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Charlotte Williams (Ed.). Social Work and the City. Urban Themes in 21st-Century Social Work. London: Palgrave MacMillan, 2016, €87,99, 299 p. ISBN 9781137516220

Envisioned as an inclusive new city and a major technology hub, Konza Technology City is said to bring stability and growth to Nairobi’s south-eastern periphery. However, for the communities living in its vicinity, the advent of this new urban core is suffused with uncertainties as its existence largely takes place in the imaginary realm of plans and billboards of which the outcome is unforeseeable today. This article is an anthropological exploration of these uncertainties and of the concept of uncertainty in general. I start this exploration with an analysis of the notions of the ‘analogue’ and the ‘digital’ that are locally used to describe increased societal pluralism and differentiation in the area under the influence of the Konza Technology City and in which social and material worlds appear intricately entwined. Subsequently, I argue that these multiplicities and the uncertainties that are inseparable from them are best approached ontologically. I maintain that such an approach engenders an underst...

Background:Data on physical inactivity, a known risk factor for noncommunicable diseases and its correlates in sub-Saharan Africa are almost absent. We assessed physical activity patterns and associated factors among adults.Methods:A populationbased study of 1208 adults was conducted in the Iganga-Mayuge Health and Demographic Surveillance Site, Uganda. Physical activity was assessed using a pedometer for 7 days. Physical inactivity was defined as a daily average of < 7500 steps while sedentary behavior was defined as a daily average of < 5000 steps. Logistic regression was conducted to identify factors associated with physical inactivity and sedentary behavior.Results:Of the 1208 participants, 18.8% were sedentary (10.6% of men; 26.9% of women, P < .001), 37.6% were physically inactive (28.5% of men; 46.6% of women, P < .001). Factors associated with sedentary behavior were being female, ≥ 65 years, peri-urban residence, being a domestic worker, formal employment and lower primary education. Factors associated with physical inactivity were being female, 55 to 64 years, ≥ 65 years, peri-urban residence, overweight and obesity.Conclusions:Sedentary behavior and physical inactivity were prevalent among the adult population. Targeted physical activity promotion interventions are needed.

Background Breastfeeding promotion is regarded as one of the most effective interventions to improve child health, and could reduce under-5-mortality by 8 % globally. Few studies have assessed the health outcomes beyond infancy of interventions promoting exclusive breastfeeding. Methods This study assessed growth in under-five children who participated in a cluster-randomised trial in Eastern Uganda (ClinicalTrials.gov.no.NCT00397150). In the intervention arm, peer counsellors promoted exclusive breastfeeding during the first 6 months of infancy. There were no interventions after 6 months of age. Mother-infant pairs were interviewed at visits scheduled at 3, 6, 12 and 24 weeks after birth and follow-up visits at 2 and 5 years, with 765 included in the analyses. Results The mean length/height-for-age and weight-for-age-z-score (HAZ, WAZ) decreased with increasing age in both the intervention and control arms. At the three weeks visit, HAZ in the intervention was −0.45 (−0.68;−0.21) and −0.32 (−0.56;−0.07) in the control arm. At the 2 year follow-up, the mean HAZ in the intervention was −1.85 (95 % CI −1.97;−1.73) compared to −1.61 (−1.87;−1.34) in the control. Similarly, at the 5 year follow-up, the mean HAZ in the intervention was −1.78 (−2.08;−1.47) compared to −1.53 (−1.79;−1.28) in the control arm. At the 2 year follow-up visit, 139 (45 %) were stunted (HAZ

Background: Growth assessment based on the WHO child growth velocity standards can potentially be used to predict adverse health outcomes. Nevertheless, there are very few studies on growth velocity to predict mortality. Objectives: We aimed to determine the ability of various growth velocity measures to predict child death within 3 mo and to compare it with those of attained growth measures. Design: Data from 5657 children ,5 y old who were enrolled in a cohort study in the Democratic Republic of Congo were used. Children were measured up to 6 times in 3-mo intervals, and 246 (4.3%) children died during the study period. Generalized estimating equation (GEE) models informed the mortality risk within 3 mo for weight and length velocity z scores and 3-mo changes in midupper arm circumference (MUAC). We used receiver operating characteristic (ROC) curves to present balance in sensitivity and specificity to predict child death. Results: GEE models showed that children had an exponential increase in the risk of dying with decreasing growth velocity in all 4 indexes (1.2- to 2.4-fold for every unit decrease). A length and weight velocity z score of ,23 was associated with an 11.8and a 7.9-fold increase, respectively, in the RR of death in the subsequent 3-mo period (95% CIs: 3.9, 35.5, and 3.9, 16.2, respectively). Weight and length velocity z scores had better predictive abilities [area under the ROC curves (AUCs) of 0.67 and 0.69] than did weight-for-age (AUC: 0.57) and length-for-age (AUC: 0.52) z scores. Among wasted children (weight-for-height z score ,22), the AUC of weight velocity z scores was 0.87. Absolute MUAC performed best among the attained indexes (AUC: 0.63), but longitudinal assessment of MUAC-based indexes did not increase the predictive value. Conclusion: Although repeated growth measures are slightly more complex to implement, their superiority in mortality-predictive abilities suggests that these could be used more for identifying children at increased risk of death. Am J Clin Nutr 2016;103:801‐7.

