Translating the social ecological model into recommendations for food safety promotion in india by

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Adaobi U. Nwoka

BS, Howard University, 2012

Submitted to the Graduate Faculty of

Health Policy and Management

Graduate School of Public Health in partial fulfillment

of the requirements for the degree of

Master of Public Health

University of Pittsburgh




This essay is submitted


Adaobi Nwoka

April 10th, 2016
and approved by

Margaret A. Potter, JD, MS ______________________________________


Health Policy and Management

Associate Dean for Public Health Practice

Graduate School of Public Health

University of Pittsburgh

Joanne Russell, MPPM ______________________________________

Assistant Professor

Behavioral and Community Health Science

Director, Center of Global Health

Graduate School of Public Health

University of Pittsburgh

Copyright © by Adaobi Nwoka



Margaret A. Potter, JD, MS

Adaobi Nwoka, MPH

University of Pittsburgh, 2016

Foodborne illnesses are a burden on public health and contribute significantly to the large numbers of mortality and morbidity in India. Common forms of foodborne diseases in India are due to bacterial contamination of foods. Foodborne illnesses are also a preventable and underreported public health problem. Currently, there is no national foodborne disease surveillance system available to enable effective detection, control and prevention of foodborne disease outbreaks.  In addition, progress in Indian infrastructure has been painstakingly slow in recent years. Despite these challenges, the Government of India enacted the Food Safety and Standards Act in 2006 as a form of public health promotion in the area of food safety. Unfortunately, policy-making in India has frequently been characterized by a failure to anticipate needs, impacts, or reactions, which could have reasonably been foreseen, thus impeding economic development. India's policymaking structures have difficulties formulating the "right" policy and adhering to it. Hence, refining the policy-making competence of India’s senior civil servants and the elected officials in Government may improve the structure involved in public policy-making in India. Furthermore, coordination can be achieved by addressing social ecological factors in pursuit of behavioral changes. Other actions to further evidence-based policy include preparing and communicating data more effectively, using existing analytic tools, conducting policy surveillance, and tracking outcomes with different types of evidence.

Keywords: Food Safety, Safe Food Practices, India Food Safety Policy, Social Ecological Model, Social Determinants of Health, Challenges in Rural Marketing, Food Safety Strategies, Food Safety Campaigns, Media and Food Safety


List of acronyms 8

preface 8

1.0 Introduction 1

1.1public health relevance 4

2.0 chapter one: The Demographic Overview of India 5

1.2The Demographical Context of India 6

1.3Historical Framework of India 8

1.4Politics in India after Independence 10

1.5Role of the Government in Public Health 13

1.6The Food Safety and Standards Act of India 15

3.0 chapter two: the application of the social ecological model to health behavior 18

1.7The Principles of the Social Ecological Model 19

1.8Understanding Multi-Level Influences on Food Safety 21

4.0 chapter three: a multilevel approach to food safety in the framework of the social ecological model 26

1.9Translating Social Ecological Model into Recommendations for Food Safety Promotion 28

5.0 recommendations 35


bibliography 39

Table 1. Key Findings of the WHO Survey of Street Vended Foods 23

Figure 1. Social Ecological Model Levels 21

Figure 2. Edgar Dale, Cone of Learning 33




Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy


Belize Agricultural Health Authority


Food business Operators


Food Safety and Standards


Food Safety and Standards Authority of India


Food Safety Officers


Global Water Partnership


Hazard Analysis Critical Control Point


Human Immunodeficiency Virus


Integrated Urban Water Management


Low and middle income countries


Ministry of Health and Family Welfare


Prevention and Food Adulteration


Social Ecological Model


Water and Power Consultancy Services


World Health Organization

This essay is in partial fulfillment of the requirements for the degree of Master of Public Health. It brings me great joy to compose a paper that highlights my interests in public health. I hope this paper will stimulate research in the area of food safety. Several people played an important part in accomplishing this submission. I would like to especially acknowledge the essay advisors of this paper for their excellent job in reviewing and providing high-quality recommendations.

