human sciences, human development, anthropology, epidemiology, public environmental and reproductive health.

This paper reports on the prevalence of growth retardation, the impact of seasonality on height and weight gains, and significant relationships between growth velocity, nutritional status and morbidity, for a population living at subsistence level in rural Nepal. Monthly variation in growth pattern was examined for 71 boys and girls 0-49 months of age. At the height of the monsoon season, 71% of children were moderately stunted, but none was wasted (mean -2.61 SD height-for-age and -0.91 SD weight-for-height by reference to NCHS z-score values). Measures of stunting deteriorated from moderate to severe after 1 year of age. No differences by sex or ethnicity were detected. Environmental changes from the winter to the monsoon seasons were reflected in significant losses of weight and lower weight-for-height z-scores, especially for 0-35 month-olds, although height for 12-35-month-olds continued to be gained over this period. Growth velocity was significantly related to previous growth status (thinner and shorter children did not show catch-up in height or weight) and to morbidity reported over the period of observation. The prevalence of illnesses rose six-fold from the winter to the monsoon, and children with a high frequency of illnesses experienced a significant shortfall in weight and height increments. A poor diet and recurrent illnesses explain the slow and uneven growth of these children. Despite an increase in women's agricultural workloads in the monsoon season, childcare patterns per se do not seem to adversely affect small children. Small stature through later childhood and in adults is one consequence of the growth pattern seen at these young ages.The monthly variation in growth pattern was examined for 71 boys and girls aged 0-49 months of age in rural Nepal. At the height of the monsoon season, 71% of children were moderately stunted, but none was wasted. Stunting worsened from moderate to severe after 1 year of age with no differences observed by sex or ethnicity. Overall measures of wasting significantly worsen over the winter to monsoon period, while measures of stunting improve. In particular, there was significant wasting especially among 0-35 month olds, while height for 12-35 month olds continued to be gained over the period. Growth velocity was significantly related to previous growth status and to morbidity reported over the period of observation. The prevalence of illnesses increased six-fold from the winter to monsoon season and children with a high incidence of illness experienced a significant shortfall in weight and height increments. Poor diet and recurrent illness explain the slow and uneven growth of these children. Increased women's workload during the monsoon season does not appear to adversely affect small children through poor child care.

This study of two natural fertility Nepali groups, the Tamang and Kami, identifies biological and behavioral factors associated with population differences in fertility. Previous research had established that Tamang experience longer interbirth intervals than Kami despite similarly intense nursing practices, and bear considerably higher energy expenditure due to workload. This cross-sectional study of 71 breastfeeding women includes prolactin determinations on three blood spot samples collected 5, 30, and 50 minutes following a timed nursing bout, and data on maternal age, BMI, menstrual status, previous birth interval, parity, infant age, nursing bout length, and durations of supplementation and postpartum amenorrhea. The findings show that Tamang breastfeeding mothers have higher average prolactin levels than Kami for as long as 22 months postpartum. Tamang mothers sustain average prolactin levels above those of nonpregnant, nonlactating women for nearly 2 years postpartum, whereas prolactin levels among Kami breastfeeding mothers are the same as this latter group after 1 year postpartum. Furthermore, the findings indicate that Tamang mothers have higher average prolactin levels regardless of maternal age, physical status (BMI, weight, or height), or infant age, and the rate of decline in prolactin from 5 to 50 minutes after suckling is significantly greater for Kami than Tamang. Since factors associated with prolactin levels differ by group, the findings also emphasize that populations vary not only in the strength of effects that proximate determinants have on fertility regulation, but also in the pathways by which they exert their effects (direct physiological versus indirect behavioral). Am. J. Hum. Biol. 10:191-210, 1998. © 1998 Wiley-Liss, Inc.

