scholarly journals Household Food Security and Nutritional Status of Under-Five-Year Children: A Case Study of Nepal

Author(s):  
Ajaya Paudel ◽  
Tulsi Ram Bhandari ◽  
Nim Bahadur Dangi

Background: Food security refers to accessing to desirable, nutritious, and healthy foods to live a healthy and productive life. Household food insecurity is an underlying cause of malnutrition in children. In this study, the household food security and its influence on the nutritional status of under-five year children were investigated. Methods: A cross-sectional analytical study was conducted from August to November 2019 in Syangja district of Nepal. Of six rural municipalities of the district, Phedikhola Rural Municipality was selected using the lottery method. We found 905 eligible households that have an under-five year child. A total of 289 children entered the study after considering the 40% overall prevalence rate of malnutrition among children under five years of age.  Data were collected proportionately from each ward considering the health status and anthropometric measurements of children and household food security using a structured interview schedule and the Household Food Insecurity Access Scale. Descriptive statistics and chi-square tests were applied to assess the situation and determine the association. Results: Food insecurity was observed in more than half (52.3%) of the households. Food insecurity was associated (P < 0.001) with the socioeconomic status of the family. Prevalence of stunting (height-for-age), underweight, and wasting (weight-for-height) in children were 28.7%, 20.0%, and 13.9%, respectively. Food security, exclusive breastfeeding, and initiation time of complementary feeding were significantly associated with wasting and underweight (P < 0.05). Conclusion: Food insecurity and under-five year malnutrition were highly frequent in the study areas. The improvement of educational, occupational, and economic conditions of the households may be a solution to this problem.

2021 ◽  
Vol 21 (105) ◽  
pp. 18912-18931
Author(s):  
U Mukherjee ◽  
◽  
JM Chalwe ◽  
S Mbambara ◽  
WH Oldewage-Theron ◽  
...  

Socio-demographic factors and household food insecurity are considered to influence the nutritional status of older women. The rapidly growing elderly population in Africa is a concern particularly in sustaining their health and nutritional status. In spite of this, there is a scarcity of information in older Zambian women and this study aimed to assess the socio-demographic factors, nutritional status and household food insecurity status of older women in rural Zambian communities. This cross-sectional study was conducted in Twatasha compound of Kitwe and Ndeke community of Ndola. The socio-demographic characteristics, anthropometric measurements, dietary intakes and household food security were evaluated in a convenience sample of 153 older women (≥ 50 years) through the Household Food Insecurity Access Scale (HFIAS). IBM SPSS version 26 was used for descriptive (frequencies, means and standard deviations, and medians with interquartile frequencies) and inferential (bivariate and Spearman correlations) statistical analyses. The socio-demographic characteristics showed that almost all (98.7%) of the participants had other members of the family residing with them. Most participants (57%) had attained primary school education, 19% had secondary education and 5% had college education. Almost half (49%) of the participants did not report their employment status and 36% reported to be unemployed. Over-nutrition was most prevalent (37.3% overweight and 39.8% obese) while 20.9 % and 2.0% of the respondents were normal weight and underweight respectively. The median (25th percentile; 75th percentile) dietary intakes showed inadequate intakes for most nutrients, except for carbohydrates (170 g [133;225]). The total fat intake represented 14% of total energy intake. The majority (86.0%) of the participants were identified as severely food insecure while only 6.0% were food secure. The majority of the participants (80-90%) used at least seven out of the nine behavioural responses to food insecurity. The findings show resource-poor and severely food insecure communities. We recommended urgent interventions to improve access to healthy foods (such as home gardening projects) and promote healthy dietary habits (including nutrition education).


2017 ◽  
Vol 2017 ◽  
pp. 1-7 ◽  
Author(s):  
Zinat Mortazavi ◽  
Ahmad Reza Dorosty ◽  
Mohammad Reza Eshraghian ◽  
Mohtasham Ghaffari ◽  
Alireza Ansari-Moghaddam ◽  
...  

