Social predictors of food insecurity during the stay-at-home order due to the COVID-19 pandemic in Peru. Results from a cross-sectional web-based survey

SUMMARYBackgroundStay-at-home orders and social distancing have been implemented as the primary tools to reduce the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, this approach has indirectly lead to the unemployment of 2·3 million Peruvians, in Lima, Perú alone. As a result, the risk of food insecurity may have increased, especially in low-income families who rely on a daily wage. This study estimates the prevalence of moderate or severe food insecurity (MSFI) and identifies the associated factors that explain this outcome during the stay-at-home order.MethodsA cross-sectional web-based survey, with non-probabilistic sampling, was conducted between May 18 and June 30, 2020, during the stay-at-home order in Peru. We used social media advertisements on Facebook to reach 18-59-year-olds living in Peru. MSFI was assessed using the Food Insecurity Experience Scale (FIES). Rasch model methodology requirements were considered, and factors associated with MSFI were selected using stepwise forward selection. A Poisson generalized linear model (Poisson GLM), with log link function, was employed to estimate adjusted prevalence ratios (aPR).FindingsThis analysis is based on 1846 replies. The prevalence of MSFI was 23·2%, and FIES proved to be an acceptable instrument with reliability 0·72 and infit 0·8-1·3. People more likely to experience MSFI were those with low income (less than 255 US$/month) in the pre-pandemic period (aPR 3·77; 95%CI, 1·98-7·16), those whose income was significantly reduced during the pandemic period (aPR 2·27; 95%CI, 1·55-3·31), and those whose savings ran out in less than 21 days (aPR 1·86; 95%CI, 1·43-2·42). Likewise, heads of households (aPR 1·20; 95%CI, 1·00-1·44) and those with probable SARS-CoV2 cases as relatives (aPR 1·29; 95%CI, 1·05-1·58) were at an increased risk of MSFI. Additionally, those who perceived losing weight during the pandemic (aPR 1·21; 95%CI, 1·01-1·45), and increases in processed foods prices (aPR 1·31; 95%CI, 1·08-1·59), and eating less minimally processed food (aPR 1·82; 95%CI, 1·48-2·24) were more likely to experience MSFI.InterpretationPeople most at risk of MSFI were those in a critical economic situation before and during the pandemic. Social protection policies should be reinforced to prevent or mitigate these adverse effects.FundingNone.

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Health status of an elderly population in Sharpeville, South Africa

Health SA Gesondheid ◽

10.4102/hsag.v13i3.282 ◽

2008 ◽

Vol 13 (3) ◽

pp. 3-17 ◽

Cited By ~ 10

Author(s):

Wilna H Oldewage-Theron ◽

Lilian Salami ◽

Francis B Zotor ◽

Christine Venter

Keyword(s):

