Measurement of food literacy among the adult population in urban Uganda and Kenya: development and validation of an East African food literacy scale.

OBJECTIVE: Food literacy (FL) is a potential approach to address the nutrition transition in Africa, but a validated tool is lacking. We developed and validated a scale to assess FL among Ugandan and Kenyan adult populations. DESIGN: A mixed-method approach was applied: (1) item development using literature, expert and target group insights, (2) independent country-specific validation (content, construct, criterion and concurrent) and (3) synchronisation of the two country-specific FL-scales. Construct validity was evaluated against the prime dietary quality score (PDQS) and healthy eating self-efficacy scale (HEWSE). SETTING: Urban Uganda and Kenya. PARTICIPANTS: Two cross-sectional cross-country surveys, adults >18 years (n = 214) and university students (n = 163), were conducted. RESULTS: The initial development yielded a forty-eight-item FL-scale draft. In total, twenty-six items were reframed to fit the country contexts. Six items differed content-wise across the two FL-scales and were dropped for a synchronised East African FL-scale. Weighted kappa tests revealed no deviations in individuals' FL when either the East African FL-scale or the country-specific FL-scales are used; 0·86 (95 % CI: 0·83, 0·89), Uganda and 0·86 (95 % CI: 0·84, 0·88), Kenya. The FL-scale showed good reliability (0·71 (95 % CI: 0·60, 0·79), Uganda; 0·78 (95 % CI: 0·69, 0·84), Kenya) and positively correlated with PDQS (r = 0·29 P = 0·003, Uganda; r = 0·26 P < 0·001, Kenya) and HEWSE (r = 0·32 P < 0·001, Uganda; r = 0·23, P = 0·017, Kenya). The FL-scale distinguishes populations with higher from those with lower FL (ß = 14·54 (95 % CI: 10·27, 18·81), Uganda; ß = 18·79 (95 % CI: 13·92, 23·68), Kenya). CONCLUSION: Provided culture-sensitive translation and adaptation are done, the scale may be used as a basis across East Africa.

Designing Mobile Phone Text Messages Using the Behavior Change Wheel Framework to Influence Food Literacy in Adults With Type 2 Diabetes in Kenya: Protocol for a Systematic Development Study.

BACKGROUND: The worldwide prevalence of type 2 diabetes (T2D) has increased in the past decade, and it is projected to increase by 126% by 2045 in Africa. At the same time, mobile phone use has increased in Africa, providing a potential for innovative mobile health interventions to support diabetes care. OBJECTIVE: This study aimed to apply the Behavior Change Wheel (BCW) framework to develop text messages to influence food literacy in adults with T2D in urban Kenya. METHODS: The 8 steps of the BCW framework guided the development of text messages: (1) Define the problem in behavioral terms; (2) select target behaviors; (3) specify the target behaviors based on who needs to perform the behaviors, what needs to change, and when, where, how often, and with whom; (4) identify what needs to change; (5) identify intervention functions; (6) select policy categories; (7) select behavior change techniques (BCTs); and (8) select the mode of delivery. Recent exploratory studies in Kenya and other low- and middle-income countries provided information that was used to contextualize the intervention. RESULTS: In step 1, the behavioral problem was defined as unhealthy dietary patterns among adults with T2D. In step 2, based on a qualitative study in the target population, the target behavior was selected to be evaluation of reliable sources of information, and selection and preparation of healthy food. In step 3, unhealthy dietary patterns were selected. In step 4, 10 domains of the Theoretical Domains Framework were identified, and in step 5, 5 intervention functions were linked to the domains and unhealthy dietary patterns were specified. In step 6, communication and regulations were identified as policy categories, while in step 7, 9 BCTs were selected from the Behavior Change Technique Taxonomy version 1. In step 8, the most suitable mode of delivery was determined to be mobile text messages. A total of 36 mobile text messages were developed based on the 9 BCTs. CONCLUSIONS: This study shows the step-by-step application of the BCW framework to develop mobile text messages to influence food literacy in adults with T2D. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/48271.