  1. Introduction

Over the years, diarrheal disease has been a serious health hazard for adults and children in India.1 In 2005, it was reported that 1.8 million people died from diarrheal diseases largely due to contaminated food and water.2 Scientific studies have investigated outbreaks from 1980-2009 of foodborne diseases in India and indicated that a total of 37 outbreaks involving 3,485 persons were due to food poisoning.3 In 2008, diarrheal disease remained one of the top leading causes of death in India with an estimated 1,181 per 100,000 deaths.1 The estimated diarrheal disease mortality due to foodborne infections in India is still unknown; however, isolating foodborne sources is a critical step towards defeating a disease that is preventable. In 2006, the Indian state government launched the Food Safety and Standards Act (FSS) as a fundamental part of promoting public health practice.4 The overall goal of this policy is to attain high levels of food hygiene and safety practices, which will promote health, control food-borne diseases and eliminate the risk of diseases related to poor food hygiene and safety.4

This study provides an overview of the FSS, the barriers to proper food safety practices in India and policy implementation strategies to improve compliance. The first chapter presents a demographical outlook of India and explains the significance of the FSS. The second chapter discusses the social determinants of health and their influence on compliance, by using to the social ecological model. The third chapter concludes by highlighting several complementary programs that would support the FSS act by harmonizing political, social, and economic factors. Beneficial to providing sound recommendations, it is important to evaluate this country’s profile in order to properly understand the difficulty in resolving the issue of food safety compliance in India.

1.1public health relevance

Food safety is increasingly becoming an important public health issue and great concern for India. Food businesses particularly should comply with food safety guidelines as failure to do so poses concerns for consumers. However, India is faced with many challenges including the inability to provide sufficient regulatory oversight. Moreover, time and inadequate training are cited as reasons why food service workers do not follow safe food handling practices in India. Food safety education is an essential factor of quality control, behavior change and reducing risk of food poisoning. This essay explains the influence governmental officials and society have on food safety, as well as multi-level strategies aimed to support the enacted Food Safety and Standards Act.
  1. chapter one: The Demographic Overview of India

1.2The Demographical Context of India

India is a country with multifaceted cultures and varied socio-economic and cultural backgrounds. India is located in the southeastern part of Asia and is surrounded by Bangladesh, Bhutan, Burma, China, Nepal, and Pakistan.5 As of 2015, India is currently home to approximately 1.3 billion. 5 The urban and rural populations of India make up 32.7% and 67.3% respectively.5 Hindi is the most widely spoken language and primary tongue of 41% of the people; however, there are 14 other official languages: Bengali, Telugu, Marathi, Tamil, Urdu, Gujarati, Malayalam, Kannada, Oriya, Punjabi, Assamese, Kashmiri, Sindhi, and Sanskrit.5 Research has shown language barriers significantly affects access to care, causes problems of comprehension and adherence, and decreases the satisfaction and quality of care.6 The internal migration across state borders over the past two decades has led to the increase in health workers encountering instances of language discordance, which makes it difficult to communicate with patients.6

Over the past several decades, India has been witnessing an increase in the population, literacy, urbanization, chronic diseases and other changes in disease patterns.5 The overall life expectancy in India has increased significantly over the past two decades from 58 years in 1990 to 66 years in 2013.5 This is a result of improved public health programs and policies, economic infrastructure and lower mortality rates over time. Although India is experiencing increasing deaths due to chronic diseases, it is noteworthy to point out that deaths related to infectious disease remain a pressing issue in India.7

In 2014, 60% of deaths were due to chronic diseases, however infectious diseases accounted for 28% of deaths in the population.7 Infectious diseases in India are related to poor sanitation, contaminated food, inadequate personal hygiene, access to safe water and lack of basic health services.8 Rural areas in India report more deaths due to communicable, maternal, perinatal and nutritional conditions than urban areas.8 This is due to large-scale poverty, developmental disparities between states, greater gender discrimination and disproportionate healthcare resources.9 These factors contribute enormously to the challenges of integrating proper health practices. For example, women are largely excluded from making decisions, have limited access to and control over resources, restricted mobility, and are often under threat of violence from male relatives.10 Other key challenges in healthcare include imbalanced resource allocation, limited physical access to quality health services, and behavioral factors that affect the demand for appropriate health care.11

In 2013, the total health expenditures was 1.3% of India’s GDP, which is below the low and middle-income countries (LMIC) average of 5.3%. 5,12 Most importantly, out of pocket expenditures were 67%, which is much higher than the LMIC average of 44%. 12 In addition, health insurance has only covered 5% of Indians. As a result, over 20 million Indians are pushed below the poverty line every year because of the effect of out of pocket spending on health care.12 Currently, 29.8% of Indians live below the poverty line, with 23.6% of those within the poverty line living on less than $1 USD a day. 13