Food Insecurity ◽

Low Income ◽

Elderly Population ◽

Health Assessment ◽

Serum Zinc ◽

Total Serum ◽

Total Serum Cholesterol ◽

Dietary Intakes ◽

Cross Sectional ◽

Increased Risk

The objective of this cross-sectional study was a comprehensive nutrition and health assessment to provide a basis for future intervention strategies for an elderly population attending a day-care centre. Socio-demographic, health and 24-hour recall dietary intake questionnaires were administered and anthropometric and biochemical measurements taken. The results indicate that the majority of respondents had an income of between R501 and R1 000 (South African rand) per month and most of them reported an occasional lack of funds to meet basic household needs, confirming the presence of food insecurity. Daily dietary intakes (mean±Standard Deviation [SD]) of the women were 5 395±2 946 kJ energy, 47±27 g protein, 28±21 g fat and 196±123 g carbohydrates compared to 8 641±3 799 kJ, 86±48 g, 49±32 g and 301±139 g of the men, respectively. The majority (83.6%) of the women were overweight (body mass index [BMI] >25) or obese (BMI > 30) whilst 78% had a mid-upper arm circumference (MUAC) of > 21.7 cm. Mean intakes of micronutrients were low in comparison to reference standards and serum zinc levels were suboptimal. Obesity, hypertension and raised total serum cholesterol levels indicated an increased risk for coronary heart disease. It can be concluded that a low income, household food insecurity and risk factors associated with malnutrition and non-communicable diseases were prevalent in this elderly population. Opsomming Die doelwit van hierdie dwarssnitstudie was ‘n omvattende bepaling van voeding- en gesondheidstatus om as basis te dien vir toekomstige intervensie-strategieë vir ’n groep bejaardes wat ’n dagsentrum besoek. Sosiodemografiese, gesondheid- en 24-uur herroep-dieetinname vraelyste is voltooi en antropometriese en biochemiese metings is geneem. Die resultate het bevestig dat die meerderheid respondente ‘n maandelikse inkomste van tussen R501 en R1 000 (Suid-Afrikaanse rand) gehad het. Die meeste het ‘n geldtekort vir basiese huishoudelike behoeftes gerapporteer wat dui op huishoudelike voedselin-sekuriteit. Daaglikse dieetinnames (gemiddeld± standaardafwyking [SA]) van die vroue was onderskei- delik 5 395±2 946 kJ energie, 47±27 g proteïen, 28±21 g vet en 196±123 g koolhidrate in vergelyking met 8 641±3 799 kJ, 86±48 g, 49±32 g en 301±139 g vir die mans. Die meerderheid (83.6%) van die vroue was oorgewig (liggaamsmassa-indeks [LMI] >25) of vetsugtig (LMI > 30) en 78% het ’n middel-bo-armomtrek (MUAC) van > 21.7 cm gehad. Gemiddelde mikronutriëntinnames was laag in vergelyking met die verwysingstandaarde en serumsink was suboptimaal. Vetsug, hipertensie en verhoogde totale serumcholesterolvlakke het op ‘n verhoogde risiko van kardiovaskulêre siekte gedui. Die resultate het dus bewys dat lae inkomste, huishoudelike voedselin-sekuriteit en die risikofaktore wat met wanvoeding en leefstylsiektes geassosieer word, teenwoordig was.

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Does Participation in Food Benefit Programs Reduce the Risk for Depressive Symptoms?

Journal of the American Psychiatric Nurses Association ◽

10.1177/1078390320983904 ◽

2021 ◽

pp. 107839032098390

Author(s):

Harry Adynski ◽

Todd A. Schwartz ◽

Hudson P Santos

Keyword(s):

Depressive Symptoms ◽

Food Insecurity ◽

Low Income ◽

The United States ◽

Elevated Risk ◽

Physical And Mental Health ◽

Cross Sectional ◽

Assistance Program ◽

Sociodemographic Variables ◽

Increased Risk

BACKGROUND: Food insecurity affects 15 million households in the United States and is associated with negative physical and mental health outcomes including Major Depressive Disorder. Governmental public assistance or food benefit programs including the Supplemental Nutrition Assistance Program (SNAP) and Women, Infants, and Children (WIC) are social intervention services that attempt to minimize food insecurity for low-income households. There is little consensus regarding the effects of food benefit participation on reducing risk of depressive symptoms. OBJECTIVE: This study aims to explore the association between household food insecurity and food benefit participation (SNAP or WIC) on risk for depressive symptoms using nationally representative samples from the Center for Disease and Control and Prevention Nutritional Health and Nutrition Examination Survey 2013-2014 and 2015-2016 cohorts. We hypothesize that food insecurity is associated with increased risk of depressive symptoms and food benefit participation with reduced risk. METHOD: Cross-sectional analyses were conducted using survey-weighted logistic regression to explore the relationship between food insecurity, food benefit participation, and the risk of depressive symptoms controlling for relevant income and sociodemographic variables. RESULTS: When controlling for sociodemographic variables, food benefit participation did not reduce the risk of depressive symptoms, while high levels of food insecurity were associated with elevated risk. CONCLUSIONS: High levels of food insecurity are associated with elevated risk of depressive symptoms. Nurses and public health professionals can address food security needs through increased knowledge of referral and eligibility requirements. Implications on clinical practice, policy, and future directions for research are discussed.