Background.Today, more than one billion people globally suffer from poverty and food insecurity. This study aimed to determine the severity of and factors related to household food insecurity in Zahedan, Southeastern Iran.Methods.This cross-sectional study was conducted on a total of 2,160 households between November 2014 and December 2015. Demographic and socioeconomic data were collected through interviewing the household mothers. Household food security status was assessed through the USDA 18-item questionnaire. The data were analyzed using chi-square test, one-way ANOVA, and logistic regression model.Results.Total food insecurity in the households investigated was 58.8%. There were significant associations (P<0.001) between household food insecurity status and the socioeconomic status of the households, ethnicity, education, age, and employment status of the head of the household and the mother of the household.Discussion.The results showed that more than half of the households examined suffer from food insecurity. Interventions to improve the food security status of people should be designed and implemented to improve people’s knowledge, skills, and attitudes related to healthy eating and food preparation. People’s access to healthy foods and knowledge of how to select healthy foods (especially on a limited budget) should also be improved.


2019 ◽  
Vol 3 (4) ◽  
pp. 201
Author(s):  
Sutyawan Sutyawan ◽  
Ali Khomsan ◽  
Dadang Sukandar

 Background: Household food insecurity is a underlaying causes on undernutrition problems in children under five years. Household food security especially from food acces dimention is reflected from many indicators that are complex and easier to understand in a composite index. Objectives: The purpose of this study was to develop a index of household food security and its relationship to nutrient intake level and nutritional status in children under five years. Method: This cross-sectional study was conducted in four villages in West Bangka Regency in December 2018 until April 2019. The study involved 219 subjects consisting of mothers and children aged 12-59 months. Data were analyzed using Rank Spearman relationship test. Results: The validation results showed that the index score has a negatively correlation (p<0.01) with the proportion of food expenditure and it has a significant correlation with dietary diversity (HDDS Score). In addition, the index score was a significant correlation (p<0.01) with the level of adequacy of energy, protein, fat, calcium, iron, zinc and dietary diversity in children. The index score was a significant associated (p<0.01) with the nutritional status of children based on height for age, weight gor age, and height for wight. Conclusions: The index was developed from this study can be an alternative to evaluate the status of household food security level and stronger marker of food consumption and nutritional status of under five children.ABSTRAKLatar Belakang: Kondisi rawan pangan pada rumah tangga merupakan salah satu penyebab masalah kekurangan gizi pada anak berusia di bawah lima tahun. Ketahanan pangan rumah tangga tercermin dari banyak indikator yang kompleks dan lebih mudah dipahami dalam indeks komposit.Tujuan: Penelitian ini bertujuan mengembangkan indeks ketahanan pangan rumah tangga serta hubungannya dengan tingkat asupan gizi dan status gizi pada anak balita.Metode: Penelitian cross-sectional ini dilakukan di empat desa di Kabupaten Bangka Barat. Penelitian ini melibatkan 219 subjek yang terdiri dari anak berusia 12-59 bulan dan ibu dari anak. Data dianalis menggunakan uji beda Kruskal Wallis dan uji hubungan Rank Spearman.Hasil: Hasil validasi menunjukkan bahwa skor indeks memiliki perbedaan yang nyata (p<0,05) berdasarkan tingkat kerentanan pangan wilayah dan terdapat hubungan negatif yang kuat (p<0,05) dengan proporsi pengeluaran pangan. Selain itu, skor indeks memiliki keterkaitan yang kuat (p<0,05) dengan tingkat kecukupan energi, protein, lemak, kalsium, besi, seng serta keragaman diet pada balita. Skor indeks juga memiliki hubungan yang nyata (p<0,05) dengan nilai z-score status gizi balita berdasarkan indeks antropometri tinggi badan menurut usia, berat badan menurut umur, dan tinggi badan menurut berat badan.Kesimpulan: Indeks yang dikembangkan dari penelitian ini dapat menjadi alternatif dalam menilai status ketahanan pangan rumah tangga serta prediktor yang kuat dalam melihat gambaran konsumsi pangan dan status gizi balita. 


2021 ◽  
Author(s):  
Mohamed Abd Alrazik Desogi ◽  
Fatima Abbas Khalid ◽  
Awadia Khojali Mohamed ◽  
Asma Mahmoud Hamza ◽  
Sarah salih Mohammed ◽  
...  