1.3Historical Framework of India

Until its independence in 1947, neighboring countries of India today including Pakistan, Bangladesh (formerly East Pakistan), Myanmar (formerly Burma) were all parts of British India and were all considered as India.37 Over the years, there has been some debate about the official date India earned its independence from the British. In accordance with the India Independence Act of July 18, 1947, the Union of India and Pakistan were partitioned from the former “British India” that had been a part of the Parliament of the United Kingdom.37 However, the British army officially left India in 1950 and India's first constitution was written shortly thereafter on January 26, 1950, which officially declared it a member of the British Commonwealth.37 Therefore, the Indians celebrate January 26, 1950 as the Republic Day of India.37

The direct administration by the British, which began in the mid 1800s, effected a political and economic unification of the subcontinent.37 When British rule came to an end in 1947, the subcontinent was divided along religious lines into two separate countries—India, with a majority of Hindus, and Pakistan, with a majority of Muslims.37 As a result, India remains one of the most ethnically diverse countries in the world.37 Apart from its many religions and sects, India is home to innumerable castes and tribes, and many spiritual groups, including Muslims, Christians, Sikhs, Buddhists, and Jains.37 Earnest attempts have been made to infuse a spirit of nationhood in such a varied population, but tensions between these groups have remained and at times have resulted in outbreaks of violence.37 Nevertheless, many social legislations have attempted in alleviating the inequality occurring among formally castes, tribal populations, women, and other traditionally disadvantaged segments of society.37

1.4Politics in India after Independence

The official name of the Indian government is Union Government of India.14 The Indian government is a parliamentary system of democratic governance.14 The government of India is the governing authority of 29 states and 7 union territories of the country as per the Constitution of India.14 The Constitution of India is federal, but contains a strong central government, which holds both extensive emergency powers and residuary powers from the Union.14 Similar to the United States system, the 29 states function autonomously in general, but the central government retains the decisive power to control and direct the administration of states under certain conditions.14 As Paul Brass, the author of the Politics of India since Independence noted in 1990
…The Constitution of India made a sharp break from with the British colonial past, though not with British colonial practices. The Constitution adopts in total a Westminster form of parliamentary government rather than a mixed parliamentary-bureaucratic authoritarian system, which is actually exists in India. (Brass, 1994, pg. 5)
Currently, the central government of India is comprised of three distinctive branches, which includes the Executive, the Legislative and the Judiciary branches.15 The Executive Branch involves the President, the Vice President, the Prime Minister and the Cabinet Ministers of India.15 The Executive branch of the nation's government is entirely responsible for the daily administration of the bureaucracies of the diverse states and union territories of India.15 The Legislative branch is commonly known as Parliament, which consists of the two Houses of People, the Rajya Sabha and the Lok Sabha.15 The members of the legislative government have many responsibilities; however, this essay will focus mainly on the obligation of the Prime Minister and the Council of Ministers for any policy failure within the government.15, 16 In terms of Article 74(1) in the constitution, the President is compelled to have a Council of Ministers with the Prime Minister at the head.15 The President appoints the Prime Minister while all other council ministers are appointed by the President with the advice of the Prime Minister.15 Although the term “Cabinet’ is absent in the constitution, the Cabinet ministers consists of the senior ministers to whom the Prime Minister consults in arriving at policy decisions.15,16

Based on the constitution, the Parliament is the nation’s supreme law making body.15 However, the Prime Minister and the cabinet have a firm control over the Parliamentary majority. 44 Therefore, the Prime Minister and the Cabinet can make the Parliament pass whatever law the Prime Minister wishes the Parliament to pass.44 Conversely, the Parliament shall never pass a bill, which the Prime Minister and the Cabinet oppose.44 Thus, the law making powers of the Parliament involuntarily become the powers of the Cabinet.44 The Prime Minister and the Cabinet also have control over the nation’s finances.44 The annual budget is prepared by the instructions of the Cabinet.44 For example, the proposals for taxes and expenditures are arranged by the Cabinet then formally approved by the Parliament.44

