1. Community Interventions for Health India K R Thankappan MD,MPH For the CIH Team Kerala, India Professor and Head Achutha Menon Centre for Health Science Studies Sree Chitra Tirunal Institute for Medical Sciences and for Medical Sciences and Technology, Trivandrum, India Email: kavumpurathu@yahoo.com kavumpurathu@yahoo.com

2. Outline of the Presentation Background Baseline Survey Findings Intervention Strategies Successes and Challenges Conclusion

3. Chirayinkeezhu Delayed Intervention Area 3

4. NCD Risk factors UrbanRural MenWomenTotalMenWomenTotal Hypertension *36.233.634.934.430.832.5 Diabetes†12.317.114.819.022.020.6 Abdominal obesity+ 30.053.741.917.848.433.9 Tobacco use (Any form) 43.02.622.645.25.524.3 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

5. Baseline Survey Findings

6. SectorsCurrent smoking (%) Smokeless tobacco (%) PA <30mts/day (%) <one hour/day for children <Five servings of fruit and / vegetables/day (%) MFMFMFMF Youth4.20.143.71.082.195.788.188.3 Workplace Industry 23.60.7014.12.634.944.986.287.6 Workplace School 8.00.14.50.236.956.682.778.0 Workplace Health sector 14.10.15.10.442.754.869.676.3 Community27.60.313.33.314.925.377.084.0

7. Biochemical Parameters of Employees Industry (N=2427) Blood parametersMean valuesProportion having high biochemical parameters Total Cholesterol197.9 mg/dl47.1 ( >= 200 mg/dl) LDL130.6 mg/dl49.0 ( >= 130 mg/dl) Triglycerides124.7 mg/dl25.9 ( >= 150 mg/dl) HDL40 mg/dl60.0 (<40mg/dl for men ) 65.5 (<50 mg/dl for women) TC/HDL ratio5.460.3 ( >= 4.5) Fasting blood glucose112.7 mg/dl17.9 ( >= 126 mg/dl)

8. 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

9. Intervention Strategies

10. 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

11. 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

12. 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 ”)

13. Few Posters on Tobacco

14. A poster outside a major intervention health centre

15. Students performing a street play for WNTD 2009

16. 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

17. A few posters

18. Canteen POD prompts

19. Healthy cooking session at a major intervention health centre

20. Vegetable garden training

21. 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

22. POD prompts for taking the stairs

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

24. Inauguration of cycle training for girls

25. Yoga training at major intervention health centre

26. InstitutionsNo of InstitutionsNo of postersReach /day Schools23394 35000 (Students, Teachers, other staff and parents) Health Centre161986500 (staff, patients and bystanders) Industry61131850 (Staff and public visiting police stations) Community16242700 (Panchayat offices and Arts and sports club) Outreach of the Posters

27. 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

28. 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

29. Coalition Building Health 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

30. Challenges Tobacco: 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

31. 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

32. 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

33. 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”

34. 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