DISORDERS CAUSED BY IODINE DEFICIENCY IN SERBIA AND MONTENEGRO 3
KAP RESEARCH 3
METHODOLOGY OF THE RESEARCH 4
Description of the sample 4
Implementation instruments of the Research 5
Data processing 5
Awareness of disorders caused by iodine deficiency and the obligation to iodise salt 6
Prevention of disorders caused by iodine deficiency 9
Supply of iodised salt 10
The type of salt most frequently found in households 14
Packaging, storage and use of iodised salt 18
Use of iodised salt 23
Salt in the feeding of domestic animals 25
Methods of communication 27
RECOMMENDATIONS (PROPOSAL OF MEASURES TO BE UNDERTAKEN) 30
Iodine deficiency is a global problem that has direct influence on the growth and development of millions of children worldwide. Iodine deficiency is the main cause of brain damage and mental retardation and can reduce the intelligence coefficient of the entire population by 10 to 15 points. The consequences are grave for each affected child, and not only for it but for its family and the society in general.
According to an evaluation of the World Health Organisation in 1992, 1,6 billion people live in regions deemed to be susceptible to iodine deficiency.
The first written and picture records (frescoes) registered by historians showed the existence of endemic goitre in the Balkan Peninsula. Surveys conducted in the early 1950s in Serbia have shown that there were some 650,000 persons suffering from endemic goitre and some 20,000 suffering from endemic cretinism. Iodine deficiency disorders were recognised as a major public health problem, and at the recommendation of the Commission for Medical and Scientific Research in 1951 universal application of iodine to salt was introduced. Salt intended for human consumption or for feeding domestic animals since then contained 10 mg of potassium iodide per kilogram of salt. These undertaken activities have given extremely good results with a significant decrease of goitre prevalence. The surveys were repeated in the period from 1990 to 1992 and showed a mild occurrence of goitre in the former endemic areas that resulted in the raising of the level of iodine content in salt to 20 mg of potassium iodide per kilogram.
DISORDERS CAUSED BY IODINE DEFICIENCY IN SERBIA AND MONTENEGRO
A survey on a representative sample of schoolchildren in Serbia in 1999 showed that disorders caused by iodine deficiency had been eliminated as a public health problem. These results were internationally verified. A similar survey was carried out in Montenegro but the results were not internationally verified due to the fact that the method used there had not been conformed to the ICCIDD recommendations (the volume of the thyroid gland was not being determined by ultrasound, but by the imprecise palpitation method).
A national survey carried out in 2000 determined that 73.3% of households consumed adequately iodised salt. A detailed analysis showed that only 1.3% of the households used non-iodised salt.
The legislature prescribing the compulsory universal salt iodisation for human consumption, in the food industry and for the feeding of domestic animals was amended in 2001, not changing the specified quantity of iodine in salt but placing it under the jurisdiction of the Federal Commission for Preventing Iodine Deficiency Disorders.
The annual needs of salt in Serbia and Montenegro are some 100,000 tonnes. The only salt producing facility is the salt factory “Bajo Sekulic” in Ulcinj. Some 260 domestic companies are involved in the import, processing, distribution and sale of salt. The salt factory “Bajo Sekulic” in Ulcinj and the five major factories that import and process salt satisfy some 60% of the domestic needs.
The KAP Research was planned in order to evaluate the degree of awareness of the population on the significance of iodising salt for a proper and healthy growth of the human body on the one hand, and on the consequences of iodine deficiency during a period when sensitivity is most prominent (women of reproductive age, pregnant women and children) on the other.
Success of the planned activities depends on the choice of the most suitable communication channels, proposed messages intended for the aimed groups and especially for the most sensitive groups.
The goals of the research are:
to evaluate the level of awareness, perceptions and behaviour linked to the consumption of iodised salt by the population in Serbia and Montenegro
to create the most acceptable communication channels in the sphere of social mobilisation
to determine the most acceptable medical messages on the basis of the results of the research.
