Publications by authors named "Stella Nordhagen"

12 Publications

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Between the City and the Farm: Food Environments in Artisanal Mining Communities in Upper Guinea.

Public Health Nutr 2021 May 12:1-34. Epub 2021 May 12.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD, USA.

Objective: Artisanal and small-scale mining (ASM) is a widespread livelihood in low- and middle-income countries, however many in ASM communities face high levels of poverty and malnutrition. The food environments in ASM communities have non-agricultural rural characteristics that differ from those in urban and subsistence rural areas examined in much existing food environment literature.

Design: We examine these complex external and personal food environments in ASM communities via a study using qualitative and quantitative methods. Market surveys and a cross-sectional household survey, plus qualitative mining site non-participant observations and in-depth structured interviews, were conducted in three waves.

Setting: Eighteen study sites in ASM communities in northern Guinea.

Participants: Surveys covered mothers in mining households with young children (n=613); in-depth interviews engaged mothers of young children (n=45), food vendors (n=40), and young single miners (n=15); observations focused on mothers of young children (n=25).

Results: The external food environment in these ASM communities combines widespread availability of commercially-processed and staple-heavy foods with lower availability and higher prices for more nutritious, non-staple foods. Within the personal food environment, miners are constrained in their food choices by considerable variability in daily cash income and limited time for acquisition and preparation.

Conclusions: We demonstrate that ASM communities have characteristics of both urban and rural populations and argue for greater nuance and appreciation of complexity in food environment research and resultant policy and programming.
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http://dx.doi.org/10.1017/S1368980021002020DOI Listing
May 2021

"If you don't find anything, you can't eat" - Mining livelihoods and income, gender roles, and food choices in northern Guinea.

Resour Policy 2021 Mar;70:101939

Department of International Health, Johns Hopkins Bloomberg School of Public Health - 615 N Wolfe St, Baltimore, MD, 21205, USA.

Artisanal and small-scale mining (ASM) continues to grow as a viable economic activity in sub-Saharan Africa. The health and environmental impacts of the industry, notably linked to the use of potentially toxic chemicals, has been well documented. What has not been explored to the same extent is how pressures associated with ASM affect food choices of individuals and families living in mining camps. This paper presents research conducted in 18 mining sites in northern Guinea exploring food choices and the various factors affecting food decision-making practices. Two of the most influential factors to emerge from this study are income variability and gender roles. Results from this study suggest that through artisanal mining, women have the opportunity to earn a larger income that would otherwise be unavailable through agriculture. However, this benefit of potentially earning a larger income is often reduced or constrained by existing gender roles both at the mines and in the home, such as disparity in pay between men and women and increased pressures on women's time. This limits the potential benefit to household food decision-making that could have been gained from higher income. These results do not seek to establish one livelihood as superior; rather, they demonstrate that even when presented with opportunities to earn higher incomes, women still face many of the same barriers and challenges that they would in other economic activities. Additionally, while work and time demands on women change upon arrival in the mining camps, existing gender roles and expectations do not, further restricting women's decision-making capacity.
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http://dx.doi.org/10.1016/j.resourpol.2020.101939DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7976851PMC
March 2021

Affordability of nutritious foods for complementary feeding in South Asia.

Nutr Rev 2021 03;79(Suppl 1):52-68

United Nations Children's Fund, Regional Office for South Asia, Kathmandu, Nepal.

The high prevalence of stunting and micronutrient deficiencies among children in South Asia has lifelong health, educational, and economic consequences. For children aged 6-23 months, undernutrition is influenced by inadequate intake of complementary foods containing nutrients critical for growth and development. The affordability of nutrients lacking in young children's diets in Bangladesh, India, and Pakistan was assessed in this study. Using data from nutrient gap assessments and household surveys, household food expenditures were compared with the cost of purchasing foods that could fill nutrient gaps. In all 3 countries, there are multiple affordable sources of vitamin A (orange-fleshed vegetables, dark leafy greens, liver), vitamin B12 (liver, fish, milk), and folate (dark leafy greens, liver, legumes, okra); few affordable sources of iron and calcium (dark leafy greens); and no affordable sources of zinc. Affordability of animal-source protein varies, with several options in Pakistan (fish, chicken, eggs, beef) and India (fish, eggs, milk) but few in Bangladesh (eggs). Approaches to reduce prices, enhance household production, or increase incomes are needed to improve affordability.
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http://dx.doi.org/10.1093/nutrit/nuaa139DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7948078PMC
March 2021

Affordability of nutritious foods for complementary feeding in Eastern and Southern Africa.

