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World Health Organization @ 2003. This publication is a
resource for training primary care workers in the prevention
and control of noncommunicable diseases based on
Philippine national guidelines. Adaptation to other countries
or reg ions will requ ire inclusion of the national or international
guidelines that are appropriate in the new context. All rights
reserved. The document may, however, be freely reviewed,
abstracted, quoted, reproduced or translated in part or in
whole, provided that such is not done in, for, or in conjunction
with commercial purposes and provided that, if it is intended
to translate or reproduce the entire work, or substantial
portions thereof, prior application is made to the Publications
Unit, WHOMPRO, Manila, PhiliPPines.
Promoting Healthy Lifestyles - An Integrated Community-based Approach
to Prevention and control of Noncommunicable Diseases
TRAINING MANUAL FOR HEALTH WORKERS

,f-6/,'z /"" AWh C/,^^A"

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The leading causes of mortality in the Philippines today are no longer communicable diseases but more
chronic, debilitating noncommunicable diseases (NCDs). These include cardiovascular diseases like
hypertension, coronary artery diseases and stroke; cancers, chronic obstructive pulmonary diseases and
diabetes mellitus. Bronchial asthma, though not among the leading causes of moftality, is fast becoming a
public concern and contributes greatlyto morbidity.

These illnesses are also called "lifestyle diseases" because nutrition, physical activ1y, smoking, alcohol
drinking and stress contribute to their development. In fact, it is now recognized thai these m{or NCDs
share common risk factors and that modifying these risk factors using community-based approaches will
have greater impact in the long-term and be more cost-effective than interventions that focus on individual
behaviors alone.

To address this need, the Philippine Department of Health, in collaboration with the World Health
Organization Western Pacific Regional Office, is establishing an integrated community-based
noncommunicable disease prevention project. lt is called the National Healthy Lifestyle program. The
programme's objectives include slowing down or reversing the increasing trend in the prevalence of life-
style-related risk factors of NCDs, including smoking, unhealthy diet, and sedentary lifestyle, and creating a
supportive environmentfor positive behavior change and healthy Iifestyles.

The University of the Philippines Manila College of Nursing was commissioned bythe Department of Health
with funding from the World Health Organization Western Pacific Regional Office to develop a training
manualandimplementatrainingprogrammefortrainersandotherhealthworkersfortwopilotareas. These
areas included the municipality of Pateros in Metro Manila (representing an urban community) and the
Province of Guimaras in Western Visayas (representing a ruralcommunity).

A training needs assessment for each site was conducted towards the end of 2001 , the results of which were
used to develop the initial draft of the training manual. The draft manual was then field-tested during the
training of trainers and two other training programmes for health workers in the two sites in 2002. After
implementing the series of training workshops in Pateros and Guimaras, feedback was collected from the
participants, particularly the trainers and end-users, and evaluation visits were conducted by the project
team. Based on ihis valuable information, the draft manual was revised and enriched to the form you see
now
This training manual, therefore, serves as a guide for primary health care providers in promoting healthy
lifestyles for individuals, groups, and communities. The approach to prevention and control of
noncommunicable diseases is integrated and primarily community-based. lt focuses on prevention and
modification of major risk factors, such as unhealthy nutrition, sedentary lifestyle and smoking, which will
prevent not only one, but most of the major NGDs. Emphasis is on population-based approaches that will
impact on a larger podion of the population than individual or clinical approaches.

Selection of content was based on a list of competencies expected of health workers, primarily, nurses,
midwives and doctors, to fulfilltheir role5 in promoting healthy lifestyle change. Existing Department of Health
guidelines, clinical guidelines and consensus statements by expert groups regarding prevention and control
of specific NCDs and risk factors provided the backbone for the content. Local guidelines were used
whenever available, such as in hypertension, cancer, obesity, and asthma. lf not available, international or
regional guidelines endorsed by local expeds were utilized such as in chronic obstructive pulmonary disease
and diabetes.

This training manualconsists of four booklets and seven sessions. Participants suggested the bookletformat
because it is handier and more convenient, Effort was taken to make the format and language simple and
more interesting to intended users of the manual.

The first booklet is the Trainer's Guide. lt contains a background of the project, a description of the training
programme and manual, the instructional plan for each session, and the framework for the prevention and
control of NCDs using an integraied approach. This is important, particularlyfortrainers and health workers
in replicating this training programme for other health workers. Instructional plans contain the objectives per
session, the key messages, and some suggested learning activities and activities to obtain padicipant
feedback and evaluation.