Perceived facilitators and barriers to healthy dietary behaviour in adults with type 2 diabetes mellitus in Kenya: A qualitative study.

OBJECTIVE: This study aimed to explore the facilitators and barriers to healthy dietary behaviour in adults with type 2 diabetes mellitus (T2DM) in Kenya. DESIGN: A qualitative descriptive design using telephone interviews was applied. An interview guide was developed through a modified theoretical framework. SETTING: This study was conducted in selected hospitals in Nakuru County, located in west-central Kenya. PARTICIPANTS: A two-step sampling strategy was used to select hospitals and study participants. Adult participants aged 30 to 85 years old, with T2DM from six hospitals were selected based on their ability to openly elaborate on the theme of dietary behaviour. RESULTS: Thirty respondents were interviewed (mean age 62 years; 43.3% females). The average duration of the interviews was 32:02 minutes (SD 17.07). The highest-ranking internal facilitators of healthy dietary behaviour were knowledge of healthy food choices, gardening, self-efficacy, food preparation skills and eating at home. External facilitators included inaccurate beliefs and information on food and diet, education by healthcare workers, food availability, proximity to food selling points and family support. Internal barriers included tastes and preferences, health conditions barring intake of certain foods, and random eating of unhealthy foods. External barriers included socioeconomic factors, seasonal unavailability of fruits and food safety concerns. CONCLUSIONS: Facilitators and barriers to healthy dietary behaviour among Kenyan adults with T2DM are related to food literacy and include selection, preparation and eating. Interventions to enhance healthy dietary behaviour should target context-specific knowledge, skills and self-efficacy.

Clinical and patient-centered implementation outcomes of mHealth interventions for type 2 diabetes in low-and-middle income countries: a systematic review.

BACKGROUND: The prevalence of Type 2 Diabetes is rising in Low- and Middle-Income Countries (LMICs), affecting all age categories and resulting in huge socioeconomic implications. Mobile health (mHealth) is a potential high-impact approach to improve clinical and patient-centered outcomes despite the barriers of cost, language, literacy, and internet connectivity. Therefore, it is valuable to examine the clinical and implementation outcomes of mHealth interventions for Type 2 Diabetes in LMICs. METHODS: The Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) guidelines were applied in framing and reporting the review criteria. A systematic search of Cochrane Library, Web of Science, PubMed, Scopus, and Ovid databases was performed through a combination of search terms. Randomized Controlled Trials (RCTs) and cohort studies published in English between January 2010 and August 2021 were included. Risk of bias for missing results in the included studies was assessed using the Cochrane risk-of-bias tool for randomized trials (RoB 2). Quantitative and qualitative methods were used to synthesize the results. RESULTS: The search identified a total of 1161 articles. Thirty studies from 14 LMICs met the eligibility criteria. On clinical outcomes, 12 and 9 studies reported on glycated hemoglobin (HbA1c )and fasting blood glucose (FBG) respectively. Text messages was the most commonly applied mHealth approach, used in 19 out of the 30 studies. Ten out of the 12 studies (83.3%) that reported on HbA1c had a percentage difference of <0.3% between the mHealth intervention and the comparison group. Additionally, studies with longer intervention periods had higher effect size and percentage difference on HbA1c (1.52 to 2.92%). Patient-centred implementation outcomes were reported variedly, where feasibility was reported in all studies. Acceptability was reported in nine studies, appropriateness in six studies and cost in four studies. mHealth evidence reporting and assessment (mERA) guidelines were not applied in all the studies in this review.   CONCLUSION: mHealth interventions in LMICs are associated with clinically significant effectiveness on HbA1 but have low effectiveness on FBG. The application of mERA guidelines may standardize reporting of patient-centered implementation outcomes in LMICs. TRIAL REGISTRATION: PROSPERO: Registration ID 154209.