Background: Linear growth faltering in the first 2 y contributes greatly to a high stunting burden, and prevention is hampered by the limited capacity in primary health care for timely screening and intervention. Objective: This study aimed to determine an approach to predicting long-term stunting from consecutive 1-mo weight increments in the first year of life. Methods: By using the reference sample of the WHO velocity standards, the analysis explored patterns of consecutive monthly weight increments among healthy infants. Four candidate screening thresholds of successive increments that could predict stunting were considered, and one was selected for further testing. The selected threshold was applied in a cohort of Bangladeshi infants to assess its predictive value for stunting at ages 12 and 24 mo. Results: Between birth and age 12 mo, 72.6% of infants in the WHO sample tracked within 1 SD of their weight and length. The selected screening criterion ("event") was 2 consecutive monthly increments below the 15th percentile. Bangladeshi infants were born relatively small and, on average, tracked downward from approximately age 6 to

Department ofPaediatrics, Catholic University of Leuven, Leuven, BelgiumSubmitted 16 August 2008: Accepted 1 December 2008: First published online 3 March 2009AbstractObjective: The present study aimed to compare two situations of endemicmalnutrition among ,5-year-old African children and to estimate the incidence,the duration and the case fatality of severe wasting episodes.Design: Secondary analysis of longitudinal studies, conducted several years ago,which allowed incidence and duration to be calculated from transition rates. Thefirst site was Niakhar in Senegal, an area under demographic surveillance, wherewe followed a cohort of children in 1983–5. The second site was Bwamanda inthe Democratic Republic of Congo, where we followed a cohort of children in1989–92. Both studies enrolled about 5000 children, who were followed byroutine visits and systematic anthropometric assessment, every 6 months in thefirst case and every 3 months in the second case.Results: Niakhar had less stunting, more wasting and higher death rates thanBwamanda. Differences in cause-specific mortality included more diarrhoeal dis-eases, more marasmus, but less malaria and severe anaemia in Niakhar. Severewasting had a higher incidence, a higher prevalence and a more marked age profilein Niakhar. However, despite the differences, the estimated mean durations ofepisodes of severe wasting, calculated by multi-state life table, were similar in thetwo studies (7?5 months). Noteworthy were the differences in the prevalence andincidence of severe wasting depending on the anthropometric indicator (weight-for-height Z-score #–3.0 or mid upper-arm circumference ,110mm) and thereference system (National Center for Health Statistics 1977, Centers for DiseaseControl and Prevention 2000 or Multicentre Growth Reference Study 2006).Conclusions: Severe wasting appeared as one of the leading cause of deathamong under-fives: it had a high incidence (about 2% per child-semester), longduration of episodes and high case fatality rates (6 to 12%).KeywordsUnder-fivesAnthropometrySevere wastingMalnutritionWeight-for-heightMid upper-arm circumferenceMortalityIncidenceCase fatalityMulti-state life tablesSub-Saharan AfricaNiakharBwamandaSevere wasting, defined as very low weight-for-height oras very small arm circumference for age, is frequentamong under-fives in developing countries, and is anindication for urgent medical attention and intensivenutritional rehabilitation. Severe wasting has drawn theattention of nutritionists for a long time and, despite overallimprovements in nutritional status, has become again asubject of research because treatment for severe wasting hasimproved dramatically and become increasingly efficient inrecent years

Data from a prospective multisite cohort study were used to examine the effect of HIV exposure, untreated HIV infection, and single-dose nevirapine on infant growth velocity. The 2009 WHO growth velocity standards constitute a new tool for this type of investigation and are in need of functional validation. In period 1 (3-24 wk), 65 HIV-infected, 502 HIV-exposed uninfected (HEU), and 216 HIV-unexposed infants were included. In period 2 (25-36 wk), 31 infants moved from the HEU group to the HIV-infected group. We compared weight velocity Z-scores (WVZ) and length velocity Z-scores (LVZ) by HIV group and assessed their independent influences. In period 1, mean WVZ (95% CI) was significantly (P < 0.001) lower in infected [-0.87 (-1.77, 0.04)] than HEU [0.81 (0.67, 0.94)] and unexposed [0.55 (0.33, 0.78)] infants. LVZ showed similar associations. In both periods, sick infants and those exposed to higher maternal viral loads had lower WVZ. Higher mean LVZ was associated with low birth weight. Infants that had received nevirapine had higher LVZ. In conclusion, HIV infection and not exposure was associated with low WVZ and LVZ in period 1. Eliminating infant HIV infection is a critical component in averting HIV-related poor growth patterns in infants in the first 6 mo of life.

Several aid groups have proposed strategies for allocating ready-to-use (therapeutic and supplementary) foods to children in developing countries. Analysis is needed to investigate whether there are better alternatives. We use a longitudinal dataset of 5,657 children from Bwamanda to construct a bivariate time-series model that tracks each child’s height-for-age z score (HAZ) and weight-for-height z score (WHZ) throughout the first 5 y of life. Our optimization model chooses which individual children should receive ready-to-use therapeutic or supplementary food based on a child’s sex, age, HAZ, and WHZ, to minimize the mean number of disability-adjusted life years (DALYs) per child during 6–60 mo of age [which includes childhood mortality calculated from a logistic regression and the lifelong effects of stunting (i.e., low HAZ)] subject to a budget constraint. Compared with the strategies proposed by the aid groups, which do not use HAZ information, the simple strategy arising from our analysis [which prioritizes children according to low values of a linear combination of HAZ, WHZ, and age and allocates the entire budget to therapeutic (i.e., 500 kcal/d) food for the prioritized children] reduces the number of DALYs by 9% (for the same budget) or alternatively incurs the same number of DALYs with a 61% reduction in cost. Whereas our qualitative conclusions appear to be robust, the quantitative results derived from our analysis should be treated with caution because of the lack of reliable data on the impact of supplementary food on HAZ and WHZ, the application of our model to a single cohort of children and the inclusion and exclusion errors related to imperfect food targeting.