The expected result is the fulfillment of the goals of the social mobilization:
increased awareness of the targeted population, information and education,
forming of correct perceptions and behaviour in regard to the purchase, storage and use of iodised salt,
correction of already formed but incorrect perceptions and habits.
METHODOLOGY OF THE RESEARCH
The KAP Research was carried out in Serbia and Montenegro in co-operation with the Public Health Institute of Serbia “Dr Milan Jovanovic Batut”, the Health Institute of Montenegro, the UNICEF Office in Belgrade and all the local health institutes in Serbia during August and September 2003.
The implementation of the Research in Serbia was carried out by the already established teams that have been organising and implementing programme activities of the health institutes in all the counties. These teams consist of a co-coordinator of health education, a hygiene specialist (or epidemiology specialist) and a patronage co-coordinator at the county level.
The Research in Montenegro was carried out throughout the Republic with the same questionnaires and methodology under the organisation of the Health Institute of Montenegro.
The Research represents a study of the representative sample of the population in Serbia and Montenegro as a whole and the population of larger areas (Central Serbia, Vojvodina, Belgrade and Montenegro).
Description of the sample
The basic set represented the entire population of Serbia and Montenegro. A two-stage stratified sample cluster of households was used. The units of the first stage were local communities and the units of the second stage were households. A cluster of seven neighbouring households was interviewed in each local community. The point of departure and itinerary were determined in advance.
Further to the request for precise evaluations and a level of acquiring reliable evaluations, the number of those (households) interviewed was determined in order to ensure the needed sample size in the strata (i.e., 2,646).
This Research encompassed 2,646 households interviewed in Serbia and Montenegro. Of this number, 592 or 22.4% were interviewed in Vojvodina, 545 or 20.6% in Belgrade, 915 or 34.6% in Central Serbia and 594 or 22.4% in Montenegro. Amongst those interviewed there were 1,575 (50.5%) from urban and 1,071 (40.1%) from rural parts of Serbia and Montenegro.
The number of households planned for interviews by counties in Serbia and Montenegro:
Unique questionnaires were created for the implementation of the Research. These questionnaires contain data about the respondents: municipality, settlement, type of household (town, village), information related to awareness regarding disorders caused by iodine deficiency, the use of iodised salt (usefulness, storage and use options, purchase options, the optimal amounts purchased, types of salt, packaging and size of package, etc.).
In order to ensure the quality of data and effecting of a unique methodology a standardising of the procedure of data collection was carried out. This was achieved by drafting specialised instructions for the filling out of the questionnaires and a necessary training of those carrying out the interviews. Furthermore, the verification of collected data was carried out, as well as a control of the data entry and processing.
A special application was created for data entry together with control mechanisms. Data entry was carried out by trained operators who were instructed on the aim and procedures of the Research, the structure of the questionnaires, the relations between the entities and the logistic control. The analysis of the collected data was carried out by the SPSS 10.0 (Statistical Package for Social Sciences) software programme.
Awareness of disorders caused by iodine deficiency and the obligation to iodise salt
The respondents were able to provide several answers to the question What are the consequences of iodine deficiency? The majority (64.2% urban and 45.7% rural) answered that goitre was the consequence, while the minority believed it was mental retardation, cretinism, blood vessel illnesses or hypertension. A large percent of respondents (32.3% urban and 48.4% rural) were not aware of any consequences of iodine deficiency. The respondents in Belgrade were more aware of the consequences than others and had the smallest number of “I do not know” answers.
Graph No. 1: Answers the question: What are the consequences of iodine deficiency?
The majority of respondents (82.7% urban and 72.7% rural) answered with “yes” to the question Must all the salt used for the consumption of human beings and domestic animals be iodised? Every fourth respondent in rural areas and every sixth in towns believed such an obligation to iodise salt did not exist. Respondents in Belgrade and Central Serbia showed somewhat greater knowledge about the obligation to iodise salt.
