Meena Daivadanam, Health Systems and Policy research group, Department of Public Health Sciences, Karolinska Institutet
How often do you think about health when you are trying to decide whether to make a vegetable curry or a fried fish preparation for lunch? Or will you go with whatever is affordable and what your husband or children are more likely to eat? Well, among women in rural households in Kerala, the answer to the first question was ‘apparently never’ and to the second was ‘yes, definitely more likely’…. Did I really need to do a PhD to understand this? Well, seems like it…
Dear friends, it is with great pleasure that I share the news of the successful defence of my thesis titled, ‘Public Health Interventions: Community-based dietary behaviour change for reduction of non-communicable risk factors’ on 12th August 2013 at Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India.
The study was carried out over four phases: pre-trial and phase I-III to develop and implement a context-specific dietary intervention focusing on changing behaviors related to fruit and vegetable intake and procurement, and salt, sugar and oil consumption. The work culminated in a cluster randomized controlled trial (CRCT) to test the effectiveness of the developed intervention to improve the defined behavioral outcomes. Here is my key take-home message: a contextually appropriate intervention delivered through community volunteers using existing community infrastructures and networks was able to change key household dietary behaviours to reduce non-communicable diseases (NCD) risk factors in rural Kerala and could potentially do so in similar settings elsewhere.
I obviously hope many of you will read the PhD thesis in full (it sure makes for some good night time reading) but, let me just share with you some of the insights I gained during this process. Firstly, we often talk about different levels of prevention (primordial, primary, secondary and tertiary) in medical and epidemiological circles, but prevention (secondary and below) as a concept was almost non-existent in the study setting. ‘NCDs, specifically diabetes could be treated or controlled once you get the disease, but preventing or delaying the onset, can it really be done?’ was the response from our rural participants. Secondly, we researchers and medical professionals develop such fabulous health interventions without considering the fact that otherwise healthy people do not consciously consider health while making day-to-day decisions (food-related decisions in this case), unless their health is already compromised or threatened in some way. A wife and mother in rural Kerala would first and foremost consider whether her husband or children would even eat the stuff, and whether it was affordable. Why would she think something like ‘Is this going to contribute to our health?’ unless she, her spouse or someone in the family was sick in the first place? Food decision-making in this setting, we found, had a greater collective component and took place at the household level. Therefore, the intervention was also targeted at that level, and all levels of the study, including planning, piloting and tool development incorporated the household aspect. This has been fully justified by the results of our CRCT. We developed a conceptual model combining three existing health behaviour theories (Health Belief Model, Theory of Planned Behaviour, and Trans Theoretical Model) with findings from primary qualitative data using a modified framework analysis methodology that provided a platform to develop effective interventions at the household level. We also developed and validated an innovative household staging tool to differentiate households based on their readiness to change behavior. The developed intervention was thus dynamic, stage-matched and sequential at three time-points and this was tested in the CRCT. The intervention was delivered to rural households of Chirayinkeezhu taluk, Thiruvanathapuram district, Kerala (about 250 each in intervention and control arms), through community volunteers (all women with a minimum of 10 years of schooling residing in the selected rural communities), using neighbourhood groups or ayalkootams, which are a part of the extensive women’s self-help group network called Kudumbasree.
Thanks in part to a household kit with containers and spoons to measure salt, sugar and oil among other things, developed in response to the exploratory research findings, the intervention was able to demonstrate significant reductions in their consumption at the household level. For fruits and vegetables, the story was slightly different. The increase in consumption in the intervention group was significantly higher only for fruits, and that too was very modest. However, here we were able to show a difference in the procurement of locally available fruits and vegetables. While this was a specific strategy taught during the intervention, we have to admit that the flattering response was in part a coping mechanism against the concomitant price-rise observed for commonly used vegetables over the past two years (see Times of India). Affordability was a key limiting factor in most households. Hence, stabilizing supply of fruits and vegetables against the backdrop of rising prices would be essential for demonstrable and sustained impact.
Of course, there is a lot more I can write about my thesis, but let me stop here for now and try to put this in global perspective. There is a lot of (and increasing?) debate globally that the promotion of NCDs is a promotional gimmick, and not a true priority in some regions; including claims that NCDs sideline the social determinants of health and the rights based approaches. I would really contest that claim. How can NCDs be tackled in a sustainable manner without addressing either of these two? Social determinants of health in particular are at the core of any effort, either explicitly stated or strongly implied, to develop sustainable solutions for the NCD problem. While infectious diseases remain a priority in many LMIC settings, the emerging NCD burden if not tackled in a timely manner threatens to undo all the work that has been done so far and might also divert scarce resources away from these issues. Over-nutrition and NCDs are the flip side of under-nutrition; diabetic mothers (not to mention fathers!) give birth to children at risk of NCDs in later life; NCDs in a family lead to catastrophic health spending with all the dire consequences we know. All these elements contribute to a continuous and vicious cycle of malnutrition, poverty and illness. Will the under-fives really be spared from malnutrition and infectious diseases if the NCDs were neglected in favor of these diseases? Can we shield them from a secondary vicious cycle owing to a spillover: never-ending debt and lack of options for future generations or even interactions between infectious diseases and NCDs, leading to more of the same i.e., more ill-health, especially malnutrition and infectious diseases?
Fifty percent of diabetes in the world remains undiagnosed, with Sub-Saharan Africa contributing 80%. Can the world afford this pandemic even in pure monetary terms? We cannot close our eyes to this reality. So, the solution lies not in trying to overthrow this ‘new kid on the block’, rather in finding ways to join forces. Can we look for unified solutions for optimal nutrition, combining both under- and over-nutrition; after all, both are threats to health? Can we expand reproductive and sexual health, and maternal and child health to include both extremes of malnutrition, and both groups of diseases, communicable and non-communicable? Can we link tuberculosis or HIV, AIDS care and management where possible with that of diabetes and hypertension, so that we are sharing and not dividing much-needed resources? Similar to the HIV model, any health systems’ strengthening that occurs in the name of NCDs can be used to address other health problems as well. Would it not be more fruitful to look for potential opportunities and synergies rather than engage in never-ending debates on real versus imagined priorities? After all, we are all in the business of saving lives…
NB: Since I completed my PhD at a university where we follow the system of having a monograph, that is neither published in print or online, I am afraid I cannot provide a web-link. Apologies for that! However, the hardcopy will be available at ITM shortly, for those in Belgium and I will circulate the papers related to the food decision-making process in households, the development of the conceptual model, and the development and validation of the household staging tool, that are currently in various stages of submission, once they get published (whenever that is!).