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In a clinical study sitagliptin had a small effect on plasma digoxin concentrations indicating that sitagliptin may be a mild inhibitor of p-glycoprotein. Caries experience was lowest among dentate persons aged years The differential diagnosis of fluoride and non-fluoride enamel opacities. Effect of different cocentration of acid chloride and neutral chloride Methodologies have been developed for making this process effective in the context of planning, for example with the method of "planning by objectives" see ZOPP , which comprises several phases: Authoritarian-type governments may provide a better context for a co-ordinated, multi-sectoral communication programme than more democratic-type governments where communication industries are independent, commercially oriented, and owned by many different people. As discussed above, management skills include planning, staffing, budgeting, controlling resources, guiding and co-ordinating people's activities, setting policies, guidelines and standards, and monitoring and evaluation.

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Disability Barrier to Attend Work or School. Electronic Cigarettes E-Cig or Vaping. Emotional Support and Life Satisfaction. End of Life Issues. Epilepsy and Seizure Disorder. Food Security and Insecurity. Fruits and Vegetables Tax. Reason for Lack of Coverage. To encourage the use of the ivy gourd plant a rich source of vitamin A and school market gardens which raised food for the children to eat as well as for school income , they solicited help from the extension service and experienced home gardeners to start local projects.

They involved key officials including school administrators, agricultural officers and the district committee to judge ivy growing and garden competitions between schools and districts.

Mobile dramas also travelled to schools in all participating districts and provided entertainment with education to reinforce the communication message. They also involved Buddhist monks who played a promotional and educational role in the project. Finally, the message was also incorporated into local festivals and holidays, including New Year's cards with an ivy gourd greeting Smitasiri, et al. Together, these various activities involved a large number of community members and opinion leaders, strengthening both the school programme and the community in the process.

Another logical linkage can be made between schools and health monitoring programmes. Children's growth and immunisation can be readily monitored in schools. Partnerships between health workers and agencies can provide access to children and needed support to all participants.

Other potentials include involvement in teacher training and medical doctor training programmes, where the schools invite students into their classrooms to learn as well as teach.

Libraries can also provide important links between the school and the larger community. Volunteers can be trained in, and work with schools to broadcast programmes, motivate audiences, and coordinate nutrition and other health-related messages to children and the broader community.

Implementing special or system wide promotions Linkages that occur at the local level can be extended to district, regional or system-wide programmes as well, especially in the area of nutrition surveillance and child growth monitoring programmes, other Ministry of Health programmes, child care centres, women's development programmes, home economics training for women's groups, or any programme that promotes home food production or home consumption.

In fact, linkages should be systematically promoted at all levels, from local community administrators and extension workers to district committees, provincial government officials, and high level government officials. Such linkages should be used to frame and institute policy changes at each of these levels to assure that nutrition education and communication programmes, especially highly successful efforts, are sustained over time. Facilitating policy development There are many areas where government policy has an impact on nutritional status, food security, and nutrition education at national, regional, and local levels.

Some of these areas include agriculture, including animal husbandry, crop production, fisheries, and forestry; health; environmental policy; women's development; population; urbanisation; international economics; and trade agreements policy.

Education, advertising and consumer policies are discussed less often in terms of their interaction with nutrition, but are probably as important. Policy is inalienably a matter of politics. At the same time, the school system is charged with a custodial responsibility for children. It therefore seems that schools should also be involved in policy development to protect and sustain children's development.

Food and nutrition policies are integral to that interest. It should be recognised that the strategies for poverty alleviation have changed significantly in the past decade or so. It is now accepted by experts in behaviour change and nutrition communication that people's participation is fundamental for any sustainable improvement in the welfare of the poor.

Participation means local people organising to shape the terms of the social, political, and economic processes that affect them. In other words, the people create organised demands upon governments and agencies as well as private and commercial bodies to meet their needs using indigenous expertise and technologies.

Participation also implies capacity building and the strengthening of local institutions Haralambous, Naturally, agenda-setting and policy formation play an important role in this effort. Food and nutrition policy may be among the most important and most obvious to people at the local level and local schools may be a natural focal point for such organization and participation. However, in some countries, the style of government does not permit the type of citizen participation discussed here.

Mass media and social communication Using mass media to increase awareness The mass media were not used widely in nutrition communication until the s.

Before then, nutrition communication relied almost entirely on face-to-face instruction in health clinics Lediard, Many early efforts using mass media in nutrition communication yielded disappointing results. This was often because the quality of many past programmes was inferior due to a lack of training or preparation, inadequate resources, or because it was used for inappropriate purposes.

