Implementation of a salt substitute intervention using social marketing in resourced-limited communities in Peru: a process evaluation study

Objective

This study aimed to conduct a process evaluation of a salt substitute trial conducted in Peru.

Methods

Through semi-structured interviews of intervention participants, we documented and analyzed process evaluation variables as defined by the Medical Research Council Framework. This study was a stepped wedge trial conducted in Tumbes, Peru in 2014. The intervention was a community-wide replacement of regular salt (100% sodium) with "Salt Liz" (75% sodium and 25% potassium) using social marketing strategies to promote the adoption and continued use of the salt substitute in daily life. The components of the social marketing campaign included entertainment educational activities and local product promoters ("Amigas de Liz"). Another component of the intervention was the Salt Liz spoon to help guide the amount of salt that families should consume. The process evaluation variables measured were the context, mechanism of action, and implementation outcomes (acceptability, fidelity and adoption, perceptions, and feedback).

Results

In total, 60 women were interviewed, 20 with hypertension and 40 without hypertension. Regarding context, common characteristics across the four villages included residents who primarily ate their meals at home and women who were responsible for household food preparation. As the mechanism of action, most participants did not notice a difference in the flavor between regular salt and Salt Liz; those that did notice a difference took around 2 weeks to become accustomed to the taste of the salt substitute. In terms of implementation outcomes, the Salt Liz was accepted by villagers and factors explaining this acceptability included that it was perceived as a "high quality" salt and as having a positive effect on one's health. Participants recognized that the Salt Liz is healthier than regular salt and that it can help prevent or control hypertension. However, most participants could not accurately recall how the compositions of the Salt Liz and regular salt differed and the role they play in hypertension. Although the use of the Salt Liz was far-reaching at the community level, the use of the Salt Liz spoon was poor. Educational entertainment activities were well-received, and most participants enjoyed them despite not always being active participants but rather sideline observers.

Conclusion

This process evaluation identifies key intervention components that enabled a successful trial. Seeking and incorporating feedback from the target population helps deepen the understanding of contextual factors that influence an intervention's success. Furthermore, feedback received can aid the development of the intervention product. Some factors that can be improved for future interventions are acknowledged.

Clinical trial registration

NCT01960972.

Sugar-sweetened beverage purchases in urban Peru before the implementation of taxation and warning label policies: a baseline study

BACKGROUND

Sugar-sweetened beverage consumption is associated with obesity and chronic disease. In 2018, Peru increased the tax on high-sugar beverages (≥6 g of sugar per 100 mL) from 17 to 25%, yet little is known about pre-existing beverage trends or demographic characteristics associated with purchases in the country. The aim of this study was to explore beverage purchasing trends from 2016 to 2017 and examine variation in purchase volume by sociodemographic characteristics among urban households in Peru.

METHODS

This study used monthly household purchase data from a panel of 5145 households from January 2016-December 2017 from Kantar WorldPanel Peru. Beverage purchases were categorized by type and tax status under the 2018 regulation (untaxed, lower-sugar taxed, high-sugar taxed). To assess beverage purchasing trends, per-capita volume purchases were regressed on a linear time trend, with month dummies for seasonality and clustered standard errors. Mean volume purchases by beverage tax status (total liters purchased per month), overall and by key demographic characteristics (education, socioeconomic status, and geographic region), were calculated. Mean volume by beverage type was assessed to identify the largest contributors to total beverage volume.

RESULTS

The trends analysis showed a decline in total beverage volume of - 52 mL/capita/month (95% CI: - 72, - 32) during the 24-month study period. Over 99% of households purchased untaxed beverages in a month, while > 92% purchased high-sugar taxed beverages. Less than half of all households purchased low-sugar taxed beverages in a month and purchase volume was low (0.3 L/capita/month). Untaxed beverage purchases averaged 9.4 L/capita/month, while households purchased 2.8 L/capita/month of high-sugar taxed beverages in 2017. Across tax categories, volume purchases were largest in the high education and high socioeconomic (SES) groups, with substantial variation by geographic region. The highest volume taxed beverage was soda (2.3 L/capita/month), while the highest volume untaxed beverages were milk and bottled water (1.9 and 1.7 L/capita/month, respectively).

