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Dietary intake during adolescence sets the foundation for a healthy life, but adolescents are diverse in their dietary patterns and in factors that influence food choice. More evidence to understand the key diet-related issues and the meaning and context of food choices for adolescents is needed to increase the potential for impactful actions. The aim of this second Series paper is to elevate the importance given to adolescent dietary intake and food choice, bringing a developmental perspective to inform policy and programmatic actions to improve diets. We describe patterns of dietary intake, then draw on existing literature to map how food choice can be influenced by unique features of adolescent development. Pooled qualitative data is then combined with evidence from the literature to explore ways in which adolescent development can interact with sociocultural context and the food environment to influence food choice. Irrespective of context, adolescents have a lot to say about why they eat what they eat, and insights into factors that might motivate them to change. Adolescents must be active partners in shaping local and global actions that support healthy eating patterns. Efforts to improve food environments and ultimately adolescent food choice should harness widely shared adolescent values beyond nutrition or health.

Adequate intake of high‐quality nutritious foods during infancy and early childhood is critical to achieving optimal growth, cognitive and behavioural development, and economic productivity later in life. Integrating high‐quality and nutrient‐dense animal source foods (ASFs), a major source of protein and micronutrients, into children's diets is increasingly considered essential to reducing the global burden of malnutrition in low‐ and middle‐income countries. While eggs are an ASF that shows promise for mitigating child undernutrition, interventions promoting egg consumption among children have had mixed results in improving egg intake and child growth outcomes. As part of an evaluation of a demand creation campaign promoting egg consumption, qualitative research was carried out in September 2019 to assess sociocultural and household factors affecting egg intake among young children living in Kaduna State, Nigeria, where a thriving egg industry and childhood stunting rates of 50% exist. Methods included freelisting exercises (11), key informant interviews (11), in‐depth interviews (25) and FGDs (4). Results illuminated cultural rules that restrict egg consumption among children living in low‐income households. These rules and norms reflect social and economic valuations that foster male dominance in household decision‐making and guide food purchasing and intrahousehold food allocation that allow men to consume eggs more regularly. Study results highlight sociocultural considerations when selecting food interventions to address child malnutrition in low‐income contexts. Interventions encouraging increased consumption of ASFs, and specifically eggs in young children, should be informed by formative research to understand sociocultural norms and beliefs guiding egg consumption. Key messages In food classification systems, eggs are considered a light, non‐filling food associated with enjoyment, status and wealth, and in low‐income households widespread consumption of eggs is reserved for special occasions. Cultural rules devised to regulate egg consumption according to age and gender in low‐income households reflect differential social and economic valuations that favour men and discourage egg consumption in young children. Interventions encouraging increased egg intake in young children must consider economic constraints and related sociocultural norms and beliefs guiding egg consumption and identify contextually appropriate strategies to buffer the effects of gender and age bias.

Identifying factors that may influence aflatoxin exposure in children under 5 years of age living in farming households in western Kenya. We used a mixed methods design. The quantitative component entailed serial cross-sectional interviews in 250 farming households to examine crop processing and conservation practices, household food storage and consumption and local understandings of aflatoxins. Qualitative data collection included focus group discussions ( 7) and key informant interviews ( 13) to explore explanations of harvesting and post-harvesting techniques and perceptions of crop spoilage. The study was carried out in Asembo, a rural community where high rates of child stunting exist. A total of 250 female primary caregivers of children under 5 years of age and thirteen experts in farming and food management participated. Study results showed that from a young age, children routinely ate maize-based dishes. Economic constraints and changing environmental patterns guided the application of sub-optimal crop practices involving early harvest, poor drying, mixing spoiled with good cereals and storing cereals in polypropylene bags in confined quarters occupied by humans and livestock and raising risks of aflatoxin contamination. Most (80 %) smallholder farmers were unaware of aflatoxins and their harmful economic and health consequences. Young children living in subsistence farming households may be at risk of exposure to aflatoxins and consequent ill health and stunting. Sustained efforts to increase awareness of the risks of aflatoxins and control measures among subsistence farmers could help to mitigate practices that raise exposure.