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Food insecurity, coping strategies and glucose control in low-income patients with diabetes

Public Health Nutrition ◽

10.1017/s1368980015002323 ◽

2015 ◽

Vol 19 (6) ◽

pp. 1103-1111 ◽

Cited By ~ 30

Author(s):

Victoria L Mayer ◽

Kevin McDonough ◽

Hilary Seligman ◽

Nandita Mitra ◽

Judith A Long

Keyword(s):

Food Insecurity ◽

Coping Strategies ◽

Low Income ◽

Glucose Control ◽

Economic Stress ◽

Poverty Level ◽

Cross Sectional ◽

Assistance Program ◽

Patients With Diabetes ◽

And Coping

AbstractObjectiveTo examine the relationship between food insecurity and coping strategies (actions taken to manage economic stress) hypothesized to worsen glucose control in patients with diabetes.DesignUsing a cross-sectional telephone survey and clinical data, we compared food-insecure and food-secure individuals in their use of coping strategies. Using logistic regression models, we then examined the association between poor glucose control (glycated Hb, HbA1c≥8·0 %), food insecurity and coping strategies.SettingAn urban medical centre, between June and December 2013.SubjectsFour hundred and seven adults likely to be low income (receiving Medicaid or uninsured and/or residing in a zip code with >30 % of the population below the federal poverty level) with type 2 diabetes.ResultsOf respondents, 40·5 % were food insecure. A significantly higher percentage of the food-insecure group reported use of most examined coping strategies, including foregone medical care, participation in the Supplemental Nutrition Assistance Program (SNAP)) and use of emergency food programmes. Food insecurity was associated with poor glucose control (OR=2·23; 95 % CI 1·22, 4·10); coping strategies that were more common among the food insecure were not associated with poor glucose control. Among the food insecure, receipt of SNAP was associated with lower risk of poor glucose control (OR=0·27; 95 % CI 0·09, 0·80).ConclusionsWhile food insecurity was associated with poor glucose control, most examined coping strategies did not explain this relationship. However, receipt of SNAP among food-insecure individuals was associated with better diabetes control, suggesting that such programmes may play a role in improving health.

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Sex Differences in the Association Between Food Insecurity and Obesity Among College Students

Current Developments in Nutrition ◽

10.1093/cdn/nzaa043_032 ◽

2020 ◽

Vol 4 (Supplement_2) ◽

pp. 181-181

Author(s):

Aseel El Zein ◽

Karla Shelnutt ◽

Sarah Colby ◽

Geoffrey Greene ◽

Wenjun Zhou ◽

...

Keyword(s):

College Students ◽

Logistic Regression ◽

Food Security ◽

Food Insecurity ◽

Cross Sectional Study ◽

High Food ◽

Cross Sectional ◽

Logistic Regression Models ◽

Food And Agriculture ◽

Increased Risk

Abstract Objectives This study aimed to assess the association between food insecurity and obesity and to examine whether it varies by sex. Methods A cross-sectional study was conducted in spring 2017 among college students from eight U.S. institutions. Participants (n = 683) completed the USDA Adult Food Security Survey and had their weight and height measured by researchers. Multivariate logistic regression models were used to estimate the sex-specific associations between food insecurity and obesity (BMI ≥ 30 kg/m2), after adjusting for socioeconomic covariates. Results Overall, 25.4% of students identified as food insecure and 10.5% were obese. The prevalence of obesity increased as the level of food insecurity increased, from 5.2% for those with high food security, 13.4% for those with marginal food security, to 17.4% and 21.6% for students with low and very low food security. In logistic regression analysis, marginal, low and very low food security students had an odds ratio of 2.83 (95% CI: 1.43, 5.57), 3.86 (95% CI: 1.88, 7.91), and 5.05 (95% CI:, 2.44, 10.48) of obesity compared to students with high food security, exhibiting a dose-response relationship. Among females, having marginal (OR = 4.21, 95% CI: 1.70, 9.75), low (OR = 4.51, 95% CI: 1.40, 12.47), or very low food security (OR = 7.08, 95% CI: 2.60, 18.41) predicted higher odds of obesity compared to female students with high food security. Among males, those with low food security had higher odds of obesity (OR = 6.40, 95% CI: 1.78, 20.7). Conclusions The association between food insecurity and obesity in U.S. college students remained after adjustment for multiple socio-economic factors. Overall, food insecure females experienced an increase in the risk of obesity as food insecurity increased; however, only males with low food security had an increased risk of obesity. Programs directed toward obesity prevention need to address any level of food insecurity as a risk factor in females, and target males with low food security. Although beyond the scope of this study, it is possible that programs to reduce food insecurity may help prevent obesity in college students. Funding Sources This material is based upon work that is supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture, under award number 2014–67,001-21,851.