CONCLUSIONS

Nearly all households purchased high-sugar taxed beverages, although volume purchases of taxed and untaxed beverages declined slightly from 2016 to 2017. Households with high SES and high education purchased the highest volume of taxed beverages, highlighting the need to consider possible differential impacts of the tax policy change by sub-population groups.

Characteristics Associated With Antihypertensive Treatment and Blood Pressure Control: A Population-Based Follow-Up Study in Peru

BACKGROUND

Over one-quarter of the world's adult population has hypertension, yet achieving adequate treatment or control targets remains a challenge.

OBJECTIVE

This study sought to identify, longitudinally, characteristics associated with antihypertensive treatment and blood pressure (BP) control among individuals with hypertension.

METHODS

Data from individuals enrolled in the population-based CRONICAS Cohort Study (adults ≥35 years, living in 4 different rural/urban and coastal/high-altitude Peruvian settings) with hypertension at baseline were used. Antihypertensive treatment and BP control were assessed at baseline and at 15 months. Multinomial logistic regressions were used to estimate relative risk ratios (RRR) and 95% confidence intervals (95% CI) of factors associated with antihypertensive treatment and BP control at follow-up.

RESULTS

At baseline, among 717 individuals with hypertension (53% women, mean age 61.5 ± 12.4 years), 28% were unaware of their hypertension status, 30% were aware but untreated, 16% were treated but uncontrolled, and 26% were treated and controlled. At follow-up, 89% of unaware and 82% of untreated individuals persisted untreated, and only 58% of controlled individuals remained controlled. Positive predictors of receiving treatment and being controlled at follow-up included age (RRR: 0.81; 95% CI: 0.73 to 0.91 for every 5 years) and family history of a chronic disease (RRR: 0.53; 95% CI: 0.31 to 0.92 vs. no history); whereas Puno rural site (RRR: 16.51; 95% CI: 1.90 to 143.56 vs. Lima) and male sex (RRR: 2.59; 95% CI: 1.54 to 4.36) were risk factors. Systolic BP at baseline (RRR: 1.27; 95% CI: 1.16 to 1.39 for every 5 mm Hg) and male sex (RRR: 1.75, 95% CI: 1.02 to 2.98) were risk factors for being treated but uncontrolled at follow-up.

CONCLUSIONS

Large gaps in treatment of hypertension were observed. Targeting specific populations such as men, younger individuals, or those without family history of disease may increase coverage of antihypertensive treatment. Also, targeting male individuals or those with higher systolic BP could yield better rates of BP control in the short term.

Behaviour change strategies for reducing blood pressure-related disease burden: findings from a global implementation research programme

Background

The Global Alliance for Chronic Diseases comprises the majority of the world’s public research funding agencies. It is focussed on implementation research to tackle the burden of chronic diseases in low- and middle-income countries and amongst vulnerable populations in high-income countries. In its inaugural research call, 15 projects were funded, focussing on lowering blood pressure-related disease burden. In this study, we describe a reflexive mapping exercise to identify the behaviour change strategies undertaken in each of these projects.

Methods

Using the Behaviour Change Wheel framework, each team rated the capability, opportunity and motivation of the various actors who were integral to each project (e.g. community members, non-physician health workers and doctors in projects focussed on service delivery). Teams then mapped the interventions they were implementing and determined the principal policy categories in which those interventions were operating. Guidance was provided on the use of Behaviour Change Wheel to support consistency in responses across teams. Ratings were iteratively discussed and refined at several group meetings.

Results

There was marked variation in the perceived capabilities, opportunities and motivation of the various actors who were being targeted for behaviour change strategies. Despite this variation, there was a high degree of synergy in interventions functions with most teams utilising complex interventions involving education, training, enablement, environmental restructuring and persuasion oriented strategies. Similar policy categories were also targeted across teams particularly in the areas of guidelines, communication/marketing and service provision with few teams focussing on fiscal measures, regulation and legislation.

Conclusions

The large variation in preparedness to change behaviour amongst the principal actors across these projects suggests that the interventions themselves will be variably taken up, despite the similarity in approaches taken. The findings highlight the importance of contextual factors in driving success and failure of research programmes. Forthcoming outcome and process evaluations from each project will build on this exploratory work and provide a greater understanding of factors that might influence scale-up of intervention strategies.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0331-0) contains supplementary material, which is available to authorized users.