The Judiciary branch is ruled by the Supreme Court of India, which consists of High Courts and several district level courts.15 In addition to the original jurisdictions given to the Supreme Court, Article 32 of the Constitution of India provides extensive jurisdiction related to the fundamental rights enforcement.15

1.5Role of the Government in Public Health

The Indian Constitution includes a list of directive principles of state policy that express ideals of social justice, equality, and welfare.15 For example, the constitution explicitly urges the government to establish a minimum wage, provide education and jobs for people from disadvantaged backgrounds, and improve public health.15 Although the directive principles have no legal status and cannot be enforced by the courts, they were intended to guide the government in policy-making. The role of government is especially crucial for addressing challenges and achieving health equity. Since independence, major public health problems such as tuberculosis, high maternal and child mortality and human immunodeficiency virus (HIV) have been addressed through intensive actions of the government.17

The Ministry of Health and Family Welfare (MOHFW) plays a key role in guiding India's public health system. The MOHFW holds cabinet rank as a member of the Council of Ministers and composed of four departments: Health & Family Welfare; Health Research; AIDS Control; and Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy (AYUSH). 17

The MOHFW is primarily responsible for health policy and family planning programs. 17 In addition MOHFW is responsible for ensuring safe food to the consumers.19 In the past, several States formulated their own food laws, however there was a considerable variance in the rules and specifications of the food that interfered with inter-provincial trade.19 Consequently, the Prevention of Food Adulteration (PFA) Act of 1954 was enacted in June 15, 1955 to ensure pure and wholesome food to the consumers and also to prevent fraud or deception.18 The PFA Act has been amended thrice in 1964, 1976 and in 1986 with the objective of closing the loopholes, making the punishments more stringent and empowering consumers and voluntary organizations to play a more effective role in its implementation.18,19 The PFA Act repealed all laws, existing at that time in States concerning food adulteration.18,19 Despite the noble attempt of the government to address issues related to food adulteration, food contamination persisted, which captured the attention of policymakers.

1.6The Food Safety and Standards Act of India

As previously noted, in 2013 diarrheal diseases remained one of the leading causes of preventable deaths in India with an estimated 1,181 per 100,000 deaths.1 Despite many challenges in formulating an effective food safety policy, these policies have been refined over the last decade by the Council on Ministers. The Government of India enacted this comprehensive act in 2006 to enforce a training and awareness program on food safety for food business operators (FBOs), regulators, and consumers.20 The Act also aims to establish a single reference point for all matters relating to food safety and standards, by moving from multi-departmental control to a single line of command.4 In other words, the Act established an independent statutory authority to the Food Safety and Standards Authority of India (FSSAI).4

The FSSAI is an agency under administrative control of the Ministry of Health and Family Welfare.4 This agency is responsible for protecting and promoting public health through regulation of food safety.4 The FSSAI was established under the Food Safety and Standards (FSS)Act of 2006, which consolidated all statutes and regulations related to food safety in India.4 The Act states that the FSSAI must perform the following functions:

  • Framing of regulations to lay down the standards and guidelines in relation to articles of food and specifying appropriate systems of enforcing various standards.

  • Laying down mechanisms and guidelines for accreditation of certification bodies engaged in certification of food safety management system for food businesses.

  • Arranging procedures and guidelines for accreditation of laboratories and notifying the accredited laboratories.

  • Providing scientific advice and technical support to Central Government and State Governments in the matters of framing the policy and rules in areas that have a direct or indirect bearing of food safety and nutrition.

  • Collecting and collating data regarding food consumption, incidence and prevalence of biological risk, contaminants in food, residues of various, contaminants in foods products, identification of emerging risks and introduction of a rapid alert system.

  • Creating an information network across the country so that the public, consumers, Panchayats (local government) receive rapid, reliable and objective information about food safety and issues of concern.

  • Providing training programs for persons who are involved or intend to get involved in food businesses.

  • Contributing to the development of international technical standards for food, sanitary and phyto-sanitary measures.

  • Promoting general awareness about food safety and food standards.