International audience; BACKGROUND: Strategies to prevent postnatal mother-to-child transmission of HIV-1 in Africa, including infant prophylaxis, have never been assessed past 6 months of breastfeeding, despite breastfeeding being recommended up to 12 months after birth. We aimed to compare the efficacy and safety of infant prophylaxis with the two drug regimens (lamivudine or lopinavir-ritonavir) to prevent postnatal HIV-1 transmission up to 50 weeks of breastfeeding.METHODS: We did a randomised controlled trial in four sites in Burkina Faso, South Africa, Uganda, and Zambia in children born to HIV-1-infected mothers not eligible for antiretroviral therapy (CD4 count >350 cells per μL). An independent researcher electronically generated a randomisation schedule; we then used sequentially numbered envelopes to randomly assign (1:1) HIV-1-uninfected breastfed infants aged 7 days to either lopinavir-ritonavir or lamivudine (paediatric liquid formulations, twice a day) up to 1 week after complete cessation of breastfeeding or at the final visit at week 50. We stratified the randomisation by country and used permuted blocks of four and six. We used a study label on drug bottles to mask participants, study physicians, and assessors to the treatment allocation. The primary outcome was infant HIV-1 infection between age 7 days and 50 weeks, diagnosed every 3 months with HIV-1 DNA PCR, in the modified intention-to-treat population (all who attended at least one follow-up visit). This trial is registered with ClinicalTrials.gov, number NCT00640263.FINDINGS: Between Nov 16, 2009, and May 7, 2012, we enrolled and randomised 1273 infants and analysed 1236; 615 assigned to lopinavir-ritonavir or 621 assigned to lamivudine. 17 HIV-1 infections were diagnosed in the study period (eight in the lopinavir-ritonavir group and nine in the lamivudine group), resulting in cumulative HIV-1 infection of 1.4% (95% CI 0.4-2.5) and 1.5% (0.7-2.5), respectively. Infection rates did not differ between the two drug regimens (hazard ratio [HR] of lopinavir-ritonavir versus lamivudine of 0.90, 95% CI 0.35-2.34; p=0.83). Clinical and biological severe adverse events did not differ between groups; 251 (51%) infants had a grade 3-4 event in the lopinavir-ritonavir group compared with 246 (50%) in the lamivudine group.INTERPRETATION: Infant HIV-1 prophylaxis with lopinavir-ritonavir was not superior to lamivudine and both drugs led to very low rates of HIV-1 postnatal transmission for up to 50 weeks of breastfeeding. Infant pre-exposure prophylaxis should be extended until the end of HIV-1 exposure and mothers should be informed about the persistent risk of transmission throughout breastfeeding.FUNDING: INSERM/National Agency for Research on AIDS and Viral Hepatitis (including funds from the Total Foundation), European Developing Countries Clinical Trials Partnership, Research Council of Norway.

Objectives To describe baseline nutritional anthropometry and its determinants in a cohort of children commencing HAART, and subsequent longitudinal anthropometric trajectories over 2 years. Methods Prospective observational study in a prepubertal cohort of children commencing HAART in Durban, South Africa. Results Among 151 children with a median baseline age of 61.3 months (IQR 29.6, 90.1), prevalence of stunting was 54% (95% CI 46, 62) and of underweight, 37% (95% CI 29, 45). There was high prevalence of preceding respiratory and diarrhoeal comorbidities, which were associated with poorer anthropometry. There were significant improvements in height, weight and mid-upper-arm circumference z-scores after initiation of HAART regardless of preceding comorbidities. Stunted children remained shorter on average after 24 months, but younger children had better catch-up. Children who eventually died had persistently worse anthropometry. Children who were exposed to improved programs for prevention of mother-to-child transmission (PMTCT) were younger and had more severe growth impairments at baseline. Conclusion Anthropometric status of children on HAART is influenced by age, preceding comorbidities, and by programmatic factors. With improved PMTCT programs, infants who would previously have died in infancy are now surviving to commence HAART. Poor outcomes are preceded by persistent anthropometric failure on HAART reaffirming the need for growth velocity monitoring. Objectifs: Decrire l’anthropometrie nutritionnelle de base et ses determinants dans une cohorte d’enfants commencant la therapie antiretrovirale hautement active (HAART) et les trajectoires longitudinales anthropometriques subsequentes sur deux ans. Methodes: Etude observationnelle prospective d’une cohorte d’enfants pre-puberes commencant l’HAART a Durban, en Afrique du Sud. Resultats: Parmi 151 enfants avec un âge median de base de 61,3 mois (IQR: 29,6–90,1), la prevalence d’un retard de croissance etait de 54% (IC95%: 46–62) et celle de l’insuffisance ponderale, 37% (IC95%: 29–45). Il y avait une forte prevalence de co-morbidites precedentes respiratoires et diarrheiques, qui etaient associees a une mauvaise anthropometrie. Il y avait des ameliorations significatives dans les z-scores pour la taille, le poids et le perimetre brachial apres l’initiation de l’HAART, independamment des co-morbidites precedentes. Les enfants avec un retard de croissance sont restes de taille plus courte en moyenne apres 24 mois, mais les plus jeunes enfants ont effectue un meilleur rattrapage. Les enfants qui sont decedes par la suite avaient une anthropometrie persistante pire. Les enfants qui etaient exposes a de meilleurs programmes de prevention de la transmission mere-enfant (PTME) etaient plus jeunes et avaient des problemes de croissance plus graves au depart. Conclusion: Le statut anthropometrique des enfants sous HAART est influence par l’âge, les co-morbidites precedentes et les facteurs programmatiques. Avec de meilleurs programmes PTME, les nourrissons qui auparavant seraient decedes a bas âge survivent maintenant pour commencer l’HAART. Les mauvais resultats sont precedes par un echec anthropometrique persistant sous HAART, ce qui reaffirme la necessite d’une surveillance de la vitesse de croissance. Objetivos: Describir la antropometria nutricional de base y sus determinantes en una cohorte de ninos que comienzan TARGA, y la subsecuente trayectoria antropometrica longitudinal a lo largo de dos anos. Metodos: Estudio observacional prospectivo de una cohorte de ninos prepuberes que comienzan TARGA, en Durban, Sudafrica. Resultados: Entre 151 ninos, con una mediana de edad de 61.3 meses al comienzo del estudio (IQR 29.6, 90.1), la prevalencia de retraso en el crecimiento era del 54% (IC 95% 46, 62) y del bajo peso del 37% (IC 95% 29, 45). Habia una alta prevalencia de co-morbilidades respiratorias y diarreicas precedentes, lo cual estaba asociado a una antropometria mas pobre. Habia mejoras significativas en los Z-scores para altura, peso y la circunferencia superior del brazo tras haber iniciado la TARGA, independientemente de las comorbilidades precedentes. Los ninos con retraso en el crecimiento se mantuvieron con una menor talla durante un promedio de 24 meses, pero los mas jovenes se reponian mas rapidamente. Los ninos que eventualmente murieron tenian una mala antropometria persistente. Los ninos expuestos a programas mejorados de prevencion de la transmision vertical eran mas jovenes, y tenian retrasos en el crecimiento mas severos en el momento de iniciar el estudio. Conclusion: El estatus antropometrico de los ninos recibiendo TARGA esta influenciado por la edad, las comorbilidades precedentes y los factores programaticos. Con programas mejorados para la prevencion de la transmision vertical, los lactantes que previamente habrian muerto en sus primeros anos, ahora sobreviven y comienzan TARGA. Unos malos resultados estan precedidos por fallos antropometricos persistentes recibiendo TARGA, reafirmando la necesidad de monitorizar la velocidad del crecimiento.