Media cannot, for example, cure poverty Lediard, But, neither can media be relied upon to change behavioural patterns by itself.

Media-based nutrition education projects are now legion. Some have produced changes in behavioural practices, such as campaigns for oral rehydration salts in Egypt, the Honduras, Gambia, and Swaziland, but changes in nutritional status are rare Hornik, It is now known that the best use of media, particularly for stand-alone media campaigns, is to build public awareness about a new issue, problem, or resolution.

One of the most powerful aspects of the media is its ability to set the public's agenda. That is, media shapes what people view as important in the world, and it identifies and defines concerns, issues and problems. This is another form of building awareness. Other forms of two-way communication may be needed to persuade the public to adopt a different behavioural approach, for example, to infant feeding.

Developing single message strategies Today, the strategies used to develop mass media communications in nutrition are taken from social marketing literature. Several sources provide good descriptions of how to plan persuasive messages such as Andrian , Rasmuson et al. Generally, four questions are posed at the beginning stages. Who is the target audience or consumer for the communication?

What is the product? What is the message? What are the channels of communication? Market research is used to answer these questions and the media messages and campaign are designed accordingly.

There are four elements involved in designing an effective single message Hornik, Some of the key points include creating messages that are clear, concise, credible, and easy to remember, all from the target audience's perspective.

Above all, the messages need to appeal to the target audience's perceived need for information. The most effective messages include a precise behaviour change recommendation, use a memorable slogan or theme, and are presented by a credible source in a positive, uplifting style that is not offensive to any member of the target audience US Department of Health and Human Services, Finally, a focus on motivation, not just information, is needed.

Of course, all media should be thoroughly pre-tested with members of the target audience, as described earlier in this chapter. A variety of media may be used to communicate a single message, including bulletin boards, booklets, pamphlets, posters, radio and television messages, newspapers, community bill boards, and promotional give-aways to name just a few.

Promotional give-aways are products that carry slogans or short messages including calendars, T-shirts, caps, vests, ball point pens and pencils, notepads, pins, and bags. Effective promotionals are items that are regularly used by the recipients, routinely reminding them and those with them, of the message.

Print messages should specifically avoid jargon and technical terms, abbreviations and acronyms, small type, and long words, sentences, and paragraphs. Text should be written in an active voice and use organising headers, bold print and "boxes" to highlight important points.

Graphics should be immediately identifiable to the target audience, relevant to the subject matter, and kept as simple, but up-to-date, as possible. Short second public service announcements, spots, or plugs on radio or television should also recommend a specific action, make a positive not a negative or fearful appeal to the audience in simple language with a memorable theme, music, visual, or character to deliver the message.

Even the best designed message needs to be repeated many times if it is to build general public awareness or accomplish any other outcomes. Any form of mass media has a limited effect when it is delivered only once or for a short period of time.

The audience needs frequent exposure to the message, even if it is familiar, but especially when it is new or novel to them. The greater the reach, frequency, and duration of a mass media message, the greater the number of people who will be reached and the greater the likelihood that change will occur. Using mass media as the centre piece for a multi-channel campaign A fundamental dilemma in nutrition communication is that interpersonal communication may be more effective at promoting behaviour change, but its reach, and ultimate impact, is limited by the size of the audience Gillespie, The mass media reach far more people in far less time.

However, single messages are unlikely to change strongly held attitudes or behaviours. Mass media campaigns are defined as planned, large scale, multimedia efforts to communicate a single concept idea to a target population s in a prescribed amount of time Wallack, Generally, mass media campaigns: Mass media campaigns may speed the rate of behaviour change, but rarely initiate it.

They can also play a role in facilitating one or more steps in the behaviour change process. They work best, however, in synchrony with other intervention components. Several family members should be targeted by messages in order to facilitate a supportive home environment for the desired behavioural changes. Different media have different effects on different people.

Heavy users of the media react differently to media messages than light users. Heavy users those who listen to or watch media for four or more hours a day tend to rely on the media for information about their community and the larger society. Some people are interested in certain topics e. A multi-channel nutrition communication campaign that introduces new messages with star personalities drawn from these interest areas can take advantage of this.

For example, in Brazil, the captain of Brazil's World Cup football team, a well-known male musical entertainer, and three well-known television actresses were used in second television commercials to support breast-feeding ad Kahn, Alternatively, nutrition messages can be incorporated into pre-existing heavily watched media e.

Other communication channels can then be used to reinforce these messages and stimulate behaviour change, especially at the local level. In Thailand, for example, Buddhist monks were very influential within communities, but mass media was useful for initiating community campaigns for change Smitasiri et al. Facilitating pro-active use of mass media Several factors contribute to the potency of any media campaign.