Abstract BackgroundMalnutrition and anemia are still major health problem in Sudan .This study aim to assess the magnitude of household food insecurity and its consequences on the nutritional status and anemia of children 6–60 months in north localities in Kassala State (Eastern Sudan) MethodWe administered a cross-sectional survey to 445 households in 16 villages. We used specially designed structured questionnaire. We measure household food insecurity by food consumption score (FCS)Data were analyzed using SPSS version 20.0 statistical package. Frequencies and Chi2 was performed. Multivariable logistic regression was used to develop the final model indicating the predictors of the outcome variable.ResultsFood insecurity and vulnerability for food insecurity was found in 181 (38.7%) of household .There was significant associations (P < 0.001) between household's food insecurity and income, household size, number of children, eating habits and avoidance of certain types of food. the overall prevalence of stunting , wasting and underweight was 52.1%, 35.6% and 53.9% respectively. The result showed that the relationship of nutrition status of children and HH food security was statistically insignificant although stunted and underweight were increased by 8% and 7% respectively in food insecure HH, though the prevalence of wasting was almost similar in food secure and insecure households. The study showed that 262 (76.4%) of children had HB level less than 11g/dL. Mild anemia was reported in only 9.3% while moderate and sever anemia in 34.4% , 32.7% respectively. This study revealed that there is negative association of HB level with HH food security (P<0.05). Among those who had normal HB level 30 (37%) were food insecure, whereas 51 (63%) where food secure in contrast to 195(75.6%) who had low level of HB were food secure. ConclusionAccording to the study findings, more attention is needed to improve household food security in the study area .Good eating habits can be achieved by designing education programs to improve knowledge, skills, and attitudes related to healthy eating and food preparation and overall, increasing household income through improving the farming methods, and finding the alternative sources of income. Other risk factors of malnutrition and anemia also should be corrected , such as improving maternal education, improving feeding practices regarding avoiding certain type of food and controlling childhood infections.


2018 ◽  
Vol 6 (3) ◽  
pp. 789-797 ◽  
Author(s):  
ABU AHAMMAD ABDULLAH ◽  
M. A. RIFAT ◽  
MD. TAREQ HASAN ◽  
MOHAMMAD ZAHIDUL MANIR ◽  
MD. MAHBUB MURSHED KHAN ◽  
...  

This study was conducted among people in the two southern most sub-districts or Upazilas (Teknaf and Ukhiya) of Bangladesh. This area is known nationally and internationally for a number of reasons including the presence of Rohingya refugees, the longest sea beach in the world, the location of a crucial international border between Bangladesh and Myanmar, and its Rakhaine ethnic population. This study focuses on the host community people of these two Upazilas from a nutritional lens. Objectives To assess the socio-economic status, infant and young child feeding (IYCF) practices, household food security levels, hygiene, sanitation and healthcare seeking behavior, and also the nutritional status of children under-five among the population of Teknaf and Ukhiya Upazilas of Cox's Bazar, Bangladesh. The study employed a cross sectional approach. A total of 300 households with at least one 6-59 month old child were randomly selected by two stage cluster sampling in 2014. Data was collected through direct interviews with the participants using a structured questionnaire. Analysis of the data was carried out using the Statistical Package for Social Sciences (version16.0 SPSS Inc, Chicago, IL, USA) and Emergency Nutrition Assessment (ENA) software. Food security was measured by Household Food Insecurity Access Score (HFIAS). The study found that 43.6% of the children were breastfed within 1 hour of birth, 41.9% ofthe children were exclusively breastfed up to six months, and the average duration of exclusive breastfeeding was 5.2 months. Age appropriate meal frequency was found inaccurate for 60.3% of the children aged 9-11 month. The rates of severe stunting, wasting, and underweight among the children were 16.0%, 3.0% and 14.6% respectively. Among the households, 46.9% were severely food insecure. It was found that household food insecurity was significantly associated with household income (p=0.000), maternal education (p=0.000),and stunting (p= 0.005) and wasting (p=0.044) for children under-five. Overall IYCF practices, nutritional status of under-five children and household food security among the studied population were not at a satisfactory level and the status was lower than reference data for the same region.