Thc three oiher booklets contain the content and reference materials needed for discussing and processing
activities for each session. These booklets are good reference materials for health workers even after the
training programme. Each booklet includes session objectives and key messages that health workers
should keep in mind.

This training manual is a vital instrument for enhancing the capability of primary health care providers to
promote healthy lifestyle and uliimately contributing to the reduction in the morbidity and mortality due to
noncommunicable diseases.

llt
/rJ /\ n-4 I

Manuel M. Dayrit, MD, Msc

Secretary of Health
Philippine Department of Health
w
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The Western Pacific Region faces a major new epidemic. Six out of ten deaths in this Region are caused by
noncommunicabte diseases, mainly cardiovascular disease, diabetes, and cancer. Many of these deaths
arecausedbyasmallgroupofcommonriskfactors,andthusare amenabletoprevention.

However, this is a new epidemic. Many of our health systems are geared to respond to more traditional
causes of disease: deficiency and infectious diseases. In order to reorient our systems io face these new
chlllenges, we need action on manyfronts. We need national action to develop healthy public policy. We
need community action to reduce risk at local level. And we need to train our health workers to support
prevention: through setting an example, through counselling and advocacy, and through direct service
provision.

This set of manuals represents a major step forward in this regard. lt is a unique compilation of guidelines
and pedagogical materials suitable for self-learning or for a workshop setting. lt is consistent with all agreed
guidelines forthe Philippines and willserve as a resourcefor learning and atoolforservice delivery.

WHO is deljghted to have supported this project technically and financially. I congratulate the Department of
Health antj tne University of the Philippines on the product. WHO looks forward to continued collaboration
on ihis project.

f/"'r/* [h:
Shigerrfoma, MD, Ph.D.
Regional Director
WHO Regional Office for the Western Pacific

I
 w
ftM

and the
The University of the philippines Manilafullysubscribes tothethrust of theWorld Health Organization
Department of Healttr on'promoting heaitrry lifestyles as an approach to preventing noncommunicable
not only
diseases (NCDs). Thus, it supportslnd contributes to the efforts to make this strategy a success
among individuals and groups but more importantly, among communities.

The orevention and control of NCDs calls for an integrated, community-based approach that
will require the
and enlightened participation of community residents and primary health care workers.
"oinritt"O
This training manual is meantto guide primary health careworkers, especially nurses,
midwives and doctors
al agents of positive lifestyle and behavior change. Through the production
in fulfilling their roles and tasks
team from the College of Nursing, led by Dr. Josefina A. Tuazon, UP Manila is
of this training manual by a
Community-
happyto havJperformeditsshare in realizing theobjectiveof Departmentof Health's lntegrated
prevention project-the reduction in the mortality and morbidity rates due
oasei Noncommunicable Disease
to NCDs.
material that details
Icommend the team members for putting togetherthis very practical and easy-to-follow
.ojectives and activities for heaith workers. The writers should also be commended
for
"p""iti"
incorporating fitting examples and simplifying application of guidelines for easier
comprehension.

""Lrf(ry*<**
Marita V.T. deYes, MD
Chancellor
University of the Philippines Manila

L
Po*i"tT*"*
(
Editors
Josefina A. Tuazon, RN, DrpH
Luz Barbara P. Dones, RN, MpH
Sheila R. Bonito, RN, MAN

Contributors
Cora A. Aflonuevo, RN, MPH
Sheila R. Bonito, RN, MAN
Luz Barbara P. Dones, RN, MpH
Cecilia M. Laurente, RN, PhD
Lydia T. Manahan, RN, MAN
Emma D. Mantilla, RN, MAN
Araceli Ocampo-Balabagno, RN, phD
Josefina A. Tuazon, RN, DrPH

Consultant
Tbodora V. Tiglao, EdD

A national publication of the Philippine Department of Health researched and prepared by the
University of the Philippines Manila, College of Nursing, and funded by the World Health
Organization, Western Pacific Regional Office.
 P*r*ory B"/-r^*in, &" "A,

Understanding Health Behavior 2

Changing Health Behavior ?

