Education Behavior Change Research Articles

The CORE Group Polio Project: An Overview of Its History and Its Contributions to the Global Polio Eradication Initiative.

.The CORE Group Polio Project (CGPP) has contributed to polio eradication by successfully engaging civil society, particularly the non-governmental organization (NGO) community. This engagement, which began with a grant from the U.S. Agency for International Development in 1999, has contributed to improvements in routine immunization programs, polio campaign quality, and surveillance for acute flaccid paralysis in many challenging geographic areas. The CGPP has worked closely with polio eradication partners in a collaborative and supportive role. The CGPP has focused largely on high-risk areas with marginalized or hard-to-reach populations where health systems and immunization programs have also been weak and where transmission of poliovirus had not been stopped. The CGPP has engaged local civic leaders and communities in ways to complement top-down vertical efforts of ministries of health and other partners in the Global Polio Eradication Initiative. The CGPP has developed innovative strategies to detect cases using community-based surveillance, promoted independent campaign monitoring, established cross-border initiatives, and developed a strong and creative cadre of community mobilizers to track missed children and deliver behavior change education. Many of the innovations and approaches that the CGPP helped to develop are now being replicated by governments and international agencies to tackle other public health priorities in underserved and marginalized communities around the world. This article is the first in a series of articles describing the work of the CGPP. Because the article describes the work of more than 40 NGOs in 11 countries over 20 years, it provides only an overview, leaving many important details and variations of the CGPP’s work to be described elsewhere, including in other articles included in this series.

The impact of unconditional child cash grant on child malnutrition and its immediate and underlying causes in five districts of the Karnali Zone, Nepal \u2013 A trend analysis

BackgroundThe impact of unconditional cash transfers on child malnutrition and its determinants remains poorly understood. The aim of this study was evaluate the impact of an unconditional child cash grant on children’s nutritional status and its immediate (infant and young child feeding, dietary diversity, food consumption, and child infection and care) and underlying (household food security; Water, Hygiene and Sanitation (WASH) determinants among children younger than five years in the Karnali Zone, Nepal.MethodsThe five districts of the Karnali Zone received standard social welfare services in the form of targeted resource transfers for eligible families, plus an unconditional child cash payment, augmented by a capacity building and behavioural change education. Repeated cross-sectional surveys, with measures taken at baseline (2009, N=3750), midline (2013, N=3750) and endline (2015, N=3647), were carried out using a two-stage cluster sampling method. Multi-level Generalized Linear Mixed Models (GLMMs) with normal, binomial, Poisson, or multinomial link were performed to detect the unadjusted and adjusted trends.ResultsThere was a linear growth among children, with a corresponding increase of 0.41 height-for-age Z-scores (p < 0.001), 0.50 weight-for-age Z-scores (p<0.001), and 0.34 weight-for-height Z-scores (p<0.001) between the study period, equating to a decline in child undernutrition of 9.4, 16.5, and 5.1 percentage points (p<0.001) for stunting, underweight, and wasting respectively. Improvements were also observed in WASH outcomes, care and health seeking behaviours, and food availability.ConclusionUnconditional child cash grant embedded within a government sponsored cash transfer program for families and complemented by capacity building and behavioural change strategies improves child nutritional status and its determinants.

The use of qualitative comparative analysis to identify pathways to successful and failed sanitation systems

Sanitation systems globally fail at high rates. Researchers and practitioners attribute the causes of both sanitation success and failure to numerous factors that include technical and non-technical issues. A comprehensive understanding of what leads to sanitation failure and how to achieve sanitation success is imperative to prioritize the use of limited resources. To determine which combinations of causal conditions led to successful and failed sanitation systems, we applied fuzzy-set qualitative comparative analysis to 20 cases in Karnataka and Tamil Nadu, India with small-scale sanitation systems. Two pathways led to successful sanitation systems, and four pathways led to failed sanitation systems. All successful systems required Sufficient O&M Funds, a Clear O&M Plan, and Technical Support in addition to either Addressed Sanitation Priorities and Community Participation in Planning or Behavior Change Education and Municipality Involved in Planning. All failed systems had Lack of Municipality in Planning, Unaddressed Sanitation Priorities, and No Technical Support. Most failed systems also had No Clear O&M Plan, Poor Construction Quality, Lack of Community Participation in Planning, and Insufficient O&M Funds. Two failed cases had unique pathways because Government Barriers permanently disrupted use and maintenance. Overall, implementing organizations who initiate sanitation projects in resource-limited communities should ensure that (1) communities have adequate technical and financial resources for maintenance; (2) community and municipality stakeholders are engaged in planning and know their maintenance responsibilities; and (3) appropriate technologies are selected that meet community needs and achieve community buy-in.