The major downfall with this enactment are the insufficient resources and assistance made available for food businesses.21 Studies have mentioned the need for an incremental program that would train Food Safety Officers (FSO) on how to inspect, audit, and conduct food surveillance to ensure food safety and hygiene.21 However, food inspection and regulatory services are often located in major cities, with little or no control exercised in small towns and rural areas.22

Another major challenge to enforcing food safety norms in India are the insufficient number of food testing laboratories.23 Currently, the number of laboratories per million people in the country is far below other countries like China and the US.23 Even in terms of staff, most Food and Drug Administrations in India operate far below the required capacity. 23 Consequently many laboratories have been shut down due to the lack of food analysts.23

In addition, the very fact that the Act extends its jurisdiction to all persons who handle food under the definition of Food Business Operators (FBOs) is a vast base to cover.4, 24 Indian FBOs range from small time street hawkers to upscale restaurants with complex processes, which creates a challenge to provide for regulatory oversight.24 Therefore, the Indian food business community must secure the support from policymakers and stakeholders to provide resources to comply with enacted food safety policies, which would bring solutions to strengthen health systems and improve health. This essay aims to address the societal barriers that FBOs are faced with in regards to food safety regulations being imposed on them without governmental support.

  1. chapter two: the application of the social ecological model to health behavior

1.7The Principles of the Social Ecological Model

Healthy behaviors are assumed to be maximized when environments and policies support healthful choices, while individuals are motivated and educated to make those choices.25 For policies to be successful, there must be alignment between the policy and the support from the environment. Educating people to make beneficial choices when environments are not supportive can produce weak and short-term effects.25 Over the years, the application of the social ecological model has been used to provide comprehensive frameworks for understanding the multiple and interacting determinants of health behaviors. Notably the combination of environmental, policy, social, and individual intervention strategies has been attributed to major reductions in tobacco use in the United States since the 1960s.26 This model considers the complex interplay between individual, community, and societal factors, which in this case would allow the governmental bodies to understand the range of factors that put people at risk for food borne illness or protect them from it.

The core concept of an ecological model is that behavior has multiple levels of influences, often including intrapersonal (biological, psychological), interpersonal (social, cultural), organizational, community, physical environmental, and policy. 25 Sallis et al. proposed four core principles of ecological models of health behavior which include:

1. There are multiple influences on specific health behaviors, including factors at the intrapersonal, interpersonal, organizational, community, and public policy levels.

2. Influences on behaviors interact across these different levels, meaning these variables work together.

3. Ecological models should be behavior-specific, identifying the most relevant potential influences at each level.

4. Multi-level interventions should be most effective in changing behavior.

These four principles collectively highlight the ultimate purpose of the ecological model, which is to develop comprehensive interventions that will systematically target behavioral change through multiple levels of influence. As previously mentioned, behavior change is expected to be maximized when environments, policies, and social norms jointly support healthful choices and when individuals are motivated and educated to make those choices.

1.8Understanding Multi-Level Influences on Food Safety

As previously mentioned, the social ecological model contributes to understanding the roles that various segments of society can play in making healthy choices more widely desirable. The ecological model considers the interactions between individuals and families, environmental settings and various sectors of influence, as well as the impact of social and cultural norms and values.

(adapted from the framework used by the CDC to address the concept of violence.) 27

Figure 1. Social Ecological Model Levels

Thus, it can be used to develop and implement comprehensive interventions at multiple levels. Figure 1, illustrates how the ecological model is applied in order to understand influences on health behavior and guiding policies and interventions for health behavior change in regards to food safety. The following describes some of the factors and influences found within each element of the model:
Individual factors. This level identifies biological and personal factors, such as age, gender, race/ethnicity, education, income, and personal or family history. Prevention strategies at this level are designed to promote attitudes, beliefs and behaviors and may include education and life skills training.25 Street vendors are a good example of how individual factors can influence food safety behaviors since vendors in India oftentimes have lower socio-economic statuses, are uneducated and lack the knowledge for safe food handling.28 Researchers in the past have acknowledged the importance of personal hygiene education as a means to prevent food borne infections originated from street vendors in rural areas in India.29 A study done by Das et al. found that street vendors in rural areas usually prepared and served the food with bare and unwashed hands, which is one of the most probable sources of contamination.29 Another study conducted by Sharmila Rane discovered that those foods prepared by street vendors were prepared either at their homes, stalls or overcrowded areas where high numbers of potential customers would congregate.30 Furthermore, the preparation surfaces of the vendors had remains of foods prepared earlier, which promoted cross contamination.30

