Increasing Awareness and Use of Iodised Salt in a Marginalised Community Setting in North-West Pakistan

Mineral content in commercially branded and local salt in selected villages from Bahi, Iramba, Manyoni, and Singida urban districts, Tanzania

The study examines the mineral content of table salts used by households in villages adjacent to the production areas. A total of 210 samples from commercial and local salts were collected, and analyzed using iodometry titration, spectrophotometry, colorimetry, and atomic absorption spectroscopy (AAS) techniques, followed by a household interview for salt type preference. The lowest detectable concentration LOD, lowest quantifiable concentration LOQ and, recovery of methods ranged (0.32-2.155 μg/kg), (0.117-6.387 μg/kg) and, (94.2-103.6 %), respectively. Significant differences in mineral contents were observed within and between local and commercially branded salts (p < 0.001). The mean iodine in the local salt samples from Kitangiri (SA), Singidani (SB), Kindai (SC), Chibumagwa (SD), and Sulunga (SE) ranged from 10.5 ± 0,02 to 16.9 ± 0.01 mg/Kg, with only SA and SC in the World Health Organization (WHO) limits, while commercially branded salt samples SF (Malindi), and SG (Dar es salaam) ranged from 23.4 ± 0.01 to 35.9 ± 0,02 mg/kg that were in the Tanzania Bureau of Standards (TBS) and WHO agreed range. Other ions recorded were nitrate (3.3-4.4 mg/kg, 5.45-7.40 mg/kg), phosphate (0.02-0.48 mg/kg, 0.03 mg/kg), sulphate (0.31-0.42 mg/kg, 0.03-0.07 mg/kg), ammonia (0.5 mg/kg, 0.5 mg/kg to 0.6 mg/kg), copper (1.0-2.0 mg/kg, 0.9-2.0 mg/kg), iron (0.5-1.8 mg/kg, 0.9 mg/kg), and manganese (0.5-1.8 mg/kg, 0.9 mg/kg) for local and commercially branded salt, respectively. Households preferred local to commercial-branded salts: Nkonkilangi 163 (69.9, 32.1 %), Mangwanjuki 96 (17.2, 82.8 %), Unyanga 54 (26.7, 73.3 %), Chibumagwa 106 (63.0, 37.0 %), and Chali Igongo 51 (74.6, 25.4 %), respectively. Public health interventions are recommended to promote the consumption of adequately iodized salt for informed dietary choices.

Adequacy of iodized salt and its associated factors among households in the Bahir Dar Zuria district, Northwest Ethiopia, 2022

Background

The inadequacy of iodine in salt is the a contributing factor behind lack of awareness and poor economic performance in developing countries. To address the issue of iodine deficiency, universal salt iodization has been implemented globally. Nevertheless, it is imperative to closely monitor the sufficiency of iodine in salts to achieve its intended objective at the household level in the Bahir Dar Zuria district.

Objective

To assess the adequacy of iodized salt and its associated factors among households in the Bahir Dar Zuria district, Northwest Ethiopia.

Methods

A community-based cross-sectional study was conducted from May to June 2022 among households in Bahir Dar Zuria district. The data were gathered from 825 households that were chosen using a multistage sampling process. Iodometric titration was used to assess the amount of iodine in salt. The data were gathered using a structured questionnaire that was administered by an interviewer. For data entry and analysis, EpiData version 3.01 and SPSS version 25.0 were used, respectively. To evaluate the association between explanatory factors and the outcome variable, binary logistic regression was conducted, and significance was determined at alpha 0.05.

Result

This study analyzed a total of 825 households. Of these, only 384 [46.5, 95% CI, 43.5-50.5%] households had adequately iodized salt at home. Age increase of 1 year [AOR = 1.04, 95% CI = 1.02-1.06], being an urban resident [AOR = 3.18, 95% CI = 1.84-5.48], diploma and above educational attainment [AOR = 3.74, 95% CI = 1.99-7.02], checking salt by asking the seller [AOR = 2.21, 95% CI = 1.26-3.88], storing salts in closed containers [AOR = 1.57, 95% CI = 1.13-2.19], and storing salts in a dry and cool area [AOR = 2.72, 95% CI =1.37-5.42] were associated with the adequacy of iodized salt at the household level.

Conclusion and recommendation

The percentage of households in the district (46.5%) that had enough iodized salt in their homes is still extremely low and falls short of the targeted level for the country. At the household level, adequate iodized salt was found to be associated with age, place of residence, level of education, checking salt iodization while purchasing, place of salt storage, and cover use for salt containers. Therefore, increasing the accessibility of iodized salt at the household level is essential.

