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Background: In 2016, Brazil scaled up the Criança Feliz Program (PCF, from the acronym in Portuguese), making it one of the largest Early Childhood Development (ECD) programs worldwide. However, the PCF has not been able to achieve its intended impact. We aimed to identify barriers and facilitators to achieving the PCF implementation outcomes across the RE-AIM dimensions (Reach, Effectiveness or Efficacy, Adoption, Implementation and Maintenance) during the COVID-19 pandemic. Methods: This comparative case study analysis selected five contrasting municipalities based on population size, region of the country, implementation model, and length of time implementing the PCF. We conducted 244 interviews with PCF municipal team (municipal managers, supervisors, home visitors), families, and cross-sectoral professionals. A rapid qualitative analysis was used to identify themes across RE-AIM dimensions. Findings: Families' limited knowledge and trust in PCF goals were a barrier to its reach. While the perceived benefit of PCF on parenting skills and ECD enabled reach, the lack of referral protocols to address social needs, such as connecting food-insecure families to food resources, undermined effectiveness. Questions about whether the social assistance sector should be in charge of PCF challenged its adoption. Implementation barriers exacerbated by the COVID-19 pandemic included low salaries, temporary contracts, high turnover, infrequent supervision, lack of an effective monitoring system, and nonexistence or non-functioning multisectoral committees. The absence of institutionalized funding was a challenge for sustainability. Interpretation: Complex intertwined system-level barriers may explain the unsuccessful implementation of PCF. These barriers must be addressed for Brazil to benefit from the enormous reach of the PCF and the evidence-based nurturing care principles it is based upon. Funding: NIH/NICHD.

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Background: Globally, 1.3 billion people were considered food insecure as of 2022. In the Caribbean region, the prevalence of moderate or severe food insecurity was 71.3% as of 2020, the highest of all subregions in Latin America. Experienced based measurement scales, like the Latin American and Caribbean Food Security Scale, are efficient measurement tools of food insecurity used globally. The Eastern Caribbean Health Outcomes Research Network (ECHORN) Cohort Study is a population-based longitudinal cohort study in the two Caribbean U.S. territories of Puerto Rico and the U.S. Virgin Islands, as well as in Barbados and Trinidad & Tobago. The purpose of this research was to examine the demographic, psychosocial, behavioral, and environmental risk factors associated with household food insecurity (HFI) among adults ≥40 years of age in the ECHORN cohort. Methods: A cross-sectional analysis of baseline ECHORN cohort study data was conducted. The primary outcome was household food insecurity (none, mild, moderate/severe). A total of 16 known and potential risk factors were examined for their association with HFI. The ANOVA and chi-square statistics were used in bivariate analysis. Ordinal logistic regression was used for the multivariable and sex stratified analyses. Results: More than one-quarter of the sample (27.3%) experienced HFI. In bivariate analyses, all risk factors examined except for sex, were significantly associated with HFI status. In the multivariable analysis, all variables except sex, education, marital status, smoking status, and residing in Puerto Rico were significant predictors of HFI in the adjusted model. In sex stratified analysis, depression, food availability, self-rated physical health, and island site were significantly associated with increased odds of worsening HFI for women, but not for men. Source of potable water was an important risk factor for both men and women. Discussion: The prevalence of HFI in the ECHORN cohort study is comparable to other studies conducted in the region. While women did not have an increased risk of HFI compared to men, a different set of risk factors affected their vulnerability to HFI. More research is needed to understand how water and food security are interrelated in the ECHORN cohort.

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Introduction: Breastfeeding (BF) is considered an essential component of optimal care for child health and development. In the past two decades, global data have shown improvements in some, but not all, BF indicators. Despite these positive changes sales and per capita intake of commercial milk formula (CMF) have increased globally. The CMF industry invests millions of dollars in marketing, which targets families and healthcare professionals (HCP). In Mexico, more than half of the mothers (53%) who feed their infants with CMF chose their Brand on the recommendation of HCP. Understanding the reasons behind the current recommendations for the use of CMF by HCP is important for the design of BF interventions. The primary objective of this study was to explore Mexican HCP' beliefs, attitudes, perceptions, and practices about early infant feeding practices, and reasons for recommending CMF. The secondary objective was to explore pregnant women and mother's perceptions of the infant feeding recommendations they received from HCP, and of the factors that influenced their infant feeding decisions. Methods: The study was based on a secondary qualitative data analysis of a WHO/UNICEF multi-country study. We analyzed focus group discussions (FGDs) and in-depth interviews (IDIs) from Mexico. Data were collected through convenience sampling in Mexico City and Guadalajara. HCP (n = 34) analysis was based on IDIs, and pregnant women or mothers of children 0-18 months (n = 74) on FGDs and IDIs. Results: Through a thematic analysis, we identified the socioecology of BF and triangulated HCP and women's accounts. HCP, pregnant women, and mothers recognized that several factors might have influenced their infant feeding decisions including healthcare facilities' policies and maternal work conditions. Although HCP believed that BF is the best way to feed newborns and young children, they routinely recommended CMF. On the other hand, pregnant women and mothers had a strong belief that BF is the best way to feed their babies. However, when women sought support from HCP, the latter often recommended switching to CMF. Discussion: This study highlights the discordance between HCP perceptions and mothers' experiences of HCP recommendations about infant feeding. Our findings support a national call for policy actions.