Higher Levels of Dairy Result in Improved Physical Outcomes: A Synthesis of 3 Randomized Controlled Trials in Guinea-Bissau Comparing Supplements with Different Levels of Dairy Ingredients Among Children 6 to 59 Months, 5 to 19 Year Olds, and Mothers in Preschools, Primary Schools, and Villages, and the Implications for Programs.

This article synthesizes the results of 3 cluster randomized controlled trials of dairy-containing ready-to-use supplementary foods (RUSFs) to address malnutrition in primary schools, preschools and villages in Guinea-Bissau, one of the world's poorest countries. Together, these studies document widespread malnutrition across infants, young children, adolescents, and pregnant and lactating women and point to intervention options that were not previously presented. To combine the evidence from the United States Department of Agriculture-funded pilot studies in Guinea-Bissau on the effects of dairy protein supplementation to gain a broader perspective on the role of dairy containing RUSFs in various age-groups, the importance of the mother-child dyad and family food dynamics for infant and child growth. Translate the results into action and the next generation of effective products. A comparative analysis of data and synthesis of evidence from 3 published studies and ongoing research conducted by our team in Guinea-Bissau. Higher dairy supplements have the potential to achieve broad benefits for malnutrition, especially in mothers and early childhood (first 1000 days and 36-59 months). Higher levels of dairy protein also can prevent moderate acute malnutrition in children younger than 2 years, independent of the family food dynamic. Community-level nutrition behavior change education should target older children and adolescents at the community level and through the preschool/school platform.

The Feasibility of Using Facebook, Craigslist, and Other Online Strategies to Recruit Young African American Women for a Web-Based Healthy Lifestyle Behavior Change Intervention.

Reports describing successful recruiting of minority participants are available; however, they focus largely on traditional strategies. Internet and mobile devices are widely used, providing alternative approaches, yet less information is available describing the success of these approaches. This article (1) evaluates the feasibility of using online advertising as a recruiting modality for a healthy lifestyle behavior change intervention targeting young African American women and (2) describes lessons learned to better inform researchers for future directions. African American women, aged 18 to 45 years, with untreated prehypertension and Internet access were eligible for a 12-week randomized study providing physical activity or nutrition behavior change education delivered via online modules. Traditional strategies included flyers, tabletop cards, blood pressure screenings, health fairs, and clinics. Online-related strategies included posting ads on Facebook, Craigslist, and on the university Web site, intranet, and "on-hold" telephone line. Descriptive statistics were used to identify frequency of recruitment strategies. χ Analysis was used to assess differences between enrolled and nonenrolled inquiries. Among all 176 inquiries, the most frequented strategies were the university Web site (44%), blood pressure screenings (15%), Facebook/Craigslist (13%), and clinics (12%). Enrollment rates differed across recruitment strategies (χ P = .046). The 3 highest enrollment rates were (1) employee in-services (100%), (2) flyers/tabletop cards (31.6%), and (3) word of mouth/physician referral (25%). Online-related strategies are convenient and have great potential for reaching large numbers of people. However, the actual rate of participants successfully enrolled online was proportionally smaller when compared with traditional recruiting strategies.

Phone Messaging to Prompt Physical Activity and Social Support Among Low-Income Latino Patients With Type 2 Diabetes: A Randomized Pilot Study.