Media effects are limited when interpersonal relations and prior beliefs conflict with the message. Media effects can be powerful when they coincide with interpersonal relations. When the public hears a message that makes them uncomfortable, they may selectively pay no attention to it, misinterpret it, fall back on their own rationalisations, disbelieve it, or attack the source's credibility to reduce their discomfort with the message.

People will be less resistant to a new message if it is introduced by opinion leaders in the local community or general society. Only sound market research prior to message development can anticipate and accommodate the conflicts the target audience might have with the messages.

Because multi-channel media campaigns are by definition complex, partnerships are highly recommended to facilitate their development, implementation, and evaluation. Nutritionists need to form partnerships with social scientists and communication or media specialists.

In addition, multi-sectoral partnerships are also routinely required. They may involve private industry, non-governmental agencies, government agencies, religious leaders, and grassroots participation at the local level. Policy-makers should, in particular, be thought of as a target audience and be included in communication design.

Desired changes are most likely to occur within a supportive environment for change. Only broadly based partnerships can create that context. Authoritarian-type governments may provide a better context for a co-ordinated, multi-sectoral communication programme than more democratic-type governments where communication industries are independent, commercially oriented, and owned by many different people.

In recent years, innovative mass communication approaches have been effectively integrated into mass media campaigns to create widespread attention, interest, motivation, and recall for particular nutrition, health and population messages. One approach has been called "enter-educate. The enter-educate productions are aired over radio and television, featured in magazines and newspapers, and even through live shows in shopping malls. A similar approach, "info-tainment", combines the objectives of informing while entertaining the public via comedy and drama programmes over radio, television, and comics.

Info-tainment has also been used by community development workers to reinforce their interpersonal approaches. Using mobile audio-visual vans, they present certain video documentaries on agricultural technology, alternating with a full length movie of the audience's choice.

The advertising industry has also introduced "values advertising" and "development plugs" to inject messages with developmental value in their advertisements. Enter-educate, info-tainment and developmental plugs are unlikely to work effectively unless they are created by a team of nutrition educators and mass media specialists. Inter-sectoral partnerships can accomplish two objectives. They may increase the broadcast of more positive nutrition messages, and thereby change the communication mix.

They may also decrease the broadcast of negative messages as partners recognise the number and kind of negative messages already broadcast in the mass media. They may then voluntarily withdraw certain negative messages or work to change some of those messages. Training media journalists There is a shortage of media specialists in developing countries, especially those associated with ministries of health or education.

In some cases, a ministry of agriculture may have access to communication expertise. Health ministries and education ministries should be encouraged to create positions for media specialists and include them in the earliest stages of programme development. They should also try to work inter-sectorally to support training for media specialists and create an infrastructure to support their activity.

Media journalists tend to be trained as generalists. Few have the expertise to correctly communicate health and nutrition information to the public. Therefore, multiple training programmes are necessary to promote effective nutrition communication campaigns: This will require training on how to incorporate innovative technologies into programme planning as well as the use of traditional communication modalities.

This will require additional training in the behavioural and social sciences. Training of media journalists and communication experts can be costly in itself, but the Union of National Radio and Television Organisations of Africa URTNA has developed an effective model that may be appropriate in many parts of the world. URTNA has 48 member countries that team together to sponsor training sessions and an exchange of programmes and teachers across international boundaries.

In a three year period, they have graduated technicians from their training programmes and have exchanged over 2, radio and television programmes for broadcast. Regular meetings held every two weeks between communicators from national broadcast organisations and experts in family planning and maternal and child health are considered a key element in this programme's success. The meetings foster open communication between these two fields and stimulate teams in different countries to produce higher quality programmes Demena, Effective training programmes are needed, but are not sufficient, for the creation of successful communication programmes.

Successful programmes require not only the incorporation of communication technologies, but also institutional infrastructure and a supportive policy and philosophy to sustain such communication efforts across a region or country. Work-site programmes Establishing the benefits to employers and employees Healthy work-site programmes became popular in the s and nutrition education is a common component of these interventions.

They have been reported in telephone companies, police departments, Fortune companies, and small local businesses. Healthy work-site programmes emphasise disease prevention or health promotion. For example, it is less costly to prevent hypertension via education than it is to treat it via medication. Some of these chronic diseases are related to food habits and choices.

Since these food-related behaviours are not fixed, communication and other interventions designed to modify these behaviours may decrease the risk associated with these diseases, and presumably increase worker productivity, decrease company costs and improve the company's public image.

