Teresa Schwendler

Pennsylvania State University

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Stephen Kodish

Pennsylvania State University

Joel Gittelsohn

Johns Hopkins University

Upul Senarath

University of Colombo

Safina Abdulloeva

United Nations Children's Fund India

Hiranya Jayawickrama

Ministry of Health, Nutrition and Indigenous Medicine

Dhammica Rowel

Sri Lanka Foundation

Chithramalee De Silva

Ministry of Health, Nutrition and Indigenous Medicine

Angela Trude

New York University

Ivory Loh

Johns Hopkins University

Muzi Na

Pennsylvania State University

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Johns Hopkins University

Pennsylvania State University

Johns Hopkins Medicine

Ohio University

Universidade Federal de São Paulo

United Nations Children's Fund Niger

Harvard University

University of Rhode Island

University of Baltimore

University of Oxford

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Development and Implementation: B’More Healthy Communities for Kid’s Store and Wholesaler Intervention

Health Promotion Practice (2017)

Teresa Schwendler Cara Shipley Nadine Budd Angela Trude Pamela J. Surkan

Higher rates of obesity and obesity-related chronic disease are prevalent in communities where there is limited access to affordable, healthy food. The B’More Healthy Communities for Kids (BHCK) trial worked at multiple levels of the food environment including food wholesalers and corner stores to improve the surrounding community’s access to healthy food. The objective of this article is to describe the development and implementation of BHCK’s corner store and wholesaler interventions through formal process evaluation. Researchers evaluated each level of the intervention to assess reach, dose delivered, and fidelity. Corner store and wholesaler reach, dose delivered, and fidelity were measured by number of interactions, promotional materials distributed, and maintenance of study materials, respectively. Overall, the corner store implementation showed moderate reach, dose delivered, and high fidelity. The wholesaler intervention was implemented with high reach, dose, and fidelity. The program held 355 corner store interactive sessions and had 9,347 community member interactions, 21% of which were with children between the ages of 10 and 14 years. There was a 15% increase in corner store promoted food stocking during Wave 1 and a 17% increase during Wave 2. These findings demonstrate a successfully implemented food retailer intervention in a low-income urban setting.

10.1177/1524839917696716

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Implementation of B’More Healthy Communities for Kids: process evaluation of a multi-level, multi-component obesity prevention intervention

Health Education Research (2018)

Cara F. Ruggiero Lisa Poirier Angela Trude Tuo Yang Teresa Schwendler

B'More Healthy Communities for Kids was a multi-level, multi-component obesity prevention intervention to improve access, demand and consumption of healthier foods and beverages in 28 low-income neighborhoods in Baltimore City, MD. Process evaluation assesses the implementation of an intervention and monitor progress. To the best of our knowledge, little detailed process data from multi-level obesity prevention trials have been published. Implementation of each intervention component (wholesaler, recreation center, carryout restaurant, corner store, policy and social media/text messaging) was classified as high, medium or low according to set standards. The wholesaler component achieved high implementation for reach, dose delivered and fidelity. Recreation center and carryout restaurant components achieved medium reach, dose delivered and fidelity. Corner stores achieved medium reach and dose delivered and high fidelity. The policy component achieved high reach and medium dose delivered and fidelity. Social media/text messaging achieved medium reach and high dose delivered and fidelity. Overall, study reach and dose delivered achieved a high implementation level, whereas fidelity achieved a medium level. Varying levels of implementation may have balanced the performance of an intervention component for each process evaluation construct. This detailed process evaluation of the B'More Healthy Communities for Kids allowed the assessment of implementation successes, failures and challenges of each intervention component.

Component (thermodynamics)

10.1093/her/cyy031

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Appetite (2019)

K. Jean Forney Teresa Schwendler Rose Marie Ward

Homophily

Perfectionism

Affect

Binge eating

10.1016/j.appet.2019.03.013

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Using Cultural Domain Analysis to Understand Community Perceptions of Infant and Young Child Foods in Sri Lanka

Current Developments in Nutrition (2021)

Teresa Schwendler Upul Senarath Hiranya Jayawickrama Safina Abdulloeva Dhammica Rowel

1) To understand how Sri Lankan caregivers conceptualize young child foods; 2) To explore local food classification systems; 3) To explain why some foods are culturally prescribed (remedies) or proscribed (taboos) for young children Design: This ethnographic sub-study was conducted within a four-phase, mixed methods formative research design across rural, estate, and urban sectors of Sri Lanka. Data collection methods and sampling. Data were collected between Oct. 2020 – Feb. 2021 using free lists, pile sorts, and semi-structured interviews in urban (Batticaloa and Colombo), rural (Kilinochchi, Ratnapura, and Matara), and estate (Nuwara Eliya) sectors of Sri Lanka. Free lists (n = 150) and pile sorts (n = 84) were conducted among caregivers of young children. Both community leaders (n = 24) and caregivers (n = 21) were purposively sampled for interviews. Data analysis. Cultural domain analysis was conducted using Anthropac. Textual analysis of interview data followed an inductive approach whereby themes were identified, coded, and extracted for interpretation using Dedoose. Findings across methods were triangulated to enhance credibility. 1. Among all sectors of Sri Lanka, caregivers identified rice as the most important food for young children diets, highlighting the importance of this staple regardless of sector or ethnicity. Only 2 animal source foods (eggs and fish) were included within the top 15 most salient foods. 2. Local food classification systems highlight a 'hot' and 'cold' paradigm, reflecting the underlying Ayurvedic medical belief system, influencing dietary choices. 3. Overall, 48 food proscriptions were identified, including 'egg' and 'fish, specifically during child illness. Some locally-available fruits and vegetables were also proscribed, depending on their 'cold' nature, level of digestibility, and relation to illness causation. Prescribed foods (n = 47) were also found, most of which were herbal remedies (22 food or spice mixtures) to address child illness. Understanding local food definitions, food classification systems, and food rules may aid in shaping policies aiming to include culturally-appropriate strategies to improve feeding practices in Sri Lanka. UNICEF.