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Factors That Protect Children From Community Violence: Applying the INSPIRE Model to a Sample of South African Children

Journal of Interpersonal Violence ◽

10.1177/0886260519898425 ◽

2020 ◽

pp. 088626051989842

Author(s):

N. Suzanne Falconer ◽

Marisa Casale ◽

Caroline Kuo ◽

Beverly J. Nyberg ◽

Susan D. Hillis ◽

...

Keyword(s):

South Africa ◽

Community Violence ◽

Low Income ◽

Interpersonal Violence ◽

Social Protection ◽

Integrated Approach ◽

World Health ◽

Young Carers ◽

Access To Treatment ◽

Cross Sectional

Community violence is a prevalent form of interpersonal violence in South Africa for children living in low-income areas. Trauma arising from violence exposure is of concern in contexts where access to treatment is often unattainable. As simultaneous multisectoral strategies show higher potential to counter interpersonal violence than single interventions, the World Health Organization with partners created INSPIRE. INSPIRE takes an integrated approach coordinated across formal and informal settings of civil and private society. Responding to research paucity on methods that counter community violence in LMIC settings, this study employed a cross-sectional correlational design consisting of a sample of 2,477 children aged 10 to 17 years from the Young Carers 2009–2010 study conducted in a low-income, HIV-endemic province of South Africa highly affected by community violence. Multiple logistic regressions assessed individual and dose associations between four INSPIRE-based violence prevention strategies—positive parenting, basic necessities, formal social support, and school structural support—and direct and indirect community violence outcomes. Three strategies had significant associations with community violence outcomes: necessities (direct p < .001; adjusted odds ratio [AOR] = .57; indirect p < .01; AOR = .62), formal support (direct p < .05; AOR = .83; indirect p < .05; AOR = .73), and school support (direct p < .001; AOR = .53; indirect p < .001; AOR = .49). Combined interventions in direct and indirect community violence analyses demonstrated that children reporting a higher number of strategies were less likely to have experienced community violence. This outcome extends the results of longitudinal studies in South Africa highlighting social protection with care as a means to overcome structural deprivation strains, thereby reducing the likelihood of children’s exposure to community violence. Moreover, these findings uphold the INSPIRE model as an effective cross-sectoral approach to prevent and reduce the community violence that children experience.

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Tablet and web-based audiometry to screen for hearing loss in adults with cystic fibrosis

Thorax ◽

10.1136/thoraxjnl-2019-214177 ◽

2020 ◽

Vol 75 (8) ◽

pp. 632-639 ◽

Cited By ~ 2

Author(s):

Anitha Vijayasingam ◽

Emily Frost ◽

Julie Wilkins ◽

Lise Gillen ◽

Presanna Premachandra ◽

...

Keyword(s):

Cystic Fibrosis ◽

Hearing Loss ◽

Intraclass Correlation ◽

Cross Sectional Study ◽

Outpatient Setting ◽

P Value ◽

Cross Sectional ◽

Web Based ◽

High Frequency Audiometry ◽

Increased Risk

IntroductionIndividuals with chronic lung disease (eg, cystic fibrosis (CF)) often receive antimicrobial therapy including aminoglycosides resulting in ototoxicity. Extended high-frequency audiometry has increased sensitivity for ototoxicity detection, but diagnostic audiometry in a sound-booth is costly, time-consuming and requires a trained audiologist. This cross-sectional study analysed tablet-based audiometry (Shoebox MD) performed by non-audiologists in an outpatient setting, alongside home web-based audiometry (3D Tune-In) to screen for hearing loss in adults with CF.MethodsHearing was analysed in 126 CF adults using validated questionnaires, a web self-hearing test (0.5 to 4 kHz), tablet (0.25 to 12 kHz) and sound-booth audiometry (0.25 to 12 kHz). A threshold of ≥25 dB hearing loss at ≥1 audiometric frequency was considered abnormal. Demographics and mitochondrial DNA sequencing were used to analyse risk factors, and accuracy and usability of hearing tests determined.ResultsPrevalence of hearing loss within any frequency band tested was 48%. Multivariate analysis showed age (OR 1.127; (95% CI: 1.07 to 1.18; p value<0.0001) per year older) and total intravenous antibiotic days over 10 years (OR 1.006; (95% CI: 1.002 to 1.010; p value=0.004) per further intravenous day) were significantly associated with increased risk of hearing loss. Tablet audiometry had good usability, was 93% sensitive, 88% specific with 94% negative predictive value to screen for hearing loss compared with web self-test audiometry and questionnaires which had poor sensitivity (17% and 13%, respectively). Intraclass correlation (ICC) of tablet versus sound-booth audiometry showed high correlation (ICC >0.9) at all frequencies ≥4 kHz.ConclusionsAdults with CF have a high prevalence of drug-related hearing loss and tablet-based audiometry can be a practical, accurate screening tool within integrated ototoxicity monitoring programmes for early detection.