Burden and trends of iodine deficiency in Asia from 1990 to 2019

OBJECTIVES

Understanding iodine deficiency (ID) burdens and trends in Asia can help guide effective intervention strategies. This study aims to report the incidence, prevalence, and disability-adjusted life years (DALYs) of ID in 48 Asian countries during the period 1990-2019.

STUDY DESIGN

Data on ID were retrieved from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 and estimated by age, sex, geographical region, and sociodemographic index (SDI).

METHODS

The estimated annual percentage change (EAPC) was calculated to evaluate the changing trend of age-standardized incidence rate (ASIR), age-standardized prevalence rate (ASPR), and age-standardized DALYs rate (ASDR) related to ID during the period 1990-2019.

RESULTS

In Asia, there were 126,983,965.8 cases with 5,466,213.1 new incidence and 1,765,995.5 DALYs of ID in 2019. Between 1999 and 2019, the EAPC in ASIR, ASPR and ASDR were -0.6 (95% confidence interval [CI], -0.8 to -0.4), -0.9 (95% CI, -1.2 to -0.7), and -1.6 (95% CI, -1.8 to -1.5), respectively. Malaysia charted the largest decrease in ASIR, ASPR, and ASDR (82.4%, 85.3%, and 80.9% separately), whereas the Philippines and Pakistan were the only two countries that witnessed an increase in ASIR and ASPR. ID burdens were more pronounced in women, countries located to the south of the Himalayas, and low-middle SDI regions.

CONCLUSIONS

The incidence, prevalence, and DALYs of ID in Asia substantially decreased from 1990 to 2019. Women and low-middle SDI countries have relatively high ID burdens. Governments need to pay constant attention to the implementation and monitoring of universal salt iodization.

Awareness of Chronic Kidney Disease, Medication, and Laboratory Investigation among Nephrology and Urology Patients of Quetta, Pakistan

Patients’ awareness is critical in medical care, as it can serve as an input into the adjustment of interventions. The aim of study was to explore the level of awareness regarding chronic kidney disease (CKD), its medications, and laboratory investigations among nephrology and urology patients of Quetta. The cross-sectional study was used by adopting and culturally modifying a questionnaire. By convenient sampling technique, a total of 500 questionnaires were self-administered to inpatients, outpatients, and dialysis patients, and 468 responses (response rate 93.6%) were analyzed. Descriptive statistics, inferential statistics, and reliability analysis were performed on SPSS v25. A majority, 50.3% (n = 235), was unaware of symptoms that will develop due to worsening of disease, while 56.2% (n = 263) were unaware of what aggravates their kidney function. Almost half of the affected individuals, 47.4% (n = 222), have no understanding about the long-term prognosis of the disease. The majority of the respondents, 51.5% (n = 248), do not know about the names and usage of medications, and 62.4% (n = 292) were unaware of the medicines that may impair kidney function; more than half, 66.7% (n = 312), were unaware about the necessary laboratory investigations. A strong association between awareness and patient education level was found (p < 0.001). Awareness regarding disease condition, medications, and laboratory investigations of CKD among nephrology and urology patients of Quetta was found out to be low, which needs immediate educational intervention.

Evaluation of Factors Affecting Thyroid Levels and its Relationship with Salt Iodine to Suggest the Way Forward!

Background:

In India, 42 million people suffer from thyroid diseases. One in 10 adults suffer from hypothyroidism. Although coverage of iodized salt utilization has increased after universal salt iodization, we are yet to achieve the goals of NIDDCP for which the present study was planned to identify the hidden factors. The aim is to identify the factors affecting thyroid hormone levels, their association with salt iodine content and suggest strategies for improvement based on patient perceptions.

Methods:

A hospital based prospective follow up study was conducted among 140 patients, with an in depth interview and testing of salt iodine content. Data were analyzed using the SPSS software.

Results:

96 (69%) patients were of age 18–35 years. 129 (92%) were females, 120 (86%) were from rural areas, 95 (68%) were literate, 116 (83%) were unemployed, and 115 (82%) were of low socioeconomic status. Most of them had poor cooking practices and dietary habits. The T3, T4, and TSH levels were within the normal range in 84 (60%) patients. Only in 28 (20%) salt samples, the iodine content was adequate. The association between factors like intake of inadequately iodized salt (P < 0.01), rural distribution (P < 0.05), illiteracy, presence of the comorbid conditions (P < 0.0001), and thyroid hormone abnormality was found to be statistically significant.