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OBJETIVO: Identificar la viabilidad de la Escala de Experiencias de Inseguridad del Agua en el Hogar (Household Water Insecurity Experiences Scale, HWISE, por sus siglas en inglés) como herramienta para evaluar las experiencias de hogares mexicanos en relación con la inseguridad en el acceso al agua. Material y métodos. La escala fue integrada en la Encuesta Nacional de Salud y Nutrición Continua 2021 (Ensanut Continua 2021) y se utilizaron tres criterios para evaluar su viabilidad: 1) Consistencia interna: Se aplicó la prueba Alfa de Cronbach para estimar la correlación entre los ítems de la escala. Se consideró un punto de corte de al menos 0.80 como criterio de confiabilidad; 2) Equivalencia de los ítems para distintos indicadores sociodemográficos; y 3) Variables asociadas con inseguridad del agua. RESULTADOS: La escala HWISE mostró: 1) Buena confiabilidad o consistencia interna (Alfa de Cronbach de 0.928); 2) comportamiento equivalente de los ítems en los contextos urbano y rural, en nueve regiones del país y por terciles de condiciones de bienestar; y 3) asociación significativa con variables predictoras de inseguridad del agua. CONCLUSIONES: La escala HWIS, adaptada para México, es apropiada para su uso en evaluar la condición de inseguridad del agua en hogares mexicanos.

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The Baby-Friendly Hospital Initiative (BFHI) is a global strategy to encourage health facilities to promote, support, and protect breastfeeding by implementing a package of policies and practices known as the Ten Steps to Successful Breastfeeding. Prior studies have found that implementing the Ten Steps has a positive impact on breastfeeding outcomes. Yet, little is known about the implementation of the Ten Steps in Mexico. The objective of this study was to conduct a systematic review to evaluate the reach, efficacy/effectiveness, adoption, implementation, and maintenance of the Ten Steps in Mexico, using the RE-AIM framework. The systematic literature review included studies published in English or Spanish without date restrictions. Two of the authors coded each of the articles through a harmonized data extraction tool, and group meetings were used to discuss any discrepancies. The reviewed data were managed in the Rayyan platform. The risk of study bias was assessed through the Johanna Briggs Institute critical appraisal checklists. Of the 1,123 articles initially identified, 6 met the review inclusion criteria. None of the articles evaluated the reach and maintenance of the Ten Steps. The articles identified major gaps in the implementation of the Ten Steps. Most of the articles had important limitations in terms of their quality. In Mexico, it is necessary to rethink the BFHI and employ multiple strategies to improve implementation of the Ten Steps, including developing transparent BFHI monitoring mechanisms that produce data on implementation and that are publicly available, as well as investing in implementation research and evaluation to generate strong evidence to support the adoption and efficient maintenance of the Ten Steps in health facilities in Mexico. When properly implemented, BFHI becomes central to promote, protect, and support breastfeeding. Therefore, it is essential for Mexico to position BFHI as a top priority of the country's public policy agenda. Systematic Review Registration: identifier: CRD42021248118.

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Introduction: While breastfeeding is recognized as providing optimal nutrition for infants and toddlers, maternal employment is a commonly mentioned barrier to breastfeeding. The goal was to (a) identify key actors participating in the design and implementation of workplace breastfeeding interventions in Mexico, (b) understand the complexity of interactions between the actors, and (c) map the connections and influence between the actors when looking into networks of Advice, Command, Funding, and Information. Method: Following the NetMap methodology, a total of 11 semi-structured interviews with 12 interview partners from 10 organizations were conducted. Interview data were analyzed, and networks were analyzed and visualized, using a social network mapping software. Results: A total of 83 actors from five different actor groups were identified. Four networks were constructed along the four types of connections: Advice, Command, Funding, and Information. The actors were connected by 580 connections with 446 unique links. Based on various network statistics, the Mexican Institute of Social Security, the Mexican Secretary of Labor and Social Welfare, UNICEF, and the Mexican Secretary of Health were identified to be key actors. Conclusion: To increase the likelihood of success of workplace breastfeeding interventions, the role of the actors "Employers" and "Women" needs to expand. They should be actively involved in the decision-making process, together with the identified key actors. It is further recommended to re-introduce a national breastfeeding strategy for Mexico that includes policies for workplace breastfeeding interventions.

