Behaviour change for better health: nutrition, hygiene and sustainability

Exploring the Influence of Social Capital on HIV Prevention with Migrants from the Democratic Republic of Congo (DRC) Living in Durban, South Africa

Background: Research shows a growing attentiveness to the role of social and environmental influences on HIV risk behaviours. Moreover, the understanding of HIV risk behaviours has moved from an earlier consideration of individual risk, to ecological models, with the understanding that behaviours are rooted in the economic, environmental and social structure. Aim: To explore how social capital, specifically on a social bonding level, operates as a risk or protective factor for the spread of HIV among French-speaking migrants from the Democratic Republic of Congo (DRC), living in Durban, South Africa. Methods: A qualitative approach using a case study design was used to conduct the study. Data were collected through focus group discussions and individual in-depth interviews from a purposive sample of French-speaking migrants from DRC, living in Durban, South Africa. Ethical approval to conduct the study was obtained from the University of KwaZulu-Natal's Human and Social Science Research Ethics' Committee. Data were analysed thematically using Creswell's steps of data analysis. Results: This study found that social capital can act as both a protective factor in certain circumstances, and a risk factor in others. Trust, norms, reciprocity and social networks are complex elements in the refugee community and are influenced by a myriad of factors including the past and present stressors that are prevalent within this community. Conclusions: The findings confirm the complexity of issues related to HIV prevention which necessitate policy and practice interventions to mitigate consequences that may result from the higher risks of HIV transmission in this community.

Personal and Household Hygiene Measures for Preventing Upper Respiratory Tract Infections among Children: A Cross-Sectional Survey of Parental Knowledge, Attitudes, and Practices

Personal and household hygiene measures are important for preventing upper respiratory tract infections (URTIs) and other infectious diseases, including coronavirus disease 2019 (COVID-19). An online survey recruited 414 eligible parents in Hong Kong to study their hygiene knowledge, attitudes, and practices (KAPs) regarding the prevention of URTIs among their children. The average knowledge score was high (10.2/12.0), but some misconceptions were identified. The majority of the participants agreed that good personal hygiene (93.5%) and good environmental hygiene (92.8%) can prevent URTIs. The average score for hand hygiene practices was high (3.78/4.00), but only 56.8% of the parents always performed hand hygiene before touching their mouths, noses, or eyes. In terms of environmental hygiene, only some household items were disinfected with disinfectants (door handles in 69.8% of the households, toilet seats in 60.4% of the households, the floor in 42.8% of the households, dining chairs in 24.2% of the households, and dining tables in 20.5% of the households). A higher knowledge score was associated with parents having tertiary educational levels or above, working as healthcare professionals, living in private residential flats or staff quarters, or having household incomes of HKD 70,000 or above. The results of multiple regression analyses also indicated that parents who were healthcare professionals and with higher household income had a better parental knowledge of hygiene measures after adjusting the attitude score. For hand hygiene, parents who achieved higher attitude scores obtained higher practice scores. Under the fifth wave of the COVID-19 epidemic, there were some misconceptions regarding hygiene among parents. Any health promotion program should target parents regarding taking proper personal and household hygienic measures, especially for those who had relatively lower socio-economic status and/or from a non-healthcare background. Motivating attitudes toward hand hygiene can lead to better practices.

Improving the Nutrient Quality of Foods and Beverages Using Product Specific Standards for Nutrients to Limit Will Substantially Reduce Mean Population Intakes of Energy, Sodium, Saturated Fat and Sugars towards WHO Guidelines

BACKGROUND

International strategies to reduce chronic diseases have called for a reduction in the amounts of saturated fat (SAFA), trans fat (TFA), salt and sugars in the global food supply. This paper describes the development approach and potential impact of a set of standards for these nutrients to drive food (re)formulation.