Consequently, street foods are perceived to be a major public health risk, particularly due to the difficulty in regulating the large numbers of street food vending operations. Their diversity, mobility and temporary nature makes regulatory oversight impossible to fulfill.28 Table 1, illustrates the key findings of a survey where World Health Organization assessed the current situation regarding street-vended food. The WHO suggests that efforts to improve street food vending should focus on educating the food handlers, improving the environmental conditions and providing essential services to the vendors to ensure safety of their commodities.28 Periodic training in safe food handling practice may improve the situation; however, resources are often limited and regulatory services are mostly located in major cities, with little or no monitoring exercised in small towns and rural areas in India.22

Table 1. Key Findings of the WHO Survey of Street Vended Foods

  • 74% of countries reported street-vended foods to be a significant part of the urban food supply;

  • Street-vended foods included foods as diverse as meat, fish, fruits, vegetables, grains, cereals, frozen produce and beverages;

  • Types of preparation included foods without any preparation (65%)*, ready-to-eat food (97%) and food cooked on site (82%);

  • Vending facilities varied from mobile carts to fixed stalls and food centers;

  • Infrastructure developments were relatively limited with restricted access to potable water (47%), toilets (15%), refrigeration (43%) and washing and waste disposal facilities;

  • The majority of countries reported contamination of food (from raw food, infected handlers and inadequately cleaned equipment) and time and temperature abuse to be the major factors contributing to foodborne disease;

  • Most countries reported insufficient inspection personnel, insufficient application of the HACCP concept and noted that registration, training and medical examinations were not amongst selected management strategies

*Percentage of countries reporting “yes” to question

Source: WHO, 1996 28

Interpersonal RelationshipsThe second level examines relationships that may increase or reduce a risk of experiencing a negative or positive outcome.25 This usually involves person's closest social circle (peers, partners and family) and how these behaviors can influence the behaviors of others.25 In the case of food safety, interpersonal factors play a key role in habit formation and thus can significantly contribute to better food safety practices. For example, if a mother and daughter occasionally cook meals together and the daughter often witnesses her mother failing to wash her hands before cooking, the daughter may adopt this routine, which would later become a poor habit. Unfortunately, this is a common behavior simply because most consumers believe that food manufacturing facilities and restaurants are obligated to follow food safety laws, while compliance is generally low in homes.31 Prevention strategies regarding this level should include home food safety messages, particularly designed through media.

Community. The third level explores settings, such as schools, workplaces, churches and neighborhoods, in which social relationships occur. 25 Religious practices play a dominant role in food handling practices in India. In the Indian culture, there is a sheer enjoyment of one’s religious celebrations. Women tend to have primary roles for any religious celebrations at their homes.32 However, the food handling methods adopted by women during religious and social ritual practices are often not adequate to ensure the safety of food.32 Therefore, strategies in this level should be designed to impact context, processes and policies. For example, social marketing campaigns are often used to foster community climates that promote healthy behaviors.25

Society/ Institutional/Policy. The fourth level includes broad societal factors that create a climate in which certain health behaviors are encouraged or inhibited, including social and cultural norms.25 Social norms are shared assumptions of appropriate behavior based on the values of a society and are often reflected in laws or personal expectations.25 With regard to food safety in India, cultural norms include collecting water from a roadside tap or mobile tankers, defecating in open areas, washing hands without soap, keeping foodstuffs uncovered at vending sites, and storing leftovers in warmers or cooking vessels.33 At this level, the responsibility for food safety rests on a variety of sectors such as the government, public health and health care systems, agriculture, and media. Many of these sectors are important in determining the degree to which all individuals and families have access to clean water and opportunities to practice proper food handling in their own communities. Furthermore they can create social policies that help to produce or maintain the status quo, which may include unjustifiable economic and/or social inequalities between social groups. Interventions in this level should focus on using mass media to educate the population of proper food preparation and hygiene, improving environmental conditions of food suppliers, providing essential services to food business operators to ensure safety of their commodities. In essence, individuals are often responsible for their own behaviors; however their societal environment largely determines these behaviors.

In summary the basic premise of ecological model helps to understand how people interact with their environments. Providing individuals with motivation and skills to change an undesirable behavior will not be effective if environments and policies make it difficult or impossible to choose healthful behaviors. Therefore, the optimal approach to promoting healthy behaviors must combine all levels to reinforce efforts that are supportive. Furthermore, interventions that address social determinants of health have the greatest potential for public health benefit, however these issues need the support of government and civil society in order to be successful. 34

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