Nutr Rev 2021 03;79(Suppl 1):35-51

United Nations Children's Fund, Regional Office for Eastern and Southern Africa, Nairobi, Kenya.

Low intake of diverse complementary foods causes critical nutrient gaps in the diets of young children. Inadequate nutrient intake in the first 2 years of life can lead to poor health, educational, and economic outcomes. In this study, the extent to which food affordability is a barrier to consumption of several nutrients critical for child growth and development was examined in Ethiopia, Mozambique, South Africa, Tanzania, Uganda, and Zambia. Drawing upon data from nutrient gap assessments, household surveys, and food composition tables, current consumption levels were assessed, the cost of purchasing key nutritious foods that could fill likely nutrient gaps was calculated, and these costs were compared with current household food expenditure. Vitamin A is affordable for most households (via dark leafy greens, orange-fleshed vegetables, and liver) but only a few foods (fish, legumes, dairy, dark leafy greens, liver) are affordable sources of iron, animal-source protein, or calcium, and only in some countries. Zinc is ubiquitously unaffordable. For unaffordable nutrients, approaches to reduce prices, enhance household production, or increase household resources for nutritious foods are needed.
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http://dx.doi.org/10.1093/nutrit/nuaa137DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7948081PMC
March 2021

Assessing the challenges to women's access and implementation of text messages for nutrition behaviour change in rural Tanzania.

Public Health Nutr 2021 Apr 29;24(6):1478-1491. Epub 2020 Oct 29.

Global Alliance for Improved Nutrition, Geneva, Switzerland.

Objective: This process evaluation aimed to understand factors affecting the implementation of a government-sponsored short message service (SMS) programme for delivering nutrition information to rural populations, including message access, acceptability and putting messages into action.

Design: The study was nested within a larger randomised controlled trial. Cross-sectional data collection included structured surveys and in-depth interviews. Data were analysed for key trends and themes using Stata and ATLAS.ti software.

Setting: The study took place in Tanzania's Mtwara region.

Participants: Surveys were conducted with 205 women and 93 men already enrolled in the randomised controlled trial. A sub-set of 30 women and 14 men participated in the in-depth interviews.

Results: Among women relying on a spouse's phone, sharing arrangements impeded regular SMS access; men were commonly away from home, forgot to share SMS or did not share them in women's preferred way. Phone-owning women faced challenges related to charging their phones and defective handsets. Once SMS were delivered, most participants viewed them as trustworthy and comprehensible. However, economic conditions limited the feasibility of applying certain recommendations, such as feeding meat to toddlers. A sub-set of participants concurrently enrolled in an interpersonal counselling (IPC) intervention indicated that the SMS provided reminders of lessons learned during the IPC; yet, the SMS did not help participants contextualise information and overcome the challenges of putting that information into practice.

Conclusions: The challenges to accessing and implementing SMS services highlighted here suggest that such platforms may work well as one component of a comprehensive nutrition intervention, yet not as an isolated effort.
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http://dx.doi.org/10.1017/S1368980020003742DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8025099PMC
April 2021

Food Security in Artisanal Mining Communities: An Exploration of Rural Markets in Northern Guinea.

Foods 2020 Apr 10;9(4). Epub 2020 Apr 10.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.