ObjectiveIn malnourished populations, the weight-for-height Z-score (WHZ) distribution is shifted to the left. The aim of nutrition interventions should be to restore a normal WHZ distribution for the whole population. The present paper examines the WHZ change needed by each individual to achieve this objective.DesignWe developed a mathematical model of required individual change in WHZ as a function of characteristics of the initial population to restore a normal distribution. This model was then tested by simulating WHZ change needed to restore a normal WHZ distribution in a test population.SettingA rural area of Democratic Republic of the Congo with a high prevalence of undernutrition.SubjectsChildren under 5 years of age.ResultsTo restore a normal distribution for the whole population, the WHZ of all children should be shifted. The desired WHZ change of each individual should be higher when the individual's initial WHZ is low, when the mean WHZ of the whole population is low and, for the most wasted individual, when the variance of WHZ and WHZ change in the population are high. Using the suggested model in a simulation on the test population resulted in a WHZ distribution close to the growth standard.ConclusionsTo restore a normal WHZ distribution in wasted populations, nutritional programmes should cover the whole population with a higher weight gain in areas where mean WHZ is low.

The interplay of factors that affect post-partum loss or retention of weight gained during pregnancy is not fully understood. The objective of this paper is to describe patterns of weight change in the six sites of the World Health Organization (WHO) Multicentre Growth Reference Study (MGRS) and explore variables that explain variation in weight change within and between sites. Mothers of 1743 breastfed children enrolled in the MGRS had weights measured at days 7, 14, 28 and 42 post-partum, monthly from 2 to 12 months and bimonthly thereafter until 24 months post-partum. Height, maternal age, parity and employment status were recorded and breastfeeding was monitored throughout the follow-up. Weight change patterns varied significantly among sites. Ghanaian and Omani mothers lost little or gained weight post-partum. In Brazil, India, Norway and USA, mothers on average lost weight during the first year followed by stabilization in the second year. Lactation intensity and duration explained little of the variation in weight change patterns. In most sites, obese mothers tended to lose less weight than normal-weight mothers. In Brazil and Oman, primiparous mothers lost about 1 kg more than multiparous mothers in the first 6 months. In India and Ghana, multiparous mothers lost about 0.6 kg more than primiparas in the second 6 months. Culturally defined mother-care practices probably play a role in weight change patterns among lactating women. This hypothesis should stimulate investigation into gestational weight gain and post-partum losses in different ethnocultural contexts.

OBJECTIVE To estimate the extent of under- and over-reporting, to examine associations with misreporting and sociodemographic and lifestyle characteristics and mental health status and to identify differential reporting in micro- and macronutrient intake and quality of diet. DESIGN A health and lifestyle questionnaire and a semi-quantitative FFQ were completed as part of the 2007 Survey of Lifestyle, Attitudes and Nutrition. Energy intake (EI) and intake of micro- and macronutrients were determined by applying locally adapted conversion software. A dietary score was constructed to identify healthier diets. Accuracy of reported EI was estimated using the Goldberg method. ANOVA, χ2 tests and logistic regression were used to examine associations. SETTING Residential households in Ireland. SUBJECTS A nationally representative sample of 7521 adults aged 18 years or older. RESULTS Overall, 33·2 % of participants were under-reporters while 11·9 % were over-reporters. After adjustment, there was an increased odds of under-reporting among obese men (OR = 2·01, 95 % CI 1·46, 2·77) and women (OR = 1·68, 95 % CI 1·23, 2·30) compared to participants with a healthy BMI. Older age, low socio-economic status and overweight/obesity reduced the odds of over-reporting. Among under-reporters, the percentage of EI from fat was lower and overall diet was healthier compared to accurate and over-reporters. The reported usage of salt, fried food consumption and snacking varied significantly by levels of misreporting. CONCLUSIONS Patterns in differential reporting were evident across sociodemographic, lifestyle and mental health factors and diet quality. Consideration should be given to how misreporting affects nutrient analysis to ensure sound nutritional policy.

ObjectiveOverweight and obesity have increased to epidemic proportions among adolescents and are associated with chronic non-communicable diseases and excess mortality in adulthood. The association of overweight/obesity with poor dietary habits has not been studied in adolescents in middle-income developing countries. The present study aimed to estimate the prevalence of overweight, obesity and high waist circumference (WC) in 15–19-year-old Jamaican adolescents and to investigate the association with fast-food and sweetened beverage consumption.DesignThe study enrolled 1317 (598 male, 719 female) adolescents aged 15–19 years using multistage, nationally representative sampling. Age-specific prevalence calculation used internalZ-score lines connecting with the WHO adult cut-off points. Logistic regression was used to examine the association of overweight or high WC with fast-food and sweetened beverage consumption, adjusting for potential confounders.ResultsThe overall prevalence of overweight, obesity and high WC was approximately 15 %, 6 % and 10 %, respectively. Prevalence estimated using internalZ-scores was similar to that using the International Obesity Taskforce cut-off points. Obesity (8·0 % in females, 3·3 % in males) and high WC (16·2 % in females, 1·7 % in males) were significantly more prevalent in females when using internalZ-score cut-offs. High WC was associated with the absence of fruit consumption (P= 0·043) and overweight with high sweetened beverage consumption (P= 0·018).ConclusionOverweight occurs frequently among Jamaican 15–19-year-olds and is associated with increased consumption of sweetened beverages. High WC is more prevalent among females and is related to low consumption of fruits and vegetables. Measures to reduce the consumption of sweetened beverages and increase fruit intake may reduce the prevalence of excess body fat among adolescents.