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It is well known that female-headed households (FHHs) are more likely to experience food insecurity (FI) than male-headed households (MHHs), however there is a dearth of evidence on how gender intersects with other social determinants of FI. Thus, this paper investigated changes in the prevalence of household FI in Brazil from 2004 to 2018 by the intersection of gender, race/skin color and marital status of the household reference person. Data from three cross-sectional nationally representative surveys that assessed the status of FI using the Brazilian Household Food Insecurity Measurement Scale were analyzed (N2004 = 107,731; N2013 = 115,108, N2018 = 57,204). Multinomial logistic regression models were used to examine the relationship between profiles of gender, race/skin color, marital status of the head of the household with household FI stratified by the presence of children <5 years of age. Over time, FHHs had a higher prevalence of mild and moderate/severe FI than did households headed by men. Food security prevalence increased from 2004 to 2013 and decreased between 2013 and 2018 for households headed by men and women. In 2018, households headed by black/brown single mothers with children < 5 years of age were at the highest FI risk. The probability of reporting moderate/severe FI in these households were 4.17 times higher (95% CI [2.96-5.90]) than for households headed by married white men. The presence of children in the household was associated with a higher probability of moderate/severe FI, especially for households headed by black/brown individuals regardless of the reference person's gender. The results suggest that gender inequities combined with darker skin color and the presence of children at home potentiate the risk of moderate/severe FI. Policy makers need to consider the principles of intersectionality when investing in codesigning, implementing, evaluating, and scaling up evidence-based programs to reduce FI.

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Breastfeeding has been consistently associated with higher intelligence since childhood. However, this relation could be confounded due to maternal selection bias. We estimated the association between predominant breastfeeding and intelligence in school-age children considering potential selection bias and we simulated the intelligence gap reduction between low versus higher socioeconomic status children by increasing breastfeeding. We analysed predominant breastfeeding practices (breastmilk and water-based liquids) of children 0-3 years included in the Mexican Family Life Survey (MxFLS-1). Intelligence was estimated as the z-score of the abbreviated Raven score, measured at 6-12 years in the MxFLS-2 or MxFLS-3. We predicted breastfeeding duration among children with censored data with a Poisson model. We used the Heckman selection model to assess the association between breastfeeding and intelligence, correcting for selection bias and stratified by socioeconomic status. Results show after controlling for selection bias, a 1-month increase in predominant breastfeeding duration was associated with a 0.02 SD increase in the Raven z-score (p < 0.05). The children who were predominantly breastfed for 4-6 months versus <1 month had 0.16 SD higher Raven z-score (p < 0.05). No associations were found using multiple linear regression models. Among low socioeconomic status children, increasing predominantly breastfeeding duration to 6 months would increase their mean Raven z-score from -0.14 to -0.07 SD and reduce by 12.5% the intelligence gap with high socioeconomic status children. In conclusion, predominant breastfeeding duration was significantly associated with childhood intelligence after controlling for maternal selection bias. Increased breastfeeding duration may reduce poverty-driven intelligence inequities.

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OBJECTIVE: Sugar-sweetened beverages (SSB) are implicated in the increasing risk of diabetes in the Caribbean. Few studies have examined associations between SSB consumption and diabetes in the Caribbean. DESIGN: SSB was measured as teaspoon/d using questions from the National Cancer Institute Dietary Screener Questionnaire about intake of soda, juice and coffee/tea during the past month. Diabetes was measured using self-report, HbA1C and use of medication. Logistic regression was used to examine associations. SETTING: Baseline data from the Eastern Caribbean Health Outcomes Research Network Cohort Study (ECS), collected in Barbados, Puerto Rico, Trinidad and Tobago and US Virgin Islands, were used for analysis. PARTICIPANTS: Participants (n 1701) enrolled in the ECS. RESULTS: Thirty-six percentage of participants were unaware of their diabetes, 33% aware and 31% normoglycaemic. Total mean intake of added sugar from SSB was higher among persons 40-49 (9·4 tsp/d), men (9·2 tsp/d) and persons with low education (7·0 tsp/d). Participants who were unaware (7·4 tsp/d) or did not have diabetes (7·6 tsp/d) had higher mean SSB intake compared to those with known diabetes (5·6 tsp/d). In multivariate analysis, total added sugar from beverages was not significantly associated with diabetes status. Results by beverage type showed consumption of added sugar from soda was associated with greater odds of known (OR = 1·37, 95 % CI (1·03, 1·82)) and unknown diabetes (OR = 1·54, 95 % CI (1·12, 2·13)). CONCLUSIONS: Findings indicate the need for continued implementation and evaluation of policies and interventions to reduce SSB consumption in the Caribbean.

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