Browsing by Author "Wahlstrom, R"

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    Changing household dietary behaviours through community-based networks: A pragmatic cluster randomized controlled trial in rural Kerala, India
    (Plose one, 2018-08) Daivadanam, M; Wahlstrom, R; Ravindran, TKS; Sarma, PS; Sivasankaran, S; Thankappan, KR
    Trial design With the rise in prevalence of non-communicable diseases in India and Kerala in particular, efforts to develop lifestyle interventions have increased. However, contextualised interventions are limited. We developed and implemented contextualised behavioural intervention strategies focusing on household dietary behaviours in selected rural areas in Kerala and conducted a community-based pragmatic cluster randomized controlled trial to assess its effectiveness to increase the intake of fruits and vegetables at individual level, and the procurement of fruits and vegetables at the household level and reduce the consumption of salt, sugar and oil at the household level. Methods Six out of 22 administrative units in the northern part of Thiruvananthapuram district of Kerala state were selected as geographic boundaries and randomized to either intervention or control arms. Stratified sampling was carried out and 30 clusters comprising 6–11 households were selected in each arm. A cluster was defined as a neighbourhood group functioning in rural areas under a state-sponsored community-based network (Kudumbasree). We screened 1237 households and recruited 479 (intervention: 240; control: 239) households and individuals (male or female aged 25–45 years) across the 60 clusters. 471 households and individuals completed the intervention and end-line survey and one was excluded due to pregnancy. Interventions were delivered for a period of one-year at household level at 0, 6, and 12 months, including counselling sessions, telephonic reminders, home visits and general awareness sessions through the respective neighbourhood groups in the intervention arm. Households in the control arm received general dietary information leaflets. Data from 478 households (239 in each arm) were included in the intention-to-treat analysis, with the household as the unit of analysis. Results There was significant, modest increase in fruit intake from baseline in the intervention arm (12.5%); but no significant impact of the intervention on vegetable intake over the control arm. There was a significant increase in vegetable procurement in the intervention arm compared to the control arm with the actual effect size showing an overall increase by19%; 34% of all households in the intervention arm had increased their procurement by at least 20%, compared to 17% in the control arm. Monthly household consumption of salt, sugar and oil was greatly reduced in the intervention arm compared to the control arm with the actual effect sizes showing an overall reduction by 45%, 40% and 48% respectively. Conclusions The intervention enabled significant reduction in salt, sugar and oil consumption and improvement in fruit and vegetable procurement at the household level in the intervention arm. However, there was a disconnect between the demonstrated increase in FV procurement and the lack of increase in FV intake. We need to explore fruit and vegetable intake behaviour further to identify strategies or components that would have made a difference. We can take forward the lessons learned from this study to improve our understanding of human dietary behaviour and how that can be changed to improve health within this context.
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    Conceptual model for dietary behaviour change at household level: a 'best-fit' qualitative study using primary data
    (BMC PUBLIC HEALTH, 2014) Daivadanam, M; Wahlstrom, R; Ravindran, TKS; Thankappan, KR; Ramanathan, M
    Background: Interventions having a strong theoretical basis are more efficacious, providing a strong argument for incorporating theory into intervention planning. The objective of this study was to develop a conceptual model to facilitate the planning of dietary intervention strategies at the household level in rural Kerala. Methods: Three focus group discussions and 17 individual interviews were conducted among men and women, aged between 23 and 75 years. An interview guide facilitated the process to understand: 1) feasibility and acceptability of a proposed dietary behaviour change intervention; 2) beliefs about foods, particularly fruits and vegetables; 3) decision-making in households with reference to food choices and access; and 4) to gain insights into the kind of intervention strategies that may be practical at community and household level. The data were analysed using a modified form of qualitative framework analysis, which combined both deductive and inductive reasoning. A priori themes were identified from relevant behaviour change theories using construct definitions, and used to index the meaning units identified from the primary qualitative data. In addition, new themes emerging from the data were included. The associations between the themes were mapped into four main factors and its components, which contributed to construction of the conceptual model. Results: Thirteen of the a priori themes from three behaviour change theories (Trans-theoretical model, Health Belief model and Theory of Planned Behaviour) were confirmed or slightly modified, while four new themes emerged from the data. The conceptual model had four main factors and its components: impact factors (decisional balance, risk perception, attitude); change processes (action-oriented, cognitive); background factors (personal modifiers, societal norms); and overarching factors (accessibility, perceived needs and preferences), built around a three-stage change spiral (pre-contemplation, intention, action). Decisional balance was the strongest in terms of impacting the process of behaviour change, while household efficacy and perceived household cooperation were identified as 'markers' for stages-of-change at the household level. Conclusions: This type of framework analysis made it possible to develop a conceptual model that could facilitate the design of intervention strategies to aid a household-level dietary behaviour change process.
