Community Interventions for HealthIndia

K R Thankappan MD,MPHK R Thankappan MD,MPHFor the CIH Team Kerala, IndiaFor the CIH Team Kerala, India

Professor and HeadProfessor and HeadAchutha Menon Centre for Achutha Menon Centre for Health Science StudiesHealth Science StudiesSree Chitra Tirunal Institute Sree Chitra Tirunal Institute for Medical Sciences and for Medical Sciences and Technology, Trivandrum, IndiaTechnology, Trivandrum, IndiaEmail: Email: kavumpurathu@yahoo.com

Outline of the Presentation

Background

Baseline Survey Findings

Intervention Strategies

Successes and Challenges

Conclusion

ChirayinkeezhuDelayed Intervention Area

3

NCD Risk factorsUrban Rural

Men Women Total Men Women Total

Hypertension * 36.2 33.6 34.9 34.4 30.8 32.5

Diabetes† 12.3 17.1 14.8 19.0 22.0 20.6

Abdominal obesity+

30.0 53.7 41.9 17.8 48.4 33.9

Tobacco use (Any form)

43.0 2.6 22.6 45.2 5.5 24.3

Thankappan K R et al. Indian J Med Res 2010;131: 53-63

* As per JNC 7 Criteria. † Fasting blood glucose >= 126 mg /dl. + >=90 cm in men and >=85 cm in women

Baseline Survey Findings

Sectors Current smoking

(%)

Smokeless tobacco

(%)

PA <30mts/day(%)

<one hour/day for children

<Five servings of fruit and / vegetables/day (%)

M F M F M F M F

Youth 4.2 0.14 3.7 1.0 82.1 95.7 88.1 88.3

Workplace Industry

23.6 0.70 14.1 2.6 34.9 44.9 86.2 87.6

Workplace School

8.0 0.1 4.5 0.2 36.9 56.6 82.7 78.0

Workplace Health sector

14.1 0.1 5.1 0.4 42.7 54.8 69.6 76.3

Community 27.6 0.3 13.3 3.3 14.9 25.3 77.0 84.0

Biochemical Parameters of Employees Industry (N=2427)

Blood parameters Mean values Proportion having high biochemical parameters

Total Cholesterol 197.9 mg/dl 47.1 ( >= 200 mg/dl)

LDL 130.6 mg/dl 49.0 ( >=130 mg/dl)

Triglycerides 124.7 mg/dl 25.9 (>=150 mg/dl)

HDL 40 mg/dl 60.0 (<40mg/dl for men )65.5 (<50 mg/dl for women)

TC/HDL ratio 5.4 60.3 (>=4.5)

Fasting blood glucose 112.7 mg/dl 17.9 ( >=126 mg/dl)

Major Areas of Concern

• Low levels of physical activity, especially among girls and women

• Low intake of fruits and vegetables and high intake of fatty diet from workplace canteens

• Smokeless tobacco use among school children

Intervention Strategies

Health Education

• Health Education classes in all sectors -participative sessions

• Seminar in health care and industry setting• Integration of CIH sessions with in-house training for

the employees especially in intervention hospitals• Information Education Communication to the

community using trained Anganwadi workers• One time events – delivery of key health message

during events like school youth festivals, sports days

Role of Anganwadi Workers

• Trained 186 Anganwadi workers (AWW)

• Each of the AWW cater to the need of 200- 250 households

• Apart from child care at the Anganwadis they visit households in the afternoon

• Outreach is of a population of 150,000-200,000 in three months

• They integrated healthy diet, anti tobacco and physical activity promotion messages along with their routine health activities

Intervention Strategies for Prevention and Control of Tobacco

• Development and Implementation of Tobacco Free Campus Policy

• Display of No Tobacco sign boards

• Developed and displayed posters related to tobacco hazards and passive smoking

• Observation of special days (e g - “World no tobacco day with street plays ”)