2017 ◽  
Vol 1 (3) ◽  
pp. 189
Author(s):  
Rika Kusuma Nagari ◽  
Triska Susila Nindya

Background: The nutritional status of elementary school children can be influence by many factors such as levels adequacy of energy and proteinand household food security status. Unbalanced levels adequacy of energy and protein possibility can cause nutritional problems in children. While the status of household food security has an impact on the household ability to access a good food. Objectives: aims of this study are to analyze the relationship between nutritional adequacy level and household food security status with nutritional status of children aged 6-8 years. Method: This study used cross sectional design with sample of 62 families with children aged 6-8 years enrolled in SDN 1 and 2 Sambirejo. Anthropometric measurement of height and weight is used to determine the nutritional status of children. The instruments used 2x24-hours food recall form (energy and protein adequacy level), and US-HFSSM (household food security status). While the statistical test used is spearman correlation test. Results: The results showed a correlation between levels of energy (p=0.000) and protein (p=0.000) adequacy and household food security status (p=0.010) with child nutritional status. Conclusion: Households with food insecurity had a higher proportion of nutritional problem than food secure family, so it is needed to children for having supplemental food, especially them who have nutritional problems and on food insecurity condition. It is intended to provide children with additional nutritious food to reduce the risk of nutritional problems.ABSTRAK Latar Belakang: Status gizi anak sekolah dasar dapat dipengaruhi oleh banyak faktor diantaranya tingkat kecukupan energi dan protein serta status ketahanan pangan rumah tangga. Ketidakseimbangan tingkat kecukupan energi dan protein, kemungkinan dapat menyebabkan masalah gizi pada anak. Status ketahanan pangan rumah tangga berdampak kepada kemampuan dalam mengakses pangan yang baik.Tujuan: Penelitian ini bertujuan untuk menganalisis hubungan antara tingkat kecukupan energi dan protein serta status ketahanan pangan rumah tangga dengan status gizi anak usia 6-8 tahun.Metode: Penelitian ini menggunakan desain cross sectional dengan sampel sebanyak 62 keluarga yang memiliki anak usia 6-8 tahun yang terdaftar di SDN 1 dan 2 Sambirejo. Pengukuran antropometri tinggi badan dan berat badan digunakan untuk mengetahui status gizi anak. Selain itu, instrumen yang digunakan adalah  formulir 2x24-hours food recall (tingkat kecukupan energi dan protein), dan US-HFSSM (status ketahanan pangan rumah tangga). Statistik uji yang digunakan adalah uji korelasi spearman.Hasil: Hasil dari penelitian ini yaitu terdapat hubungan antara tingkat kecukupan energi (p=0,000) dan protein (p=0,000) serta status ketahanan pangan rumah tangga (p=0,010) dengan status gizi anak.Kesimpulan: Rumah tangga yang rawan pangan akan memiliki risiko mengalami masalah gizi yang lebih tinggi bila dibandingkan dengan rumah tangga yang tahan pangan, sehingga perlu adanya pemberian makanan tambahan kepada anak, terutama kepada anak yang memiliki masalah gizi dan berada pada kondisi rawan pangan. Hal tersebut dimaksudkan untuk memberikan anak tambahan makanan yang bergizi agar menurunkan risiko masalah gizi.


2017 ◽  
Vol 1 (3) ◽  
pp. 189
Author(s):  
Rika Kusuma Nagari ◽  
Triska Susila Nindya