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    Design and methodology of a community-based cluster randomized controlled trial for dietary behaviour change in rural Kerala
    (Global Health Action 2013, 2013-09) Daivadanam, D; Wahlstrom, R; Ravindran, TK; Sarma, S; Sivasankaran, S; Thankappan, KR
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    Design and methodology of a community-based cluster-randomized controlled trial for dietary behaviour change in rural Kerala
    (GLOBAL HEALTH ACTION, 2013) Daivadanam, M; Wahlstrom, R; Ravindran, TKS; Sarma, PS; Sivasankaran, S; Thankappan, KR
    Background: Interventions targeting lifestyle-related risk factors and non-communicable diseases have contributed to the mainstream knowledge necessary for action. However, there are gaps in how this knowledge can be translated for practical day-to-day use in complex multicultural settings like that in India. Here, we describe the design of the Behavioural Intervention for Diet study, which was developed as a community-based intervention to change dietary behaviour among middle-income households in rural Kerala. Methods: This was a cluster-randomized controlled trial to assess the effectiveness of a sequential stage-matched intervention to bring about dietary behaviour change by targeting the procurement and consumption of five dietary components: fruits, vegetables, salt, sugar, and oil. Following a step-wise process of pairing and exclusion of outliers, six out of 22 administrative units in the northern part of Trivandrum district, Kerala state were randomly selected and allocated to intervention or control arms. Trained community volunteers carried out the data collection and intervention delivery. An innovative tool was developed to assess household readiness-to-change, and a household measurement kit and easy formulas were introduced to facilitate the practical side of behaviour change. The 1-year intervention included a household component with sequential stage-matched intervention strategies at 0, 6, and 12 months along with counselling sessions, telephonic reminders, and home visits and a community component with general awareness sessions in the intervention arm. Households in the control arm received information on recommended levels of intake of the five dietary components and general dietary information leaflets. Discussion: Formative research provided the knowledge to contextualise the design of the study in accordance with socio-cultural aspects, felt needs of the community, and the ground realities associated with existing dietary procurement, preparation, and consumption patterns. The study also addressed two key issues, namely the central role of the household as the decision unit and the long-term sustainability through the use of existing local and administrative networks and community volunteers.
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    Developing a conceptual model using primary qualitative data to facilitate dietary intervention planning at the household level
    (BMC Public Health, 2014) Daivadanam, M; Wahlstrom, R; Ravindran, TKS; Thankappan, KR; Ramanathan, M
    Background: Interventions having a strong theoretical basis are more efficacious, providing a strong argument for incorporating theory into intervention planning. The objective of this study was to develop a conceptual model to facilitate the planning of dietary intervention strategies at the household level in rural Kerala. Methods: Three focus group discussions and 17 individual interviews were conducted among men and women, aged between 23 and 75 years. An interview guide facilitated the process to understand: 1) feasibility and acceptability of a proposed dietary behaviour change intervention; 2) beliefs about foods, particularly fruits and vegetables; 3) decision-making in households with reference to food choices and access; and 4) to gain insights into the kind of intervention strategies that may be practical at community and household level. The data were analysed using a modified form of qualitative framework analysis, which combined both deductive and inductive reasoning. A priori themes were identified from relevant behaviour change theories using construct definitions, and used to index the meaning units identified from the primary qualitative data. In addition, new themes emerging from the data were included. The associations between the themes were mapped into four main factors and its components, which contributed to construction of the conceptual model. Results: Thirteen of the a priori themes from three behaviour change theories (Trans-theoretical model, Health Belief model and Theory of Planned Behaviour) were confirmed or slightly modified, while four new themes emerged from the data. The conceptual model had four main factors and its components: impact factors (decisional balance, risk perception, attitude); change processes (action-oriented, cognitive); background factors (personal modifiers, societal norms); and overarching factors (accessibility, perceived needs and preferences), built around a three-stage change spiral (pre-contemplation, intention, action). Decisional balance was the strongest in terms of impacting the process of behaviour change, while household efficacy and perceived household cooperation were identified as ‘markers’ for stages-of-change at the household level. Conclusions: This type of framework analysis made it possible to develop a conceptual model that could facilitate the design of intervention strategies to aid a household-level dietary behaviour change process.