Little is known about dietary diversity of children residing in areas of high HIV prevalence. This study examined dietary diversity in 381 children ages 6-24 mo in rural South Africa. Twenty-eight (7.3%) children and 170 mothers (44.6%) were HIV infected. Home visits were conducted weekly and a detailed history of dietary intake obtained. A dietary diversity score was computed based on the weekly consumption of 8 food classes. Low dietary diversity was defined as falling within the lowest quartile of the diversity scale. There were 22,772 child weeks of observation: 1369 for HIV-infected children, 8876 for HIV-uninfected children born to HIV-infected mothers, and 12,527 for HIV-uninfected children born to HIV-uninfected mothers. Low dietary diversity was more common in HIV-infected children [crude odds ratio (OR), 2.59; 95% CI, 1.52 to 4.41) compared with children born to HIV-uninfected mothers. In a multiple logistic regression analysis adjusting for socioeconomic and health status, HIV-infected children had lower dietary diversity (conditional OR, 1.76; 95% CI, 1.06 to 2.94) than HIV-uninfected children. HIV-infected children consumed less in 6 of 8 food classes compared with HIV-uninfected children, with the 2 exceptions being breast milk and formula milk. In rural South Africa, HIV-infected children's diets are significantly less diverse than those of HIV-uninfected children. This may be a factor contributing to increased morbidity and poorer survival in these children.

Background In sub-Saharan Africa (SSA), the rising prevalence of overweight, obesity and non-communicable diseases co-exists with the high burden of under-nutrition. The paucity of data on adulthood overweight and obesity, disaggregated by socio-demographic characteristics and in rural settings in SSA calls for research. We determined the prevalence of underweight, overweight/obesity and associated factors among adults in peri-urban and rural Uganda. Methods A cross-sectional study of 1210 randomly selected adults aged ≥ 18 years was conducted in Iganga-Mayuge Health and Demographic Surveillance Site in eastern Uganda in 2013. Height, weight and socio-demographic variables were assessed. Overweight was defined as BMI = 25.0-29.99 kg/m2, obesity ≥ 30 kg/m2 and overweight/obesity ≥ 25 kg/m2. Logistic regression was used to identify factors associated with overweight/obesity. Results Of the participants, 7 % were underweight (8.1 % of men; 5.9 % of women, p = 0.99); 17.8 % were overweight (12.4 % of men; 23.1 % of women, p

Introduction The magnitude of child malnutrition including severe child malnutrition is especially high in the rural areas of the Democratic Republic of Congo (the DRC). The aim of this qualitative study is to describe the social context of malnutrition in a rural part of the DRC and explore how some households succeed in ensuring that their children are well-nourished while others do not. Methodology This study is based on participant observation, key informant interviews, group discussions and in-depth interviews with four households with malnourished children and four with well-nourished children. We apply social field theory to link individual child nutritional outcomes to processes at local level and to the wider socio-economic environment. Findings We identified four social fields that have implications for food security and child nutritional outcomes: 1) household size and composition which determined vulnerability to child malnutrition, 2) inter-household cooperation in the form of ‘gbisa work party’ which buffered scarcity of labour in peak seasons and facilitated capital accumulation, 3) the village associated with usufruct rights to land, and 4) the local NGO providing access to agricultural support, clean drinking water and health care. Conclusions Households that participated in inter-household cooperation were able to improve food and nutrition security. Children living in households with high pressure on productive members were at danger of food insecurity and malnutrition. Nutrition interventions need to involve local institutions for inter-household cooperation and address the problem of social inequalities in service provision. They should have special focus on households with few resources in the form of land, labour and capital publishedVersion

This paper describes the use of non-prescribed medications given to a cohort of infants in the first 3 months of life in a rural South African district and discusses some of the implications for primary health care. As part of an ongoing study on breastfeeding a cohort of 110 infants were visited at home at 6 and 12 weeks of age. Any medications given to the infant since the last visit the reasons for their administration and any visits made to traditional healers were recorded via a semi-structured questionnaire. Determinants of administration of non-prescribed medication were analysed including maternal age education infant gender and socio-economic factors. A total of 107 (97%) infants received non-prescribed medications in the first 3 months of life: 98 (89%) rectally and 64 (58%) orally. The most common enema contained traditional Zulu medicine made from herbs given more than once weekly usually for perceived constipation; the most common oral medication was gripe water given once daily mainly for ‘colic’ or ‘wind’. Twenty-nine (26%) mothers had consulted a traditional healer most commonly because of concerns about a capillary naevus thought to cause pain. Mothers with a ‘clean’ water supply were more likely to give nonprescribed oral medications than those without (OR = 2.7 and P = 0.0223) whilst those who had no education were less likely to administer them than those who had completed school (OR = 0.19 and P = 0.0326). Non-prescribed medications are given almost universally to young infants in our area irrespective of socio-economic class. Health professionals need to be aware of the extent of and reasons for administration of non-prescribed medications to young infants so that effective health messages can be targeted at mothers and caregivers. (authors)