Conclusion:

The factors that adversely affect thyroid levels were higher age, female gender, rural distribution, comorbid conditions and patients with low salt iodine were prone to abnormal levels. Monitoring salt iodine content, training of health care workers to create awareness were the key strategies proposed for improvement.

Knowledge, Practice, and Availability of Iodized Salt and Associated Factors in Jibat Woreda, West Shoa Zone, Ethiopia

Appropriate knowledge, practice, and availability of iodized salt are used to eliminate iodine deficiency disorders. However, little is known about the availability of adequately iodized salt in the western part of Ethiopia. Thus, the aim of this study was to assess knowledge, practice, and availability of iodized salt and associated factors at household level in Jibat woreda, Ethiopia. Community-based cross-sectional study was conducted using structured and pretested questionnaire interview. Sampling salt was tested by the iodometric titration method. The result showed that iodine content more than 90% was considered as adequately iodized salt. The result of this study shown that among the 357 salt samples, 191(53.5%) households had good knowledge on iodized salt while 166 (46.5%) had poor knowledge on iodized salt. In addition, the result of the study revealed that 162 (45.4%) had good practice of iodized salt, whereas 195 (54.6%) had poor practice of iodized salt. The result of this study also shown that 149 (41.7%) households were using adequately iodized salt while 208 (58.3%) were using inadequate iodized salt in study area. Residence area, education level, household job, and average monthly income were significantly associated with knowledge of iodized salt at household level. Residence area, educational level, average monthly income, and expose to sunlight were significantly associated with availability of adequately iodized salt. In this finding, the knowledge and practices of iodized salt at household level in Jibat woreda, Ethiopia, were poor, and the availability of iodine in iodized salt was inadequate. This is associated to residence area, education level of household, and average monthly income. Therefore, any concerned body/institution should have to work in the above gabs of the knowledge, practice, and availability of iodized salt.

Individual and community level factors associated with use of iodized salt in sub-Saharan Africa: A multilevel analysis of demographic health surveys

Introduction

Iodine deficiency disorder a common problem in sub-Saharan Africa (SSA). It affects not only the health of the affected individual but also the economic development of the country. However, to the best of our knowledge, there is a scarcity in literature about the associated factors of iodized salt utilization in sub-Saharan Africa. Therefore, this study aimed to identify both individual and community level determinants of iodized salt utilization in sub-Saharan Africa.

Methods

This study used the appended datasets of the most recent demographic and health survey from 31 sub-Saharan countries. A total weighted sample of 391,463 households was included in the study. Both bivariable and multivariable multilevel logistic regression were done to determine the associated factors of iodized salt utilization in SSA. P value ≤ 0.05 was used to declare statistically significant variables.

Results

Those households with primary (AOR  =  1.53, 95% CI  =  1.50–1.57), secondary (AOR  = 1.81, 95% CI  =  1.76–1.86) and higher education level (AOR  =  2.28, 95% CI  =  2.17–2.40) had higher odds of iodized salt utilization. Households with middle (AOR  =  1.05, 95% CI  =  1.02–1.08), richer (AOR  = 1.13, 95% CI  =  1.09–1.17) and richest wealth index (AOR  =  1.23, 95% CI  =  1.18–1.28) also had an increased chance of using iodized salt. Households from high community media exposure (AOR  =  2.07, 95% CI  =  1.71–2.51), high community education level (AOR  =  3.78, 95% CI  =  3.14–4.56), and low community poverty level (AOR = 1.29, CI  =  1.07–1.56) had higher odds of using salt containing iodine.

Conclusion

Both individual and community level factors were found to be associated with use of salt containing iodine in sub-Saharan Africa. Education level, media exposure, community poverty level, wealth index, community education, and community media exposure were found to be associated with use of salt containing iodine in SSA. Therefore, to improve the use of iodized salt in the region, there is a need to increase access to media sources and develop the socioeconomic status of the community.

Knowledge, attitude and behaviour of university students regarding salt and iodine: a multicentre cross-sectional study in six countries in Europe and Asia

Background

Strategies to reduce salt intake are encouraged to be implemented in parallel with those that aim to ensure iodine adequacy at the population level. The aim of the present study was to assess and compare knowledge, attitudes and behaviours related to salt and iodine among students in Europe and Asia.

Methods

A multicentre cross-sectional study was conducted with 2459 university students in total (42.7% males, median age 21 years) from four countries in Europe and two countries in Asia. Data were collected with the use of a self-administered questionnaire, and univariate and multivariate statistical analyses were performed to explore any association between variables.