Work-site nutrition education programmes are appealing for many reasons. From the employer's perspective, they may increase workers' productivity, decrease absenteeism and turnover, improve recruitment of personnel, and generally improve company morale. From the health-care provider's perspective, work-site nutrition education programmes provide access to workers who may not otherwise be served by the health-care community, enable cost-effective and efficient screening opportunities, provide a forum where nutrition information can be efficiently disseminated, and an environment where behaviour can be monitored and social or peer influences can be used to reinforce behaviours.

From the employees' perspective, work-site nutrition education programmes may be attractive because they are convenient, meaningful, credible, and ongoing. If successful, they can decrease health-care costs and improve the happiness, health, and quality of life for individual workers and their families Johnson, et al. Screening and needs assessment Groups of participants can be screened, counselled, and followed in a time-efficient and cost-efficient way Johnson, et al.

These screening data should be used to design appropriate interventions and communication campaigns for the company as a whole and possibly, for individuals within the company. Baseline data should be collected about the individual workers, their home and community environment, and their employers and work environment before a work-site programme is designed and implemented.

Assessment of the work-site should include management style e. Some of these variables are important in order to determine how to introduce and sustain a work-site programme in the most acceptable manner to both workers and management. Catering programmes, nutritional improvements of food services, and point of sale promotions Many family members, including school children, spend a major part of their day in the workplace or in school.

This means that they must eat at least one meal and about two snacks outside the home. This has led to the growth of the food service industry, particularly street-food vending in developing countries. The street-food trade is a source of livelihood for many people among the low income group, and is a source of cheap food for low to middle income people.

Recognising the need to protect consumers against unhygienic and low quality street-foods, FAO supported pilot projects on the improvement of street-food safety and quality in several developing countries in Asia and Latin America.

An education and communication component was built into the projects, addressing consumers on one hand, and educating street-food vendors on the other, on topics like basic nutrition, food preparation, hygiene, and sanitation. Seminars and training in the workplace had been successfully carried out for both groups, reinforced by well researched and properly designed print and audio-visual media such as posters, flyers, brochures, flipcharts, and training modules.

In these programmes, employers offer their workers choices of nutrient-dense foods e. These foods may or may not be offered along with other less desirable choices. Often nutrient information in the form of labels or posters accompanies the foods in the cafeteria environment. Entrepreneurial lunch wagons can offer nourishing food to field work-sites that are remote from feeding facilities.

Facilities for washing before eating are also important. Some companies subsidise in-plant food services partially or totally, making them nutritious, attractive and convenient to employees. Some employers have also added nutrition awareness games and incentive raffles e.

Research studies have generally produced positive trends in dietary intake but often only outcomes over a short period of time are evaluated. Most of the catering programmes reported in the literature have concentrated on heart health issues, but other issues that could be considered include use of fluoridated water, iodised salt, adequate protein, clean water, and iron.

Nutrition education as a stand-alone work-site programme Nutrition education that is not connected to any other form of health education at the work-site can be described as a stand-alone programme. Carefully targeted materials and classes can have a significant impact on nutritional status, not only for employees, but for their family members as well. The success of stand-alone programmes depends on how supportive the company environment is of the recommendations.

Stand-alone programmes are unlikely to work if they include only information dissemination. Generally, work-site nutrition education programmes require supportive environments such as cafeteria or food catering programmes as described above.

It is essential that employees have access to appropriate food choices. Release time from work and employer commitment to the programme are also viewed as important to success. Employees respond best to healthy work-site programmes that are simple, practical, and relevant and that allow them to participate actively in the learning activity during work time. Eating pattern messages which include specific foods or brand names and behaviourally oriented programmes are better accepted than messages containing medical jargon and lengthy background explanations McCarthy et al.

Nutrition education as part of an integrated health programme Nutrition education can also be integrated into a more comprehensive health programme at the work-site that might include, for example, smoking cessation programmes, drug and alcohol education, stress management, child-care education, and breast-feeding support.

It may be combined with an exercise or fitness programme or more often, a weight control programme. Work-site nutrition education programmes can also be integrated into the broader community. Community-based wellness councils, for example, team non-profit health organisations with small businesses and vendors within and across communities. The councils do not compete. Rather, they bring together local providers with common interests to share ideas and resources to offer healthy work-site programmes that they cannot afford themselves.