METHODS

To set the standards, WHO nutrient guidelines for daily intake were translated into product group specific standards. The impact of reformulation towards these standards on population nutrient intakes was modelled using the food consumption data of five countries: UK, France, US, Brazil and China. The impact of the TFA standards could not be modelled due to lack of data.

RESULTS

(Re)formulation of foods and beverages towards these standards would substantially decrease mean population intakes of energy, sodium, SAFA and sugars, with reductions up to 30%.

CONCLUSIONS

These science-based standards for nutrients to limit could drive impactful reductions in energy, sodium, SAFA and sugars in food and beverage products, enabling mean population intakes to move closer to WHO nutrient guidelines.

Public Perception and Hand Hygiene Behavior During COVID-19 Pandemic in Indonesia

Hand hygiene practices are important not only during the corona virus disease 2019 (COVID-19) pandemic, but also critical to prevent the possible spread of other infectious diseases. This study aims to examine the current hand hygiene behaviors during the COVID-19 pandemic, post pandemic behavior intentions, and the relationship between behavior, psychosocial and contextual factors. A cross-sectional online survey was conducted from 28 May to 12 June 2020, with 896 valid responses obtained from Indonesian citizens over 18 years old. The survey questions included demographic characteristics, individual practices, risk perceptions, attitude, norm factors and ability factors related to hand hygiene during the COVID-19 pandemic. Descriptive analysis, chi square and multiple logistic regression tests were used to analyse the data. The results showed that 82.32% of female respondents and 73.37% male respondents reported handwashing practice 8 times or more per day during COVID-19 pandemic. Participants who perceived themselves at higher risk of contracting SARS-CoV-2 (OR 7.08, 2.26-22.17), had less negative perception toward the practice (OR 1.93, 1.32-2.82), perceived handwashing as an effective preventive measure (OR 1.77, 1.23-2.54), were female (OR 1.71, 1.21-2.41), perceived a more supportive norm (OR 1.68, 1.15-2.44) and noticed more barriers in access to handwashing facilities (OR 1.57, 1.05-2.36) were more likely to engage in hand hygiene practice more frequently during the pandemic. In conclusion, the majority of respondents did increase their frequency of hand hygiene practices during COVID-19 pandemic. In line with previous studies in other pandemic contexts, sex, perceived susceptibility and effectiveness are important predictors of hand hygiene practices, which are similar to findings from previous studies in other pandemic contexts. Addressing social norm related to the perceived hand hygiene practices of friends and important people is a potential health promotion strategy by creating hand hygiene norms in the community.

Role of Traditional Ethnobotanical Knowledge and Indigenous Communities in Achieving Sustainable Development Goals

The sustainable development goals (SDGs) are a set of 17 goals with 169 targets. The Agenda 2030 of the United Nations envisages a holistic approach to achieve these goals by focusing on humankind and the planet. In this review, we analyzed the scientific literature and technical reports of international bodies such as the United Nations and Food and Agriculture Organization relating to traditional ethnobotanical knowledge (TEK). The literature on TEK was mapped with the targets of the SDGs to determine the role of traditional knowledge in the realization of selected goals and targets. Our extensive and systematic reviewing of available literatures suggests that, of the 17 goals, at least seven goals are associated with TEK. To achieve these seven goals, a thorough understanding is required to disentangle the intricacies involving TEK, indigenous people holding TEK, and their future role in achieving the SDGs. Our review points towards the role of TEK in achieving goals linked to poverty, health and wellbeing, responsible consumption and production, climate action, life on land, and partnerships. In summary, we argue that achieving the intended outcomes of the SDGs and the targets requires concerted efforts of all relevant stakeholders, including indigenous communities, common citizens, scientists, policy makers, and world leaders.