Results

Only 6.5% of all participants knew the correct salt recommendations. Nearly a quarter of them (24.4%) found salt recommendations confusing and/or contradictory. There were significant differences between European and Asian participants, with those from Europe being better informed about salt recommendations, but significantly less knowledgeable about iodine. The reported frequency of use of salt and salt-containing sauces either at the table or for cooking, as well as knowledge about ways to reduce salt intake among those who indicated to make conscious efforts to do so, differed significantly between countries. Significant differences between countries were also observed with respect to the type of salt used, with about one third of all participants (34%) not being aware of the kind of salt they used.

Conclusion

The results of this survey highlight serious salt- and iodine-related knowledge gaps among university students in Europe and Asia. Raising awareness and conducting information campaigns is needed to promote changes in behaviour that would result in a reduction of salt intake and conscious use of iodised salt at the individual level.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-021-00593-5.

The global challenge of hidden hunger: perspectives from the field

The aim of this review paper is to explore the strategies employed to tackle micronutrient deficiencies with illustrations from field-based experience. Hidden hunger is the presence of multiple micronutrient deficiencies (particularly iron, zinc, iodine and vitamin A), which can occur without a deficit in energy intake as a result of consuming an energy-dense, but nutrient-poor diet. It is estimated that it affects more than two billion people worldwide, particularly in low- and middle-income countries where there is a reliance on low-cost food staples and where the diversity of the diet is limited. Finding a way to improve the nutritional quality of diets for the poorest people is central to meeting the UN sustainable development goals particularly sustainable development goal 2: end hunger, achieve food security and improved nutrition and promote sustainable agriculture. As we pass the midpoint of the UN's Decade for Action on Nutrition, it is timely to reflect on progress towards achieving sustainable development goal 2 and the strategies to reduce hidden hunger. Many low- and middle-income countries are falling behind national nutrition targets, and this has been exacerbated by the COVID-19 pandemic as well as other recent shocks to the global food system which have disproportionately impacted the world's most vulnerable communities. Addressing inequalities within the food system must be central to developing a sustainable, cost-effective strategy for improving food quality that delivers benefit to the seldom heard and marginalised communities.

Impact of knowledge, attitude, and practice on iodized salt consumption at the household level in selected coastal regions of Bangladesh

BACKGROUND

Iodine deficiency disorder is one of the major hidden hunger for poverty-stricken coastal rural areas of Bangladesh. Despite various programs, including universal salt iodization, IDD is significantly persistent due to poverty, inadequate knowledge, poor attitude, and practice of iodized salt consumption. The present study aimed to determine iodine concentration in salt at the household level as well as the magnitude of knowledge, attitude, and practice related to iodized salt utilization and iodine deficiency disorders (IDDs).

MATERIAL AND METHOD

A population-based cross-sectional study was carried out using multistage sampling among 400 households in four coastal districts in Bangladesh. A standard pretested questionnaire was used to determine the knowledge, attitude, and practice towards iodized salt consumption. The iodine level was measured using the gold standard iodometric titration technique in the collected salt samples from the selected households.

RESULT

The study results revealed that almost half of the participants had good knowledge regarding a balanced diet, whereas the positive attitude and practice of balanced diet consumption was relatively low (only 16.2% and 11.3%, respectively). The respondents' education profile and age were strongly correlated with knowledge and attitude; however, the practice was not significantly correlated with age and education. The concentration of iodine in salt at household levels was strongly associated with the practice of using iodized salt. Use of adequate iodized salt was 2.838 times (OR: 2.838, 95% CI: 1.7-4.735) and 3.884 times (OR: 3.884, 95%CI: 2.029-7.433) more likely to have a positive attitude and good practice towards iodized salt and IDDs respectively.

CONCLUSION

Proper knowledge about iodized salt and IDDs should be introduced to all public education premises levels. Interventions and programs can be formulated to enhance knowledge, attitude, and practice at the household level so that the consumption of adequate iodized salt can be ensured to reduce iodine deficiency problems.

Effect of nutrition education on iodine deficiency disorders and iodized salt intake in south west Ethiopian women: a cluster randomized controlled trial

BACKGROUND

Although iodine nutrition status is improving globally, the progress is not uniform throughout the world due to several factors. Among these, poor knowledge, negative attitude and improper practice of iodized salt are the main risk factors for poor iodine nutrition in Ethiopia. This study was aimed to assess the effect of nutrition education intervention on knowledge, attitude and practice (KAP) of iodine deficiency and iodized salt utilization.

