From information to action: towards context-specific nutrition and noncommunicable disease research, interventions, and policies in Sri Lanka

Background: Suboptimal diet is the leading risk factor for global morbidity and mortality, and an important preventable risk factor for noncommunicable diseases (NCDs). As urbanisation, economic development, and income growth lead to shifts in diet, many low- and middle-income countries, including Sri Lanka, are increasingly exposed to foods and diets that increase the risk of developing NCDs. Although improving population diets is recognised as a global health priority, there is an increasing awareness that one size does not fit all when it comes to intervention development and implementation. Effective action therefore requires context-specific solutions informed by context-specific data collected by context-specific tools.
Aim: The overarching aim of this thesis is to improve the assessment of nutrition-related behaviours so as to target interventions better and inform policy in Sri Lanka.
Methods: This thesis follows a mixed methods approach to address diverse study objectives. Data were collected through: 1) a systematic review of the published literature; 2) semi-structured interviews conducted with 23 policymakers, researchers, and research funders working in the areas of NCDs, nutrition, and urban health; 3) dietary surveys (a novel brief dietary survey instrument and a 24-hour Dietary Recall) conducted with 94 Sri Lankan adults residing in Colombo, Kalutara, and Trincomalee; and 4) semi-structured interviews conducted with 93 of the participants in the dietary survey study.
Results and discussion: This thesis identifies and describes the barriers to and facilitators of evidence generation, communication, and uptake in the areas of NCDs, nutrition, and urban health in the Sri Lankan context. Whilst many of the study findings confirm that much of what is known about the barriers to and facilitators of evidence-based policymaking from the ‘global’ literature applies to the Sri Lankan context, important context-specific differences also emerge. Some of the context-specific barriers include: English language communication barriers between evidence generators and users; the strong involvement of clinicians and ‘medical mindsets’ in public health research and policymaking; and a lack of context-specific research tools. Based on stakeholders’ needs revealed through these interviews, this thesis then describes the development and relative validation of a context-specific dietary survey instrument, the Sri Lankan Brief Dietary Survey (SLBDS). The findings from this study show that the SLBDS demonstrates promise as a fit for purpose research tool. Through semi-structured interviews, factors that might impact SLBDS participation, engagement, and social validity are revealed. These factors include the time of day interviews occur, recall ease, level of commitment required, perceived survey value, emotional response to surveys, and interviewer positionality. Finally, this thesis explores some of the context-specific factors that might impact the success of dietary interventions aimed at influencing day-to-day practice. The findings from this study recommend that the promotion of healthier diets should not be targeted at women exclusively, but rather directed to all family members – especially men and children whose attitudes and preferences are a crucial determinant of what and how family members eat.
Conclusion: The central message of this thesis is that context is everything. What works to improve health depends on context, but context is complex. This thesis responds to a need for setting-specific mixed-methods research to inform the appropriate, effective, and equitable development and implementation of dietary improvement interventions in Sri Lanka.

Keywords: Sri Lanka
Noncommunicable disease
Nutrition
Policy
Diet
Advisor: Rayner, M
Scarborough, P