Dr. Miettinen has called for a debate on his ideas about the single etiologic study and the use of trial data for the construction of smooth-in-time risk prediction functions [1]. He did so admittedly as an attempt to influence the possible achievement of a paradigm shift. Dr. Miettinen is one of the founding fathers of modern epidemiology. Many of the concepts and terms he has introduced have found their way into current epidemiological thinking and discourse, respectively. Why has the same not yet happened with his ideas on the single etiologic study and with the significance of this new paradigm for intervention-prognostic research? Dr. Miettinen wonders and so do presumably many of those who have made a serious effort to study his writings. Although the roots of the single etiologic study can be traced back to Miettinen’s 1985 book [2], the formal concept is a bit more recent than the other concepts that are already accepted in epidemiology. So is it simply a matter of time? It might well be, but Dr. Miettinen’s concern is to change the’prognostic profile’ by opening a debate, which is fair enough and offers an exciting prospect. Remarkably, Pearl, a founder of modern causal theories with wide potential for implementation notably theories and methods of structural causal modelling, recently noted a similar difficulty in getting the message down to the masses. His attempt to solution was to produce an article aimed at making the recent advances more accessible through a ‘gentle introduction’ to the generally unfamiliar complexities of methods such as path analysis [3]. What we are seeing in both cases is a need for highly complex theory to marry with didactics and dissemination strategy. This could mean incorporation into a pedagogical framework that enables future students of epidemiology to embrace this shift for inclusion into mainstream applications. Epidemiology Journals currently form an important part of the pedagogical framework for epidemiology students. Therefore, in the hope of contributing something to the inception of the debate we would like to ask Dr. Miettinen some questions here about the single etiologic study and its relevance to trial analysis. One of the passages that struck us in the recent paper is where Dr. Miettinen insists that the single etiologic study should not be presented as a unification of the traditional cohort and case–control studies, but that it is a design that differs from both and that should replace any old one. This made us wonder: can or should old etiologic study data be re-analysed in the spirit of the single etiognostic study? If so, would the results in terms of rate ratios be any different, or, when are they expected to be different and why? In the event, would it be possible to provide a practical step-by-step example of how to re-analyse data from a traditional observational follow-up study? If it turns out that re-analysis would be a good idea in more than a minimal proportion of old studies, this could have an enormous impact on epidemiological practice in the coming decennia. Our own tentative answer is that, yes, re-analysis can often be envisaged because documented population time (in terms of exposure histories) of both study base and of cases arising from it will often be available, whether the old etiologic study was of the traditional ‘case–control’, ‘nested case–control’ or ‘cohort’ type. We have no full insight into the procedures needed but we think that there may be two main keys. The first of those is the different handling of etiologic time, which, in the single etiologic study of Miettinen, is negative as from the time of manifestation of case status i.e. as from time of first manifestation of case-defining status in cases, and, end of individual follow-up time in non-cases. This different handling is needed also if the old study was based on a cohort with a planned fixed individual follow-up period. The reversal of etiologic time during re-analysis of traditional cohort data then leads to a situation where the exposure data become left-censored instead of right-censored. The second main key to re-analysis may be the (re-)sampling from the study base for the formation of a reference series, which should never be restricted to the non-case domain, and again this would need to hold for re-analysis of all ‘old types of design’. Another question we have relates to the desideratum, mentioned in the recent paper [1], for the case series to be much smaller than the reference series in the suggested additional analysis of trial data. What would be a good operational definition of ‘much smaller’ in these matters? We think that, especially in smaller trials, the outcome is often a relatively frequent event (in terms of incidence) so that the base will not be that much bigger than the case series? Would there be any recommended approach to constructing a prognostic function in such instances? On the matter of advancing the quality of intervention studies we agree that the paradigm of the single etiognostic study would not only advance quality but also cost efficient use of the research infrastructure invested in intervention studies. Questions here revolve around how best to abstract the base series, bearing in mind both left- and right censoring of the ‘source population’ in intervention studies. As always, the ideas of Dr. Miettinen are well worth studying and debating. We are thrilled by the prospect of an interesting debate but, for many, (examples of) implementation will be a condition for deeper understanding.

Background: Studying the influence of geographical factors on child growth is important, especially given the increasing interest in climate change and health in resource-poor settings and the recognized importance of growth faltering as a general marker of population health. We describe patterns in children’s weight and length velocity and relate them to seasonal and spatial factors in rural DR Congo. The study setting is a food-insecure area with a majority dependent on rain-fed subsistence farming and expected to be one of the regions most affected by climate change. Methods: We studied the effect of selected geographical factors, i.e. season, village size and distances to hospital, health center, forest, fishing grounds and market on growth of children under two years old. We calculated individual growth velocity Z-scores according to the WHO-2009 growth velocity standards for up to five successive 3-month growth periods. Associations with geographical factors were examined in multivariate mixed effects regression models. Results: For the study population of 2223 children is characterized by low nutritional status. Age and season were the only independent predictors of growth velocity in the multivariate regression analysis. Mean velocity Z-scores were already low in children aged 0-6 months for weight [-1.34 (95% CI: -1.45, -1.22)] and for length [-0.99 (95% CI: -1.13, -0.84)]. They increased with age, while Z-scores of attained growth gradually decreased. Mean growth velocities were lowest before the main harvest season with a mean improvement of 1.2 and 2.3 Z-scores for weight and length velocity thereafter. A seasonal pattern was not seen in attained growth. No relation to spatial factors was found. Conclusions: In this rural subsistence economy area, geographical factors relating to distances to food sources and health services are less important determinants than harvest season, which is the major underlying determinant of child growth in these settings. publishedVersion

