Cherian Varghese, MD, PhD

Community-Based Approach in the Prevention of NCD’s: Evidences

and Lessons in Health Promotion

Structure
NCD prevention:
Application

NCD prevention:
Evidence

Current approaches in the prevention of NCDs:

Evidence and Lessons in Health Promotion NCD prevention:
Issues

Dr. Cherian Varghese MD., M Phil., Ph.D.

Technical Officer (NCD)
8/19/2009 HP-NCD-Cherian Varghese-ISDFI-23 June 2009
8/19/2009 HP-NCD-Cherian Varghese-ISDFI-23 June 2009

Communicable vs Non communicable diseases

Structure Points to consider in control strategies

NCD prevention:
Application  Communicable Diseases  NCDs
 Sudden onset  Gradual onset
 Single cause  Multiple aetiology
 Short natural history  Long natural history
NCD prevention:
Evidence  Short Trt schedule  Prolonged trt
 Cure is achieved  Care predominates
 Single discipline  Multidisciplinary
NCD prevention:
 Short follow up  Prolonged follow up
Issues  Back to normalcy  Quality of life

8/19/2009 HP-NCD-Cherian Varghese-ISDFI-23 June 2009

8/19/2009 HP-NCD-Cherian Varghese-ISDFI-23 June 2009

Changing times

D is ta l H ealth ou tc o m es
1.HIV
determ in a nts
P ro xim al 2.V io le nc e
1.P ov erty
d ete rm ina nts 3.Inu ries
2.P rom otio n o f
1. A lc o ho l ab u s e 4.R T A
alc o hol
2. D rug us e 5.T B
3.A d v ertis em e nt a nd Vulnerable
3. T ob a c c o us e 6.S T I
av ailab ility o f population
4. O b e s ity 7.NC D s
un he alth y fo o ds 5. H yp erten s io n 8.DM
4.N o fac ility fo r 6. D rink dr iv ing
9.C V D
p hy s ic al ac tiv ity
10 .C an c er
5.L ac k of healthy
11 .D ep res s io n
c hoic es fo r fo od
12 .S uic ide
6.U ns afe
e nv iro nm e n t
Interventions in non health
sectors can lead to impacts
on health
8/19/2009 HP-NCD-Cherian Varghese-ISDFI-23 June 2009
8/19/2009 HP-NCD-Cherian Varghese-ISDFI-23 June 2009
Cherian Varghese, MD, PhD
Community-Based Approach in the Prevention of NCD’s: Evidences
and Lessons in Health Promotion
Recipe for NCD
Tobacco/Alcohol
THE MEDICAL MODEL

SCREEN DIAGNOSE
Lack of vegetables
& fruits Focus is on Disease.

TREAT
Sexual behaviour/ poor (FIX)
genital hygiene
Excess
Sedentary dietaryFAT
habits

HEALTH EDUCATION: WHY CHANGE TO HEALTH PROMOTION? KNOWLEDGE BEHAVIOUR PARADOX

Behavioral intention Behavior change

 Hearing is not KNOWING

 Knowing is not
UNDERSTANDING
 Understanding is not
PRACTICING (doing)
 HOW DO WE ACHIEVE
DESIRED BEHAVIOR
CHANGE? Factors affecting
* Knoweldge * Decision making * Time * Resources *Facilities

8/19/2009 HP-NCD-Cherian Varghese-ISDFI-23 June 2009

THE HP MODEL
ENABLING D
PROMOTE PREVENT
I
Focus is on Health

SUSTAIN
E
ENVIRONMENT
T
Cherian Varghese, MD, PhD
Community-Based Approach in the Prevention of NCD’s: Evidences
and Lessons in Health Promotion
Overweight and obesity are risk factors for
Eating habits
Diabetes  Established early in life
 Diet
Stroke  Composition
 Periodicity
Heart Disease / Hypertension  Amount of energy derived
Gall Bladder Disease  ‘Eat least’ category foods are
promoted maximum
Osteoarthritis  Advertising
Sleep Apnoea  Marketing
Cancers  Culture
 Fashion
Kidney/Uterine/  Convenience
Breast/Colon

Food and beverage marketing

Physical inactivity
 Array of marketing venues and
vehicles
 School based, promotions, television,  Work- mostly sitting
movie product placement, internet, mobile
phones  At home – in front of TV
 Over the ages 2-11 years, children  Play-on computer
develop consumption motives and  Travel-motorized
values
 Develop strategies for purchase requests  Everything to make us
and negotiation more sedentary
 Candy, carbonated soft drinks and salty
snacks  ‘Obesogenic’ environment
 Children aware of food brands as young
as 2-3 yrs of age

8/19/2009 HP-NCD-Cherian Varghese-ISDFI-23 June 2009

Physical Activity Upstream interventions

 Different types and amounts of

physical activity are required for
different health outcomes:
 At least 30 minutes of regular,
moderate-intensity physical
activity on most days reduces
the risk of cardiovascular
disease and diabetes, colon
cancer and breast cancer.