Behavior Change Interventions 8

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Utilizing Existing Community Data 20

Creating Community Awareness zl

Developing an Action Plan 24

I
t6^67"" /." l./.44h C/"^.V, n fraining Manual for Health Workers on Promoting Healthy !-ifestyle
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 P*r*ory B"A^.^bo g"^"A,

Understanding Health Behavior

Why Change Health Behavior

Factors Affectinq Health Behavior

Changing Health Behavior

Principles in Changing Health Behavior

Strategies in Changing Health Behavior

Behavior Change Interventions

Strengthening Individual Intention to Change

Creating Supportive Environment for Healthy Lifestyles

I
t6^6fnz /.o AWl- 9. ".A" A Training Manual for Health Workers on Promoting Healthy Lifestyle
I
 !fudlt{ Wort<ers on Promoting Healthy Lifestyles

SESSION

Promoting Behavior Change

Noncommunicable diseases, such as cardiovascular diseases, diabetes mellitus, cancer and

COPD are also known as lifestyle diseases. This is because these NCDs are mostly due to unhealthy
behaviors, such as eating salty and fatty foods, living a sedentary life and smoking
tobacco/cigarettes.

Preventing noncommunicable diseases, therefore, means promoting a healthier lifestyle.

Reducing caloric intake and increasing physical activity help prevent obesity and the risk of
cardiovascular diseases and diabetes. Eating salt and fat in moderation also prevent hypertension.
Plenty of fruits and vegetables can significantly reduce the risk of cancer and help control diabetes.
Avoiding smoking prevents chronic lung diseases and acute attacks of asthma and reduces risk of
lung cancer and other types ofcancers.

Unfortunately, these behaviors are not easy to change. Behaviors develop over time and become
away of life. As such, health workers need to know the basics of promoting lifestyle change. The
first step is to understand why people behave as they do. If we understand human behavior, then we
can be more effective in promoting lifestyle change. In a sense, we have to promote good health
behaviors and discourase bad health behaviors.

Session Objectives
At the end ofthis session, the health worker will be able to:

1 . Explain reasons for promoting healthy lifestyles

2. Explain the different factors affecting health behavior
3. Discuss the principles and strategies in changing behavior
3.1 Assess client's readiness to change based on stages of change
4. Plan/implement behavior change interventions appropriate for the
community

I'
 Understanding health behavior

Health behavior refers to the way of life a person has cultivated over the years that relate to health
maintenance, health restoration and health improvements. The health behavior can be eating a
balanced meal everyday, daily walking, weekly attendance to the gym, or bi-annual visits to the
dentist. These are established patterns that have positive effects on a person's health. There are also
negative health behaviors, such as eating foods high in cholesterol and salt, living a sedentary life or
smoking tobacco/ci garettes.

F actors ffi cting b e ahb b eb az: io r

Why do people behave the way they do? There are many factors thataffect human behavior.
For simplicity, we can categorize them into: (1) personal factors and (2) environmental factors.
Personal factors include the person's knowledge, attitudes, beliefs, motivation, self-concept,
past experience and skills that may constrain or promote behaviors. Environmental factors
include sociocultural determinants such as rules, regulations, policies and formal or informal
social or orgarizational structures that may constrain or promote behaviors.

For example, the behavior of eating salty foods may be influenced by the
irrdividual's/family's knowledge of food, regional/cultural tradition in food preparation, food
access, and availability. Imagine a fishing community that is on a constant diet of salted fish.
The people are used to eating salted fish because it is the most accessible and available food.
They are used to drying/salting fish ever since, and are not aware that too much salt in the diet can
raise blood pressure.

Another example is the sedentary lifestyle. Some people in the urban community are used to
modern conveniences that they have neglected their physical activities. They usually ride
instead of walk, use elevators instead of climb stairs, and sit in their off,rces all day. They do not
have the time, opportunity, nor the facilities to engage in more strenuous activities. They may
also not have the skill and motivation to engage in phy sical activities like sports.

Smoking is another example and is one of the most

complicated behaviors. Smoking behavior usually starts
during adolescence due to curiosity, peer pressure or
attraction made by the images of "glamour" and ***
"independence" portrayed by heroes in films or
advertisements. The availability of cigarettes in retail stores
and having parents/relatives and other role models who
smoke also encourage the behavior. Some smokers are
ignorant of the bad consequences of smoking to health. For
some who are informed, the addicting substance in the
cigarettes also makes it difficult for them to quit the habit.
The lack of a no-smoking policy in schools, offices and
public areas does not help control the behavior.

,l
 on Promoting HealthY LifestYles

Changing Health Behavior

Health behaviors influence health status. People who are fond of eating fatty foods and lead
sedentary lives tend to develop cardiovascular diieases and other noncommunicable diseases
in
later life. persons who smoke are at risk of developing lung cancer, cardiovascular diseases,
respiratory problems and other types of cancer. Avoiding salty foods, engaging in physical
activities ind not smoking can make a difference in the health ofthese people.