METHODS

A cluster randomized controlled trial was carried out among 652 women of reproductive age group in southwest Ethiopia. A total of 24 clusters were selected and randomized in to an intervention and control villages. Women in the intervention village received iodine nutrition related education for 6 months; while those in the control village did not receive any education. Baseline and endline data were collected from both groups. Generalized Estimating Equations (GEE) was used to determine the effect of intervention.

RESULTS

A total of 647 (99.2%) participants were successfully involved in the study. In the intervention group the median attendance was 10 out of 12 sessions. Women in the intervention group had shown statistically significant change in knowledge, attitude and practice scores as compared to control one. In multivariable GEE linear model, after adjusting for other background characteristics, the mean difference (95% CI) scores were 8.81 (8.46, 9.16) for knowledge, 3.35 (3.17, 3.54) for attitude and 2.90 (2.74, 3.05) for practice in the intervention arm.

CONCLUSIONS

Well designed and community-based iodine nutrition education is an effective strategy to improve the KAP of iodine deficiency disorders and iodized salt utilization. Trial registration PACTR201809544276357 (Retrospectively registered on 14, Sept. 2018). https://www.pactr.org .

Spatial distribution and determinants of household iodized salt utilization in Ethiopia: a spatial and multilevel analysis of Ethiopian demographic and Health survey

BACKGROUND

Iodine deficiency disorder is a significant public health problem, affecting both developed and developing nations worldwide. It is associated with poor body growth and irreversible mental retardation. However, little is known about the spatial distribution and determinants of household iodized salt utilization in Ethiopia. Therefore, this study aimed to explore the spatial distribution and determinants of iodized salt utilization at national level.

METHODS

Ethiopian Demographic and Health Survey 2016 data was used to investigate the spatial distribution and determinants of household iodized salt utilization in Ethiopia. ArcGIS 10.6 and SaTScan™ version 9.6 software were used to explore the spatial distribution and detect significant clusters, respectively. The odds ratio with its 95% confidence interval (CI) was determined for potential determinants included in the multivariable multilevel logistic regression model.

RESULTS

Household iodized salt utilization was spatially clustered in Ethiopia (Moran's Index = 0.076, p-value = 0.01). The significant hotspot areas with high iodized salt utilization were located in Benishangul, Amhara, Gambella, Tigray and Northwest Oromia regions. Significant cold spot areas (areas with low iodized salt utilization) were found in Somali, and East Afar regions. Those households with higher education level ((Adjusted Odds Ratio [AOR] =1.49, 95% CI =1.14-1.93), high community level education (AOR = 1.51, 95% CI = 1.03-2.20), middle wealth index (AOR = 1.31, 95% CI = 1.04-1.65) and high community media exposure (AOR = 1.52, 95% CI = 1.07-2.17) had higher odds of iodized salt utilization.

CONCLUSIONS

Household iodized salt utilization had significant spatial variation across the country. Both household and community level variables were found to be associated with household iodized salt utilization in Ethiopia. Therefore, increasing the education level, wealth status and community media exposure is recommended to improve iodized salt utilization in a country. A targeted intervention is also needed for those regions with low household iodized salt utilization.

Exploring community perceptions in preparation for a randomised controlled trial of biofortified flour in Pakistan

Background

Biofortification of staple food crops may be a cost-effective and sustainable approach to reducing micronutrient deficiencies in resource-poor settings with low dietary diversity. However, its success depends on uptake by the local population. This paper presents formative research conducted in a remote, rural community in North West Pakistan, prior to commencing a randomised controlled trial to test the effectiveness of consuming zinc-biofortified wheat flour for alleviating zinc deficiency. It explored local community members’ knowledge, understanding and attitudes towards biofortification and views on members of their community taking part in the trial.

Methods

Four focus group discussions were conducted with male and female community members (separately for cultural reasons) and four in-depth interviews were conducted with Jirga members—respected male elders. Participation was limited to households that were ineligible for the trial so that we could explore the perspectives of community members who were not influenced by the incentives of the trial. Focus group participants were selected at community events for transparency. Data collection took place at the local school and homes of Jirga members. Thematic analysis was undertaken, using a combination of deductive and inductive approaches to identify key themes.

Results

A total of 47 men and women participated in this study. Participants reported clear motivation to access and consume more nutritious flour, believing this would bring health benefits, particularly to women and children. Trusted members of the local community, including Jirga members and female health workers, should be involved in providing information on biofortified flour (and the trial) to increase levels of awareness and acceptance. Without their involvement, there is a risk that biofortified flour would be mistrusted. The cost of flour is the main factor affecting purchasing decisions, and biofortified flour will need to be cost-competitive to achieve widespread uptake in marginalised, rural communities.

