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Title:Behavioral health policies and associated factors: do they influence health behaviors among adolescents in low- and middle- income countries?
Author(s):Darfour-Oduro, Sandra Asantewaa
Director of Research:Grigsby-Toussaint, Diana
Doctoral Committee Chair(s):Grigsby-Toussaint, Diana
Doctoral Committee Member(s):Andrade , Juan; Alston, Reginald; Buchner, David
Department / Program:Kinesiology & Community Health
Discipline:Community Health
Degree Granting Institution:University of Illinois at Urbana-Champaign
Degree:Ph.D.
Genre:Dissertation
Subject(s):Fruit and vegetable policies
Physical activity policies
World Health Organization (WHO) recommendations
Lower middle income countries (LMICs)
School-based policies
Behavioral health policies
Non-communicable diseases
Fruit and vegetable consumption
Physical activity behavior
Adolescents
Abstract:Physical inactivity and inadequate consumption of fruits and vegetables are known risk factors for non-communicable diseases (NCDs). Cognizant of these well-established risk factors to optimal health, the World Health Organization (WHO) encourages countries to develop policies to minimize these risk factors for their populations. However, few studies have reviewed these policies in low-and middle-income countries (LMICs). Moreover, there have been few cross-national studies from LMICs examining patterns of fruit and vegetable consumption and physical activity among adolescent boys and girls. Additionally, several factors are known to influence the intake of fruits and vegetables among adolescents. However, few studies in LMICs have examined the role that behavioral health policies and associated factors (such as availability of food at home, parental support and physical activity) play on consumption of fruits and vegetables particularly among adolescents. In this dissertation, I first reviewed policies available between 2004 ¬and 2013 to increase fruit and vegetable consumption and physical activity behavior among 49 LMICs. Countries were selected based on the availability of the Global School-based Student Health Survey (GSHS) national data for LMICs (n=49). Information on national policies were obtained from government ministries (e.g., Ministry of Health, Ministry of Agriculture, Ministry of Education and Ministry of Sports) involved with the formulation of nutrition and physical activity policies, WHO databases including the Global Database on the Implementation of Nutrition Action (GINA), Nutrition Landscape Information System (NLiS) and the 2011 WHO NCDs Country Profiles, as well as abstract and citation databases including Scopus and the US National Library of Medicine’s PubMed. The study results showed that of the 49 countries, 28 countries (57%) had policies to increase fruit and vegetable consumption and 37 countries (76%) had policies to promote physical activity. Strategies identified from policy reviews indicated a focus on schools, communities, the general public, the environment, the economy, mass media and an alignment with WHO recommendations. Of the 28 countries with fruit and vegetable policies, only five (18%) had policies that met the WHO recommendations for daily intake of fruits and vegetables. Likewise, of the 37 countries with physical activity policies, only nine (24%) had policies that promoted the WHO recommendations for daily physical activity. Some progress has been made in developing policies to increase physical activity compared to policies to increase fruit and vegetable consumption in LMICs. However, it is important to note that most countries are still lagging behind in developing policies to meet the WHO recommendations for daily intake of fruits and vegetables and physical activity. Secondly, I examined the consumption of fruits and vegetables and physical activity behavior among adolescents in LMICs using the GSHS data. The total analytic sample was 164,771 adolescents from 49 LMICs. Descriptive statistics were generated to determine the number and percentage of adolescents in each of the LMICs meeting the WHO recommendations. The Rao-Scott adjusted chi-square statistic was used to test if there was a statistically significant difference between adolescent boys and girls in meeting the WHO recommendations. In addition, the mean daily servings of fruits, vegetables, fruits and vegetables and physical activity behavior were generated for adolescents in each country. The 2-sample t-test was then used to determine if the mean serving of fruits, vegetables, fruits and vegetables, and physical activity was significantly different between adolescent boys and girls in each country. Across all countries, variations were found in pre-established WHO definitions of adequate fruit consumption (>=2 servings daily), vegetable consumption (>=3 servings daily), fruit and vegetable consumption (5 servings of 2 fruits & 3 vegetables) and physical activity behavior (60 minutes daily) among adolescents. In most countries (38 out of 49) less than 50% of adolescents consumed two or more servings of fruits daily. The Former Yugoslav Republic of Macedonia had the highest percentage (60.3%) of adolescents meeting the recommended intake of >=2 fruits daily. Vegetable consumption was consistently low; in all countries less than 50% of adolescents consumed three servings daily with adolescents in Morocco recording the highest daily consumption (40.7%). In addition, Morocco had the highest percentage (29.5%) of adolescents consuming five servings of fruits and vegetables daily. Compared to adequate consumption of fruits (>=2 servings daily), and vegetables (>=3 servings daily), the percentage of adolescents engaging in adequate daily physical activity (60 minutes daily) was much lower. The country with the highest percentage of adolescents being active at least 60 minutes/day was India (29.5%) with adolescents in Sudan (8.2%) being the least active. The study results show that the WHO recommendations for daily consumption of fruits and vegetables and physical activity were consistently low among adolescents in all countries. More importantly, the study found that adolescent boys were more active than girls and this difference was more notable in the Middle East and North African region. Thirdly, I examined adolescent physical environment (presence or absence of fruit and vegetable policy in a country and food insecurity), social environment (parental connectedness, supervision and bonding) and physical activity to determine if these factors influence consumption of fruits and vegetables in LMICs. All adolescent data (with the exception of policy status) was obtained from the GSHS between 2004 and 2013. Information on fruit and vegetable policies was obtained from government ministries websites (Ministry of Health, Ministry of Agriculture and Ministry of Education), the World Health Organization Global database on the Implementation of Nutrition Action (GINA), and Nutrition Landscape Information System (NLiS) as well as abstract and citations databases including Scopus and the US National Library of Medicine’s PubMed. Countries were designated as having policies if the policy document was present at least one year before collection of GSHS data. Thirteen countries were designated as having fruit and vegetable policies and 11 were designated as not having any policies. The sample included 89,843 adolescents from 24 countries. The study results showed that the presence of fruit and vegetable policy was positively associated with adequate consumption of fruits and vegetables {Adjusted Odds Ratio (AOR) = 2.04; 95%CI (1.74 – 2.40); p-value < 0.001}. Adolescents’ social environment (parental supervision) was also positively associated with sufficient intake of fruits and vegetables {AOR = 1.62; 95%CI (1.42 – 1.84); p-value < 0.001} among adolescents. Adolescents who were active 60 minutes daily for 7-days were also more likely to consume >= 5 servings of fruits and vegetables daily {AOR = 1.30; 95%CI (1.13 – 1.50); p-value < 0.001} compared to adolescents not meeting the WHO recommendations for daily physical activity. In addition, the physical environment (presence of fruit and vegetable policies, food insecurity), social environment (parental connectedness, supervision, and bonding) and personal factors (physical activity) of adolescents in LMICs were all found to be significant predictors of the daily intake of fruits and vegetables.
Issue Date:2016-11-21
Type:Thesis
URI:http://hdl.handle.net/2142/95474
Rights Information:Copyright 2016 Sandra Darfour-Oduro
Date Available in IDEALS:2017-03-01
Date Deposited:2016-12


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