The number of people engaged in artisanal and small-scale mining (ASM) has grown rapidly in the past twenty years, but they continue to be an understudied population experiencing high rates of malnutrition, poverty, and food insecurity. This paper explores how characteristics of markets that serve ASM populations facilitate and pose challenges to acquiring a nutritious and sustainable diet. The study sites included eight markets across four mining districts in the Kankan Region in the Republic of Guinea. Market descriptions to capture the structure of village markets, as well as twenty in-depth structured interviews with food vendors at mining site markets were conducted. We identified three forms of market organization based on location and distance from mining sites. Markets located close to mining sites offered fewer fruit and vegetable options, as well as a higher ratio of prepared food options as compared with markets located close to village centers. Vendors were highly responsive to customer needs. Food accessibility and utilization, rather than availability, are critical for food security in non-agricultural rural areas such as mining sites. Future market-based nutrition interventions need to consider the diverse market settings serving ASM communities and leverage the high vendor responsiveness to customer needs.
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http://dx.doi.org/10.3390/foods9040479DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7231122PMC
April 2020

Commercial Snack Food and Beverage Consumption Prevalence among Children 6-59 Months in West Africa.

Nutrients 2019 Nov 9;11(11). Epub 2019 Nov 9.

Helen Keller International, Villa SOPIM 12, le Vallon, J 12, Abidjan, Côte d'Ivoire.

Consumption of commercial snack food and beverage products among infants, young, and school-aged children may have negative effects on child nutritional outcomes, as these foods are typically dense in energy but not in micronutrients. However, there is limited information available about the consumption of such snacks in low-income settings, particularly in Africa. We contribute to filling this gap using data from 11,537 children aged 6-59.9 months from four West African countries (i.e., Burkina Faso, Cote d'Ivoire, Mali, and Niger). We estimated the prevalence of commercial snack food and drink consumption and explored variations within the sample by age group, urban or rural residence, household wealth status, and caregiver educational attainment. The results show that 25.7% of children in Niger, 31.5% in Burkina Faso, 42.9% in Mali, and 45.4% in Cote d'Ivoire ate at least one commercial snack food or beverage in the prior 24 h. Consumption prevalence was significantly higher in urban areas than rural areas, among older children (ages 2-5 y) than those in the complementary feeding period (6-23.9 months), and among children in wealthier households. These relationships were confirmed via logistic regression. Our results confirm the widespread consumption of commercial snack foods and drinks by young children in West Africa, a finding with relevance for nutrition policy and programming.
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http://dx.doi.org/10.3390/nu11112715DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6893794PMC
November 2019

Gender Equity and Vitamin A Supplementation: Moving Beyond Equal Coverage.

Food Nutr Bull 2020 03 17;41(1):38-49. Epub 2019 Oct 17.

Africa Regional Office, Helen Keller International, Nairobi, Kenya.

Background: Vitamin A supplementation (VAS) is currently implemented in over 80 countries worldwide, but little attention has been paid to gender equity in the design or implementation of these programs.

Objective: This article describes the ways in which gender equity can impact or be impacted by VAS programs and suggests ways to ensure these programs better support gender equity in the future.

Methods: We undertook a desk review of research on gender equity in health services and extrapolated findings to VAS, highlighting gender equity issues throughout the VAS implementation process and across delivery platform types. We also amassed secondary data on VAS coverage from 45 surveys in 13 countries and analyzed it to examine differences in VAS coverage between boys and girls.

Results: Despite few significant differences in coverage between boys and girls, we identify numerous ways in which gender equity can impact or be impacted by VAS programs, including through the choice of VAS distributors and the communication materials used to promote VAS campaigns. Examining these different entry points reveals that there are several missed opportunities for better integration of gender within VAS.

Conclusions: VAS program implementers and policymakers should revisit VAS approaches to identify opportunities for advancing gender equity through this wide-reaching platform.
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http://dx.doi.org/10.1177/0379572119860310DOI Listing
March 2020

Fostering CHANGE: Lessons from implementing a multi-country, multi-sector nutrition-sensitive agriculture project.

Eval Program Plann 2019 12 31;77:101695. Epub 2019 Jul 31.

