Why this case study?

This case illustrates the importance of adapting interventions to the local context and piloting them prior to scale up.

The case study also highlights some of the barriers and facilitators to the adaption and piloting process and proposes ways in which to address these.

Title

Adapting policies and interventions to new contexts

Source

The George Institute for Global Health, Sydney, Australia

Health issue

Hypertension and comorbidities

Setting

Mongolia

Target population

General population of Ulaanbaatar (Mongolia’s capital city)

Background

Population-wide salt reduction programmes are widely viewed as one of the most cost-effective interventions for the prevention of hypertension and associated NCDs.

The number of such national programmes has almost doubled between 2010 and 2014 and programmes are now being implemented in most regions of the world. However, to date, most of those that have demonstrated an impact are from HICs. There is some way to go to translate the lessons from these countries to low and medium income countries (LMICs).

Description of policy or intervention

Successful salt reduction programmes identify the main sources of salt in the diet and then develop a strategy to reduce them.

The Ministry of Health in Mongolia (MMoH) implemented a pilot intervention to reduce population salt intake in Ulaanbaatar during 2012–2013. The results of this pilot, combined with a series of other initiatives, informed the development of a National Salt Reduction Strategy.

What took place

The MMoH established an intersectoral working party and organized a two-week national consultation and training programme on salt reduction. Actions arising included implementation of a pilot salt reduction intervention.

The main objective of the pilot intervention was to reduce salt intake of the employees of three factories, based on the notion that simply telling people what they should/should not eat does not work – the food environment also needs to change. Adapting this to the Mongolian context, implementation strategies included training employees on the negative health impact of salt and on consuming a healthy diet, as well as actually reducing salt levels in the food served in company canteens/kitchens.

Pre- and post-intervention monitoring showed that salt intake reduced between 2011 and 2013. The number of people that did not know which foods were high in salt also declined substantially during the same period.

These activities demonstrated the potential for action and helped to convince policy-makers to scale up the policy to national level, resulting in the Mongolian National Salt Reduction Strategy being endorsed by the government in 2015 – with the ultimate goal to reduce population salt intake in Mongolia by 30%.

What was learnt

Success of the pilot intervention and scaling up of the policy to national level was possible for a number of reasons:

• The importance of multisectoral action was recognized from the outset.
• The project emerged from consultation and training on salt reduction and raised awareness of the health impacts of salt.
• The approach started by trying to understand the main sources of salt in the diet and how best to reduce them (rather than simply replicating salt reduction initiatives from other countries).

Lessons for other countries:

• Do not just replicate other programmes. A good understanding of how consumption patterns are contributing to salt intake in the country of interest is also needed.
• Do ensure that your strategy is multifaceted, combining a change of the food environment together with programmes to change consumer behaviour.
• Do continue with advocacy programmes to ensure strong government support and adequate financing.
• Do establish effective multisectoral stakeholder engagement, community participation and training procedures from the outset.
• Do, where possible, implement pilot interventions.
• Do not leave evaluation until the end of the programme. Regular monitoring ensures programmes are on track to achieve targets.

Why this case study?

This illustrates the negative consequences of implementing an effective intervention without first assessing acceptability in a new context.

Title

The importance of establishing acceptability

Source

Beltramo T, Levine DI. The effect of solar ovens on fuel use, emissions and health: Results from a randomised controlled trial.⁽¹⁾

Health issue

Respiratory diseases

Setting

Senegal

Target population

Households where cooking is conducted using solid fuels

Background

Traditional stoves for cooking and heating in LMICs are frequently fuelled with dung, coal and wood. The smoke resulting from burning such solid fuels pollutes the air and has been linked to a range of respiratory and other diseases.

Improved stoves have the potential to reduce exposure to household air pollution and so improve health outcomes. One such improved stove is the solar oven. During laboratory testing in highly controlled contexts, solar ovens frequently show positive results and do not emit any emissions. However, studies in real-world contexts are far less promising.

Description of policy or intervention

A phased, randomized controlled trial to test the effects of a solar oven called ‘the HotPot’ was carried out in Senegal.

What took place

The solar oven was provided to 465 households. After six months, the intervention group had just as high carbon monoxide exposure as the control group and there was no reduction in self-reported health symptoms.

In the laboratory these stoves were shown to be effective – so what went wrong?

The study showed poor levels of adoption of the HotPot, with households using the stove very infrequently. A major reason for this was that the solar oven was far too small for the majority of households in the study.

Other studies⁽²⁾ indicated additional reasons for solar oven unacceptability to communities: cooking could take longer, the ovens could not be used for heating and light, and the oven might need be used outdoors during sunlight.

What was learnt

Adoption of new technologies is challenging and interventions must be tailored to the needs and preferences of communities in order to succeed.⁽³⁾

References:

1. Beltramo, T. and D.I. Levine, The effect of solar ovens on fuel use, emissions and health: Results from a randomised controlled trial. Journal of Development Effectiveness, 2013. 5(2): p. 178-207.
2. Otte, P.P., Solar cookers in developing countries-What is their key to success? Energy Policy, 2013. 63: p. 375-381.
3. Thomas, E., et al., Improved stove interventions to reduce household air pollution in low and middle income countries: a descriptive systematic review. BMC Public Health, 2015. 15: p. 650.

The Kerala Diabetes Prevention Program (K-DPP) is a group-based peer-support lifestyle intervention aimed at reducing the risk of Type 2 Diabetes in high-risk individuals. The details of the K-DPP intervention program included increasing the consumption of fruit, vegetables and fibre; reducing the intake of carbohydrates with high glycaemic index and total and saturated fats; increasing physical activity; reducing tobacco use; reducing alcohol consumption; and setting realistic goals for weight loss and other lifestyle risks. 

The K-DPP intervention program consisted of the following four core components: (1) a group-based peer-support program consisting of 15 sessions for high-risk individuals, (2) peer-leader training and ongoing support for intervention delivery, (3) diabetes education resource materials and (4) strategies to stimulate broader community engagement. 

The findings of this unique community-based intervention model using low technology and local expertise for reducing diabetes incidence are also relevant and have been applied to other LMICs as well as resource-poor settings in high-income countries. The program findings have been used to inform the future development, adaptation and implementation of diabetes prevention programs to reduce long-term diabetes risk in India and other LMICs. Lessons from this study will also be relevant and have applicability to other rapidly developing low- and middle-income countries with high burdens of type 2 diabetes.

References:

1. Kerala Diabetes Prevention Program 2020 [cited 2021 25 February 2021]. Available from: https://mspgh.unimelb.edu.au/research-groups/nossal-institute-for-global-health/non-communicable-disease-unit/the-kerala-diabetes-prevention-program-kdpp.

As part of the StopDia project and supported by the European CHRODIS PLUS project, an operating model aimed at identifying the risk of diabetes in people with an Somali immigrant background living in Finland and preventing diabetes has been developed in 2019.  The intervention was organized in the mosque by a Somali researcher and volunteer health care students and comprised of T2D risk detection with FINDRISC risk score followed by group and digital lifestyle counselling. 

Findings from this pilot study have suggested moderate positive changes in some health measurements, diet and physical activity. The pilot is a good example of cultural adaptation in implementation research in the real world. It also may be also a feasible model to provide prevention interventions to be transferred to other Somali communities and other immigrant groups in Finland and other countries, but would require close collaboration with the target population as well as training of the local implementers. 

Reference

1. Somaliväestölle mukautettu StopDia -toimintamalli [cited 2021 26 February 2021]. Available from: https://sites.uef.fi/stopdia/2021/01/26/somalivaestolle-mukautettu-stopdia-toimintamalli/.