Graph No. 2: Answer the question: Must all the salt used for the consumption of human beings and domestic animals be iodised?
The majority of respondents (80.9% urban and 76.4% rural) answered with “yes” to the question Is the salt that you buy iodised? The biggest percent that answered with “yes” were respondents from Belgrade.
Graph No. 3: Answer the question: Is the salt that you buy iodised?
Prevention of disorders caused by iodine deficiency
Respondents were able to choose between several answers to the question: What are the positive effects of the consumption of iodised salt? Some 36.7% of respondents in towns and 50.0% in villages answered with “I do not know”. Of the listed effects, the majority (56.2% in towns and 42.6% in villages) believed it was proper physical development, followed by correct psychological development, the development of mental capacities and other effects. Respondents from Belgrade and Central Serbia had the best knowledge of these effects.
Graph No. 4: Answer the question: What are the positive effects of the consumption of iodised salt?
Supply of iodised salt
The majority of respondents (79.2% urban and 85.5% rural) answered that they purchased salt for their household in the nearest shop, while only a much smaller number said that they purchased salt in large supermarkets, other towns or abroad.
Asked How often do you buy salt?, the majority of respondents (39.6% urban and 38.9% rural) answered once a month or once in two to three months (38.7% urban and 29.9% rural).
Graph No. 6: Answer the question How often do you buy salt?
An analysis of the amount of salt that respondents buy every time shows that 67.0% of the urban population usually purchase one kilogram of salt while only 33.9% of the rural population purchase one kilogram and 32.7% between one and five kilograms.
Graph No. 7: Answer the question What amount of salt do you buy each time?
The majority of respondents (87.9% urban and 84.6% rural) answered that iodised salt was always available in shops.
Graph No. 8: Answer the question Is iodised salt always available when you wish to buy it?
The type of salt most frequently found in households
Regarding the type of salt, respondents mostly purchase finely ground crystal salt. Larger ground crystal salt is more prevalent in Montenegro. Salt substitute is used by 15.0% of the respondents in Vojvodina, 11.9% in Belgrade and only 1% in Central Serbia and Montenegro. Only 2.6% of the urban and 1.8% of the rural population do not use salt.
Graph No. 9: Answer the question What type of salt to you buy?
Answer: Large crystals
Answer: Fine crystals (finely ground)
Answer: Salt substitute
Answer: I do not use salt
Packaging, storage and use of iodised salt
The majority of respondents in towns (82.2%) and villages (52.2%) answered that they purchased salt in carton packaging in response to the question In what type of packaging do you buy salt? A large percent of respondents in villages (44.7%) purchased salt in plastic bags.
Graph No. 10: Answer the question In what type of packaging do you buy salt?
The majority of respondents store the salt not used for the daily preparation of meals in the kitchen (55.8% of town and 34.5% of village population) or in a storage room (39.0% urban and 52.8% rural).
Graph No. 11: Answer the question Where do you store the salt that you do not use during the daily preparation of meals?
Salt not used during the daily preparation of meals is stored open and on the floor by 2.2% of respondents in towns and 4.5% in villages, while 13.0% in towns and 14.1% in villages kept their salt open on shelves.
Graph No. 12: Answer the question How do you store the salt that you do not use for the daily preparation of meals?
In general, salt not used for the daily preparation of meals is mainly stored in a closed box (83.4% urban and 83.6% rural), less often in an open box (10.2% and 12.4%) or in the same package in which it had been purchased (5.5% and 3.4%).
Graph No. 13: Answer the question How do you store the salt that you use for the daily preparation of meals?
Use of iodised salt
For cooking, the majority of respondents add salt (or seasonings that contain salt such as Zacin C or Vegeta) during the cooking of the food (72.7% urban and 68.3% rural) or when starting to cook (24.8% urban and 28.9% rural).