Background The maternal mortality ratio in the Democratic Republic of the Congo (DRC) remains among the highest globally. Despite ongoing investments in maternal health, there is only limited evidence on the effectiveness of health systems strengthening interventions in improving maternal health service quality and utilization in fragile settings. The study assesses the impact of a large, complex health systems strengthening program on maternal health care utilization in the DRC. Methods A difference-in-differences approach was applied using population-based household survey data at baseline (2014) and endline (2017) from treatment and matched comparison areas in three provinces. The dependent variables were antenatal care (ANC) utilization and facility-based delivery. Additionally, qualitative data were analyzed to assess perceptions of maternal health care offered and identify barriers and strategies to improve care delivery. Results The health systems strengthening program significantly increased the probability of facility-based delivery, but had no significant impact on receiving at least four ANC visits. Qualitative findings suggest that uptake of ANC was constrained by travel distance, time burdens, limited community outreach, and cultural norms discouraging early ANC initiation. Conclusions Findings highlight the reliance on health centers and posts offering basic maternal services and limited accessibility of hospitals offering lifesaving comprehensive emergency obstetric care. This underscores the importance of formative research to inform interventions that align with social norms, address local barriers, and enhance the effectiveness of maternal health programs in fragile settings.

Background Refugees are at high risk for communicable diseases due to overcrowding and poor water, sanitation, and hygiene conditions. Handwashing with soap removes pathogens from hands and reduces disease risk. A hepatitis E outbreak in the refugee camps of Maban County, South Sudan in 2012 prompted increased hygiene promotion and improved provision of soap, handwashing stations, and latrines. We conducted a study 1 year after the outbreak to assess the knowledge, attitudes, and practices of the refugees in Maban County. Methods We conducted a cross sectional survey of female heads of households in three refugee camps in Maban County. We performed structured observations on a subset of households to directly observe their handwashing practices at times of possible pathogen transmission. Results Of the 600 households interviewed, nearly all had soap available and 91 % reported water was available “always” or “sometimes”. Exposure to handwashing promotion was reported by 85 % of the respondents. Rinsing hands with water alone was more commonly observed than handwashing with soap at critical handwashing times including “before eating” (80 % rinsing vs. 7 % washing with soap) and “before preparing/cooking food” (72.3 % vs 23 %). After toilet use, 46 % were observed to wash hands with soap and an additional 38 % rinsed with water alone. Conclusions Despite intensive messaging regarding handwashing with soap and access to soap and water, rinsing hands with water alone rather than washing hands with soap remains more common among the refugees in Maban County. This practice puts them at continued risk for communicable disease transmission. Qualitative research into local beliefs and more effective messaging may help future programs tailor handwashing interventions.

Background Diarrhea and acute respiratory infections (ARI) account for 30% of deaths among children displaced due to humanitarian emergencies. A wealth of evidence demonstrates that handwashing with soap prevents both diarrhea and ARI. While socially- and emotionally-driven factors are proven motivators to handwashing in non-emergency situations, little is known about determinants of handwashing behavior in emergency settings. Methods We conducted a qualitative investigation from June to August 2015 in a camp for internally displaced persons with a population of 6360 in the war-torn eastern region of the Democratic Republic of Congo. We held key informant interviews with 9 non-governmental organizations and camp officials, in-depth interviews and rating exercises with 18 mothers of children < 5 years, and discussions with 4 groups of camp residents and hygiene promoters to identify motivators and barriers to handwashing. Results At the time of the study, hygiene promotion activities lacked adequate resources, cultural acceptability, innovation, and adaptation for sustained behavioral change. Lack of ongoing provision of hygiene materials was a major barrier to handwashing behavior. When hygiene materials were available, camp residents reported that the primary motivator to handwashing was to prevent illness, particularly diarrheal disease, with many mentioning an increased need to wash hands during diarrhea outbreaks. Emotionally- and socially-related motivators such as “maintaining a good image” and social pressure to follow recommended camp hygiene practices were also reported to motivate handwashing with soap. Residents who engaged in day labor outside the camp had limited exposure to hygiene messages and handwashing facilities. Interviewees indicated that the harsh living conditions forced residents to prioritize obtaining basic survival needs over good hygiene. Conclusions Hygiene promotion in camp settings must involve preparedness of adequate resources and supplies and ongoing provision of hygiene materials so that vulnerable populations affected by emergencies can apply good hygiene behaviors for the duration of the camp’s existence. Compared to non-emergency contexts, illness-based messages may be more effective in emergency settings where disease poses a current and ongoing threat. However, failure to use emotive and social drivers that motivate handwashing may present missed opportunities to improve handwashing in camps.