Conclusion

This formative study generated rich, qualitative data from a range of community stakeholders to improve the understanding of important barriers and facilitators to the widespread acceptability and adoption of biofortified wheat. Implementation research such as this will inform future decision-making in relation to scaling up biofortified wheat in Pakistan.

Iodine status of non-pregnant women and availability of food vehicles for fortification with iodine in a remote community in Gulf province, Papua New Guinea

Adequate iodine status of women of childbearing age is essential for optimal growth and development of their offspring. The objectives of the current study were to assess the iodine status of non-pregnant women, availability and use of commercial salt, extent to which it is iodised, and availability of other industrially processed foods suitable for fortification with iodine. This prospective cross-sectional study was carried out in 2018 in a remote area in Gulf province, Papua New Guinea. Multistage cluster sampling was used to randomly select 300 women visiting local markets. Of these, 284 met study criteria of being non-pregnant and non-lactating. Single urine samples were collected from each of them. Discretionary salt intake was assessed; salt samples were collected from a sub-sample of randomly selected households. A semi-structured, pre-tested questionnaire to assess use and availability of commercial salt and other processed foods was modified and used. Salt was available on the interview day in 51.6% of households. Mean iodine content in household salt samples was 37.8 ± 11.8 ppm. Iodine content was below 30.0 ppm in 13.1% and below 15.0 ppm in 3.3% of salt samples. Mean iodine content of salt available at markets was 39.6 ± 0.52 ppm. Mean discretionary intake of salt per capita per day was 3.9 ± 1.21 g. Median UIC was 34.0 μg/L (95% CI, 30.0-38.0 ppm), indicating moderate iodine deficiency. For women with salt in the household, median UIC was 39.5 μg/L (95% CI, 32.0-47.0 μg/L), compared to median UIC of 29.0 μg/L (95% CI, 28.0-32.0 μg/L) for those without salt. This community has low consumption of iodised salt, likely due to limited access. Investigation of other industrially processed foods indicated salt is the most widely consumed processed food in this remote community, although 39.8% of households did use salty flavourings.

Knowledge, attitude, and practice regarding household consumption of iodized salt among rural women of Tripura, India: A mixed-methods study

INTRODUCTION

Iodine is an essential element for thyroid function; it is necessary in minute amounts for normal growth, development, and well-being of all humans. There is gap in the utilization of adequately iodized salt in the rural areas due to nonavailability, poverty, poor knowledge of iodine deficiency diseases, and faulty storage practices.

OBJECTIVE

The objective was to find out knowledge, attitude, and practices (KAP) regarding iodized salt consumption and association of sociodemographic factors, if any, among rural women of Tripura.

MATERIALS AND METHODS

This community-based study was conducted among 270 rural women residing at Madhupur village, Tripura. A self-made pretested schedule (Cronbach's alpha = 0.7) was used as the study tool to collect information on KAP regarding iodized salt consumption.

RESULTS

Majority of the participants belonged to 31-40 years (30.4%), with a mean age of 38.6 (±13.8) years; all were predominantly Hindus (90.4%). Knowledge and attitude regarding iodized salt consumption were significantly associated with age groups ≤36 years, literacy, and general caste (P < 0.05), but practice was not significant (P > 0.05). Good knowledge and attitude regarding use of iodized packed salt were less than half (46.7% and 41.1%, respectively), but higher level (83.3%) of correct practice was found (P > 0.05).

CONCLUSION

The existing knowledge and attitude of participants toward iodized salt usage were less, but majority were consuming iodized salt without knowing its benefits. Hence, there is a need to educate rural people through nutrition education or knowledge, with active participation of grassroot level workers in generating awareness about the health benefits of consuming adequately iodized salt.

Iodine status of children and knowledge, attitude, practice of iodised salt use in a remote community in Kerema district, Gulf province, Papua New Guinea