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DOES BREASTFEEDING DURATION INFLUENCE FAMILY FOOD INSECURITY?

Paediatrics & Child Health ◽

10.1093/pch/pxy054.016 ◽

2018 ◽

Vol 23 (suppl_1) ◽

pp. e6-e6

Author(s):

Peter Wong ◽

Rosemary Moodie ◽

David Dai ◽

Jonathon Maguire ◽

Catherine Birken ◽

...

Keyword(s):

Public Policy ◽

Food Insecurity ◽

Low Income ◽

Family Income ◽

Cross Sectional Study ◽

Research Network ◽

Breastfeeding Duration ◽

Cross Sectional ◽

Adequate Food ◽

Low Income Families

Abstract BACKGROUND Across all demographics, families without consistent access to adequate food place children at health risk. Consequences may persist beyond early life into adulthood. Public policy positions breastfeeding, the ideal nutrition for infants, as an important solution to reducing family food insecurity (FFI). However, few studies have investigated the association between breastfeeding duration and FFI. OBJECTIVES To evaluate the association between total breastfeeding duration and FFI in Canadian urban children. DESIGN/METHODS A cross-sectional study was conducted of children aged 0–2 years, from a practice-based child research network. Total breastfeeding duration was collected from parent-reported questionnaires. FFI was measured using 2-item food insecurity and validated 1-item NutriSTEP screens. Multivariable regression analysis was performed adjusting for pre-specified covariates. RESULTS Among 3838 children, the mean total breastfeeding duration was 10.6 months (SD=6.7). Families with food insecurity (14.7%) had increased odds of younger mothers, more males and older and more children. In adjusted model, breastfeeding duration was not associated with FFI (OR 0.99; 95% CI 0.98, 1.01). Low-income families were 9 times more likely to be family food insecure than high-income families (p=0.00). CONCLUSION Contrary to public policy, our study found no association between breastfeeding and family food insecurity (FFI). However, other factors may predominate, in particular family income and structure. Given the detrimental impact of FFI, further research is needed to understand the role of infant feeding practices within the larger political, policy and cultural framework.

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Effect of Income Level and Perception of Susceptibility and Severity of COVID-19 on Stay-at-Home Preventive Behavior in a Group of Older Adults in Mexico City

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph17207418 ◽

2020 ◽

Vol 17 (20) ◽

pp. 7418 ◽

Cited By ~ 2

Author(s):

Maria Esther Irigoyen-Camacho ◽

Maria Consuelo Velazquez-Alva ◽

Marco Antonio Zepeda-Zepeda ◽

Maria Fernanda Cabrer-Rosales ◽

Irina Lazarevich ◽

...

Keyword(s):

Older Adults ◽

Mexico City ◽

Low Income ◽

Income Level ◽

Cross Sectional Study ◽

Total Effect ◽

Preventive Behavior ◽

Cross Sectional ◽

Perceived Severity ◽

At Home

Early information on public health behaviors adopted to prevent the spread of coronavirus (COVID-19) may be useful in controlling the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) transmission. The objective of this study was to assess the role of income level (IL) and the perception of older adults, regarding COVID-19 susceptibility and severity, on adopting stay-at-home preventive behavior during the first week of the outbreak in Mexico. Participants in this cross-sectional study were urban community dwellers, aged ≥ 65 years from Mexico City. A total of 380 interviews were conducted over the phone. The mean respondent age was 72.9 years, and 76.1% were women. Over half (54.2%) of the participants perceived their susceptibility to COVID-19 as very low or low. Similarly, 33.4% perceived COVID-19 severity as being very low or low, and 57.6% had decided to stay at home: this behavior was associated with IL (β = 1.05, p < 0.001), and its total effect was partially mediated (15.1%) by perceived severity. Educational attainment was also associated with staying at home (β = 0.10, p = 0.018) and its total effect was partially mediated (15.0%) by perceived susceptibility. Interventions aimed at low income and less educated older adults should be developed to improve preventive behaviors in this vulnerable group during the COVID-19 pandemic.