Background: Longitudinal studies describing incidence and natural course of malnutrition are scarce. Studies defining malnutrition clinically [moderate clinical malnutrition (McM) marasmus, kwashiorkor] rather than anthropometrically are rare. Our aim was to address incidence and course of malnutrition among pre-schoolers and to compare patterns and course of clinically and anthropometrically defined malnutrition. Methods: Using a historical, longitudinal study from Bwamanda, DR Congo, we studied incidence of clinical versus anthropometrical malnutrition in 5 657 preschool children followed 3-monthly during 15 months. Results: Incidence rates were highest in the rainy season for all indices except McM. Incidence rates of McM and marasmus tended to be higher for boys than for girls in the dry season. Malnutrition rates increased from the 0–5 to the 6 – 11 months age category. McM and marasmus had in general a higher incidence at all ages than their anthropometrical counterparts, moderate and severe wasting. Shifts back to normal nutritional status within 3 months were more frequent for clinical than for anthropometrical malnutrition (62.2-80.3% compared to 3.4-66.4.5%). Only a minority of moderately stunted (30.9%) and severely stunted children (3.4%) shifted back to normal status. Alteration from severe to mild malnutrition was more characteristic for anthropometrically than for clinically defined malnutrition. Conclusions: Our data on age distribution of incidence and course of malnutrition underline the importance of early life intervention to ward off malnutrition. In principle, looking at incidence may yield different findings from those obtained by looking at prevalence, since incidence and prevalence differ approximately differ by a factor “duration”. Our findings show the occurrence dynamics of general malnutrition, demonstrating that patterns can differ according to nutritional assessment method. They suggest the importance of applying a mix of clinical and anthropometric methods for assessing malnutrition instead of just one method. Functional validity of characterization of aspects of individual nutritional status by single anthropometric scores or by simple clinical classification remain issues for further investigation. publishedVersion

Linear growth from birth to 2 years of children enrolled in the World Health Organization Multicentre Growth Reference Study was similar despite substantial parental height differences among the six study sites. Within‐site variability in child length attributable to parental height was estimated by repeated measures analysis of variance using generalized linear models. This approach was also used to examine relationships among selected traits (e.g. breastfeeding duration and child morbidity) and linear growth between 6 and 24 months of age. Differences in intergenerational adult heights were evaluated within sites by comparing mid‐parental heights (average of the mother's and father's heights) to the children's predicted adult height. Mid‐parental height consistently accounted for greater proportions of observed variability in attained child length than did either paternal or maternal height alone. The proportion of variability explained by mid‐parental height ranged from 11% in Ghana to 21% in India. The average proportion of between‐child variability accounted for by mid‐parental height was 16% and the analogous within‐child estimate was 6%. In the Norwegian and US samples, no significant differences were observed between mid‐parental and children's predicted adult heights. For the other sites, predicted adult heights exceeded mid‐parental heights by 6.2–7.8 cm. To the extent that adult height is predicted by height at age 2 years, these results support the expectation that significant community‐wide advances in stature are attainable within one generation when care and nutrition approximate international recommendations, notwithstanding adverse conditions likely experienced by the previous generation.

ObjectiveTo describe the cost of diarrhoeal illness in children aged 6–24 months in a rural South African community and to determine the threshold prevalence of stunting at which universal Zn plus vitamin A supplementation (VAZ) would be more cost-effective than vitamin A alone (VA) in preventing diarrhoea.DesignWe conducted a cost analysis using primary and secondary data sources. Using simulations we examined incremental costs of VAZ relative to VA while varying stunting prevalence.SettingData on efficacy and societal costs were largely from a South African trial. Secondary data were from local and international published sources.SubjectsThe trial included children aged 6–24 months. The secondary data sources were a South African health economics survey and the WHO-CHOICE (CHOosing Interventions that are Cost Effective) database.ResultsIn the trial, stunted children supplemented with VAZ had 2·04 episodes (95 % CI 1·37, 3·05) of diarrhoea per child-year compared with 3·92 episodes (95 % CI 3·02, 5·09) in the VA arm. Average cost of illness was $Int 7·80 per episode (10th, 90th centile: $Int 0·28, $Int 15·63), assuming a minimum standard of care (oral rehydration and 14 d of therapeutic Zn). In simulation scenarios universal VAZ had low incremental costs or became cost-saving relative to VA when the prevalence of stunting was close to 20 %. Incremental cost-effectiveness ratios were sensitive to the cost of intervention and coverage levels.ConclusionsThis simulation suggests that universal VAZ would be cost-effective at current levels of stunting in parts of South Africa. This requires further validation under actual programmatic conditions.

When proposing a study, one first briefly formulates the ‘general study objectives’ and then describes the ‘specific aims’ to clearly articulate the essence of the design used to generate empirical evidence about the research question(s) at hand. This is a crucial step in the development of the research plan. Indeed, reviewers of study proposals often consider the ‘specific aims section’ as the most important section of the proposal, as this section provides them a first insight into the validity and efficiency of the design and methods to be used. This chapter explains that the essence of a study design lies in specifications of the study domain, occurrence relation(s), study base, study variables, and outcome parameters. This chapter also offers practical advice for investigators in pinpointing and describing the specific aims of a research project.

Data management in research is a process geared towards making recorded information available for use in analyses. This process involves a computerized data system that structures and stores electronic data. The main purposes of a computerized data system are to archive, retrieve, and extract data, and these processes must maintain the integrity of original data. In support of these purposes, data systems should be set up to make input, retrieval, and extraction as efficient (fast, easy) as possible. Moreover, privacy and confidentiality concerns should be of primary consideration when creating and limiting the range of possibilities for data retrieval and extraction. Thus, the principles of validity, efficiency, and ethics apply to the way data systems are set up and managed.

Data have integrity when they are free of data abnormalities and data manipulations. Maintaining data integrity is a responsibility of all those involved in research, not only data managers. The costs of data integrity problems and of responding to them when they are discovered can be high; therefore, prevention of data integrity problems is far better than correcting them after they have been made. However, even when good strategies are employed to prevent data integrity problems (a topic discussed previously), it is inevitable that some data integrity problems will occur. The specific foci of this chapter are thus on (1) operational problems occurring in spite of detailed quality assurance and data management plans and (2) adaptive responses. Some data integrity challenges and possible solutions in resource-limited settings are also highlighted.

