Evaluating and Enhancing an Educational Intervention to Reduce Smallholder Farmers' Exposure to Pesticides in Uganda Through a Digital, Systematic Approach to Behavior Change: Protocol for a Cluster-Randomized Controlled Trial.

BACKGROUND: Smallholder farmers receive educational interventions on safe pesticide handling by governmental agencies, industries, or nongovernmental organizations to reduce exposure risks. However, existing educational interventions have limited effects on changing behaviors. Targeting psychosocial determinants of behavior change in educational interventions through theory- and evidence-based approaches may enhance their effectiveness. OBJECTIVE: We aim at describing the intervention development and study design of a 3-arm cluster-randomized controlled trial to assess the effects in improving safe pesticide handling and reducing pesticide exposure of (1) an existing educational intervention and (2) a newly developed SMS text messaging intervention based on the Risks, Attitudes, Norms, Abilities, and Self-regulation (RANAS) behavior change approach. METHODS: We enrolled 539 Ugandan smallholder farmers in 12 clusters (subcounties). The clusters, each with 45 farmers, were randomly allocated to one of the three arms: (1) educational intervention, (2) educational intervention+RANAS-based SMS text messages, or (3) control group. The educational intervention comprised a 2-day workshop that targeted multiple aspects of safe pesticide handling, whereas the SMS text messages targeted the use of personal protective equipment (PPE) and were based on the RANAS approach. For intervention development in this study, this approach includes identifying psychosocial determinants of PPE use at baseline and selecting behavior change techniques to target them in SMS text messages. The primary outcomes of the study are (1) pesticide knowledge, attitude, and practice scores indicating performance throughout the educational intervention; and (2) frequency of PPE use. Secondary outcomes are the RANAS-based behavioral determinants of PPE use, the frequency of glove use, algorithm-based pesticide exposure intensity scores, and signs and symptoms of pesticide poisoning. The outcomes were assessed in structured interviews before the intervention (baseline) and at the 12-month follow-up. The effect of the interventions among the arms will be analyzed using the intervention arms and baseline measures as predictors and the follow-up measures as outcomes in linear multivariable mixed models including the clusters as random effects. The mediating psychosocial determinants of the interventions will be assessed in multiple mediation models. RESULTS: The study was conducted from 2020 to 2021-baseline interviews were conducted in October 2020, and the educational intervention was delivered in November 2020. The RANAS-based SMS text messages were developed based on the baseline data for relevant behavioral determinants of PPE use and sent between February 2021 and September 2021. Follow-up interviews were conducted in October 2021. Overall, 539 farmers were enrolled in the study at baseline; 8.3% (45/539) were lost to follow-up by the end of the study. CONCLUSIONS: This study will contribute to a better understanding of the effectiveness and behavior change mechanisms of educational interventions by using an experimental, cluster-randomized study design to improve pesticide handling among smallholder farmers. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number (ISRCTN) 18237656; https://doi.org/10.1186/ISRCTN18237656. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/55238.

Interrelatedness of women's health-behaviour cognitions: A dyadic study of female family members on carrying heavy loads during pregnancy in Nepal.

OBJECTIVES: Decisions about reproductive health are often influenced by women's female family members, particularly in low-resource contexts. However, previous research has focused primarily on individual behavioural determinants. We investigated the interrelatedness of female family members' reproductive health behaviour with a dyadic version of an extended health action process approach. We investigated this for carrying heavy loads during pregnancy and postpartum, a risk factor for reproductive health in many low-income countries such as Nepal. DESIGN: This cross-sectional study included dyads of daughters-in-law and mothers-in-law in rural Nepal (N = 476, nested in 238 dyads). METHODS: Dyads of daughters- and mothers-in-law were surveyed about avoiding carrying heavy loads during pregnancy and postpartum. The effects of a woman's cognitions and her female dyadic partner's cognitions on their intention and behaviour about avoiding carrying loads were estimated using linear mixed models. RESULTS: The results showed that a mother-in-law's cognitions were related to her daughter-in-law's intentions and vice versa. The mother-in-law's cognitions were also related to the daughter-in-law's behaviour. The mother-in-law's self-efficacy and injunctive norms related to the daughter-in-law's intention and behaviour over and above the daughter-in-law's own self-efficacy and injunctive norms. CONCLUSION: Female Nepali family members' cognitions about carrying heavy loads during pregnancy and postpartum are interrelated. Including female family members in interventions to help women manage their reproductive health in low-resource populations seems promising. These novel findings add to the growing body of research indicating the importance of including a dyadic perspective when understanding and changing health behaviour.

Water carrying in hills of Nepal-associations with women's musculoskeletal disorders, uterine prolapse, and spontaneous abortions.

