A Social Ecological Approach to Develop a Nutrition Education Program for Preventing Iron Deficiency Anemia in Young Children in Rural Pakistan.

Inappropriate feeding practices puts infants and young children at risk of iron deficiency anemia. Maternal complementary feeding (CF) behavior is determined by influences at various levels, including knowledge and attitude about feeding, inter-personal interaction with family/friends, community norms and support. The aim of this study is to understand the various influences on maternal CF behavior in order to develop a culturally appropriate nutrition education program to improve iron status of children aged 9-24 months. Using a social ecological approach, in-depth interviews with stakeholders revealed restraining factors that prevented behavior change. Culturally appropriate nutrition education messages were developed to address these constraints.

HEALTH LITERACY, MEDICATION ADHERENCE, AND BLOOD PRESSURE LEVEL AMONG HYPERTENSIVE OLDER ADULTS TREATED AT PRIMARY HEALTH CARE CENTERS.

We conducted this study to explore the causal relationships between health literacy, individual characteristics, literacy, culture and society, cognitive ability, medication adherence, and the blood pressure levels of hypertensive older adults receiving health care services at Primary Health Care Centers in Sa Kaeo Province, Thailand. Six hundred hypertensive older adults had their blood pressure level recorded and were interviewed using questionnaires. Structural Equation Modeling (SEM) was used to determine the effect size, both direct and indirect, among factors. Almost half (48.7%) of studied subjects had inadequate health literacy, 98.3% had good medication adherence, and 80% had good blood pressure levels. The highest effect size on health literacy was literacy, followed by cognitive ability, and culture and society. Medication adherence was affected directly and indirectly by cognitive ability, literacy, and culture and society. Health literacy had not only a direct effect on medication adherence but was also the mediator. Finally, the highest effect size on blood pressure level was critical and communicative health literacy. These findings suggest that health literacy should be considered in the Health Literacy Program of the National Public Health Policy and Plan, Ministry of Public Health.

Peer Support for Diabetes Management in Primary Care and Community Settings in Anhui Province, China.

PURPOSE: We evaluated a peer leader-support program (PLSP) for diabetes self-management in China in terms of acceptability and feasibility; implementation; perceived advantages; disadvantages and barriers; reach and recruitment; effectiveness in terms of diabetes knowledge and clinical impacts; adoption; and sustainability. METHODS: Within each of 3 cities in Anhui Province, 2 subcommunities were randomly assigned to usual care or PLSP. Peer leaders and staff of Community Health Service Centers (CHSCs) co-led biweekly educational meetings. Peer leaders also led biweekly discussion meetings, promoted regular care through the CHSCs, organized informal health promotion activities (eg, walking and tai chi groups), and provided informal individual support to participants through casual contact. RESULTS: Qualitative evaluations indicated acceptance of and positive responses to the program among patients, peer leaders, and CHSC staff. Implementation was successful in 2 of 3 subcommunities, the third failing for lack of staff resources. Reported advantages included peer support as a bridge between CHSCs and their patients. In 2 sites where the PLSP was implemented, analyses controlling for baseline differences and site showed significant benefits for PLSP relative to controls (P <0.05) for knowledge, self-efficacy, BMI, systolic blood pressure, diastolic blood pressure, and both fasting and 2-hour post-prandial blood glucose. The Anhui Provincial Health Bureau has extended the PLSP model to other communities and to cardiovascular disease prevention and management. CONCLUSION: The PLSP was well accepted, feasible given sufficient administrative and staff resources, effective for those who participated, and generalizable to other sites and health problems.

Barriers and facilitating factors among lay health workers and primary care providers to promote children's oral health in Chon Buri Province, Thailand.

This study explored the barriers and facilitating factors among lay health workers (LHWs) and primary care providers (PCPs) in implementing a multi-level program to promote children's oral health care in a rural Thai community. Twelve focus groups and 11 in-depth interviews were conducted with LHWs and PCPs who implemented the program from January 2008 to January 2009. The findings showed that the PCPs encountered the constraints of time and human resources, lack of ownership, and problem of coordination with the district hospital. The barriers among LHWs during home visits were related to their assumption of caregiver's knowledge, some conflicting beliefs, and limited counseling skills. The facilitating factors were the training program, caregivers' positive feedback, and available resources such as brochures and toothbrushes. The PCPs identified LHWs as the main facilitators of the program and indicated that policy should be developed for better integrating oral health services in local health Centers. This study provides a better understanding of the barriers and facilitating factors to promote children's oral health in rural Thai communities. While the barriers to integrating oral health activities to primary care are complex, the use of LHWs to promote the children's oral health was feasible and should be supported.

