Development of a school-based health promotion intervention in Ecuadorian adolescents and its cluster randomised-controlled evaluation design

Driven by economic and societal changes, obesity levels and chronic diseases have surged in many low- and middle-income countries (LMICs) in recent years. An estimated 25% (51.8 million) of Latin American children and adolescents are considered overweight or obese. Poor dietary and physical activity (PA) behaviours fuel these developments. Considering their impact on overall health, well-being and quality of life, preventive actions and informed policies are needed to tackle chronic diseases effectively. Preventive interventions promoting a healthy diet and an active lifestyle are promising means of improving child and adolescent health, and curbing the rise of this disease burden. Most of the available evidence, however, originates from high-income countries (HICs). In addition, a number of key conceptual and methodological concerns hamper their potential to alleviate the disease burden of chronic diseases and obesity. This research targets school-going adolescents in Ecuador, a Latin American country with a high incidence of obesity and chronic diseases. The purpose of this research was to provide evidence at different levels of the systematic and stepwise planning and development processes of preventive interventions. In this context, a preventive school-based health promotion intervention, aiming to improve dietary and PA behaviours among 11 to 15-year old adolescents was developed as a case study. To facilitate the development of an intervention, existing evidence on the effectiveness of school-based obesity prevention interventions was evaluated using a systematic review. This review focused on interventions targeting dietary and/or PA behaviour in children and adolescents aged 6 to 18 years in LMICs. Most of the identified interventions (82%) had a positive effect on dietary and PA behaviour but few decreased Body Mass Index (BMI). Effective interventions targeted both diet and PA, involved multiple stakeholders, and integrated educational activities into the school curriculum. However, to reach their full potential, the current interventions need to address important methodological and conceptual issues. In general, more and better quality research is needed that examines contextual influences of PA and eating behaviours and uses theory, rigorous evaluation designs, valid evaluation tools and methods that are not prone to reporting bias. To address the latter, the validity and reliability of a PA record as a tool for PA measurement was evaluated in a sample of 302 adolescents. The PA record provided acceptable estimates for reliability and validity within a group and showed an overall fair measurement agreement for validity. There was modest reliability for assessing PA in each intensity level. Sex and setting were associated with better validity, whereas perceived difficulty in filling out the record was associated with better reliability estimates for low PA. Additional insights are needed into factors determining young adolescents’ food and PA choices to develop the intervention. Focus groups with adolescents, parents and school staff were conducted for this purpose. Financial autonomy, perceived food safety, lack of self-control, habit strength, changes in both the socio-cultural (increased workload, changed food patterns, new transport modes) and the built environment (traffic and crime perceptions, distances) were identified as culture-specific factors. Measures that recognise environmental changes are thus needed to complement health education activities. Interestingly, various factors differed between settings and socio-economic groups. As a consequence, two composite conceptual frameworks were proposed. Both conceptualised adolescent eating or PA behaviour as a function of the identified individual and environmental influences. The usefulness of a multi-level, interactive framework for understanding and explaining the drivers of dietary behaviour was also evaluated. The framework is a comprehensive and valid model that specified the inter-relationships of individual and environmental factors and their influence on key components of adolescents’ eating behaviour (i.e., sugary drink intake, breakfast intake, unhealthy snacking, and fruit and vegetable intake). The framework confirmed that factors varied with reference to the different components of eating behaviour and socio-economic status (SES) and provides valuable entry points for developing future interventions and contributes to the evidence-base of theory development in LMICs. Based on the above and using theory, local evidence and a participatory approach, a school-based health promotion intervention was developed. It involved a comprehensive, culturally-appropriate intervention package, with intervention strategies consisting of an individual classroom-based and environment-based (school and family level) component. A pair-matched cluster randomised-controlled trial was conducted in 20 schools (1430 adolescents) to assess effectiveness. An in-depth process evaluation was also carried out. Primary outcomes assessed were dietary and PA behaviour and their influencing factors. Secondary outcomes were anthropometric measurements including BMI and the prevalence of overweight and obesity in the adolescents. The transparent and stepwise planning provides clear and detailed insights into the processes of intervention development in LMICs. This will help identify both effective and ineffective intervention strategies, and subsequently allow for the replication, adoption and/or dissemination of the identified strategies in LMICs. In conclusion, this PhD research adds to the available evidence on health promotion interventions in the wider context of obesity and chronic diseases in LMICs. This work has resulted in further insights into the current evidence-base for preventive measures in schools in LMICs, validation studies for PA measures, and the identification and conceptualisation of influencing factors of adolescents’ dietary and PA behaviours. It also delivers detailed information on the systematic processes associated with intervention development through the use of local evidence, theory, and participation. Lastly, it provides a niche exploration of further implications in the progress of understanding and implementing school-based interventions in LMICs