Sri lanka

Participatory rural appraisal

10.1093/cdn/nzab045_066

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Negative attitudes towards obesity in nutrition students: Examining associations with eating pathology and the student social network

K. Jean Forney Teresa Schwendler Rose Marie Ward

10.31076/2019.p5

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P17-057-23 Observational Methods in Studies of Infant and Young Child Feeding Practices in Low–And Middle-Income Countries: A Twenty-Year Retrospective Review

Current Developments in Nutrition (2023)

Teresa Schwendler Muzi Na Leif Jensen Kathleen Keller Joel Gittelsohn

10.1016/j.cdnut.2023.100952

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A comparison of observed feeding practices of infants and young children aged 6–23 months to national responsive feeding recommendations in Sri Lanka

Maternal and Child Nutrition (2023)

Teresa Schwendler Dhammica Rowel Safina Abdulloeva Hiranya Jayawickrama Chithramalee De Silva

Abstract To describe the extent to which Sri Lankan caregivers follow current national responsive feeding recommendations and the factors limiting and enabling those behaviours. Study design . This ethnographic substudy was conducted using a four‐phase, mixed methods formative research design across rural, estate and urban sectors of Sri Lanka. Data collection methods . Data were collected using direct meal observations and semistructured interviews. Participants including infants and young children aged 6–23 months ( n = 72), community leaders ( n = 10), caregivers ( n = 58) and community members ( n = 37) were purposefully sampled to participate in this study. Data analysis . Observational data were summarized using descriptive statistics while textual data were analysed thematically using Dedoose. Findings were then interpreted vis‐à‐vis six national responsive feeding recommendations. During observed feeding episodes, caregivers were responsive to nearly all food requests (87.2% [34/39]) made by infants and young children. Many caregivers (61.1% [44/72]) also positively encouraged their infant and young child during feeding. Despite some responsive feeding practices being observed, 36.1% (22/61) of caregivers across sectors used forceful feeding practices if their infant or young child refused to eat. Interviews data indicated that force‐feeding practices were used because caregivers wanted their infants and young children to maintain adequate weight gain for fear of reprimand from Public Health Midwives. Despite overall high caregiver knowledge of national responsive feeding recommendations in Sri Lanka, direct observations revealed suboptimal responsive feeding practices, suggesting that other factors in the knowledge‐behaviour gap may need to be addressed.

Sri lanka

Infant feeding

Research Design

10.1111/mcn.13522

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Understanding Why Behavioral Interventions Pose Challenges - Using Cultural Domain Analysis to Compare Malnutrition Risk Perception in 6 Global Contexts

Current Developments in Nutrition (2020)

Stephen Kodish Teresa Schwendler

Within formative research to inform behavioral interventions since 2013, we have sought to understand community risk perceptions toward nutrition-related illnesses. This analysis compares findings from 6 countries to 1) describe the extent to which nutrition-related illnesses are salient to community members, and 2) to compare malnutrition risk perception across cultural contexts. We conducted formative research in 6 countries between 2013–2018 to inform preventative nutrition interventions where behavior change was a focus. In both rural and urban sites of each country context, we used two ethnographic methods for cultural domain analysis. Free listing of 'childhood illnesses' was conducted in Malawi (n = 64), Mozambique (n = 115), Nigeria (n = 81), Marshall Islands (n = 86), Solomon Islands (n = 89), and Kiribati (n = 84). Smith's statistic (S) was used to assess illness term salience. The most salient terms in each setting were then pile sorted by participants who were asked to sort illness terms by perceived severity/seriousness for young child health. Data were analyzed using ANTHROPAC. Semi-structured interview data contextualized and triangulated findings. Across 6 global contexts, community members perceived nutrition-related illnesses to be less serious/severe than other childhood illnesses. Consistently, the most salient child illness terms identified were malaria/fever, flu/cough, and stomachache/diarrhea. Terms referring to malnutrition were mentioned in just half of the country contexts, with iron deficiency anemia ('loss of blood') and wasting-related terms the most salient. Local terms referring to the biomedical equivalent of stunting did not exist in most contexts. Most participants categorized nutrition-related illness terms into 'least serious/severe' or 'moderately serious/severe' rather than 'most serious/severe' where other more salient childhood illnesses were placed. Interview data corroborated these findings, revealing an important discrepancy between the priorities of global nutrition practitioners and the communities with whom they work, regardless of cultural or geographic context. This study provides insight into why nutrition interventions where behavior change is needed may face challenges achieving desired effectiveness. Not applicable.