Background: The nutritional status of elementary school children can be influence by many factors such as levels adequacy of energy and proteinand household food security status. Unbalanced levels adequacy of energy and protein possibility can cause nutritional problems in children. While the status of household food security has an impact on the household ability to access a good food. Objectives: aims of this study are to analyze the relationship between nutritional adequacy level and household food security status with nutritional status of children aged 6-8 years. Method: This study used cross sectional design with sample of 62 families with children aged 6-8 years enrolled in SDN 1 and 2 Sambirejo. Anthropometric measurement of height and weight is used to determine the nutritional status of children. The instruments used 2x24-hours food recall form (energy and protein adequacy level), and US-HFSSM (household food security status). While the statistical test used is spearman correlation test. Results: The results showed a correlation between levels of energy (p=0.000) and protein (p=0.000) adequacy and household food security status (p=0.010) with child nutritional status. Conclusion: Households with food insecurity had a higher proportion of nutritional problem than food secure family, so it is needed to children for having supplemental food, especially them who have nutritional problems and on food insecurity condition. It is intended to provide children with additional nutritious food to reduce the risk of nutritional problems.ABSTRAK Latar Belakang: Status gizi anak sekolah dasar dapat dipengaruhi oleh banyak faktor diantaranya tingkat kecukupan energi dan protein serta status ketahanan pangan rumah tangga. Ketidakseimbangan tingkat kecukupan energi dan protein, kemungkinan dapat menyebabkan masalah gizi pada anak. Status ketahanan pangan rumah tangga berdampak kepada kemampuan dalam mengakses pangan yang baik.Tujuan: Penelitian ini bertujuan untuk menganalisis hubungan antara tingkat kecukupan energi dan protein serta status ketahanan pangan rumah tangga dengan status gizi anak usia 6-8 tahun.Metode: Penelitian ini menggunakan desain cross sectional dengan sampel sebanyak 62 keluarga yang memiliki anak usia 6-8 tahun yang terdaftar di SDN 1 dan 2 Sambirejo. Pengukuran antropometri tinggi badan dan berat badan digunakan untuk mengetahui status gizi anak. Selain itu, instrumen yang digunakan adalah  formulir 2x24-hours food recall (tingkat kecukupan energi dan protein), dan US-HFSSM (status ketahanan pangan rumah tangga). Statistik uji yang digunakan adalah uji korelasi spearman.Hasil: Hasil dari penelitian ini yaitu terdapat hubungan antara tingkat kecukupan energi (p=0,000) dan protein (p=0,000) serta status ketahanan pangan rumah tangga (p=0,010) dengan status gizi anak.Kesimpulan: Rumah tangga yang rawan pangan akan memiliki risiko mengalami masalah gizi yang lebih tinggi bila dibandingkan dengan rumah tangga yang tahan pangan, sehingga perlu adanya pemberian makanan tambahan kepada anak, terutama kepada anak yang memiliki masalah gizi dan berada pada kondisi rawan pangan. Hal tersebut dimaksudkan untuk memberikan anak tambahan makanan yang bergizi agar menurunkan risiko masalah gizi.


2018 ◽  
Vol 2 (1) ◽  
pp. 44
Author(s):  
Devi Eka Jayarni ◽  
Sri Sumarmi

Background: Households experiencing food insecurity in Indonesia is 30%, while vulnerable to food is 11%. Food insecurity is related to nutrional status. Based on Riskesdas Indonesia data in 2007 the prevalence of underfive children less than 19.6%, decreased to 18.4% in 2010, but increased to 19.6% in 2013.Objective: The purpose of this study was to analyze relationship between food security, family characteristics with nutritional status of children aged 2-5 years old at area Puskesmas Wonokusumo Kota Surabaya.Methods: This study was an observasional analytic using cross sectional design. Sample size of 97 from 4101 of underfive children used Lemeshow with simple random sampling method. Collecting data used US-HFSSM questionnary for examine household food security, weight- age index for measuring nutritional status of children. Statistical analysis test used Spearman correlate test and chi square test.Results:Most of mother graduated from primary school by 38.1%, mostly mothers doesn’t work by 85.6%, most of parents income are below average amount IDR 2,363,092 by 53.6%, as well as spending on food consumption expenditure amount IDR 1,724,943 by 7.3%, while mostly household have food insecurity by 54.9%. However, there is relationship between parents incomes (p=0.006) and household food security (p=0.045) with nutritional status of children under five years old.Conclusion: The higher household income the higher food expenditure. Household’s food insecurity is mostly below average expenditure.ABSTRAKLatar Belakang : Rumah tangga yang mengalami rawan pangan di Indonesia sebesar 30%, sedangkan sangat rawan sebesar 11%.Ketahanan pangan erat kaitannya dengan masalah gizi. Berdasarkan data Riskesdas tahun 2007 prevalensi balita mengalami gizi kurang di Indonesia sebesar 19,6%, menurun menjadi 18,4% tahun 2010, namun meningkat menjadi 19,6% tahun 2013.Tujuan : Tujuan pada penelitian ini untuk menganalisis hubungan ketahanan pangan dan karakteristik keluarga dengan status gizi balita di wilayah kerja Puskesmas Wonokusumo Kota Surabaya.Metode : Jenis penelitian ini menggunakan observasional analitik dengan studi desain cross sectional. Besar sampel 97 dari 4101 balita menggunakan rumus Lemeshow dengan metode simple random sampling. Pengumpulan data menggunakan kuisioner US – HFSSM untuk mengukur status ketahanan pangan rumah tangga, indeks BB/U digunakan untuk menilai status gizi balita. Uji statistik yang digunakan adalah uji korelasi spearman dan uji chi-square.Hasil : sebagian besar ibu balita pendidikan terakhir tamat SD/ sederajat sebesar 38,1%, sebagian besar ibu balita tidak bekerja sebesar 85,6%, pendapatan keluarga sebagian besar kurang dari rata –rata Rp 2.363.092 sebesar 53,6%, sebagian besar pengeluaran rumah tangga kurang dari rata – rata Rp 1.724.943 sebesar 75,3%, sebagian besar rumah tangga rawan pangan derajat kelaparan sedang sebesar 54,9%, Terdapat hubungan antara pendapatan keluarga (p=0,006) dan ketahanan pangan rumah tangga (p=0,045) dengan status gizi balita.Kesimpulan : tingginya pendapatan rumah tangga maka mempengaruhi pengeluaran untuk pangan. Rumah tangga rawan pangan sebagian besar penegeluaran untuk pangan dibawah rata – rata. 