BackgroundGiven disparities in diabetes prevalence, receipt of diabetes education, diabetes knowledge, and self-management behaviors among Latinos, there is a need to provide education and ongoing support to this population. Phone-based interventions have the potential to reach and engage both patients and their family members and friends.ObjectiveThe aim of this study was to investigate the feasibility, perceived usefulness, and potential effectiveness of a short text or voice message (STVM) intervention to activate (1) physical activity (PA) behavior change among urban, low-income Latino adults with type 2 diabetes and (2) supportive behaviors by their family members and friends.MethodsA 12-week pilot study randomized 42 participants recruited in person from a safety-net ambulatory care clinic in Los Angeles into one of the 3 study arms: control, phone messaging (PM), and phone messaging plus social support from family members and friends (PM+FF). All participants were prompted to set PA goals and to self-monitor PA behavior using pedometers and walking logs. PM and PM+FF participants received STVMs with reminders to review goals and self-monitor, PA behavior change education, and feedback on performance. Participants in the PM+FF arm also had their family members and friends receiving STVMs with suggestions for how they could support the participant’s PA behavior change efforts. Participants completed semistructured assessments in person at baseline, 6 weeks, and 12 weeks. Outcomes were PA (steps/day) and perceived social support from family members and friends.ResultsAmong PM and PM+FF participants, those who opted to receive text messages (short message service, SMS) responded to 62.7% (128/204) of SMS text messages requiring a response while those who opted to receive voice messages responded 30% (12/40) of the time. Participants perceived guidance in self-regulation as useful, particularly self-monitoring, goal setting, self-instruction, feedback, and social support. All participants increased PA at 6 weeks, but only the PM and PM+FF arms increased PA at 12 weeks. All study arms experienced an increase in perceived social support from family members and friends at 6 weeks, but only those in the PM+FF arm had an increase in the perception of social support at 12 weeks.ConclusionDesigning an STVM intervention based on self-regulation techniques is feasible and perceived as useful by participants. The STVM intervention has the potential to improve PA in terms of daily steps and perceived social support from family members and friends.Trial RegistrationClinicaltrials.gov NCT02850770; https://clinicaltrials.gov/ct2/show/NCT02850770 (Archived by WebCite at http://www.webcitation.org/query?id=1495567756845570)

Designing a Text Messaging Intervention to Improve Physical Activity Behavior Among Low-Income Latino Patients With Diabetes: A Discrete-Choice Experiment, Los Angeles, 2014-2015.

IntroductionAutomated text messaging can deliver self-management education to activate self-care behaviors among people with diabetes. We demonstrated how a discrete-choice experiment was used to determine the features of a text-messaging intervention that are important to urban, low-income Latino patients with diabetes and that could support improvement in their physical activity behavior.MethodsIn a discrete-choice experiment from December 2014 through August 2015 we conducted a survey to elicit information on patient preferences for 5 features of a text-messaging intervention. We described 2 hypothetical interventions and in 7 pairwise comparisons asked respondents to indicate which they preferred. Respondents (n = 125) were recruited in person from a diabetes management program of a safety-net ambulatory care clinic in Los Angeles; clinicians referred patients to the research assistant after routine clinic visits. Data were analyzed by using conditional logistic regression.ResultsWe found 2 intervention features that were considered by the survey respondents to be important: 1) the frequency of text messaging and 2) physical activity behavior-change education (the former being more important than the latter). Physical activity goal setting, feedback on physical activity performance, and social support were not significantly important.ConclusionA discrete-choice experiment is a feasible way to elicit information on patient preferences for a text-messaging intervention designed to support behavior change. However, discrepancies may exist between patients’ stated preferences and their actual behavior. Future research should validate and expand our findings.

Remotely Delivered Exercise-Based Cardiac Rehabilitation: Design and Content Development of a Novel mHealth Platform.

BackgroundParticipation in traditional center-based cardiac rehabilitation exercise programs (exCR) is limited by accessibility barriers. Mobile health (mHealth) technologies can overcome these barriers while preserving critical attributes of center-based exCR monitoring and coaching, but these opportunities have not yet been capitalized on.ObjectiveWe aimed to design and develop an evidence- and theory-based mHealth platform for remote delivery of exCR to any geographical location.MethodsAn iterative process was used to design and develop an evidence- and theory-based mHealth platform (REMOTE-CR) that provides real-time remote exercise monitoring and coaching, behavior change education, and social support.ResultsThe REMOTE-CR platform comprises a commercially available smartphone and wearable sensor, custom smartphone and Web-based applications (apps), and a custom middleware. The platform allows exCR specialists to monitor patients’ exercise and provide individualized coaching in real-time, from almost any location, and provide behavior change education and social support. Intervention content incorporates Social Cognitive Theory, Self-determination Theory, and a taxonomy of behavior change techniques. Exercise components are based on guidelines for clinical exercise prescription.ConclusionsThe REMOTE-CR platform extends the capabilities of previous telehealth exCR platforms and narrows the gap between existing center- and home-based exCR services. REMOTE-CR can complement center-based exCR by providing an alternative option for patients whose needs are not being met. Remotely monitored exCR may be more cost-effective than establishing additional center-based programs. The effectiveness and acceptability of REMOTE-CR are now being evaluated in a noninferiority randomized controlled trial.