Syndemic

10.1093/cdn/nzaa053_059

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Understanding the Multi-Level Factors Influencing Maternal Diets in Sri Lanka

Current Developments in Nutrition (2022)

Teresa Schwendler Upul Senarath Hiranya Jayawickrama Safina Abdulloeva Dhammica Rowel

To understand the multi-level factors influencing maternal diet in Sri Lanka. Study design. This ethnographic sub-study was conducted using an iterative four-phase, mixed methods formative research design. Data collection methods and sampling. To understand the multi-level factors influencing maternal diets across the rural, urban and estate sectors of Sri Lanka, community members from each sector were purposefully sampled. Pregnant women (n = 21), community leaders (n = 10) and influencers (n = 37) were interviewed using a semi-structured interview guide. Data analysis. Data were analyzed using Dedoose software and the socio-ecological model to conceptualize influencing factors of maternal diets across sectors. In Sri Lanka, a variety of multi-level factors reportedly influence maternal diets. At the community level, high food availability and inter-household food sharing facilitate diverse maternal diets while traditional food rules (e.g., 20 prescriptions and 21 proscriptions) may negatively influence them. Strong social protection and antenatal care programs provided by the Sri Lankan government promote improved nutrition, but food baskets provided as part of social assistance are not always utilized by beneficiaries as intended. At the interpersonal level, pregnant women receive health and nutrition information from many social influencers such as Public Health Midwives, female elders, and husbands, among others. At the individual level, differential nutrition knowledge, food preferences, risk perception, competing demands, and food access influence maternal diet synergistically. Upstream factors (e.g., culturally bound food taboos) seem to be more important drivers of maternal diets than individual-level knowledge and personal food preferences addressing multi-level determinants of maternal diets in concert may positively impact population-level maternal nutrition in Sri Lanka. UNICEF Sri Lanka.

Snowball sampling

10.1093/cdn/nzac060.060

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B'More Healthy Communities for Kids, a multilevel obesity prevention program for African American children: Wave 1 process and impact results

The FASEB Journal (2016)

Joel Gittelsohn Angela Trude Cara Shipley María José Mejía Ruiz Teresa Schwendler

Background Limited research exists on the impact of multi‐level, multi‐component (MLMC) interventions. BHCK is an ongoing MLMC obesity prevention program, which targets multiple levels of the urban food environment, addressing child (via youth leaders), adult caregiver (via text messaging, social media), community (via corner store, carry‐out, wholesaler programs), and policy levels to increase healthy food access, purchasing, and consumption among low income African American (AA) youth between the ages of 10–14 in Baltimore City. Methods Wave 1 of BHCK was evaluated through a combination of process and impact measures at different levels. We observed small food stores/carryout to detect change in availability of BHCK healthy promoted products such as produce, whole grain products, lower fat snacks, and lower sugar beverages, low fat entrees/side dishes. In youth, we used the 2004 Block Kids FFQ to estimate impact on dietary intake. Our baseline sample was composed of 299 child‐caregiver dyads (pre‐intervention), with 70% assessed post‐intervention. Estimated difference in food group intake was calculated using the least‐squares mean regression, adjusted by child's age, sex, energy intake, baseline value of the dependent variable, BMI percentile, caregiver's income and education level. Analysis of covariance (ANCOVA) was used to assess difference in intake between intervention and control groups. Results Different components of the intervention were implemented with moderate to high reach, dose and fidelity observed. Twelve of our original sixteen youth‐leaders conducted a total of 98 nutrition sessions across seven intervention recreation centers, with an average of 10 low‐income AA children in our target age range (10–14) attending each session, and a total of 1600 child interactions in recreation centers and community venues combined. Educational sessions and promotional activities at stores reached 5–10 youth in our target age range per store session. 80% of study families received text‐messages during the program. We found an 8.6% increase in availability of whole wheat bread in intervention stores while control stores decreased 37.8% (p<0.01). FFQ data shows that youth in the intervention group increased consumption of whole grain foods from pre‐ to post‐intervention, whereas youth in the control group decreased. Intervention group had a 0.47 (± 0.04) adjusted mean intake of whole grains, whereas control group showed a 0.41 (±0.43) adjusted mean intake. Additional analyses will examine impact of the BHCK program on access, purchase, and consumption of healthier beverages and snacks. Conclusions This study is an example of a successful MLMC intervention. Findings will inform public health strategies to improve dietary quality and access to healthy food in low‐income urban settings. Future directions include scaling up to other cities and sustaining/institutionalizing successful strategies. Support or Funding Information Research reported in this work was supported by the Global Obesity Prevention Center (GOPC) at Johns Hopkins, and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and the Office of the Director, National Institutes of Health (OD) under award number U54HD070725. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

10.1096/fasebj.30.1_supplement.422.1

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