Development of natural helper characteristic scale (NHCS): an instrument for identifying natural helpers for health area in Thai context.

BACKGROUND: Volunteerism in health through cadres of village health volunteers (VHV) has been common since the "health for all" campaign. At present, with political support, the VHV receives monthly financial support, and this creates a conflict of interest and competition among the VHV groups. Therefore, a tool to identify the VHV who has natural helper characteristics, a voluntary mind set and a readiness to help is needed. OBJECTIVE: The purpose of the present study was to develop and test the quality of the natural helper characteristic scale (NHCS). MATERIAL AND METHOD: The present study used a multi-methods design to identify natural helper characteristic constructs in the Thai public health context by interviewing community leaders and public health professionals who have experience in working with natural helpers successfully. Suggested constructs have been validated with key informants using telephone interview to confirm the common constructs before reconfirmation with factor analysis and reliability statistical test. RESULTS: Qualitative data indicated 3 constructs is commonly found and statistically tested by exploratory factor analysis revealed a 30-item with a five-factor solution (altruism, role recognition, openness to new experiences, family readiness, and social acceptance) that accounted for 62.24% of the variance. The finding of confirmatory factor analysis indicated that the 5-factor model with 24 items demonstrated acceptable fit indicated a good fit to the data (2 = 439.91; df = 217 (p < 0.001); chi2/ df = 2.02; RMSEA = 0.05; GFI = 0.90; and, CFI = 0.96). Cronbach's alpha coefficients of the total scale's Cronbach's alpha was 0.94. CONCLUSION: The NHCS demonstrated evidence of the content and construct validity, and adequate internal consistency reliability. The NHCS can be used for identifying natural helpers in working for the health programs.

The evaluation of a multi-level oral health intervention to improve oral health practices among caregivers of preschool children.

Abstract. This study reports the effects of a pilot multi-level oral health intervention on caregivers' oral health practices and their determinants. Quasi-experimental, pretest-posttest evaluations using a comparison group design were employed to evaluate the effectiveness of a proposed intervention for promoting caregiver oral health behavior. The intervention consisted of three components: home visits by lay health workers (LHWs), enhancing oral health education and services at health centers, and community mobilization. These components were designed to target factors at intrapersonal, interpersonal, organizational and community levels based on a Social Ecological Model (SEM). Four oral health behaviors associated with early childhood caries (infant bottle feeding, tooth brushing, snack consumption and fluoride use), and multi-level determinants were assessed during pre- and post-tests. The one-year intervention demonstrated a positive effect on tooth brushing, using toothpaste, and fluoride supplements, but did not have a significant effect on bottle feeding and snack consumption among children. The intervention also had no effect on dental caries; in fact caries increased in both control and experimental groups. The caregiver knowledge, attitudes, outcome expectations, and self-efficacy towards these behaviors were significantly increased in the experimental group after intervention. Caregivers in the experimental group received greater social support by LHWs and health center staff than those in the control group (p < 0.001). The program had an impact on integrating oral health services at health centers and community participation in children's oral health. These findings confirm multi-level factors influence reported oral health behavior, but not outcomes in terms of caries. Process evaluation is needed to determine actual implementation levels, barriers and suggests for modification of the program in the future to improve outcomes in terms of caries.

Three intervention levels for improving smoking behavior among Royal Thai Army conscripts.

We evaluated a smoking cessation program based on an ecological model among Royal Thai Army conscripts with three levels of behavioral change intervention: intrapersonal level, interpersonal level and organizational level. The program applied processes of change in the Transtheoretical Model for intervention at the intrapersonal level; social support from the family at the interpersonal level; strengthening policies and activities to support quitting, including providing a smoke-free workplace at the organizational level. Eighty-nine participants were purposively selected from the first regiment of conscripts at the King's Royal Guard, recruited into the Army in 2009. The behavioral change intervention was conducted during their first six months of duty. A self-administered questionnaire was used to collect data between May and November 2009. Individual interviews and checklist observations were employed to collect data. Data was analyzed using inferential statistics, comparing means by paired t-test and the chi-square test was used to analyze correlations. Qualitative data were analyzed thematically. Sixty-three percent of participants significantly (p<0.001) reduced the number of cigarettes smoked, and 4.5% quit smoking. There was significant improvement in self-efficacy for improving smoking behavior (p=0.002) and making an effort to quit (p<0.001).

