Strategies for Mitigating Vitamin A Deficiency in Mekelle, Ethiopia

The fourth United Nations Millennium Development Goal (MDG) is to reduce worldwide child mortality by two-thirds. In the impoverished African country of Ethiopia, child mortality has declined from 123 per 1,000 in 2004/2005 to 88 per 1,000 in 2011/2012 (World Bank, 2013). Yet the rate remains alarmingly high. Micronutrient deficiencies (including iron, zinc, and vitamin A) are contributing to the worldwide child mortality rate. Vitamin A deficiency is one of the most common micronutrient. Between 250,000 and 500,000 children with vitamin A deficiency become blind each year. Within 12 months of becoming blind, half of these children die (World Health Organization (WHO), n.d.). The WHO supports three types of solutions to eliminate vitamin A deficiency; supplementation, dietary diversification, and food fortification. Worldwide, supplementation is the most common practice for providing micronutrients to communities. However, this practice is successful in mainly urban communities and excludes 45% of children around the world. Supplementation programs alone are not fiscally sustainable (Golden Rice Project, 2012). A study by Mekelle University public health faculty concluded vitamin A capsules are a short-term life saving intervention and a transition towards sustainable food-based interventions is needed. Additionally, an intervention to serve the diets of low-income individuals as well as the urban population is crucial (Kidane, Abegaz, Mulugeta, Singh, 2013). In order to fulfill the practicum requirement for the graduate program in public health, Erika Strehl traveled to Mekelle, Ethiopia in June 2014. The objective of this project was to investigate strategies used for mitigating vitamin A deficiency within the Mekelle community. Specific learning objectives included identifying organizations working toward eliminating vitamin A deficiency, classifying the type of project (supplementation, food fortification, dietary diversification), exploring the current and potential barriers within these projects, identifying the gaps in education and supplementation, and identifying communities not receiving education or supplementation. Supplementation of Vitamin A is provided by the Health Extension Workers (HEW), which is a recent program established by the Ethiopian government. The HEW’s are the primary distributors for vitamin A and iron supplements. Infants receive a vitamin A supplement every six months at the Health Post and it is the responsibility of the mother return every six months. Each year thousands of HEW’s are trained to treat various medical problems such as burns, cuts, maternal health, and malnutrition. Food fortification in Mekelle is in the initial stages of implementation, Ethiopia is one of four countries in Africa without a legal food fortification program (Head, Getachew, 2014). The Ministry of Health has appointed a task force to investigate the use of food fortification and potentially propose a legislation to legalize food fortification. A Fulbright Scholar (Ms. Head) collaborated with the Chemistry department at Mekelle University to create technology for food fortification. Currently, there is a lack of locally available technology to fortify food and what is available is currently imported from other countries, which is accompanied by high import duties and a value added tax (VAT) of 15%. Producing the technology in Ethiopia would alleviate the financial burden of importation. Ms. Head worked with local manufacturers to design and build equipment that would be replicable and cost effective. For the past fourteen years Mums for Mums, a local non-governmental organization, has educated women on the importance of dietary diversification. Mums for Mums assists homeless women to learn income generating and life skills to become self-reliant. Food preparation training is accompanied by nutrition demonstrations, which focuses on locally available and highly nutritional food, such as the sweet potato. One cup of the boiled sweet potato everyday satisfies the requirement for vitamin A. Women are instructed how to incorporate the sweet potato into meals to provide a balanced diet for their families. The sweet potato is widely available in Ethiopia and not expensive (Asmelash, personal communication, June 2014). Mekelle currently satisfies the three suggested strategies from the WHO, yet these programs work in isolation from each other. There is a lack of communication and information sharing between the aforementioned programs. With a heavy reliance on supplementation, a shift towards preventive strategies such as nutrition education is a crucial element needed to decrease the prevalence of vitamin a deficiency

Assessing the Integrity of Motivational Interviewing Interventions: Reliability of the Motivational Interviewing Skills Code