A cross sectional descriptive study of hand washing knowledge and practices among primary school children in Mumbai, Maharashtra, India

Background: Hand washing has been widely accepted worldwide as a cost effective intervention to prevent the spread of communicable diseases. However, despite proven effectiveness, practices of hand washing have found to be poor in developing nations. As children are vulnerable to communicable diseases, the present study aims to assess hand washing knowledge and practices among primary school children in municipal schools in Mumbai. Methods: A cross sectional descriptive study was carried out among randomly selected primary school children of municipal corporation schools in Mumbai, India. Two thousand two hundred and eighty three students were interviewed using a structured interview schedule regarding socio-demographic characteristics, history of illness and hand washing knowledge and practices. Results: More than half (54%)of the study population reported a history of illnesses in the past one month, out of which 81.4% reported absenteeism due to illness. Around 34% children were unaware about health related consequences of not washing hands. When asked about the important times when hands ought to be washed, only 18% mentioned after toilet use. Of the 2283 students, a very small percentage of respondents (0.7%) reportedly practiced five steps of hand washing; only 1% practiced four steps of hand washing. Forgetfulness was cited as the primary reason for missing washing hands before eating food (88%) and after toilet use (84%). Conclusions: Knowledge regarding hand washing was found to be inadequate while practices were not up to the recommended standard. This suggests that both behaviour change education and infrastructure improvements are equally important to improve hand washing practices in the long run.

Hierarchical multiple regression modelling on predictors of behavior and sexual practices at Takoradi Polytechnic, Ghana.

Introduction:Various psychosocial studies on health related lifestyles lay emphasis on the fact that the perception one has of himself as being at risk of HIV/AIDS infection was a necessary condition for preventive behaviors to be adopted. Hierarchical Multiple Regression models was used to examine the relationship between eight independent variables and one dependent variable to isolate predictors which have significant influence on behavior and sexual practices.Methods:A Cross-sectional design was used for the study. Structured close-ended interviewer-administered questionnaire was used to collect primary data. Multistage stratified technique was used to sample views from 380 students from Takoradi Polytechnic, Ghana. A Hierarchical multiple regression model was used to ascertain the significance of certain predictors of sexual behavior and practices.Results:The variables that were extracted from the multiple regression were; for the constant; β=14.202, t=2.279, p=0.023, variable is significant; for the marital status; β=0.092, t=1.996, p<0.05, variable is significant; for the knowledge on AIDs; β= 0.090, t=1.996, p<0.05, variable is significant; for the attitude towards HIV/AIDs; β=0.486, t=10.575, p<0.001, variable is highly significant. Thus, the best fitting model for predicting behavior and sexual practices was a linear combination of the constant, one’s marital status, knowledge on HIV/AIDs and Attitude towards HIV/AIDs.,Y (Behavior and sexual practices) = β0 + β1 (Marital status) + β2 (Knowledge on HIV AIDs issues) + β3 (Attitude towards HIV AIDs issues)β0, β1, β2 and β3 are respectively 14.201, 2.038, 0.148 and 0.486; the higher the better.Conclusions:Attitude and behavior change education on HIV/AIDs should be intensified in the institution so that students could adopt better lifestyles.

P4.036 Condom Use Among Female Sex Workers (FSWs) Increased Through Drop In Center (DIC) Based Service Delivery Approach in Bangladesh

BackgroundThe HIV prevalence in Bangladesh remains low (< 1%) among FSWs. Since June 2008, with the funding supports from the Global Fund, Save the Children gradually scaled up essential services...