Exploring the focus of prenatal information offered to pregnant mothers regarding newborn care in rural Uganda

Background: Neonatal death accounts for one fifth of all under-five mortality in Uganda. Suboptimal newborn care practices resulting from hypothermia, poor hygiene and delayed initiation of breastfeeding are leading predisposing factors. Evidence suggests focused educational prenatal care messages to mitigate these problems. However, there is a paucity of data on the interaction between the service provider and the prenatal service user. This study aims to understand the scope of educational information and current practices on newborn care from the perspectives of prenatal mothers and health workers. Methods: A qualitative descriptive methodology was used. In-depth interviews were conducted with lactating mothers (n = 31) of babies younger than five months old across Masindi in western Uganda. Additional interviews with health workers (n = 17) and their employers or trainers (n = 5) were conducted to strengthen our findings. Data were audio-taped and transcribed verbatim. A thematic content analysis was performed using NVivo 8. Results: Vertical programmes received more attention than education for newborn care during prenatal sessions. In addition, attitudinal and communication problems existed among health workers thereby largely ignoring the fundamental principles of patient autonomy and patient-centred care. The current newborn care practices were largely influenced by relatives' cultural beliefs rather than by information provided during prenatal sessions. There is a variation in the training curriculum for health workers deployed to offer recommended prenatal and immediate newborn care in the different tiers of health care. Conclusions: Findings revealed serious deficiencies in prenatal care organisations in Masindi. Pregnant mothers remain inadequately prepared for childbirth and newborn care, despite their initiative to follow prenatal sessions. These findings call for realignment of prenatal care by integrating education on newborn care practices into routine antenatal care services and be based on principles of patient-centred care

Effectiveness of a nutrition education package in improving feeding practices, dietary adequacy and growth of infants and young children in rural Tanzania : rationale, design and methods of a cluster randomised trial

Background: Strategies to improve infant and young child nutrition in low and middle-income countries need to be implemented at scale. We contextualised and packaged successful strategies into a feasible intervention for implementation in rural Tanzania. Opportunities that can optimise delivery of the intervention and encourage behaviour change include mothers willingness to modifying practices; support of family members; seasonal availability and accessibility of foods; established set-up of village peers and functioning health system. The primary objective of the study is to evaluate the effectiveness of a nutrition education package in improving feeding practices, dietary adequacy and growth as compared to routine health education. Methods/Design: A parallel cluster randomised controlled trial will be conducted in rural central Tanzania in 9 intervention and 9 control villages. The control group will receive routine health education offered monthly by health staff at health facilities. The intervention group will receive a nutrition education package in addition to the routine health education. The education package is comprised of four components: 1) education and counselling of mothers, 2) training community-based nutrition counsellors and monthly home visits, 3) sensitisation meetings with health staff and family members, and 4) supervision of community-based nutrition counsellors. The duration of the intervention is 9 months and infants will be recruited at 6 months of age. Primary outcome (linear growth as length-for-age Z-scores) and secondary outcomes (changes in weight-for-length Z-scores; mean intake of energy, fat, iron and zinc from complementary foods; proportion of children consuming 4 or more food groups and recommended number of semi-solid/soft meals and snacks per day; maternal level of knowledge and performance of recommended practices) will be assessed at baseline and ages 9, 12 and 15 months. Process evaluation will document reach, dose and fidelity of the intervention and context at 8 and 15 months. Discussion: Results of the trial will provide evidence of the effectiveness of the nutrition education package in community settings of rural Tanzania. They will provide recommendations for strengthening the nutrition component of health education in child health services

Perspective: Consideration of values when setting priorities in nutrition research : guidance for transparency