Often they share newsletters and strategies with one another. Wellness councils may publish "how to" guides, hold delegate meetings and annual meetings, or share the cost of bringing in an outside consultant or nationally known speaker Kizer, Ideally, community-based wellness councils match local expertise to local needs and help small businesses lever their limited resources for maximal impact. Together, they may also affect an entire community to create a more healthful and supportive environment for its citizens.

Number of work-site programmes Given the advantages of, and opportunities for work-site nutrition education programmes, it is interesting to note their small number, especially in developing countries.

This may, in part, be due to the lack of an infrastructure for these programmes, but there are several other considerations as well. Work-site programmes have been criticised because many tend to serve only healthy workers or well-paid, professional employees, neglecting those in greatest need. They may increase personnel costs to the company, at least initially, and they may subject a company to liability concerns Ostby, Relatively little attention has been given to developing methods for institutional commitment, and this seems critical to programme success.

Conclusions This review has led us to draw four broad conclusions: These conclusions are further developed below. Nutrition education and communication should be thought of as an integral part of a country's development plan. The nutritional status of a country's population is an important indicator of national development. The causes of poor food habits are complex. The simple provision of food or supplements does little to resolve long-term nutritional problems. Nutrition education and communication can have a significant impact on a population when there is political stability, social coherence, and a favourable economic climate.

Nutrition education and communication provide people with the knowledge, know-how, motivation, and reinforcement to empower them to effectively address their own long-term food and nutrition problems. Changing food and nutrition behaviours to improve nutritional status at a country level is a long process comprising many steps in many sectors at many levels. Recognition of this fact may call for a reorientation in thinking about nutrition programmes.

A long-term, holistic view of nutrition education and communication is needed, with nutrition education seen as a central component, not merely as a tool to use on occasion. This holistic view may also require a re-examination of the philosophy, processes, strategies, messages, and methodologies used in nutrition interventions.

It involves many actors including policy makers, planners at community and national levels, educators and communicators, NGOs and other providers of resources, field support staff and service delivery personnel, community leaders, and finally, mothers, children, and other family members. Nutrition education and communication programmes need to be comprehensive and coordinated for effectiveness.

Mass media messages, although cosmetically perfect, will be ineffective as stand-alone interventions. Rather, several communication channels should be used. At least some of these channels should involve two-way communication.

These activities require an administrative infrastructure, including organisational structure and managerial mechanisms to support a coordinated effort. Usually these efforts will have to be multi-sectoral in nature. Commitment to the programme effort at all levels is needed for sustained programmes. Nutrition education and communication programmes need to be participatory in order to effective.

Interventions should be problem-solving, decision-making and action-oriented. Ideally, the target audience should feel a sense of ownership of the programmes. Therefore regular interpersonal communication is needed with at least some representatives in all development, implementation, and evaluation procedures.

Recommendations The conclusions lead to four specific recommendations: These recommendations are described in further detail below. The commitment of political leaders, policy makers and resource providers should be sought as an initial step to programme planning and launching of the implementation strategy.

Advocacy efforts can help to enlighten policy-makers and resource-providers about the importance and effectiveness of nutrition communication in influencing behaviour changes to improve nutritional well-being. Continuous support and commitment is essential to success. A two-way flow of information and resources should be emphasised in all nutrition and communication programmes.

A two-way flow implies the effective use of both top-down and bottom-up as well as lateral communication. It assumes that programme or project formulation begins with the target groups and it uses consultation, co-ordination, collaboration, and co-operation m feedback, information-sharing and decision-making. As a result of the public's participation in the process, they should be able to decentralise the provision of services and institutionalise policy for communication and behaviour change in their own community development strategy.

More and better quality training programmes are recommended. Training should not be a mere one-off effort. Rather, continuous in-service training is needed in order to respond to changing priorities and problems, to share relevant experiences or lessons learned, and to develop educational and communication technology.

Training in programme management should also be included in education and communication technology. A train-the-trainer approach could be used within country or across national boundaries. The first level of training, then, would be the training of more trainers. The second level should be training of field support staff, community workers, teachers, and curriculum developers. The third level should be the training of specific target groups such as women or school children.

Nutrition communication and education efforts should effectively combine the processes and approaches of social marketing, social mobilisation, and development support communication. No single approach will be continuously effective or suitable to the resolution of all problems, but each of these approaches has proven effective for certain problems at certain stages of behaviour change and development.

Programme planners should be adept at all these strategies and employ each wherever it is suitable, again in a comprehensive and co-ordinated manner. Other theories and approaches to behaviour change should also be explored. In conclusion, development should concern everyone. Nutrition improvement is a basic requisite to development. Concerted efforts in nutrition education and communication may facilitate its realisation, providing sufficient resources are available.

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