Graph No. 14: Answer the question When you are cooking your meal, you add the salt (or seasonings that contain salt such as Zacin C or Vegeta):
The majority of respondents do not check the date of expiry of the salt they purchase (43.4% urban and 52.2% rural) or only from time to time (17.9% urban and 16.2% rural).
Graph No. 15: Answer the question Do you check the date of expiry of the salt that you buy?
Salt in the feeding of domestic animals
Respondents that keep domestic animals (cattle) in rural areas usually add to the animals’ food salt for cattle (34.9%) or salt used for domestic purposes (26.9%).
Graph No. 16: Answer the question If you have domestic animals (cattle), do you add to their food:
Rural respondents that keep domestic animals most frequently (29.2%) add up to one kilogram of salt per month or between one and five kilograms (21.7%).
Graph No. 17: Answer the question What amount of salt do you add to the food of animals (total per month)?
Methods of communication
The information that all salt used for human or domestic animal consumption must be iodised the respondents mainly obtained during schooling, then from watching television or listening to radio broadcasts, the press, from doctors, neighbours, relatives, and friends or from other sources.
Graph No. 18: Answer the question Where did you obtain information that all salt for human or domestic animal consumption must be iodised?
The respondents from urban areas, as opposed to those from rural areas, showed greater knowledge about the consequences of iodine deficiency and the obligation to iodise salt used for consumption by human beings and domestic animals. Respondents from Belgrade and Central Serbia showed greater knowledge than those from Vojvodina and Montenegro. Despite this, there is a large number of respondents who are not aware of the consequences of iodine deficiency (32.3% urban and 48.4% rural; according to regions from 28.8% in Belgrade to 44.9% in Montenegro), nor are they aware of the obligation of iodising salt (17.3% urban, 26.3 rural; by regions from 16.3% in Belgrade to 27.1% in Montenegro). The urban population is more aware of the positive effects of the consumption of iodised salt than the rural population, while the population in Belgrade and Central Serbia has greater knowledge of this than those living in Vojvodina and Montenegro.
The respondents mainly purchase salt once per month or once every two to three months, regardless where they live (town, village or the region that was researched). Respondents living in towns mainly purchased one kilogram of salt at a time while those living in villages almost equally one kilogram at a time or between one and five kilograms. Regardless where they live or the type of household, the vast majority of the respondents said that iodised salt was always available. The majority of those interviewed purchased finely ground crystal salt. Larger crystal salt was mainly purchased in Montenegro (43.1%). Salt substitute was mainly purchased in Vojvodina (15.0%) and in Central Serbia (14.3%), somewhat less in Belgrade (11.9%) and very little in Montenegro (1.0%).
Urban population mainly purchase salt in carton boxes (82.2%) while 52.2% of the rural population purchase in carton boxes and 44.7% in plastic bags. Respondents mainly stored salt that they were not using for the daily cooking of meals in their kitchens or storage rooms, on the floor or on shelves. Some 13% of urban and 14.1% rural respondents stored their salt in open packages on shelves, the least percent those living in Belgrade ((9.0%) and the most those living in Montenegro (16.8%). More rural respondents (12.4% in relation to 10.2% urban) and those from Montenegro (13.1%) and Vojvodina (12.3%), as a difference to the other regions, kept the salt used for the daily preparation of meals in open packages.
The majority of respondents, regardless where they live or the type of household, when cooking meals add salt during the cooking or when starting to cook. Most of those interviewed do not check the date of expiry of the salt they purchase (43.4% urban, 52.2% rural; from 36.4% in Montenegro to 52.8% in Central Serbia).
The majority of rural respondents who keep domestic animals add salt for cattle or salt for domestic use to the animals’ food, primarily up to one kilogram per month or between one and five kilograms.
Information related to the iodising of salt and its effects on health the majority of urban respondents obtained in school (43.5%), while those living in villages obtained it through media. Viewed by regions, most of those living in Belgrade (44.8%) and Central Serbia (41.1%) obtained this information during schooling while those living in Montenegro obtained it through media (39.7).