Human capital identification process: linkage for family medicine and community medicine to mobilize the community.

BACKGROUND: Community diagnosis and approach has shifted from a professional focus to a community focus. The information system has also been developed to reflect socio-cultural information. This new system has been established throughout the country and is being recorded in the computer system. However these data still lack human capital information to promote community mobilization. OBJECTIVE: The present study aims to develop a process which reflects human capital from the insider and outsider points of view and which builds on the existing work system of primary care service, family medicine, and community medicine. MATERIAL AND METHOD: The present study applies the participatory action research design with mixed methods including community grand-tour, household survey socio-metric questionnaire and focus group discussion in order to gather insider view of human capital. A key instrument developed in the present study is the socio-metric questionnaire which was designed according to the community grand tour and household survey results. RESULTS: The findings indicate that the process is feasible and the insider point of view given a longer evidence based list of the human capital. The model enhanced a closer relationship between professional and community people and suggested the realistic community mobilizer name list. CONCLUSION: Human capital identification process is feasible and should be recommended to integrate in the existing work process of the health staff in family and community practice.

Awareness and practices of self-management and influence factors among individuals with type 2 diabetes in urban community settings in Anhui Province, China.

This study aimed to determine the knowledge of diabetes, practices of self-management (SM), and potential factors influencing patient knowledge and practices of self-management among individuals with type 2 diabetes in urban Anhui Province, China. A cross-sectional study was conducted between October and November, 2009. Three hundred sixty-five subjects with type 2 diabetes were randomly selected from three urban communities in three seperate cities. An interview was conducted to determine subject knowledge regarding diabetes, practices of self-management, and potential factors influencing this knowledge and these practices of self-management. Fewer than half of subjects (45.6%) had a basic knowledge of diabetes and 49.7% practiced adequate self-management. Significant associations were found between subject knowledge of diabetes and their education level (OR 2.096, 95% CI 1.578-2.784) and the length of disease (OR 1.307, 95% CI 1.016-1.681). Those with good self-management were influenced by greater knowledge, (OR 2.057,95% CI 1.228-3.445), strong self-efficacy in diabetes self-management (OR 1.899, CI 1.253-2.878), and household income (OR 0.537, 95% CI 0.419-0.689). Factors found by univariate analysis regarding self-management included: glucose monitoring was influenced by perception of social support (p = 0.006), adherence to medication was influenced by attitude toward self-management (p < 0.001), physical activity was influenced by knowledge (p < 0.01), attitude (p < 0.01), self-efficacy (p < 0.01), and social support (p < 0.01). However, there were no factors significantly related to healthy dietary practices. Our findings show that best performance in self-management is achieved when those with type 2 diabetes have a high degree of knowledge of diabetes, positive attitudes toward diabetes, strong self-efficacy for self-management and perceptions of good social support.

Factors related to tobacco use among middle school students in China.

The objectives of this study were to determine the status of tobacco use among middle school students in China, and to identify factors related to tobacco use. The study was conducted in December 2009. An ecological model was used to formulate the conceptual framework of the study. Three thousand two hundred twenty-one middle school students aged 12-17 years were selected by three stage stratified cluster sampling. Data were collected by self-completed questionnaires and interviews. The prevalence of current smoking was 10.6%; 16.2% among males and 4.3% among females. The prevalence of ever having smoked was 19.7%, 25.3% among males and 13.4% among females. Zero point seven percent of middle school students used other forms of smoked tobacco products other than cigarettes. Multinomial logistical regression analysis found gender, age, knowledge, attitude, life skills, self-concept, parental smoking, friends smoking, friends attitudes toward smoking, peer pressure, family rules, availability of cigarettes, tobacco-free school environment, smoking intervention program, community tobacco control activities, and tobacco control policies had significant associations with smoking behavior. Structural equation modeling (SEM) analysis found intrapersonal factors had direct relationships with smoking behavior among smoking middle school students. Interpersonal factors, organizational factors and policies had indirect relationships with smoking behavior, and through intrapersonal factors affected smoker behavior among middle school smoking students.