Study implementation starts with the necessary training of personnel, planning of logistics, and establishment of infrastructure. At this stage of the study, management and training skills as well as practical experience become as important for the investigators as theoretical scientific skills. Literature on this important aspect of a study is sparse; therefore, in this chapter we present experience-based recommendations for preparing for the implementation of a study.

This chapter offers practical advice for investigators on how to report the quality of their own data in scientific papers. The proposed guidelines are based on an analysis of the concept of aggregate data quality. We first clarify the multidimensional concept of aggregate data quality and then proceed by deriving principles and practical recommendations for reporting data quality. When describing data quality, one may need to consider study-specific and variable-specific factors that influence data quality requirements. In this chapter we argue that reporting on data quality should be more comprehensive than currently accepted practices. Among the array of useful data quality parameters, we selected digit preference and intra- and inter-observer reliability statistics for more in depth discussion. Finally, we discuss the quality of laboratory data, an issue that deserves separate reporting.

The first purpose of this chapter is to outline the roots of epidemiology as a metho­dological discipline, using a multiple-threads historical approach. We unravel what we see as the main historical threads relevant to the development of current health research methods involving human subjects, giving attention to the ethical, scientific-theoretical, and practical aspects. Roots of epidemiological concepts and methods go back a long time, to before epidemiology became a named discipline and before formal statistical comparisons of occurrence frequencies started being made. We take the stance that ancient thinkers, dating back at least as far back as Aristotle, formed early concepts that have been essential to the development of modern epidemiology as we know it. We therefore treat such critical developments as directly relevant to the history of epidemiology. As an introduction, we begin with a discussion of belief systems. We then discuss a series of historical threads, starting from health research topics, over ways of causal thinking about health, to the design of empirical information, research ethics and stakeholder participation. Other threads relevant to epidemiology such as history of data management, analysis, and study reporting, are not covered. Finally, we explore some possible and desirable future developments in epidemiological research.

In planning and proposing a study, a paramount concern is the likelihood that the study will provide useful or meaningful information. An important factor in demonstrating that a study will be informative is sample size. If a study has a sub-optimal number of subjects, it may be under-powered to detect statistical significance even in the presence of a true effect, or estimates produced by the study may lack useful precision. On the other hand, if a study has too many subjects, one may encounter resource limitations and ethical issues associated with exposing an unnecessarily large number of subjects to risk. An optimal study size therefore balances the need for adequate statistical power or precision, the limited nature of resources, and the ethical obligation to limit exposure to risk. As such, study proposals and scientific papers often include sections on the planning of study size. This chapter begins with an exploration of various factors that contribute to optimal study size. We then briefly review some useful sample size calculations in the contexts of surveys, cohort studies, case–control studies, and randomized trials.

In the previous chapters we discussed specifications of research questions, general study designs, and study size. The next step in developing a study proposal is to create a practical plan for how to find and enroll participants or other observation units. It is important to be clear about what particular characteristics are needed (inclusion and exclusion criteria), how to identify an appropriate number of participants (recruitment, sampling, and eligibility screening), and how to get the necessary permissions to access secondary data or to obtain new information after informed consent and enrollment. The principles and guidelines for each of these tasks are described in this chapter (terminology in Panel 9.1), except that we devote a separate chapter (Chap. 16) to the management of the informed consent process.

Good Clinical Practice (GCP) is a set of guidelines for trial research, not for the practice of clinical care, as the name might suggest. This chapter aims to introduce the large topic of GCP, to orient those researchers who are unfamiliar with trial research to the essence and scope of GCP guidelines, and to discuss some practical GCP-related tasks. First, the concept of GCP as a standard rooted in general ethical principles and as a new paradigm in experimental research involving human subjects is explained. Next we review the wide scope of GCP-related responsibilities of investigators and discuss the resources required to establish minimum GCP capacity. This leads us to the topic of the relevance of GCP for observational research and implementation difficulties in resource-poor areas. Finally, we introduce in some more detail three selected GCP-related activities that are of particular practical importance during execution of a trial: the maintenance of a regulatory file, adverse events reporting, and site monitoring visits. Basic terminology is listed in Panel 21.1

Informed consent is the process of fully informing potential study subjects about the study and obtaining their voluntary agreement to participate or (if already enrolled in the study) to continue their participation. Informed consent is an ongoing process and a key responsibility of researchers using information or biological samples provided by human subjects. Ethics committees play vital roles in ensuring that necessary steps are taken to fulfill the ethical obligations linked to the informed consent process, but even with the best intentions, the informed consent process can be mismanaged. The chapter outlines the principles and the stages of the informed consent process, and it highlights issues to consider when managing and executing the informed consent process.

Quality assurance relates to all actions taken to ensure respect for general epidemiological principles. Consequently, quality assurance includes many aspects of study design and conduct, including quality control activities. Quality control (QC) relates to the monitoring and documentation of the validity and efficiency of study procedures and, if necessary, actions for adapting procedures or improving adherence to them. Ultimately, the purpose of QC is to achieve optimal data quality. In this chapter we outline QC methods and tools, prime among them being the monitoring of measurement error and other factors that could bias the statistical results of a study.

Epidemiology is a methodological discipline offering principles and practical guidelines for the creation of new quantitative evidence about health-related phenomena. Its aim is to contribute to knowledge in support of clinical medicine and community medicine. Epidemiological research uses scientific methods, in which empirical evidence is obtained from a study population to make inferences about a target population. In this chapter we first establish a definition of epidemiology and describe the wide scope of epidemiology in terms of its subject domains, types of research topics, types of study designs, and range of research activities that occur from a study’s inception to its publication. Since epidemiology concerns both ‘scientific studies’ and ‘particularistic fact-finding investigations,’ we further orient the reader to the scope of epidemiology through a discussion of these. We then introduce general epidemiological principles that health researchers should continuously keep in mind during the planning, gathering and presentation of the empirical evidence. All of these topics are pursued in more depth in the chapters that follow.