Formative research on hygiene behaviors and geophagy as part of interventions to improve infant growth

The predominant pathways for fecal‐oral transmission of bacteria for infants may differ from adults and these have not been studied. We conducted direct observation of 23 caregiver‐infant pairs for a total of 130 hours and recorded WASH related behaviors. We identified “potential key vectors” for fecal‐oral transmission of bacteria and enumerated Escherichia coli, Total coliforms, Enterobacteriaceae and total aerobic counts. In addition to infant's fingers, food, and drinking water, three infants actively ingested soil 11.3 ±9.2 times (mean ±SD) and two ingested chicken feces 2± 1.4 times in 6 hours. Infants’ hands were rarely washed and never with soap unless as part of a bath. Drinking water was contaminated with E. coli in 12/22 (54.5 %) households, while no infant food samples tested positive for E coli. Quantitatively, a year old infant ingesting 1 gram chicken feces in a day, 20 grams of soil from a laundry area of the kitchen yard and 400 ml of contaminated water consumes 4,700,000 to 23,000,000, 440 to 4,240 and 400 to 1,200 E. coli counts, respectively, from these sources. These findings suggest that predominant pathways for fecal‐oral transmission of bacteria among infants include direct ingestion of soil and chicken. Behavior change education should include breaking socio‐cultural beliefs that soil ingestion is beneficial for infant health, which are common throughout the world.Grant Funding Source : Department for International Development (DFID), United Kingdom

Population‐based study of self‐reported ocular trauma in Fiji

To characterize causes, risk factors and outcomes for ocular trauma among adults aged ≥40 years in Fiji. Population-based cross-sectional survey; multistage cluster random sampling. 1381 (= 73.0% participation); eight provinces on Viti Levu. Interview-based questionnaire. Visual acuity measurement. Dilated ocular examination. Circumstances, management and consequences of self-reported ocular trauma. Of participants, 20.6% recalled ocular trauma: being Melanesian (P < 0.001) and male (P < 0.001) were predictive. Age at injury was ≤15 years for 13.0%: 78.4% occurred at home; 72.4% caused by sharp objects. For injury at >15 years: 38.5% occurred inside the home, most by sharp objects (51.6%) and domestic violence (28.4%); agricultural activities caused 20.6% of injuries; non-agricultural workplace incidents caused 16.2%, with chemicals responsible for 27.5% of these; public alcohol consumption was associated with 13.8% of injuries, mostly by assault (91.2%). Conventional medical services were the primary source of care for 47.2% of injured participants: 61.9% attended on injury day. For trauma: sample prevalence of vision impairment in at least one eye was 1.7% (95% confidence interval 1.1-2.4%), and 0.1% (95% confidence interval 0.02-0.5) for bilateral blindness. Injury at ≤15 years (P = 0.008) and at the workplace (P = 0.044) were predictive of ongoing vision impairment. Of visually impaired eyes, 36% had corneal opacity that may have been caused by relatively minor trauma. Ophthalmic service strengthening (including minor corneal trauma management) and specific injury prevention strategies (including behaviour change education and advocacy for legislation) are required to decrease the ocular trauma burden in Fiji.

RCT of a High‐protein Diet on Hunger Motivation and Weight‐loss in Obese Children: An Extension and Replication

This study aimed to evaluate the weight loss and hunger motivation effects of an energy-restricted high-protein (HP) diet in overweight and obese children. In total, 95 overweight and obese children attended an 8-week (maximum) program of physical activity, reduced-energy intake, and behavior change education. Children were randomly assigned to one of two isoenergetic diets (standard (SP): 15% protein; HP: 25% protein), based on individually estimated energy requirements. Anthropometry and body composition were assessed at the start and end of the program and appetite and mood ratings completed on the first 3 consecutive weekdays of each week children attended camp. The HP diet had no greater effect on weight loss, body composition, or changes in appetite or mood when compared to the SP diet. Overall, campers lost 5.2 +/- 3.0 kg in body weight and reduced their BMI standard deviation score (sds) by 0.25. Ratings of desire to eat increased significantly over the duration of the intervention, irrespective of diet. This is the third time we have reported an increase in hunger motivation in weight-loss campers and replicates our previous failure to block this with a higher protein diet. Further work is warranted into the management of hunger motivation as a result of negative energy balance.