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    Development of a Tool to Stage Households Readiness to Change Dietary Behaviours in Kerala, India
    (PLOS one, 2016-12) Daivadanam, M; Ravindran, TKS; Thankappan, KR; Sarma, PS; Wahlstrom, R
    Dietary interventions and existing health behaviour theories are centred on individuals; therefore, none of the available tools are applicable to households for changing dietary behaviour. The objective of this pilot study was to develop a practical tool that could be administered by community volunteers to stage households in rural Kerala based on readiness to change dietary behaviour. Such a staging tool, comprising a questionnaire and its algorithm, focusing five dietary components (fruits, vegetables, salt, sugar and oil) and households (rather than individuals), was finalised through three consecutive pilot validation sessions, conducted over a four-month period. Each revised version was tested with a total of 80 households (n = 30, 35 and 15 respectively in the three sessions). The tool and its comparator, Motivational Interviewing (MI), assessed the stage-of-change for a household pertaining to their: 1) fruit and vegetable consumption behaviour; 2) salt, sugar and oil consumption behaviour; 3) overall readiness to change. The level of agreement between the two was tested using Kappa statistics to assess concurrent validity. A value of 0.7 or above was considered as good agreement. The final version was found to have good face and content validity, and also a high level of agreement with MI (87%; weighted kappa statistic: 0.85). Internal consistency testing was performed using Cronbach’s Alpha, with a value between 0.80 and 0.90 considered to be good. The instrument had good correlation between the items in each section (Cronbach’s Alpha: 0.84 (fruit and vegetables), 0.85 (salt, sugar and oil) and 0.83 (Overall)). Pre-contemplation was the most difficult stage to identify; for which efficacy and perceived cooperation at the household level were important. To the best of our knowledge, this is the first staging tool for households. This tool represents a new concept in community-based dietary interventions. The tool can be easily administered by lay community workers and can therefore be used in large population-based studies. A more robust validation process with a larger sample is needed before it can be widely used.
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    Development of a Tool to Stage Households' Readiness to Change Dietary Behaviours in Kerala, India
    (PLOS ONE, 2016) Daivadanam, M; Ravindran, TKS; Thankappan, KR; Sarma, PS; Wahlstrom, R
    Dietary interventions and existing health behaviour theories are centred on individuals; therefore, none of the available tools are applicable to households for changing dietary behaviour. The objective of this pilot study was to develop a practical tool that could be administered by community volunteers to stage households in rural Kerala based on readiness to change dietary behaviour. Such a staging tool, comprising a questionnaire and its algorithm, focusing five dietary components (fruits, vegetables, salt, sugar and oil) and households (rather than individuals), was finalised through three consecutive pilot validation sessions, conducted over a four-month period. Each revised version was tested with a total of 80 households (n = 30, 35 and 15 respectively in the three sessions). The tool and its comparator, Motivational Interviewing (MI), assessed the stage-of-change for a household pertaining to their: 1) fruit and vegetable consumption behaviour; 2) salt, sugar and oil consumption behaviour; 3) overall readiness to change. The level of agreement between the two was tested using Kappa statistics to assess concurrent validity. A value of 0.7 or above was considered as good agreement. The final version was found to have good face and content validity, and also a high level of agreement with MI (87%; weighted kappa statistic: 0.85). Internal consistency testing was performed using Cronbach's Alpha, with a value between 0.80 and 0.90 considered to be good. The instrument had good correlation between the items in each section (Cronbach's Alpha: 0.84 (fruit and vegetables), 0.85 (salt, sugar and oil) and 0.83 (Overall)). Pre-contemplation was the most difficult stage to identify; for which efficacy and perceived cooperation at the household level were important. To the best of our knowledge, this is the first staging tool for households. This tool represents a new concept in community-based dietary interventions. The tool can be easily administered by lay community workers and can therefore be used in large population-based studies. A more robust validation process with a larger sample is needed before it can be widely used.