Specialized Nutritious Food Combined With Cash Transfers and Social and Behavior Change Communication to Prevent Stunting Among Children Aged 6 to 23 Months in Pakistan: Protocol for a Cluster Randomized Controlled Trial

Background

In Pakistan, the prevalence of stunting in children younger than 5 years has remained above global critical levels over the past two decades, with the stunting rate being 40.2% in 2018. Children living in rural areas and in the poorest households suffer the most from stunting across the country—43.2% in rural areas and 51.4% in the lowest wealth quintile. As a continuing public health concern, it is essential that stunting prevention is a national priority in order to ensure human capital development, especially among the poorest households.

Objective

The primary objective of this study is to determine the effect of a medium quantity of a lipid-based nutrient supplement (LNS) combined with unconditional cash transfers and social and behavior change communication (SBCC) on reduction of stunting in children aged 6 to 23 months.

Methods

A 5-arm cluster randomized controlled trial will be conducted in the district of Rahim Yar Khan in Punjab, Pakistan. The intervention packages will be (1) cash only, (2) cash with LNS, (3) cash with SBCC, and (4) cash with SBCC and LNS. The control arm will receive routine standard of care. We will enroll children at 6 months of age and follow up on a monthly basis up to 24 months of age. A total of 2000 children, 400 in each arm, will be enrolled to detect a 20% reduction in the prevalence of stunting among children aged 24 months. Length, weight, food intake, compliance to interventions, morbidities, and other relevant data will be collected at enrollment and on a monthly basis over the period of 18 months. The process evaluation will assess acceptability of the interventions and potential barriers to implementation through focus group discussions and in-depth interviews with the target population and relevant stakeholders. Furthermore, a cost analysis will be conducted to assess the cost-effectiveness of each intervention package.

Results

The study protocol was approved by the Ethics Review Committee of Aga Khan University in Pakistan on January 4, 2017. Data collection began in May 2017 and was completed in July 2019. Data analyses are yet to be completed. This study will explore the effectiveness of intervention packages comprised of cash transfers from Benazir Income Support Programme with or without additional LNS and SBCC in preventing childhood stunting. We expect the results to be published in peer-reviewed journals by autumn of 2020.

Conclusions

The findings of this trial will provide robust evidence as to which intervention packages can have significant effects on linear growth of children and design effective intervention packages to prevent stunting in children aged 6 to 23 months.

Trial Registration

ClinicalTrials.gov NCT03299218; https://clinicaltrials.gov/ct2/show/NCT03299218

International Registered Report Identifier (IRRID)

DERR1-10.2196/19001

Health Competency Standards in Physical Therapist Practice

Although the physical therapist profession is the leading established, largely nonpharmacological health profession in the world and is committed to health promotion and noncommunicable disease (NCD) prevention, these have yet to be designated as core physical therapist competencies. Based on findings of 3 Physical Therapy Summits on Global Health, addressing NCDs (heart disease, cancer, hypertension, stroke, diabetes, obesity, and chronic lung disease) has been declared an urgent professional priority. The Third Summit established the status of health competencies in physical therapist practice across the 5 World Confederation for Physical Therapy (WCPT) regions with a view to establish health competency standards, this article's focus. Three general principles related to health-focused practice emerged, along with 3 recommendations for its inclusion. Participants acknowledged that specific competencies are needed to ensure that health promotion and NCD prevention are practiced consistently by physical therapists within and across WCPT regions (ie, effective counseling for smoking cessation, basic nutrition, weight control, and reduced sitting and increased activity/exercise in patients and clients, irrespective of their presenting complaints/diagnoses). Minimum accreditable health competency standards within the profession, including use of the WCPT-supported Health Improvement Card, were recommended for inclusion into practice, entry-to-practice education, and research. Such standards are highly consistent with the mission of the WCPT and the World Health Organization. The physical therapist profession needs to assume a leadership role vis-à-vis eliminating the gap between what we know unequivocally about the causes of and contributors to NCDs and the long-term benefits of effective, sustained, nonpharmacological lifestyle behavior change, which no drug nor many surgical procedures have been reported to match.