The motivational interviewing skills code (MISC) was used to review 86 audiotaped interactions between clinicians and patients participating in a smoking cessation intervention. Intraclass correlations (ICCs) were completed for two of the MISC elements: global evaluations and behavior counts. Results indicate 75% of the global ratings yielded ICCs in the good to excellent range, while only 44% of the behavior counts yielded this level of accuracy. Adherence scores were created to form overall ratings of clinician adherence to using motivational interviewing and 80% of these competence measures yielded ICCs in the good to excellent range. Specific recommendations regarding modifications for the MISC are suggested based on the data presented

Adaptation of a Lay Health Advisor Model as a Recruitment and Retention Strategy in a Clinical Trial of College Student Smokers

This study describes and provides results from a process evaluation of a lay health advisor (LHA) model to enhance participation in a clinical trial of the effectiveness of motivational interviewing on smoking cessation in college fraternity and sorority members. The implementation of the model had two phases: (a) the selection and training of LHAs as liaisons between research staff and participants and (b) LHAs’ roles in recruitment and retention. Perceptions of the LHA model were explored using survey questionnaires. Trial participants (N = 118) and LHAs (N = 8) were generally satisfied with the model and identified LHAs as helpful to participation. Seventy-four percent of chapter members were screened and 73% of participants received three of the four motivational interviewing sessions. These results indicate the LHA model was well received and met the needs of the research project

Utilizing community-based participatory research strategies to determine intervention strategies for childhood obesity prevention in a community on a Native American Reservation

Childhood obesity is a complex public health issue that impacts physical and psychological health, academic success and future health outcomes. As of 2012, nearly 17% of children and adolescents in the United States were classified as obese, and the rate is approximately 10% higher for children of color than it is for white children.[1] The intricacies associated with childhood obesity suggest a community-based approach may be necessary to achieve measurable and sustainable reductions in childhood obesity. To determine initial intervention strategies for addressing childhood obesity in one community (population ~25% Native American) on a Native American Reservation in the Northwestern United States, this study utilized the Community Readiness key informant interview approach[2] from Colorado State University. Six key informants were selected at random and interviewed by members of a community-university partnership. These informants were selected from five randomly selected community sectors in addition to a preselected community member sector. The six interviews were then conducted using a standardized questionnaire, one via telephone and five in person. Each interview was audio recorded and members of the research team summarized responses into text, which was used for scoring. Three coders followed the anchored scoring protocol in the Colorado State University Community Readiness Manual to score each interview across six dimensions. Each dimension was assigned a numeric score ranging from 1 to 9, with 1 indicating little readiness and 9 indicating very high readiness. The six dimensions coded were: community efforts, community knowledge of efforts, leadership, community climate, knowledge about the issue, and resources for prevention efforts. Once each of the six interviews was independently scored, the three scorers met to determine consensus scores for each of the dimensions. To determine the inter-rater reliability, the codes from each of the raters were compared to each other, and additionally compared to the consensus score by calculating both exact agreement and near agreement (+/- 1 score). Three researchers, one from the Reservation community, a faculty member who has previously worked with the Reservation community, and a graduate student new to the community, scored each of the six interviews. Agreement was defined as the number of agreements divided by the number of agreements plus disagreements between raters. The faculty member and the student, and the community member and the student both shared the highest rate of exact agreement (50%), followed by the faculty member and the community member (47%). The exact agreement with the consensus score was highest with the community member (72%), followed by the student (61%) and the faculty member (56%). Calculating the percent agreement using adjacent categories, with the threshold for agreement being within +/-1, it was found that the highest agreement was between the community and faculty member (92%), followed by the community member and student (89%). The faculty member and student had the lowest level of agreement (78%). Levels of agreement with the consensus score and coders also varied, with the highest level agreement found by the community member (97%) and student (97%), followed by the faculty member (89%). Researchers explored different methods to assess rater agreement in scoring the interviews. Results suggest that the exact agreement method yielded low agreement scores, but agreement was considerably higher when using the adjacent category method. The adjacent category method may be sufficient given the goal of the community readiness process is to identify potential candidate interventions that will ultimately be further discussed by community members. The Community Readiness key informant interview process is one way to assess the community’s readiness to address childhood obesity and assist with the selection of intervention strategies. Based on direction from the project’s Advisory Board, the interview process may be replicated in additional communities to determine how to best implement childhood obesity strategies in each community. While the data have not been released for analysis, the process of key informant interviews suggested changes that may improve future iterations of the assessment of community readiness for childhood obesity interventions. [1] Ogden, C. L., Carroll, M. D., Kit, B. K., & Flegal, K. M. (2014, February 26). Prevalence of childhood and adult obesity in the United States, 2011-2012 [Electronic version]. Journal of the American Medical Association, 311(8), 1-9. [2] Plested, B. A., Jumper-Thurman, P., & Edwards, R. W. (2009). Community Readiness Manual. Fort Collins, CO: Colorado State University. Funding statement: Research reported in this publication was supported by the Eunice Kennedy Shriver National Institute Of Child Health & Human Development of the National Institutes of Health under Award Number R13HD080904. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health