Iodine deficiency is the single most common cause of preventable mental impairment in communities with suboptimal iodine intake. Objective of the present study was to assess in more detail the iodine status and knowledge, attitudes and practice (KAP) relating to use of iodised salt in a remote community in Kotidanga area, Kerema district, Gulf province, Papua New Guinea. This prospective school and community based cross-sectional study was carried out in 2017. Simple random sampling was used to select schools. Multistage sampling was used to randomly select 300 children aged 6 to 12 years, of which 289 consented to participate in the study. A single urine sample was collected from each of the consenting children, as well as a salt sample from their households. Discretionary salt intake was assessed in a sub-sample of the children's households. Salt iodine content and urinary iodine concentration (UIC) were analysed. A semi-structured modified Food and Agriculture Organisation questionnaire was used to assess KAP of three different community groups. Only 64% of households had salt on the day of data collection. Mean iodine content in household salt samples was 29.0 ± 19.1 ppm. Iodine content was below 30.0 ppm in 54.8% and below 15.0 ppm in 31.2% of salt samples. Mean per capita discretionary intake of household salt was 2.9 ± 1.8 g/day. Median UIC was 25.5 μg/L and Interquartile Range was 15.0 to 47.5 μg/L, indicating moderate status iodine nutrition. Median UIC was 34.3 μg/L for children in households with salt, compared to 15.5 μg/L for children in households without salt, indicating severe iodine deficiency in the latter group. The three community groups had limited knowledge about importance of using iodised salt and consequences of iodine deficiency on health outcomes. This remote community has limited access to adequately iodised household salt due to high cost, inappropriate packaging, storage and food preparation, resulting in iodine deficiency. Strategies to increase iodine intake are needed.

Regional Influences on Nutritional Iodine Status of Pregnant Women in Pakistan

BACKGROUND

Pregnant women are particularly vulnerable to iodine deficiency. Considering the rural-urban disparities in nutritional status in Pakistan, this study aimed to assess regional influences on nutritional iodine status of pregnant women in Pakistan.

METHODS

Data were collected from 1246 pregnant women in all trimesters of pregnancy who visited antenatal clinics for routine checkups in five Khyber Pakhtunkhwa province districts. Information concerning iodized salt intake and knowledge of iodine deficiency disorders (IDD) was obtained through an interview questionnaire. Goiter and urinary iodine concentration (UIC) levels were assessed by the palpation method and Sandell-Kolthoff reaction, respectively. Logistic regression analysis was used to quantify associations between residence (rural-urban), pregnancy trimester, and previous pregnancy outcomes with knowledge about IDD, iodized salt intake, presence of goiter, and UIC <150 μg/L.

RESULTS

Among study participants, 87.7% had no knowledge about IDD, and only 21.0% were consuming iodized salt. Goiter was present in 25.5% of the women. The median UIC level was 131 μg/L, and 41.3% of study participants had a UIC ≥150 μg/L. There were no significant differences between pregnant women from rural and urban settings in regions with a solid socioeconomic status with respect to knowledge about IDD, iodized salt intake, iodine deficiency, and goiter prevalence. Urban-rural differences were observed only in socioeconomically disadvantaged districts. Only pregnant women living in the Lakki Marwat district had higher odds of having knowledge of IDD and iodized salt intake than those from rural regions. Trimesters of pregnancy and previous pregnancy outcomes had no significant effect on the outcome measures.

CONCLUSIONS

Relative to a national nutrition survey conducted in Pakistan in 2011, the results from this study indicate that UIC levels remained stable with mild iodine deficiency, whereas rates of goiter and iodized salt intake remained high and low, respectively, especially in rural areas. Rural-urban disparities were observed only in socioeconomically disadvantaged districts, and these disparities limit the effectiveness of the IDD prevention program in rural areas in Pakistan. Thus, implementation of mandatory salt iodization requires improvement, and program effectiveness should be continuously monitored to prevent adverse health effects of iodine deficiency during pregnancy.

Knowledge and practice of iodized salt utilization among reproductive women in Addis Ababa City

OBJECTIVE

The objective of this study was to assess knowledge and practice of iodized salt utilization among reproductive women in Addis Ababa city. A cross-sectional study was carried out on 549 households. A sample district was designated by using the simple random sampling techniques. Data were collected by a face-to-face interview and household salt was tested to check whether its practice was good. p < 0.2 in the bivariate logistic regression was entered into the multivariable logistic regression, and p < 0.05 was considered as significantly associated.

RESULTS

Mothers who had good knowledge and practice of iodized salt were 78% (95% CI 74.9, 81.2) and 76.3% (95% CI 72.7, 79.8), respectively. Monthly household income (AOR = 2.97; 95% CI 1.20, 7.37) was associated with knowledge of iodized salt of respondents. Similarly, educational status (AOR = 2.45; 95% CL 2.10, 6.43) of respondents was significantly associated with the practice of iodized salt. This study indicated that increasing the level of knowledge and practice of iodized salt was good. Monthly household income and educational status were associated with knowledge and practices of iodized salt of respondents. Hence, improving mothers' education is a highly recommended strategy for addressing public health problems of iodine deficiency.