8/19/2009 HP-NCD-Cherian Varghese-ISDFI-23 June 2009

8/19/2009 HP-NCD-Cherian Varghese-ISDFI-23 June 2009
Cherian Varghese, MD, PhD
Community-Based Approach in the Prevention of NCD’s: Evidences
and Lessons in Health Promotion

Structure Evidence
NCD prevention:  Policy and environment
Application
 Government regulatory policies
 Mass media campaigns with policy support
 School settings
NCD prevention:
Evidence  High intensity programmes with multiple components
 Workplace
 Multicomponent programme
NCD prevention:  Community
Issues  With multisectoral interventions

8/19/2009 HP-NCD-Cherian Varghese-ISDFI-23 June 2009

8/19/2009 HP-NCD-Cherian Varghese-ISDFI-23 June 2009

NCDs and risk factors in Singapore

Areas for W hole of Government Approach 1992-2004

30
 MEDIA 25
Agestandardizedprevalence

 INFRASTRUCTURE 25

 AGRICULTURE
20 17.8
17
 EDUCATION SECTOR
15
 TAXATION 15 13.5
12.5

 TRADE/INDUSTRY 10 9.5
10 7.8
 MARKETING
5

0
1991 1998 2004
8/19/2009 HP-NCD-Cherian Varghese-ISDFI-23 June 2009 Hypertension DM Obesity High Cholesterol Cigarette s moking Regular exercise

Structure ‘Settings’ based approach

 ‘Captive’ population
NCD prevention:  Usually under one command
Application  Facilitates policy level changes
 Enabling environment
 Availability of resources
 Ability to demonstrate results
NCD prevention:  Sustainability of interventions
Evidence
 Health promoting schools
 Healthy workplace
 Health promoting churches
NCD prevention:  Healthy markets
Issues
 Healthy cities
 Healthy Islands

8/19/2009 HP-NCD-Cherian Varghese-ISDFI-23 June 2009

8/19/2009 HP-NCD-Cherian Varghese-ISDFI-23 June 2009
Cherian Varghese, MD, PhD
Community-Based Approach in the Prevention of NCD’s: Evidences
and Lessons in Health Promotion

School Health Commitment for becoming HPS

Programme  Willingness on part of the
school authorities to take
Theory to responsibility to develop the
school as a health
practice promoting setting

Approach to HPS
 Joint planning by Education and
Health Departments
 Policies for tobacco, alcohol,
drugs, physical punishment etc
 Sustained activities
 Whole of school approach
 Focus on promoting health
 Versus detecting and treating
disease
 Repeated assessment

School based programme

 Many habits are

formed early in life
 Organized approach
 Sustained
 Policy changes
 Facilities
 Responsive
teachers
 Equip the children
with the right skills
to face life
Cherian Varghese, MD, PhD
Community-Based Approach in the Prevention of NCD’s: Evidences
and Lessons in Health Promotion

Work place…

HEALTHY WORKPLACE
 Commitment-Continuity in care EMPLOYEE
 Feasible, Multisectoral, COMMITMENT
PARTICIPATION
approaches,
 Service providers-existing and new HWP
 Build capacity
 Public health training
 Surveillance systems INTERVENTIONS
 Insurance coverage Surveillance
Tobacco cessation
Baseline data
Diet
 Special groups Current spending
Physical activity
on health
 Health care workers, radiation workers Sickness absenteeism Stress reduction
Occupational health Check list
 Linkage with other programmes Environment
Noise, Dust
 TB, HIV, Tobacco, Nutrition, Water
environment Sanitation
 Formal and informal sectors
 Healthy workplace-healthy industry

What is a healthy, active city?

A healthy city is not one that has achieved a particular health status. Ban transfats
Rather, it is a city that is conscious of health and striving to improve it. What
is required is a commitment to health and a process and structure to achieve  With the stroke of a pen
it. this afternoon, Governor
A healthy, active city is one that is continually creating and improving Arnold Schwarzenegger
opportunities in the built and social environments and expanding community
resources to enable all its citizens to be physically active in day-to-day life. will make California the
first state in the nation to
make its restaurant foods
free of artificial trans fat.
It’s a bold move that will
prevent thousands of
heart attack deaths in that
state and save millions of
health care dollars.
8/19/2009 HP-NCD-Cherian Varghese-ISDFI-23 June 2009
8/19/2009 HP-NCD-Cherian Varghese-ISDFI-23 June 2009
Cherian Varghese, MD, PhD
Community-Based Approach in the Prevention of NCD’s: Evidences
and Lessons in Health Promotion
Trans Fat Ban Population
New York City, NY 8 million

Philadelphia, PA 5 million
Traffic light labels UK
Montgomery County, MD 932,000

Brook line, MA 58,000

King County, W A 1.8 million

Trans Fat Bans in Nassau County, NY 1.3 million

Restaurants W estchester County, NY 949,355
United States Population: Suff olk County, NY 1.5 million
301 Million
Boston, MA 600,000

Stamford, CT 118,000

Cambridge, MA 100,000

California 36.5 million

Albany County, NY 298,000

Also
Puerto Ric o 4 million

8/19/2009 HP-NCD-Cherian Varghese-ISDFI-23 June 2009

8/19/2009 HP-NCD-Cherian Varghese-ISDFI-23 June 2009
Cherian Varghese, MD, PhD
Community-Based Approach in the Prevention of NCD’s: Evidences
and Lessons in Health Promotion

Health promotion champions

 Nurses are most suited to become health
promotion champions
 Health knowledge
 Clinical skills
 Communication skills
 Attitude
 Confidence among people
 Friendly

8/19/2009 HP-NCD-Cherian Varghese-ISDFI-23 June 2009

Monitoring and Evaluation EARLY EASY

 Availability and implementation of policies
 Programmatic indicators
 Surveillance-Risk factor profile-using WHO STEPwise
approach
Mortality and morbidity-selected sites

 Health expenditure
Healthy Lifestyle
 Process indicators depending on the intervention
 Programmes conducted
 Policies and orders
 Implementation
 Number of healthy settings

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HP-NCD-Cherian Varghese-ISDFI-23 June 2009
ENJOYABLE EVERYWHERE
HP-NCD-Cherian Varghese-ISDFI-23 June 2009