Dietary Intake and Beliefs of Pregnant Women with Gestational Diabetes in Cape Town, South Africa

This study investigated the dietary intake of pregnant women with gestational diabetes mellitus (GDM) and their beliefs relating to the consumption of fruits and vegetables (F&V) and sugary foods and drinks. A cross-sectional study was conducted on 239 pregnant women with GDM in Cape Town. Dietary intake was assessed using a quantified Food Frequency Questionnaire and beliefs relating to food choices were assessed using the Theory of Planned Behaviour (TPB). The mean energy intake was 7268 KJ, carbohydrate was 220 (±104.5) g, protein 60.3 (±27.5) g and fat 67.7 (±44.2) g. The macronutrient distribution was 55% carbohydrates, 14.5% protein and 30.5% fat of total energy. The majority of the sample had inadequate intakes of vitamin D (87.4%), folate (96.5%) and iron (91.3%). The median (IQR) amount of added table sugar and sugar sweetened beverages (SSBs) was 4.0 (0.00–12.5) g and 17.9 (0.0–132.8) mL per day, respectively. Only 31.4% met the recommendation (400 g per day) for F&V. Beliefs that it was not easy to exclude sugary foods/drinks and that knowing how to control cravings for sugary foods/drinks are areas to target messages on the sugar content of SSBs. In conclusion, the dietary intake of these women was not optimal and fell short of several nutritional guidelines for pregnant women with hyperglycaemia. The strongly held beliefs regarding sugary foods/drinks may contribute to poor adherence to nutritional guidelines among pregnant women with GDM in South Africa.

Associations of multidimensional health literacy with reported oral health promoting behaviour among Slovak adults: a cross-sectional study

BACKGROUND

Modification of health literacy (HL) is an important factor for improving and maintaining oral health. The aim of the study is to examine the association of HL with oral health-promoting behaviour (OHPB) and assess possible mediating effects of HL on the impact of socioeconomic status on OHPB.

METHODS

A cross-sectional questionnaire survey on the Slovak general adult population (N = 360, mean age 39) was conducted in 2014 and 2015. The association of HL (9 domains of the Health Literacy Questionnaire) and OHPB was analysed using logistic regression models adjusted for gender, age and educational level. Testing the mediating effect of HL domains between education attainment and OHPB was performed using the Sobel test.

RESULTS

Women and respondents with higher education reported better OHPB. Regular tooth-brushing is associated with better HL in five domains: Feeling understood and supported by healthcare provider, Having sufficient information to manage my health, Activelymanaging my health, Social support for health, Appraisal of health information (Odds ratios (ORs) from 1.64 to 2.33, p < 0.05). Using interdental tools is in association with better HL in two domains: Feeling understood and supported by a healthcare provider and Having sufficient information to manage my health (ORs 1.71 to 1.80, p < 0.05). Respondents who visited a dentist for prevention score higher in Social support for health (OR 1.79, p < 0.05). Using a tongue scraper and single brush and reporting gums bleeding is notstatistically significantly associated with HL. Mediation was confirmed between the effect of respondents' education on using fluoride toothpaste - mediated respondent's ability to find good health information. Frequency of tooth-brushing and using interdental hygiene aids were both mediated by patient's sufficient information to manage health.

CONCLUSIONS

Our results indicate HL to be an important factor related to good oral health, and HL should be considered when planning oral health interventions.

Protozoan Parasites in Drinking Water: A System Approach for Improved Water, Sanitation and Hygiene in Developing Countries

Improved water, sanitation and hygiene (WASH) are significant in preventing diarrhea morbidity and mortality caused by protozoa in low- and middle-income countries. Due to the intimate and complex relationships between the different WASH components, it is often necessary to improve not just one but all of these components to have sustainable results. The objective of this paper was to review the current state of WASH-related health problems caused by parasitic protozoa by: giving an overview and classification of protozoa and their effect on people's health, discussing different ways to improve accessibility to safe drinking water, sanitation services and personal hygiene behavior; and suggesting an institutional approach to ensure improved WASH. The findings indicate that Giardia and Cryptosporidium are more often identified during waterborne or water-washed outbreaks and they are less sensitive than most of the bacteria and viruses to conventional drinking water and wastewater treatment methods. There are various institutions of control and prevention of water-related diseases caused by protozoa in developed countries. Unfortunately, the developing regions do not have comparable systems. Consequently, the institutional and systems approach to WASH is necessary in these countries.

