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.

Interventions to Reduce Pesticide Exposure from the Agricultural Sector in Africa: A Workshop Report.

Despite the fact that several cases of unsafe pesticide use among farmers in different parts of Africa have been documented, there is limited evidence regarding which specific interventions are effective in reducing pesticide exposure and associated risks to human health and ecology. The overall goal of the African Pesticide Intervention Project (APsent) study is to better understand ongoing research and public health activities related to interventions in Africa through the implementation of suitable target-specific situations or use contexts. A systematic review of the scientific literature on pesticide intervention studies with a focus on Africa was conducted. This was followed by a qualitative survey among stakeholders involved in pesticide research or management in the African region to learn about barriers to and promoters of successful interventions. The project was concluded with an international workshop in November 2021, where a broad range of topics relevant to occupational and environmental health risks were discussed such as acute poisoning, street pesticides, switching to alternatives, or disposal of empty pesticide containers. Key areas of improvement identified were training on pesticide usage techniques, research on the effectiveness of interventions targeted at exposure reduction and/or behavioral changes, awareness raising, implementation of adequate policies, and enforcement of regulations and processes.

Prevalence, incidence, and reported global distribution of noma: a systematic literature review.

Noma (cancrum oris) is a severely debilitating orofacial disease. The global annual incidence and prevalence figures of noma are outdated and were not based on epidemiological studies. Therefore, we systematically reviewed the scientific literature about the prevalence, incidence, and reported global distribution of noma. We searched ten databases and Google Scholar from 1950 up to Sept 23, 2020. We used an adapted Newcastle-Ottawa scale for quality assessment of the studies we included. Epidemiological data could be extracted from eight publications. Because of the differences in quality and the limited geographical range of the studies, no new estimate of the global incidence and prevalence of noma could be calculated. Our updated world map indicates that patients with noma were diagnosed in at least 23 countries in the past decade. Additionally, we identified a strong focality, with most cases being reported from only a few countries in west Africa. This systematic review has identified a striking scarcity of research and surveillance programmes considering noma. We argue that a first step to noma elimination should be the inclusion of noma in the WHO list of neglected tropical diseases, followed by broad-based integrated control programmes aiming at noma elimination.

What agro-input dealers know, sell and say to smallholder farmers about pesticides: a mystery shopping and KAP analysis in Uganda.

BACKGROUND: Pesticides can have negative effects on human and environmental health, especially when not handled as intended. In many countries, agro-input dealers sell pesticides to smallholder farmers and are supposed to provide recommendations on application and handling. This study investigates the role of agro-input dealers in transmitting safety information from chemical manufacturers to smallholder farmers, assesses the safety of their shops, what products they sell, and how agro-input dealers abide by laws and recommendations on best practices for preventing pesticide risk situations. METHODS: Applying a mixed-methods approach, we studied agro-input dealers in Central and Western Uganda. Structured questionnaires were applied to understand agro-input dealers' knowledge, attitude and practices on pesticides (n = 402). Shop layout (n = 392) and sales interaction (n = 236) were assessed through observations. Actual behavior of agro-input dealers when selling pesticides was revealed through mystery shopping with local farmers buying pesticides (n = 94). RESULTS: While 97.0% of agro-input dealers considered advising customers their responsibility, only 26.6% of mystery shoppers received any advice from agro-input dealers when buying pesticides. 53.2% of products purchased were officially recommended. Sales interactions focused mainly on product choice and price. Agro-input dealers showed limited understanding of labels and active ingredients. Moreover, 25.0% of shops were selling repackaged products, while 10.5% sold unmarked or unlabeled products. 90.1% of shops were lacking safety equipment. Pesticides of World Health Organization toxicity class I and II were sold most frequently. Awareness of health effects seemed to be high, although agro-input dealers showed incomplete hygiene practices and were lacking infrastructure. One reason for these findings might be that only 55.7% of agro-input dealers held a certificate of competency on safe handling of pesticides and even fewer (5.7%) were able to provide a government-approved up-to-date license. CONCLUSION: The combination of interviews, mystery shopping and observations proved to be useful, allowing the comparison of stated and actual behavior. While agro-input dealers want to sell pesticides and provide the corresponding risk advice, their customers might receive neither the appropriate product nor sufficient advice on proper handling. In light of the expected increase in pesticide use, affordable, accessible and repeated pesticide training and shop inspections are indispensable.