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Household food insecurity among people living with HIV in Sagamu, Nigeria: A preliminary study

Nutrition and Health ◽

10.1177/0260106017704798 ◽

2017 ◽

Vol 23 (2) ◽

pp. 95-102 ◽

Cited By ~ 5

Author(s):

Oluwafolahan O Sholeye ◽

Victor J Animasahun ◽

Albert A Salako ◽

Bankole K Oyewole

Keyword(s):

Food Insecurity ◽

Vegetable Consumption ◽

Systematic Sampling ◽

Consumption Pattern ◽

Household Food Insecurity ◽

People Living With Hiv ◽

Cross Sectional ◽

Household Food ◽

Increased Risk ◽

Living With Hiv

Background: Household food insecurity has been associated with increased risk of transmission of HIV infection and poor treatment outcomes. This study therefore determined the prevalence of household food insecurity and its associated factors among people living with HIV in Sagamu, Ogun State, Nigeria. Methods: A cross-sectional descriptive study was carried out among 244 adult clients accessing care and support at the teaching hospital in Sagamu, Nigeria, selected via systematic sampling. Data was collected with the aid of a semi-structured, interviewer-administered questionnaire. Data was analysed using SPSS 21.0. Relevant descriptive and inferential statistics were calculated. Informed consent was obtained and strict confidentiality was ensured. Results: The mean age of respondents was 38.8 ± 9.2 years; 84% of respondents were female; 69.3% were married, 12.9% had lost their partners. About 12% spent more than three-quarters of the household income on food. The prevalence of household food insecurity was 71.7%. Food insecurity was associated ( p < 0.05) with educational status; occupation; type of housing; availability of toilet facilities; benefiting from food assistance; delaying drugs to prevent hunger; skipping drugs; vegetable consumption pattern; and exchanging sex for food. Conclusion: The prevalence of household food insecurity in this study was high. Living conditions were significantly associated with food insecurity. Socio-economic conditions need to be improved, to optimize the health and food security status of people living with HIV in Sagamu.

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Are low-to-middle-income households experiencing food insecurity in Victoria, Australia? An examination of the Victorian Population Health Survey, 2006–2009

Australian Journal of Primary Health ◽

10.1071/py16082 ◽

2017 ◽

Vol 23 (3) ◽

pp. 249 ◽

Cited By ~ 20

Author(s):

Sue Kleve ◽

Zoe E. Davidson ◽

Emma Gearon ◽

Sue Booth ◽

Claire Palermo

Keyword(s):

Food Insecurity ◽

Population Health ◽

Low Income ◽

Home Ownership ◽

Cross Sectional ◽

Middle Income ◽

Income Levels ◽

Factors Associated ◽

Health And Wellbeing ◽

Using Data

Food insecurity affects health and wellbeing. Little is known about the relationship between food insecurity across income levels. This study aims to investigate the prevalence and frequency of food insecurity in low-to-middle-income Victorian households over time and identify factors associated with food insecurity in these households. Prevalence and frequency of food insecurity was analysed across household income levels using data from the cross-sectional 2006–09 Victorian Population Health Surveys (VPHS). Respondents were categorised as food insecure, if in the last 12 months they had run out of food and were unable to afford to buy more. Multivariable logistic regression was used to describe factors associated with food insecurity in low-to-middle-income households (A$40000–$80000 in 2008). Between 4.9 and 5.5% for total survey populations and 3.9–4.8% in low-to-middle-income respondents were food insecure. Food insecurity was associated with limited help from friends, home ownership status, inability to raise money in an emergency and cost of some foods. Food insecurity exists in households beyond those on a very low income. Understanding the extent and implications of household food insecurity across all income groups in Australia will inform effective and appropriate public health responses.

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