Assessing other children in the household support of exercise and healthy eating

Childhood obesity is on the rise throughout the world. Overweight/obesity in childhood is a major risk factor for serious health consequences (Patchucki, Lovenheim, Harding, 2014). The family unit can address childhood obesity when the family works together to support each other in physical activity (PA) and healthy eating decisions. Sibling support may be particularly important due to the amount of time siblings spend with each other. Siblings’ impact on informal social behavior may be a more powerful motivator compared to formal parenting norms (Patchucki, Lovenheim, Harding, 2014). Having an obese younger sibling creates a five times greater likelihood the older sibling will be obese (Patchucki, Lovenheim, Harding, 2014), thus, interventions aimed at siblings may be particularly effective. The literature suggests this is an understudied topic in need of attention. During February 2015, 22 families from a Boys and Girls Club participated in a 2 week pilot study testing an intervention designed to improve PA and healthy eating within family units. Families were randomly assigned to a treatment group (n=12 families and 20 children) or a measurement-only control group (n=12 families and 15 children). Children in the treatment group participated in 40 minutes of PA and 20 minutes of nutrition education during after school time. Three times a week program staff distributed take home cards to parents that described an exercise or nutrition activity to complete as a family. Families also participated in family night and parents participated in a nutrition educational session. Researchers developed a quantitative survey to assess sibling support by modifying the Coordinated Approach to Child Health questionnaire that was designed to measure parent and friend support for healthy eating and exercise (Nadar, Stone, Perry, Osganian, Kelder et al, 1999). The survey contained 10 questions on PA and nutrition by querying children about the support of other children in their household (i.e., “When I am active, other children in my house smile and cheer for me.”). The three response options were “almost never/never,” “sometimes,” and “almost always/ always.” Other children in the house were defined as brothers, sisters, stepbrothers, stepsisters, cousins or other children that live with the family. Child participants (age 6-11) completed the survey at baseline (pretest) and at the end of the 2-week intervention (posttest). Scores will be added to give an overall score. Changes from baseline to posttest will be compared across treatment groups. Data are expected to be released for dissemination prior to the conference so that the results can be presented. In addition, the process of pilot testing this measure 68 times suggested changes that may improve future iterations of this assessment of sibling support. It would be beneficial to add a question asking if there are other children in the house. Assessing the quality of the sibling relationship could be considered using the Sibling Relationship Questionnaire (SRQ) (Leeuw, Snoek, Leeuwe, Strien, 2007), a higher SRQ score signifies better sibling relationship. The quality of the sibling’s relationship may impact how support for healthy choices is received within the sibling group. Children are prone to picking the extreme answer on a questionnaire based on their current emotional state (Chambers, Johnston, 2002). Thus, it may be beneficial to change the answer choices from “never or almost never” to “almost never” and “always or almost always” to “always” to avoid extreme answers. Siblings participate in PA and mealtime together on a regular basis (Patchucki, Lovenheim, Harding, 2014). This new assessment provides a first step in measuring sibling support for PA and healthy eating. Understanding how siblings can positively influence one another to promote healthy choices may help reduce risk factors for childhood obesity