2020 ◽  
Author(s):  
Naser Kalantari ◽  
Neda Ezzeddin ◽  
Hassan Eini-Zinab

Objective: The aim of this study was to investigate the association of food insecurity score with the status of Covid-19 infection. Design: An online cross-sectional study. Demographic and socio-economic information were collected by questionnaire. Household Food Insecurity Access Scale (HFIAS) was used in assessing household food security status. The analysis data was done by IBM SPSS 22.0, using Chi-square test, ANOVA test and Multinomial logistic regression model. Setting: Iran Participants: 2871 Iranian adults (over 18 years old) Results: findings indicated that men [OR=0.60, CI= (0.41, 0.87), P<0.05], and healthcare personnel [OR=3.66, CI= (1.90, 7.05), P<0.001] were at higher risk for Covid-19. It was also shown that the food insecurity score is significantly higher among infected people compared to not-infected [OR=1.03, CI= (1.00, 1.05), P<0.05]. The comparison between suspected and not-infected individuals only indicated the significant differences in perceived COVID-19 prevention score, which was higher among not-infected people [OR=0.88, CI=(0.84,0.93), P<0.001]. Conclusion: Based on the results, in addition to long-term policies to improve food security, policymakers and planners need to plan and implement short-term policies (financial or food assistance) to reduce society vulnerability to the Covid-19.


2021 ◽  
Vol 5 (Supplement_2) ◽  
pp. 106-106
Author(s):  
Hemanta Bhandari ◽  
Per Ole Iversen ◽  
Heidi Fjeld

Abstract Objectives Little is known about the nutritional status of elderly in Nepal, in particular among indigenous communities in high altitude areas. The main objective of this study was therefore to determine the nutritional status of elderly and their household food security status on the Nepal-China border. Methods The study was conducted in Mugu Karmarong rural municipality, as part of Mugu district that habitats mostly indigenous Tibetan-speaking communities. We used a descriptive cross-sectional design and a total of 128 participants were identified using purposive sampling. Anthropometry and the Mini Nutritional Assessment Short Form (MNA-SF) were used to determine nutritional status and the Household Food Insecurity Access Scale (HFIAS) was used to categorize households according to a food insecurity scale. Results The mean (range) age of participants was 69 (60–84) years. The majority (81%) of the 128 participants had no any education, they were mostly (86%) Buddhist and 72% were married. Based on the MNA-SF scores, 30.5% had a normal nutritional status, 40.6% were at risk for malnutrition while 28.9% were malnourished. In somewhat contrast, our BMI measurements (using the cut-off values from a national survey) suggested that the majority (79.7%) had BMI values within the normal reference range. Based on the HFIAS, only 30.4% of the households were scored as food secure whereas 29% of the households belonged to the severe food insecurity category followed by 26% being moderately food insecure and 11% being mildly food insecure. Our findings revealed that type of the household, use of iodized salt, seasonal migration and household food security status, were all significantly associated with nutritional status of the elderly. Those living in severely food insecure households were 3.2 times more likely to be malnourished than those from food secured households while those living in moderately insecure household was 1.8 times more at risk of malnutrition than those from food secure households. Conclusions We found that about 2/3 of the elderly were either at risk of malnutrition or were malnourished. Only 1/3 of the surveyed households were food secure. Hence, there are alarming risks of malnutrition and food insecurity among elderly in this remote, mountainous region. Funding Sources This study was partly sponsored by the University of Oslo.


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