Diversifying Food Systems in the Pursuit of Sustainable Food Production and Healthy Diets

Increasing demand for nutritious, safe, and healthy food because of a growing population, and the pledge to maintain biodiversity and other resources, pose a major challenge to agriculture that is already threatened by a changing climate. Diverse and healthy diets, largely based on plant-derived food, may reduce diet-related illnesses. Investments in plant sciences will be necessary to design diverse cropping systems balancing productivity, sustainability, and nutritional quality. Cultivar diversity and nutritional quality are crucial. We call for better cooperation between food and medical scientists, food sector industries, breeders, and farmers to develop diversified and nutritious cultivars that reduce soil degradation and dependence on external inputs, such as fertilizers and pesticides, and to increase adaptation to climate change and resistance to emerging pests.

Effective nutrition education and communication for sustainable maternal and child health

Maternal and child health (MCH) consists of an interdependent reproductive system that collectively determines the survival of the mother during childbirth, and determines the health and survival of the child. This interdependency underscores the importance of appropriate and timely interventions during pregnancy through the first 1000 d at the minimum. The Millennium Development Goals (MDG) recommended the use of the continuum of care for the development of interventions by addressing all the stages of MCH. The purpose of the present paper is to review the factors that contributed to the attainment of the MDG 4 and MDG 5 by analysing the interventions conducted by the countries that achieved at least 5·0 and 5·5 %, respectively, and determine the level of their intervention based on the MCH conceptual framework. Out of the eighteen selected countries discussed, fifteen countries achieved their target for either MDG 4 or MDG 5 or both, while three countries did not achieve their target. The countries that were more likely to achieve their targets addressed the societal, underlying and direct causes, and implemented country wide policies. In contrast, the countries that did not succeed were more likely to address the direct causes with poor policy implementation. Understanding the motivation and limitations of the target population, including nutrition education and targeting behaviour change has the potential to result in sustainable MCH. This information has the potential to enlighten the policymakers as we progress to the sustainable development goals, specifically goals 2 and 3.

Raising the Priority of Lifestyle-Related Noncommunicable Diseases in Physical Therapy Curricula

Given their enormous socioeconomic burdens, lifestyle-related noncommunicable diseases (heart disease, cancer, chronic lung disease, hypertension, stroke, type 2 diabetes mellitus, and obesity) have become priorities for the World Health Organization and health service delivery systems. Health care systems have been criticized for relative inattention to the gap between knowledge and practice, as it relates to preventing and managing noncommunicable diseases. Physical therapy is a profession that can contribute effectively to patients'/clients' lifestyle behavior changes at the upstream end of prevention and management. Efforts by entry-to-practice physical therapist education programs to align curricula with epidemiological trends toward best health care practices are varied. One explanation may be the lack of a frame of reference for reducing the knowledge translation gap. The purpose of this article is to provide a current perspective on epidemiological indicators and societal priorities to inform physical therapy curriculum content. Such content needs to include health examination/evaluation tools and health behavior change interventions that are consistent with contemporary values, directions, and practices of physical therapy. These considerations provide a frame of reference for curriculum change. Based on 5 years of experience and dialogue among curriculum stakeholders, an example of how epidemiologically informed and evidence-based best health care practices may be systematically integrated into physical therapy curricula to maximize patient/client health and conventional physical therapy outcomes is provided. This novel approach can serve as an example to other entry-to-practice physical therapist education programs of how to align their curricula with societal health priorities, specifically, noncommunicable diseases. The intentions are to stimulate dialogue about effectively integrating health-based competencies into entry-level education and advancing best practice, as opposed to simply evidence-based practice, across professions and health services and to establish accreditable, health promotion practice standards for physical therapy.