Few Posters on Tobacco

A poster outside a major intervention health centre

Students performing a street play for WNTD 2009

Intervention Strategies for Healthy Diet Promotion

• Introduction of healthy food options in the canteens

• Advocacy with canteen committee

• Healthy cooking session in the intervention hospital

• Training on vegetable cultivation and distribution of vegetable seeds

• Display of POD prompts in front of canteen

• Developed and displayed posters on healthy diet

A few posters

Canteen POD prompts

Healthy cooking session at a major intervention health centre

Vegetable garden training

Intervention Strategies for Physical Activity (PA) Promotion

• Display of POD prompts in front of elevators

• Sports kit distribution based on the “felt need” and “demand”

• Cycle training for girls in school

• Yoga training to adults in work place

• Developed and displayed posters on health benefits of Physical activity

POD prompts for taking the stairs

Sports kit distribution by the Honorable minister for Education, Mr M A Baby

Inauguration of cycle training for girls

Yoga training at major intervention health centre

Institutions No of Institutions No of posters Reach /day

Schools 23 394 35000(Students, Teachers, other staff and parents)

Health Centre 16 198 6500 (staff, patients and bystanders)

Industry 6 113 1850 (Staff and public visiting police stations)

Community 16 242 700(Panchayat offices and Arts and sports club)

Outreach of the Posters

High Demand for Posters

• From a branch of one of our industries from a neighboring state

• From a Medical officer of the neighboring district

• From officials, elected representatives and representatives of youth club

• Advocacy for the institutionalization of NCD risk factor prevention : – Health projects for Prevention of NCD risk

factors taken up by Local Self Governments and Youth welfare board

This would make the CIH activities sustainable in the intervention area

Intervention Strategies in the Community

Coalition BuildingHealth sector

• Directorate of Health Services• health centres• Integrated Child development

Scheme• Athiyannur Sree Chitra Action • Regional cancer centre• Quit Tobacco India project

supported by the NIH• Role of women health workers in

NCD prevention, AMCHSS

Other sectors• Local Self Government

Institutions• Department of Education• All Schools,• Industries• Mahila Samakkhya Samiti• Youth welfare board• Kerala Agricultural University• Local libraries, arts and

sports clubs in the community

ChallengesTobacco:

• Wider availability, subtle ways of selling and undercover use of tobacco despite the ban

• Weak anti tobacco law enforcement

Diet:

• Abundance in availability of fried/high fat/sugar sweetened beverages

• Increasing “Eating out culture”

• High impact advertisements targeting children

Challenges Contd..

• Exorbitant prices and high use of pesticides as a cause for less intake of fruits and vegetables

• Lack of experts in training healthy cooking practices

Physical activity:

• “Exercise” is not a part of daily life in our culture

• Misconception- household activity is sufficient to be physically active

• Cultural barrier for women and girls

• Unfavorable environment- vehicle density, lack of play grounds/walkways

Success Stories• Were able to successfully advocate institutionalization

of NCD risk factor prevention with Local self Government by introducing projects

• Were able to convince the importance of NCD risk factor prevention and obtain the cooperation of all partner institutions for the interventions

• Enhanced the implementation process of anti tobacco laws

Reflections from the Field• A heart patient after watching tobacco posters, “ Had

somebody told me this 20 years back, I wouldn’t have suffered like this”

• A nurse after watching the diet posters, “These would have been displayed a long time back. It is useful for the patients as well as staff”

• A school head master commented on all posters “ You did a good job, These are all very useful information, timely and essential”

• A school teacher on health education classes: “After your classes my son insisted of not eating chips/fried items”

• AWWs on health education classes, “Now we find ourselves competent to respond to the queries on lifestyle modification in relation to chronic diseases like diabetes and heart diseases”

Conclusion • Baseline survey revealed high prevalence of

tobacco use and unhealthy practices in terms of diet and physical activity

• Biochemical parameters reveals high levels of NCD risk factors

• Intervention strategies were tailored for each sector to address the NCD risk factors

• Although there were many challenges especially in the context of lack of wider policies for prevention and control of NCDs, we succeeded in initiating many activities in this area as we planned