Considerable attention has been devoted to variation in levels of energy expenditure between and within populations; these are commonly evaluated following international guidelines for grading light, moderate, and heavy physical activity levels (PAL). This study presents activity profiles by season and sex for subsistence agro-pastoralists in Nepal, comparing data for a sample of 20 men observed four times across the year with previously published data on women. Total energy expenditure (TEE) was estimated from direct minute-by-minute observation (totaling 1,679 h for men, 3,601 h for women) and measures of the energy cost of single tasks (117 for men, 168 for women). PAL were calculated and graded as multiples of predicted basal metabolic rate (BMR). Despite an explicitly egalitarian organization of labor, men achieved higher PAL than women (P < .0001), although according to international gradings, both men and women assume moderately heavy PAL in the winter and very heavy PAL in the monsoon. PAL were 1.88 and 2.22 × BMR for men in respective seasons (P < .005; TEE, 11.8 MJ/d and 13.9 MJ/d) and 1.77 and 2.0 × BMR for women (TEE, 9.1 MJ/d and 10.5 MJ/d). High TEE values result from time-consuming work in subsistence tasks, most of which are of moderate energy cost. Results show that the international guideline (FAO/WHO/UNU [1985]) for grading levels of energy expenditure, which adopts discrepant sex-specific values to define thresholds for moderate or heavy PAL, can mask significant gender variation. Male/female ratios of PAL values are suggested instead for population-level comparisons. © 1996 Wiley-Liss, Inc.

The aim of the study was to determine the association between PRL responses to suckling and maintenance of postpartum amenorrhea among breastfeeding mothers. Three blood spot samples (5, 30, and 50 min following a timed nursing bout) were collected from 71 intensively breastfeeding Nepali women for PRL determination. Maternal age, BMI (weight/height2), menstrual status, caste, infant age, nursing bout length, and duration of supplementation were recorded at time of sample collection. Independent and paired t tests, linear regression analyses, and general linear models were used to evaluate differences between cycling (n = 36) and amenorrheic (n = 35) women and associations among variables. Logistic regression analyses were used to relate PRL measures to the odds of maintaining lactational amenorrhea. Amenorrheic breastfeeding mothers had higher (P.001) PRL levels at all 3 collection times than cycling breastfeeding mothers, and PRL levels declined with time since birth (P0.05). The odds (OR) of having ceased lactational amenorrhea was significantly higher (OR = 5.0, 95% Cl = 1.3-19.9) among mothers with lower PRL levels (or = 10 ng/mL) at 50 min post-sucking, and PRL at 50 min showed a significant dose response relationship with menstrual status. The association between 50 min PRL levels and lactational amenorrhea appears to be independent of time postpartum, maternal age, BMI, nursing bout length, and duration of supplementation. Among intensively nursing women, maintenance of elevated PRL levels across the interbout interval increases the odds of maintaining lactational amenorrhea.In August 1991, in Nepal, all women aged 19-45 from the Tamang caste (agro-pastoralists of Tibetan origin) and from the Kami caste (low-caste blacksmiths of Aryan origin) who were intensively breast feeding and lived in remote villages in the foothills of the Himalayas were included in a study aiming to examine the association between post-suckling prolactin (PRL) and menstrual status. The study also aimed to determine what PRL response time after suckling best predicts the odds of having resumed menses. There were 36 women whose menses had returned and 35 women who remained amenorrheic. 50-minute post-suckling PRL levels were more linked to menstrual status than 5-minute levels (odds ratio [OR] = 5 vs. 2.1). They (but not 5-minute post-suckling PRL levels) also had a significant dose relationship with menstrual status. During the first year postpartum, PRL levels were significantly higher at all three collection times (5, 30, or 50 minutes) in amenorrheic women than cycling women (p 0.001). PRL levels fell as infant age increased (16 ng/ml for 11 months or less, 13.7 ng/ml for 11-15 months, and 7.4 ng/ml for 15 months; p 0.05). At 50 minutes post-suckling, mothers with PRL levels at or below 10 ng/ml were much more likely to have returned to menses than those with higher levels (OR = 5; p = 0.041). The association between 50-minute PRL levels and lactational amenorrhea were independent of time postpartum, maternal age, body mass index, nursing bout length, and duration of supplementation. The maintenance of high PRL levels across the interbout interval increased the odds of maintaining lactational amenorrhea (p 0.05). In conclusion, intensively nursing women whose PRL levels remain high across the interbout interval are most likely to maintain lactational amenorrhea.

SummaryChanges in body weight were examined for non-pregnant women in rural Nepal, using 183 anthropometric measures between the early winter and monsoon seasons in 1982, 1982–83, 1990–91 and 1993. The women gained weight when work loads decreased after the monsoon, but despite substantial changes in total energy expenditure, which were out of phase with changes in food intake, seasonal changes were small, averaging only up to 2.6% of initial body weight.There were notable differences between individual women, changes in body weight ranging from-5·6 kg to 4·8 kg. Weight change was examined with respect to lactation status, age, body mass index, mid upper arm circumference and skinfolds as well as total energy expenditure and intake. Non-lactating women, very thin women and women aged under 25 years gained more weight than their counterparts, both before and after the monsoon. Data for a sub-sample in 1982–83 indicated that women who maintained high physical activity levels throughout the year were less prone to weight loss than women whose activity fluctuated between seasons. Initial energy reserves, age-related maturation factors, levels of physical activity and energy intake combine to produce the notable inter-individual variation in body weight changes observed in this population.