Risk factors of visceral leishmaniasis in East Africa: a case-control study in Pokot territory of Kenya and Uganda

In East Africa, visceral leishmaniasis (VL) is endemic in parts of Sudan, Ethiopia, Somalia, Kenya and Uganda. It is caused by Leishmania donovani and transmitted by the sandfly vector Phlebotomus martini. In the Pokot focus, reaching from western Kenya into eastern Uganda, formulation of a prevention strategy has been hindered by the lack of knowledge on VL risk factors as well as by lack of support from health sector donors. The present study was conducted to establish the necessary evidence-base and to stimulate interest in supporting the control of this neglected tropical disease in Uganda and Kenya. A case-control study was carried out from June to December 2006. Cases were recruited at Amudat hospital, Nakapiripirit district, Uganda, after clinical and parasitological confirmation of symptomatic VL infection. Controls were individuals that tested negative using a rK39 antigen-based dipstick, which were recruited at random from the same communities as the cases. Data were analysed using conditional logistic regression. Ninety-three cases and 226 controls were recruited into the study. Multivariate analysis identified low socio-economic status and treating livestock with insecticide as risk factors for VL. Sleeping near animals, owning a mosquito net and knowing about VL symptoms were associated with a reduced risk of VL. VL affects the poorest of the poor of the Pokot tribe. Distribution of insecticide-treated mosquito nets combined with dissemination of culturally appropriate behaviour-change education is likely to be an effective prevention strategy.

Modelling a traditional game as an agent in HIV/AIDS behaviour-change education and communication

The level of HIV/AIDS awareness among the Luo of western Kenya is at its highest yet the epidemic continues unabated. While HIV/AIDS is locally recognised as an emergent deadly condition, people seem unconcerned. Deaths related to HIV/AIDS are often euphemistically explained in terms of tuberculosis, respiratory diseases, and 'thinning disease' or chira. The situation is aggravated by gender-based cultural attitudes that are unfortunately predisposing to risk of HIV infection. This ethnographic study explores the potential to model cultural constructs such as traditional games as a means of health communication and agent of behaviour change. The gender undertones and implications for HIV/AIDS in the language of the game ajua are significant in understanding community-specific HIV infection risk. Modelling this traditional game as an agent in HIV/AIDS behaviour-change education and communication allows for forging a socially and culturally compatible and enabling intervention mechanism. The study leads to the conclusion that behaviour-change education and communication in a complex cultural setting should be culture specific and internally derived. Significantly, cultural constructs like traditional games can provide 'rootedness' in terms of HIV/AIDS communication and intervention.

Assessing Long Term Weight Maintenance Results

A retrospective analysis was performed on all patients active in the maintenance phase (n=82) of the weight management/behavior change education program at the Springfield Diabetes & Endocrine Center in November 1998, to evaluate success in losing weight and maintaining weight loss. Three methods for weight loss were used: very low calorie diets (520kcal/day) (HMR™500) for morbidly obese, low calorie diets (800kcal/day)(HMR™800) for patients at minimal health risk, and moderate calorie deficit diets. Patients attended weekly group classes conducted by registered dietitians, which emphasized physical activity, calories, low rat cooking, environmental control, Failure Syndrome™ issues, and self-management of weight. All staff are trained and skilled in teaching the Health Management Resources (HMR™) behavioral change education program. All patients attended a minimum of 6 months of weekly one hour maintenance classes, while high risk morbidly obese patients attended a minimum of 18 months of classes. 59% patients had voluntarily chosen to extend their initial maintenance contract period of service. 57% patients were at least 2 years in maintenance, while 26% were beyond 5 years. Average weight loss of all patients (n=82) was 64lbs. & 27% of initial body weight. Average % initial body weight being kept off is 21%. Patients beyond 2 years in maintenance (n=40) lost an average of 75lb., equal to 13% initial body wt Patients beyond 5 years in maintenance (n=21) lost an average of 80 lbs. and are maintaining wt. loss equal to 15% initial body wt. Authors conclude it is possible to get patients to attend behavior change education classes regularly even after 5 years in maintenance. Participation in the HMR™ maintenance program enables patients to keep off significant amounts of weight. It appears mat periods of non-participation in maintenance affect weigjht maintenance adversely.