Factors affecting sustainable iodine deficiency elimination in Pakistan: A global perspective

Iodine deficiency remains a considerable challenge worldwide, even after decades of efforts to address the problem. The aim of this review is to present the current situation in historically iodine-deficient Pakistan regarding iodine nutritional status and place it in a global perspective. We collected relevant articles from online bibliographic databases and websites of concerned organizations that addressed prevalence of goiter/iodine deficiency and barriers to sustainable control. We divided the studies into pre- and post-1994, a landmark year when Pakistan formally adopted the universal salt iodization (USI) programme. Overall, 56 studies reported goiter/iodine deficiency prevalence in Pakistan. Before 1994, six studies (30%) reported a goiter prevalence ≥70%, while nine studies (45%) reported a goiter prevalence between 30% and 70%. Only five studies (25%) found a goiter prevalence less than 30%, of which only two studies reported prevalence <10%. From 1994 onwards, 15 studies (41.7%) reported a goiter/iodine deficiency (ID) prevalence ≥50%, of which seven studies reported prevalence ≥70%, while three studies (8.3%) found a goiter prevalence of 30%-49%, nine studies (25%) found a goiter prevalence of 10%-29%, and five studies (13.9%) reported prevalence of <10%. Four studies (11.1%) reported lower goiter prevalence but higher prevalence of iodine deficiency. The efforts in the past two decades resulted in up to a 50% decline in iodine deficiency disorders (IDD). Variable remaining factors and the recent results, however, indicate that this decline may be non-uniform and even over-estimated. Coordinated and regionally adopted efforts for eradication of IDD from all stakeholders should be pursued. Policy makers should take steps to protect future generations and alert concerned organizations about the importance of careful assessments and estimates of iodine nutritional status.

Large-scale fortification of condiments and seasonings as a public health strategy: equity considerations for implementation

Fortification of staple foods with vitamins and minerals is an effective approach to increase micronutrient intake and improve nutritional status. The specific use of condiments and seasonings as vehicles in large-scale fortification programs is a relatively new public health strategy. This paper underscores equity considerations for the implementation of large-scale fortification of condiments and seasonings as a public health strategy by examining nonexhaustive examples of programmatic experiences and pilot projects in various settings. An overview of conceptual elements in implementation research and equity is presented, followed by an examination of equity considerations for five implementation strategies: (1) enhancing the capabilities of the public sector, (2) improving the performance of implementing agencies, (3) strengthening the capabilities and performance of frontline workers, (3) empowering communities and individuals, and (4) supporting multiple stakeholders engaged in improving health. Finally, specific considerations related to intersectoral action are considered. Large-scale fortification of condiments and seasonings cannot be a standalone strategy and needs to be implemented with concurrent and coordinated public health strategies, which should be informed by a health equity lens.

Understanding communication pathways to foster community engagement for health improvement in North West Pakistan

BACKGROUND

This paper describes the community engagement process undertaken to ascertain the focus, development and implementation of an intervention to improve iodised salt consumption in rural communities in North West Pakistan. The Jirga is a traditional informal structure, which gathers men respected within their community and acts in a governing and decision-making capacity in the Pukhtoon culture. The Jirga system had a dual purpose for the study: to access men from the community to discuss the importance of iodised salt, and as an engagement process for the intervention.

METHODS

A number of qualitative data collection activities were undertaken, with Jirga members and their wives, male and female outreach workers and two groups of women, under and over 40 years old. The aim of these was to highlight the communication channels and levers of influence on health behaviour, which were multiple and complex and all needed to be taken into consideration in order to ensure successful and locally sensitive community engagement.

RESULTS

Communication channels are described within local families and the communities around them. The key influential role of the Jirga is highlighted as linked both to the standing of its members and the community cohesion ethos that it embodies. Engaging Jirga members in discussions about iodised salt was key in designing an intervention that would activate the most influential levers to decision making in the community. Gendered decision-making processes within the household have been highlighted as restricting women's autonomy. Whilst in one respect our data confirm this, a more complex hierarchy of decisional power has been highlighted, whereby the concept of 'wisdom'- an amalgamation of age, experience and education- presents important possibilities. Community members with the least autonomy are the youngest uneducated females, who rely on a web of socially and culturally determined ways to influence decision-making.

CONCLUSIONS

The major lines of communication and influence in the local community described are placed within the wider literature on community engagement in health improvement. The process of maximisation of local cultural knowledge as part of a community engagement effort is one that has application well beyond the particular setting of this study.