Nutrition research can guide interventions to tackle the burden of diet-related diseases. Setting priorities in nutrition research, however, requires the engagement of various stakeholders with diverse insights. Consideration of what matters most in research from a scientific, social, and ethical perspective is therefore not an automatic process. Systematic ways to explicitly define and consider relevant values are largely lacking. Here, we review existing nutrition research priority-setting exercises, analyze how values are reported, and provide guidance for transparent consideration of values while setting priorities in nutrition research. Of the 27 (n=22 peer-reviewed manuscripts and 5 grey literature documents) studies reviewed, 40.7% used a combination of different methods, 59.3% described the represented stakeholders, and 49.1% reported on follow-up activities. All priority-setting exercises were led by research groups based in high-income countries. Via an iterative qualitative content analysis, reported values were identified (n = 22 manuscripts). Three clusters of values (i.e., those related to impact, feasibility, and accountability) were identified. These values were organized in a tool to help those involved in setting research priorities systematically consider and report values. The tool was finalized through an online consultation with 7 international stakeholders. The value-oriented tool for priority setting in nutrition research identifies and presents values that are already implicitly and explicitly represented in priority-setting exercises. It provides guidance to enable explicit deliberation on research priorities from an ethical perspective. In addition, it can serve as a reporting tool to document how value-laden choices are made during priority setting and help foster the accountability of stakeholders involved

Validity of two physical activity questionnaires (IPAQ and PAQA) for Vietnamese adolescents in rural and urban areas

<p>Abstract</p> <p>Background</p> <p>Although physical activity is recognised to be an important determinant of health and nutritional status, few instruments have been developed to assess physical activity in developing countries. The aim of this study was to compare the validity of the short form of the International Physical Activity Questionnaire (IPAQ) and a locally adapted version of the Physical Activity Questionnaire for Adolescents (PAQA) for use in school going adolescents in rural and urban areas in Vietnam.</p> <p>Methods</p> <p>Sixteen year old adolescents from rural areas (n = 137) and urban areas (n = 90) completed the questionnaires in 2006. Test-retest reliability was assessed by comparing registrations after 2 weeks. Criterion validity was assessed by comparison with 7 days continuous accelerometer logging. Validity of the two methods was assessed using Spearman correlation coefficient, intra class correlation coefficients (ICC) and Kappa statistics.</p> <p>Results</p> <p>Reliability of both questionnaires was poor for both the IPAQ (ICC = 0.37) and the PAQA (ICC = 0.40). Criterion validity of both questionnaires was acceptable and similar for the IPAQ (ρ = 0.21) and the PAQA (ρ = 0.27) but a significantly lower validity was observed in rural areas. Both forms poorly estimated time spent on light, moderate and vigorous physical activity. Agreement of both questionnaires to classify individuals was also low but the IPAQ performed better than the PAQA.</p> <p>Conclusion</p> <p>Both questionnaires have a similar and overall poor validity to be used as a population instrument in Vietnam. Low reliability and classification properties in rural areas call for further research for specific use in such settings.</p

Two years of school-based intervention program could improve the physical fitness among Ecuadorian adolescents at health risk : subgroups analysis from a cluster-randomized trial

Background: Adolescents with overweight and poor physical fitness have an increased likelihood of developing cardiovascular diseases during adulthood. In Ecuador, a health promotion program improved the muscular strength and speed-agility, and reduced the decline of the moderate-to-vigorous physical activity of adolescents after 28 months. We performed a sub-group analysis to assess the differential effect of this intervention in overweight and low-fit adolescents. Methods: We performed a cluster-randomized pair matched trial in schools located in Cuenca–Ecuador. In total 20 schools (clusters) were pair matched, and 1440 adolescents of grade 8 and 9 (mean age of 12.3 and 13.3 years respectively) participated in the trial. For the purposes of the subgroup analysis, the adolescents were classified into groups according to their weight status (body mass index) and aerobic capacity (scores in the 20 m shuttle run and FITNESSGRAM standards) at baseline. Primary outcomes included physical fitness (vertical jump, speed shuttle run) and physical activity (proportion of students achieving over 60 min of moderate–to-vigorous physical activity/day). For these primary outcomes, we stratified analysis by weight (underweight, normal BMI and overweight/ obese) and fitness (fit and low fitness) groups. Mixed linear regression models were used to assess the intervention effect. Results: The prevalence of overweight/obesity, underweight and poor physical fitness was 20.3 %, 5.8 % and 84.8 % respectively. A higher intervention effect was observed for speed shuttle run in overweight (β = −1.85 s, P = 0.04) adolescents compared to underweight (β = −1.66 s, P = 0.5) or normal weight (β = −0.35 s, P = 0.6) peers. The intervention effect on vertical jump was higher in adolescents with poor physical fitness (β = 3.71 cm, P = 0.005) compared to their fit peers (β = 1.28 cm, P = 0.4). The proportion of students achieving over 60 min of moderate-to-vigorous physical activity/ day was not significantly different according to weight or fitness status. Conclusion: Comprehensive school-based interventions that aim to improve diet and physical activity could improve speed and strength aspects of physical fitness in low-fit and overweight/obese adolescents