The cost of illness attributable to diabetic foot and cost-effectiveness of secondary prevention in Peru

BACKGROUND

Diabetes mellitus is a public health challenge worldwide, and roughly 25% of patients with diabetes in developing countries will develop at least one foot ulcer during their lifetime. The gravest outcome of an ulcerated foot is amputation, leading to premature death and larger economic costs.

METHODS

This study aimed to estimate the economic costs of diabetic foot in high-risk patients in Peru in 2012 and to model the cost-effectiveness of a year-long preventive strategy for foot ulceration including: sub-optimal care (baseline), standard care as recommended by the International Diabetes Federation, and standard care plus daily self-monitoring of foot temperature. A decision tree model using a population prevalence-based approach was used to calculate the costs and the incremental cost-effectiveness ratio (ICER). Outcome measures were deaths and major amputations, uncertainty was tested with a one-way sensitivity analysis.

RESULTS

The direct costs for prevention and management with sub-optimal care for high-risk diabetics is around US$74.5 million dollars in a single year, which decreases to US$71.8 million for standard care and increases to US$96.8 million for standard care plus temperature monitoring. The implementation of a standard care strategy would avert 791 deaths and is cost-saving in comparison to sub-optimal care. For standard care plus temperature monitoring compared to sub-optimal care the ICER rises to US$16,124 per death averted and averts 1,385 deaths.

CONCLUSION

Diabetic foot complications are highly costly and largely preventable in Peru. The implementation of a standard care strategy would lead to net savings and avert deaths over a one-year period. More intensive prevention strategies such as incorporating temperature monitoring may also be cost-effective.

Applying the Triangle Taste Test to Assess Differences between Low Sodium Salts and Common Salt: Evidence from Peru

Background

In resourced-constrained settings, daily cooking practices are still the norm. Replacing sodium in regular salt to produce potassium-enriched salts are potential alternative routes to reduce sodium intake, paired with the benefit associated with potassium intake. This change would likely have effects on palatability and taste of prepared foods, yet a threshold to discriminate sensorial changes can be determined. The main goal of this study was to assess if the use of potassium-enriched salt substitutes lead to perceived differences in taste utilizing a sensory discrimination test.

Methods and Results

A triangle taste test was conducted and participants were offered samples of cooked rice prepared with different salts. The only ingredient that differed in the preparation was the salt used: 100%NaCl (regular salt) and salts where sodium was replaced by 50%, 33% or 25% KCl (potassium-enriched salt). Comparisons were carried out according to the minimum number of correct judgments. A total of 156 subjects, 49% males, mean age 41.0 years (SD±15.5) years, participated in the study. Samples using 25% potassium-enrichment were indistinguishable in terms of taste from regular salt, whereas samples with 33% and 50% potassium-enrichment were distinguishable. Results were consistent when stratified by sex and age. Less than 10% of participants attributed the differences to bitterness or metallic flavor.

Conclusions

The 25% potassium-enriched salt is indistinguishable from regular salt. These findings suggest a potential to achieve sodium intake reduction strategies in cooking practices by substituting regular salt with potassium-enriched salt without affecting palatability.

Rapid implementation of new TB diagnostic tests: is it too soon for a global roll-out of Xpert MTB/RIF?

In 2011 the World Health Organization approved Xpert MTB/RIF for tuberculosis diagnosis and recommended its rapid implementation. Xpert MTB/RIF is accurate: sensitivity is 72.5 -98.2% (smear-negative and -positive cases, respectively) and specificity 99.2%. Benefits include same-day diagnosis and simultaneous detection of rifampicin resistance. However, the test has some shortcomings and has not had time for thorough evaluation. Cost-effectiveness studies are difficult to perform and few have been completed. Existing data suggest cost-effectiveness in some, but not all, settings. The urgent need for better diagnostics is evident. Yet, serial implementation of new technologies causes ineffective spending and fragmentation of services. How new tests are incorporated into existing diagnostic algorithms affects both outcomes and costs. More detailed data on performance, effect on patient-important outcomes, and costs when used with adjunct tests are needed for each setting before implementation. While awaiting further clarification it seems prudent to slow its implementation among resource-constrained tuberculosis control programs.