More than a third of women in Nepal have to carry water from source to home to satisfy their families' daily needs. A cross-sectional study was carried out in a hilly area in Nepal to assess water-carrying practices and their association with women's health. Quantitative interviews were conducted with 1001 women of reproductive age and were complemented with health surveys carried out by health professionals and structured observations of water carrying. Multivariate mixed logistic regression models were used to assess the associations between water-carrying-related risk factors and health issues for women. Around 46% of women faced considerably increased to excessive physical stress due to water carrying during the dry season. Women suffered from a disproportionately high prevalence of back pain (61%), with about 18% of this pain being horrible to excruciating; pain in the knees (34%); uterine prolapse (11.3%); and at least one spontaneous abortion (9%). The risk category of water carrying was significantly associated with uterine prolapse (OR = 1.44, 95%CI = 1.12-1.85, p = 0.031) and pain in the hips (OR = 1.69, 95%CI = 1.27-2.26, p<0.001). Receiving help with water carrying during pregnancy and during the first three months after delivery was associated with reduced odds ratios for uterine prolapse (OR = 0.10, 95% CI = 0.01-0.87, p = 0.037), and strong back pain (OR = 0.32, 95% CI = 0.12-0.87, p = 0.026). Improvements to water supply infrastructure and the promotion of social support for carrying water during pregnancy and after delivery are recommended to reduce water-carrying-related health risks.

The importance of collective and individual psychological ownership for safe sanitation: A multilevel analysis in rural Ghana.

Unsafe sanitation practices can severely affect public health. Strengthening psychological ownership, the feeling of owning an object (e.g. the latrine) individually or collectively, may promote safe sanitation practices, e.g. decreased open defecation. This study investigated psychological ownership in communities that participated in a sanitation intervention. We used follow-up survey data of a cluster-randomised controlled trial in rural Ghana (N = 2012 households), which assessed psychological ownership, and safe sanitation outcomes. The data were analysed using multilevel modelling and generalised estimating equations. In line with our assumptions, greater psychological ownership for the latrine related to decreased open defecation. Higher individual psychological ownership for the open defecation space related to safe sanitation outcomes, whereas collective ownership related to lesser safe sanitation. The present study shows that the concept of psychological ownership may play an important role in safe sanitation. Collective and individual psychological ownership seem to distinctly relate to safe sanitation outcomes, which has high relevance for promoting communities' health behaviour.

Understanding safe water-carrying practices during pregnancy and postpartum: A mixed-methods study in Nepal.

Daily carrying of heavy loads of domestic water, especially during pregnancy and postpartum, bears a threat to maternal health in low-income countries. Using an extended health action process approach (HAPA), we examined women's reasons for and psychosocial determinants of safe water-carrying during pregnancy and postpartum. In a mixed-methods study, trained local interviewers conducted 1001 quantitative interviews with women of reproductive age (n = 921 analyzed) and 21 qualitative interviews with women of reproductive age, in-laws, and spouses in rural Nepal. We analyzed the quantitative data with generalized estimating equations to model the HAPA-based psychosocial determinants of avoiding water-carrying during pregnancy and postpartum. Subjective perspectives were investigated with thematic analysis. Outcome expectancies (B = 0.24), self-efficacy (B = 0.20), and injunctive norms (B = 0.23) were significantly associated with the intention to avoid water-carrying. Self-efficacy (B = 0.36) and instrumental support (B = 0.05) are related to behavior (all p < 0.05). Women explained water-carrying during pregnancy by a lack of family support, a shift of health decision-making power to in-laws, and low behavioral control. Overall, the necessity of water, family decision-making structures, and low support make it difficult for women to discontinue water-carrying. Additionally to infrastructural improvements, behavioral interventions may increase women's self-efficacy for safe water-carrying (e.g. reducing weight) and social support.

The Physical Burden of Water Carrying and Women's Psychosocial Well-Being: Evidence from Rural Nepal.

Many women in low-income countries carry heavy loads of drinking water for their families in difficult terrain. This can adversely affect their health and well-being. The present study is the first to investigate the physical burden of water carrying and women's psychosocial well-being, and how this relationship is moderated by environmental and health conditions. Trained local interviewers conducted interviews with 1001 women across five rural communities in Nepal. In addition, objective measurement was used to assess the weight carried and distance from the water source. The physical burden of water carrying was calculated from weight, distance, and frequency of trips. Its association with psychosocial well-being was modeled using generalized estimating equations. Two additional models included the terrain and uterine prolapse as moderators. The physical burden of water carrying is directly related to higher emotional distress and reduced daily functioning. This correlation was exacerbated for women carrying in hilly versus flat terrain, and for those who had uterine prolapse. Our results underline the importance of adequate water access for women's psychosocial well-being, especially for vulnerable populations such as women with impaired health (e.g., uterine prolapse) or those living in hilly terrain. The results further highlight the interconnectedness of the Sustainable Development Goal (SDG) 6: water access, SDG 3: health and well-being, and SDG 5: gender equality.