Based on the results of the Research about awareness, perception and behaviour related to the use of iodised salt in Serbia and Montenegro, the following conclusions can be reached:
Awareness of disorders caused by iodine deficiency and the obligation of iodising salt is present in a large percent of the respondents, but we cannot be completely satisfied with such results.
Some 32.3% of urban and 48.4% of rural respondents are not aware of the consequences of iodine deficiency.
Some 17.3% of urban and 26.3% of rural respondents, or by regions ranging from 16.3% in Belgrade to 27.1% in Montenegro, were not aware of the legal obligation in our country that all salt for domestic use or for the feeding of animals must be iodised.
Some 80.9% of urban and 76.4% of rural respondents were aware that salt for domestic use was iodised.
Some 63.3% of urban and 50.0% of rural respondents were aware of the positive effects of iodising salt.
The majority of respondents purchased their iodised salt in the nearest shop (79.2% urban and 85.5% rural).
Salt for domestic use is most frequently obtained (purchased) once a month or once in two to three months.
Urban population mainly purchase one kilogram of salt at a time, while rural population almost equally purchase one kilogram or between one and five kilograms at a time.
More than 85% of the respondents said that iodised salt was always available when they wished to purchase it.
Finely ground crystal salt is most frequently purchased, except in Montenegro where 43.1% of the respondents purchased larger ground crystal salt.
Most of the urban respondents (82.2%) purchased salt in carton packages while 52.2% of those living in villages purchased in carton packages and 44.7% in plastic bags.
If a larger package of salt is obtained, the salt not used for the daily preparation of meals is stored either in the kitchen or in the storage room.
The practice of storing salt used for the daily preparation of meals is adequate in 83% of the cases.
During the cooking of meals, salt or seasonings that contain salt are most frequently added during cooking or at the beginning of the cooking, which is inappropriate as it causes de-iodising of the salt by the thermal processing of the food.
The majority of the respondents do not check the date of expiry of the salt (43.4% urban and 52.2% rural) or do so only from time to time.
Mainly salt for cattle is used for feeding domestic animals, or salt for domestic use.
Urban respondents mainly acquired in school, and to a less extent through media, the information that all salt used for the feeding of human beings and domestic animals must be iodised, while rural respondents obtained such information equally through media or in school.
RECOMMENDATIONS (PROPOSAL OF MEASURES TO BE UNDERTAKEN)
Based on the Research related to awareness, perception and habits of using iodised salt in Serbia and Montenegro and with the aim of achieving sustainable elimination of disorders caused by iodine deficiency, future activities should be planned in accordance with the following recommendations:
It is necessary to maintain the legal obligation of iodising kitchen salt, the salt for the food industry and salt for the feeding of domestic animals, as well as the carrying out of regular inspections in this sphere.
It is necessary to plan activities in the sphere of social mobilisation, with the main target being improved information of the population, as well as habits and behaviour related to the acquisition, storage and use of salt in households. The most appropriate health education messages are:
Better health with the help of iodised salt
Add salt at the end of the cooking of a meal
Check the expiry date of the salt
Store in a closed glass jar
Purchase only iodised salt
The best way to achieve these goals:
The work of the existing teams in health institutes (panel discussions, lectures in schools and companies, local television shows, articles in local newspapers, i.e., programme and campaign endeavors).
Appearance of members of the Commission for Prevention of Iodine Deficiency in Serbia and Montenegro in major television stations and publishing of articles in specialised magazines.
The placing of billboards at central locations in the major cities in Serbia and Montenegro
Production of posters and leaflets for distribution in schools, health institutions and companies
It is necessary to involve the Ministries of Education of Serbia and of Montenegro in order to include this matter in the school education programmes
The packaging of salt should not exceed one kilogram.
Those employed in health institutions, especially in primary health protection institutions – health centres and polyvalent patronage departments, in their daily contacts with patients/households, should be actively involved in promoting iodised salt and its proper storage and use.