Wietse Tol and colleagues lay out a a consensus-based research agenda for mental health and psychosocial support in humanitarian settings.

New methods for monitoring ovarian function have allowed an extension of research venue beyond typical clinical settings to studies of human populations in their natural settings. Such studies have confirmed that patterns of variation in ovarian function with age and energetic factors are general features of human reproductive biology. Age patterns of ovarian function are extremely robust across populations of distinct genetic, ecological and cultural backgrounds. Comparable ovarian responses to energetic stresses are likewise observable in different populations where they arise as correlates of local ecologies rather than as correlates of voluntary patterns of diet or exercise. Maternal age and energetic factors also appear to interact with lactation in the modulation of postpartum, ovarian function. Average levels of ovarian function, however, differ considerably between populations, perhaps correlated with chronic environmental conditions that affect growth, development, and the establishment of adult set-points. Western populations appear to represent an extreme of the spectrum of variation in ovarian function, a fact which may relate to the epidemiology of breast and ovarian cancer.

Menstrual and hormonal disturbances have been reported in thin, dieting and exercising Western women, and also recently in rural African women. A study of salivary progesterone profiles was undertaken in a Nepali population to examine whether seasonal increases in workload and changes in energy balance influenced ovarian function. Women's energy expenditure levels were moderately heavy in the winter and very heavy in the monsoon, and body mass fluctuated by -2.8 to +4.8 kg. Samples were collected from 24 normally menstruating women in two seasons, each individual serving as her own control. Progesterone levels were significantly depressed in the monsoon relative to winter for women who lost weight, but not for women who gained weight, indicating that energy imbalance is associated with a loss of fecundity. No differences in body mass index were found between women who lost or gained weight. Progesterone levels were age-dependent, and the degree of hormonal disturbance between age-groups was related to weight loss. The study demonstrates seasonal changes in the fecundity of hard-working Nepali women and a direct link between ovarian function and weight loss (negative energy balance), which is independent of current nutritional status.In October-November 1990 and August-September 1991, anthropologists collected saliva samples from 24 17-46 year old nonpregnant, nonlactating, and normally menstruating Tamang women in a remote village in the foothills of the Himalayas in northwestern Nepal to measure progesterone levels (indicative of ovarian function). They used these levels to determine whether a very heavy workload during the monsoon season and changes in dietary intake affected ovarian function. Anthropometric measurements were also taken. The women served as their own controls. Seasonal changes in body mass ranged from -2.8 kg to 4.8 kg. Mean and mid-luteal progesterone levels fell 27% (104-76 pmol/l) and 38% (138-85 pmol/l), respectively, between the winter and monsoon (p .01). The levels of ovarian function were much lower than those of healthy, regularly menstruating Western women and of menstruating Lese women of the Ituri forest in Zaire (mean luteal phase progesterone levels, 104 pmol/l vs. 232 pmol/l for Boston women and 140 pmol/l for Lese women). Reduction in progesterone levels was most significant for 24-34 year old women. In fact, the reduction in mid-luteal progesterone levels was only significant in this age group (p .05). Body mass index did not influence progesterone levels, regardless of changes in weight or age. Reduced progesterone levels was only significant for women who lost weight between the winter and the monsoon seasons, suggesting that energy imbalance is linked to loss of fecundity. Younger women were more likely to gain weight than older women (.6 kg vs. -1.1 kg for middle aged women and -.2 for older women; p .05). The regression between changes in progesterone levels and degree of weight loss was also significant (p .01). Between the winter and the monsoon, the percentage of ovulatory cycles decreased from 71 to 38%. These findings showed seasonal changes in the fecundity of these women and a direct association between ovarian function and weight loss, regardless of current nutritional status.

1. Introduction: biosocial research on children Catherine Panter-Brick 2. Evolutionary and biological aspects of childhood Barry Bogin 3. From the child's point of view: issues in the social construction of childhood Allison James 4. Biological anthropology and child health: context, process and outcome Catherine Panter-Brick 5. Child psychology and anthropology: an environmental view Robert A. LeVine 6. The meeting of nature and nurture and the development of children: some conclusions Martin Richards Glossary Index.