Reducing salt in food; setting product-specific criteria aiming at a salt intake of 5 g per day

Background/Objectives:

There is an increasing public health concern regarding high salt intake, which is generally between 9 and 12 g per day, and much higher than the 5 g recommended by World Health Organization. Several relevant sectors of the food industry are engaged in salt reduction, but it is a challenge to reduce salt in products without compromising on taste, shelf-life or expense for consumers. The objective was to develop globally applicable salt reduction criteria as guidance for product reformulation.

Subjects/Methods:

Two sets of product group-specific sodium criteria were developed to reduce salt levels in foods to help consumers reduce their intake towards an interim intake goal of 6 g/day, and—on the longer term—5 g/day. Data modelling using survey data from the United States, United Kingdom and Netherlands was performed to assess the potential impact on population salt intake of cross-industry food product reformulation towards these criteria.

Results:

Modelling with 6 and 5 g/day criteria resulted in estimated reductions in population salt intake of 25 and 30% for the three countries, respectively, the latter representing an absolute decrease in the median salt intake of 1.8–2.2 g/day.

Conclusions:

The sodium criteria described in this paper can serve as guidance for salt reduction in foods. However, to enable achieving an intake of 5 g/day, salt reduction should not be limited to product reformulation. A multi-stakeholder approach is needed to make consumers aware of the need to reduce their salt intake. Nevertheless, dietary impact modelling shows that product reformulation by food industry has the potential to contribute substantially to salt-intake reduction.

Sustaining Behavior Changes Following a Venous Leg Ulcer Client Education Program

Venous leg ulcers are a symptom of chronic insufficiency of the veins. This study considered the sustainability of behavior changes arising from a client focus e-Learning education program called the “Leg Ulcer Prevention Program” (LUPP) for people with a venous leg ulcer. Data from two related studies were used to enable a single sample (n = 49) examination of behavior maintenance across an average 8 to 9 months period. Physical activity levels increased over time. Leg elevation, calf muscle exercises, and soap substitute use were seen to fluctuate over the follow up time points. The use of a moisturizer showed gradual decline over time. The provision of a client-focused venous leg ulcer program was associated with behavior changes that had varied sustainability across the evaluation period.

A common evaluation framework for the African Health Initiative

BACKGROUND

The African Health Initiative includes highly diverse partnerships in five countries (Ghana, Mozambique, Rwanda, Tanzania, and Zambia), each of which is working to improve population health by strengthening health systems and to evaluate the results. One aim of the Initiative is to generate cross-site learning that can inform implementation in the five partnerships during the project period and identify lessons that may be generalizable to other countries in the region. Collaborators in the Initiative developed a common evaluation framework as a basis for this cross-site learning.

METHODS

This paper describes the components of the framework; this includes the conceptual model, core metrics to be measured in all sites, and standard guidelines for reporting on the implementation of partnership activities and contextual factors that may affect implementation, or the results it produces. We also describe the systems that have been put in place for data management, data quality assessments, and cross-site analysis of results.

RESULTS AND CONCLUSIONS

The conceptual model for the Initiative highlights points in the causal chain between health system strengthening activities and health impact where evidence produced by the partnerships can contribute to learning. This model represents an important advance over its predecessors by including contextual factors and implementation strength as potential determinants, and explicitly including equity as a component of both outcomes and impact. Specific measurement challenges include the prospective documentation of program implementation and contextual factors. Methodological issues addressed in the development of the framework include the aggregation of data collected using different methods and the challenge of evaluating a complex set of interventions being improved over time based on continuous monitoring and intermediate results.