Comparing a Social and Communication App, Telephone Intervention, and Usual Care for Diabetes Self-Management: 3-Arm Quasiexperimental Evaluation Study.

BACKGROUND: Many technology-assisted innovations have been used to manage disease. However, most of these innovations are not broadly used by older adults due to their cost. Additionally, disease management through technology-assisted innovations has not been compared with other interventions. OBJECTIVE: In this study, we tested the employment of a free and widely used social and communication app to help older adults with diabetes manage their distress and glycemic control. We also compared the effectiveness of the app with 2 other methods, namely telephone and conventional health education, and determined which subgroup experiences the most effects within each intervention. METHODS: Adults aged ≥50 years with type 2 diabetes were recruited from Southern Taiwan (N=231) and were allocated to different 3-month interventions. Informed consent was obtained at the Ministry of Science and Technology and approved by the National Cheng Kung University Hospital Institutional Review Board (No. A-ER-102-425). RESULTS: Participants in the mobile-based group had significant reductions in hemoglobin A1c compared with the telephone-based and usual care groups (mean changes of -0.4%, 0.1%, and 0.03%, respectively; P=.02). Diabetes-specific distress decreased to a greater extent in the mobile-based group compared to the other 2 groups (mean changes of -5.16, -3.49, and -2.44, respectively, P=.02). Subgroup analyses further revealed that the effects on reducing blood glucose levels in the social and communication app groups were especially evident in patients with lower distress scores, and diabetes-related distress was especially evident in participants who were younger than 60 years or had higher educational levels. CONCLUSIONS: The findings of this study inform more flexible use of social and communication apps with in-person diabetes education and counselling.

Ways of healthy aging: a case study of elderly people in a Northern Thai village.

This ethnographic study was conducted to explore ways of healthy aging and the influence of culture on health-related behaviors in a rural community in Northern Thailand. In-depth interviews, focus group discussions, participant observations and field notes were used to understand the lives of seven healthy Thai older adults aged 75 years and over. Data were collected from March 2007 to February 2008, with ongoing ethnographic analysis involving coding, identifying patterns, generalizing and making reflective notes to elucidate the cultural patterns of behavior. All informants perceived health as interrelated with their life styles, which was, in turn, closely related to their cultural roots, suggesting that culture influences the health of all members of smaller, closely knit communities, including the elderly, by integrating physical, social and spiritual health for older adults and their families.

Effectiveness of school network for childhood obesity prevention (SNOCOP) in primary schools of Saraburi Province, Thailand.

This research was designed to test the effectiveness of a school network for childhood obesity prevention (SNOCOP) in primary schools; a program that aimed to improve student behavior in terms of knowledge, attitude, intention towards obesity prevention, and their food consumption behavior. A quasi-experimental pretest-posttest time series study was conducted. By 2-stage stratified sampling selection 180 students from 6 schools were assigned to the intervention group and 195 students from 6 schools to the control group at Saraburi Province, Thailand in 2006- 2007. In addition, thirty-one participants being school administrators, teachers, parents, and community members from six schools formed the social network initiating the intervention. The schoolchildren in the intervention group improved their eating behavior, knowledge, attitude, intention towards obesity preventive behavior. The six schools of the intervention group changed school policies and school activities aiming to reduce the proportion of obesity among their student. No such activities could be observed in the control group. These findings suggest that the School-Social Network of Childhood Obesity Prevention program is an effective means to prevent childhood obesity.

Peer support for self-management of diabetes improved outcomes in international settings.

Self-management of diabetes is essential to reducing the risks of associated disabilities. But effective self-management is often short-lived. Peers can provide the kind of ongoing support that is needed for sustained self-management of diabetes. In this context, peers are nonprofessionals who have diabetes or close familiarity with its management. Key functions of effective peer support include assistance in daily management, social and emotional support, linkage to clinical care, and ongoing availability of support. Using these four functions as a template of peer support, project teams in Cameroon, South Africa, Thailand, and Uganda developed and then evaluated peer support interventions for adults with diabetes. Our initial assessment found improvements in symptom management, diet, blood pressure, body mass index, and blood sugar levels for many of those taking part in the programs. For policy makers, the broader message is that by emphasizing the four key peer support functions, diabetes management programs can be successfully introduced across varied cultural settings and within diverse health systems.