Helen Keller International, c/o Organization of American States (OAS), 1889 F Street, NW, Floor 4, Washington, DC, USA; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

Using agriculture to improve nutrition is an approach growing in popularity, with programs becoming increasingly complex and multisectoral. While there is an active line of research assessing the impacts of such programs, little has been written about the process of successfully implementing them. As such, this paper uses a multisectoral nutrition-sensitive agriculture program implemented in four African countries as a case study to address key challenges in and lessons learned from implementation. We highlight the overall flexibility of nutrition-sensitive agriculture but also the need to adapt certain aspects to the particular context, as well as the opportunities for cross-context learning (and the limits to this). Integrating rigorous evaluation into such complex programs and forging diverse cross-sectoral partnerships offer both rewards and challenges, upon which we reflect. Main lessons learned from the program include the importance of carefully sequencing interventions, retaining flexibility in implementation, allowing for considerable time for cross-sector integration and coordination, and considering community impacts when designing research.
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http://dx.doi.org/10.1016/j.evalprogplan.2019.101695DOI Listing
December 2019

Implementing small-scale poultry-for-nutrition projects: Successes and lessons learned.

Matern Child Nutr 2018 10;14 Suppl 3:e12676

Headquarters Nutrition Division, Helen Keller International, Washington, District of Columbia, USA.

This paper examines Helen Keller International's model for nutrition-sensitive poultry production using a programme implemented in four diverse African contexts-three rural and one urban. Consecutive cross-sectional surveys conducted every 5 months among ~15% of participating households show that despite project-provided training and inputs, there was only limited uptake of many "best practices." Few households constructed improved henhouses; vaccination rates varied and were highest when support was provided. Poultry mortality was high. Egg productivity remained average for village poultry systems, and egg consumption remained low (two to six eggs consumed per household per fortnight). However, children whose mothers were exposed to project messages on nutrition were more likely to eat eggs, and consumption was consistently higher among households with chickens. Women's involvement in chicken rearing was widespread, but their control over revenues from the sale of poultry products was limited. Key lessons learned from implementation were as follows: (a) strong behaviour change communication is needed to encourage egg consumption, (b) nutrition-sensitive village poultry programmes should often focus more on improved practices than improved breeds, (c) supporting women's chicken production is not a route to empowerment without complementary activities that directly support women's ownership and decision making. There is also a need for rigorous research on the role of village poultry in livelihoods, food systems, and consumption as well as the structure of poultry and egg markets in low-resource areas.
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http://dx.doi.org/10.1111/mcn.12676DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6865962PMC
October 2018

Are Americans feeling less healthy? The puzzle of trends in self-rated health.

Am J Epidemiol 2009 Aug 29;170(3):343-51. Epub 2009 Jun 29.

Harvard University Initiative for Global Health, Cambridge, MA 02138, USA.

Although self-rated health is proposed for use in public health monitoring, previous reports on US levels and trends in self-rated health have shown ambiguous results. This study presents a comprehensive comparative analysis of responses to a common self-rated health question in 4 national surveys from 1971 to 2007: the National Health and Nutrition Examination Survey, Behavioral Risk Factor Surveillance System, National Health Interview Survey, and Current Population Survey. In addition to variation in the levels of self-rated health across surveys, striking discrepancies in time trends were observed. Whereas data from the Behavioral Risk Factor Surveillance System demonstrate that Americans were increasingly likely to report "fair" or "poor" health over the last decade, those from the Current Population Survey indicate the opposite trend. Subgroup analyses revealed that the greatest inconsistencies were among young respondents, Hispanics, and those without a high school education. Trends in "fair" or "poor" ratings were more inconsistent than trends in "excellent" ratings. The observed discrepancies elude simple explanations but suggest that self-rated health may be unsuitable for monitoring changes in population health over time. Analyses of socioeconomic disparities that use self-rated health may be particularly vulnerable to comparability problems, as inconsistencies are most pronounced among the lowest education group. More work is urgently needed on robust and comparable approaches to tracking population health.
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http://dx.doi.org/10.1093/aje/kwp144DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714952PMC
August 2009

Coverage of cervical cancer screening in 57 countries: low average levels and large inequalities.

PLoS Med 2008 Jun;5(6):e132

Institute for Health Metrics and Evaluation at University of Washington, Seattle, Washington, United States of America.

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http://dx.doi.org/10.1371/journal.pmed.0050132DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2429949PMC
June 2008