Community-identified strategies to increase physical activity during elementary school recess on an American Indian reservation: A pilot study

AbstractThe aim of this study was to determine the effect of an 8-week recess intervention on physical activity levels in children attending elementary school on an American Indian reservation during fall 2013.Physical activity was measured with direct observation in three zones on the playground. Lines were painted on existing pavement in zone 1. Zone 2 had permanent playground equipment and was unchanged. Zone 3 contained fields where bi-weekly facilitators led activities and provided equipment. Pre- to post-changes during recess in sedentary, moderate physical activity, moderate-to-vigorous, and vigorous physical activities were compared within zones.Females physical activity increased in Zone 1 (moderate: 100% increase; moderate-to-vigorous: 83%; vigorous: 74%, p<0.01 for all) and Zone 3 (moderate: 54% increase, p<0.01; moderate-to-vigorous: 48%, p<0.01; vigorous: 40%, p<0.05). Male sedentary activity decreased in Zone 2 (161%, p<0.01). Physical activity changes in Zone 3 were not dependent upon the presence of a facilitator.Simple and low-cost strategies were effective at increasing recess physical activity in females. The findings also suggest that providing children games that are led by a facilitator is not necessary to increase physical activity as long as proper equipment is provided

Adherence to Principles of Motivational Interviewing and Client Within-Session Behavior

The purpose of this study was to examine whether counselor adherence to Motivational Interviewing (MI) principles was associated with more productive within-session client behavior in a smoking cessation trial for African American smokers. For these analyses 89 baseline counseling sessions of the trial were audiotaped and coded using the Motivational Interviewing Skill Code (MISC). Counselor adherence indicators included a global subjective rating of MI adherence and the frequency of MI-consistent and MI-inconsistent counselor behaviors described in the MISC. Indicators of productive client behaviors included global subjective ratings of within-session client functioning and counselor-client interaction, as well as the frequency of statements by the client favorable toward changing behavior (“change talk”) and resistant regarding changing behavior (“resist-change talk”). Results provided support for the principles of MI. Counselor adherence indexed by both the global subjective rating and MI-consistent behavior frequency was significantly positively associated with global ratings of within-session client functioning and counselor-client interaction, as well as more change talk

Physical Activity Intervention Adaptation: Recommendations from Rural American Indian Older Adults

Preventive interventions are critical to improving health equity among American Indian (AI) populations, yet interventions that promote physical activity (PA) among AI populations are scarce. This research addresses the research-to-practice gap by informing the adaption and implementation process of evidence-based interventions (EBIs) among rural AI older adults. We used a community-based approach and an Indigenous-focused adaptation theoretical framework. Qualitative, semi-structured interviews elicited detailed information on preferences for PA intervention among rural AI older adults. We applied a collaborative directed content analysis strategy, and established trustworthiness and relevance using an inter-rater reliability process and member checking. We conducted 21 interviews, all participants identified as AI, the mean age was 66 years (SD = 7.6), and 57% were female. Themes characterized contextual and cultural intervention considerations for adapting and implementing evidence-based PA interventions in rural AI older adults. Key findings included an emphasis on social and community interaction, strategies for targeted engagement, preference for group format, pairing PA sessions with shared meals, and inclusiveness in the PA intervention across ability levels and age groups. This study identified opportunities for adaptation of PA-focused EBIs among rural AI older adults. Findings can be applied to support the adaptation and implementation of effective and relevant PA-focused preventive interventions among this population which is at high risk for chronic disease and health disparities.Ye