Diarrhea and acute respiratory infections account for nearly 30% of deaths among children displaced by humanitarian emergencies. Handwashing with soap reduces the risk of diarrhea and acute respiratory infection in non-emergency settings. However, the practice and the effectiveness of handwashing promotion efforts and the health benefits are not well documented in emergency settings. We conducted key informant interviews with 12 experts working in water, sanitation, and hygiene and examined current approaches, challenges, and knowledge gaps in relation to handwashing promotion in emergency settings. We identified many constraints to implementing effective handwashing promotion efforts including a failure to define objectives and targets for improvements in handwashing rates, lack of technical expertise and attention to the development and implementation of effective behavior change communication approaches, and limited understanding of the appropriateness, use, and acceptability of different handwashing hardware. Respondents identified multiple knowledge gaps and research needs that could improve current efforts. Collaborations between response agencies and research institutions could generate high quality data and facilitate contextualized and potentially more effective and robust handwashing promotion strategies.

Little is known about the physical and socioeconomic postpartum consequences of women who experience obstetric complications and require emergency obstetric care (EmOC), particularly in resource-poor countries such as Bangladesh where historically there has been a strong cultural preference for births at home. Recent increases in the use of skilled birth attendants show socioeconomic disparities in access to emergency obstetric services, highlighting the need to examine birthing preparation and perceptions of EmOC, including caesarean sections. Twenty women who delivered at a hospital and were identified by physicians as having severe obstetric complications during delivery or immediately thereafter were selected to participate in this qualitative study. Purposive sampling was used for selecting the women. The study was carried out in Matlab, Bangladesh, during March 2008 - August 2009. Data-collection methods included in-depth interviews with women and, whenever possible, their family members. The results showed that the women were poorly informed before delivery about pregnancy-related complications and medical indications for emergency care. Barriers to care-seeking at emergency obstetric facilities and acceptance of lifesaving care were related to apprehensions about the physical consequences and social stigma, resulting from hospital procedures and financial concerns. The respondents held many misconceptions about caesarean sections and distrust regarding the reason for recommending the procedure by the healthcare providers. Women who had caesarean sections incurred high costs that led to economic burdens on family members, and the blame was attributed to the woman. The postpartum health consequences reported by the women were generally left untreated. The data underscore the importance of educating women and their families about pregnancy-related complications and preparing families for the possibility of caesarean section. At the same time, the health systems need to be strengthened to ensure that all women in clinical need of lifesaving obstetric surgery access quality EmOC services rapidly and, once in a facility, can obtain a caesarean section promptly, if needed. While greater access to surgical interventions may be lifesaving, policy-makers need to institute mechanisms to discourage the over-medicalization of childbirth in a context where the use of caesarean section is rapidly rising.

Few studies have assessed whether the poorest people in developing countries benefit from giving birth at home rather than in a facility. We analysed whether socioeconomic status results in differences in the use of professional midwives at home and in a basic obstetric facility in a rural area of Bangladesh, where obstetric care was free of charge. We routinely obtained data from Matlab, Bangladesh between 1987 and 2001. We compared the benefits of home-based and facility-based obstetric care using a multinomial logistic and binomial log link regression, controlling for multiple confounders. Whether or not a midwife was used at home or in a facility differed significantly with wealth (adjusted odds ratio comparing the wealthiest and poorest quintiles 1·94 [95% CI 1·69–2·24] for home-based care, and 2·05 [1·72–2·43] for facility-based care). The gap between rich and poor widened after the introduction of facility-based care in 1996. The risk ratio (RR) between the wealthiest and poorest quintiles was 1·91 (adjusted RR 1·49 [95% CI 1·16–1·91] when most births with a midwife took place at home compared with 2·71 (1·66 [1·41–1·96]) at the peak of facility-based care. In this area of Bangladesh, a shift from home-based to facility-based basic obstetric care is feasible but might lead to increased inequities in access to health care. However, there is also evidence of substantial inequities in home births. Before developing countries reinforce home-based births with a skilled attendant, research is needed to compare the feasibility, cost, effectiveness, acceptability, and implications for health-care equity in both approaches.