The ultimate goal is not simply health, but overall wellness of individuals and decreased
socio-
that is,
economic burden ofNCDs on society. We now recognize that primary prevention of NCDs,
promotion of health and prevention of disease, is m&e cost-effective than diagnosis, treatment and
rehabilitation.
only
As health workers, we are in the business of promoting health. Health promotion is not
for their health but also providing
educating people to change their behaviors that ire not good
enui.onientai support to-achieve and maintain behavior change. The idea is to make health
the
easier choice.

affecting
To change behavior, it is important that health workers understand the reasons/factors
u"rr"i.;
ri."rir, Bi focusing on the factors that help or inhibit behavior, we can be more successful
in promoting lifestyle change beneficial to health'

affect behavior'
In promoting change in health behavior, it is important to recall the factors that
such as knowledge,
Recall that there ur" iurronal factors that influenie an individual's action,
skills' Also, there are environmental
attitudes, belief-s, motivation, self-concept, past experience and
health bihavior, such as rules, regulations and policies in
factorsthat either support or constrain the strategies that should guide you in
the communitv ana siiiety. These factors form the principles and
changing health behaviors.

principles and strategies in changing I{ealth Behavior

but also on
1 . Behavior change is dependent not only on the individual's knowledge
perceptions, motivations, skills and otherfactors in the social environment'
threat of a
2. Behavior change is dependent on the individttal's perceptions of the
health probtim and acceptability of recommended behavior for preventing or
managingthe Problem.
to change toward
3. Behavior change is dependent on the individual's readiness
healthy behaviors.
among personal
4. Behavior change is dependent on the triadic relationship
nv iro nme nt al infl u e nc e s'
fa c t o r s, b e hav i o r and e

I'
 ,6-F*"*5.+ /,l",tqb

Beba,uior cbange is dependent not only on tbe indipidwal's knowledge bwt also on
perceptions, moti,uations, skills and other factors in tbe social enaironment.

Scenario L

You are talking to a group of mothers about proper nutrition. You are talking about the value
of a balanced diet and limiting salty, processed, and fatty foods. One young mother asked
vthat a balanced diet is and wants to know some tips in cooking. One commented that she
knows all about **hat you are saying but she cannot change her family's preference for
tocino, hotdog and longganisa. Another said that she hqs limited options since she can only
alford instant noodles and dried fish most of the time. Fruits and vegetables are expensive
and scarce.

Improving knowledge is very important in changing behavior. Health education strategies are
directed toward increasing awareness on the reasons for changing behavior and how to change
behavior. In the given scenario, it shows that it is not enough to say that a balanced diet is important
to health, but to specify what a balanced diet is. It is important to give specific examples. It is also
important to teach some skills, when appropriate and.needed. For example, meal planning and food
preparation are two skills that can be taught in the above scenario.
Knowledge is not enough to change behavior. There are practices that are deeply rooted in the
family and sometimes, tradition affects a person's choices, especially in food preferences. For
example, mothers perceive that the use of salty condiments in cooking or preference for fatty foods
and for sweets are difficult to change. There is a need to change these perceptions before they can
follow the recommended dietary guidelines.

Individuals need motivation to change behavior. Motivations can come in different forms, such
as telling them benefits of a balanced diet, giving them sample menus and recipes, or supporting
them in backyard gardening projects. Teaching them skills is also parl of motivating them and
making them change. If they lack the skill to prepare and cook foods that are less in fat content, they
will notbe able to change their family's diet.

Social
Norms ga.."
2 ? l- cl'
v',/"
Behavioral ?
Change

Knowledge is not enough 4z\

r%
Organization

^l
 Healthy Lifestyles

Changing an individual's behavior also involves looking at his/her social environment. The
social environment is composed of significant individuals and groups, such as family, work
colleagues, peers, neighbors and other social entities. These significant individuals have their own
thoughts, advices, examples, and emotional support, which affect their own perceptions, feelings,
behavior and health. These significant others should also be part of the campaign for behavior
chanse.

,, Behaaior change is dependent on tbe indieidwal's perceptions of tbe threat of a beahh

.. problem and acceptability of recommended bebavior for pre,rsenting or managing the
problem.

Scenario 2

Aling Marta is one of the community leaders and a likely candidate for heart attack or
stroke. She is hypertensive, obese, smokes and spends all her time working inside her ffice
at home. She is not interested in NCD prevention and control since she doesn't feel any
symptom and thinks that it is impossible for her to reduce weight anymore and cannot stop
smoking. Shealsobelievesthatwomenpasttheirfiftiesarepronetohigh-bloodpressure.

Aling Marta is a good example of this principle. She is the classic case of a person who does not
recognize nor believe that she is high-risk for stroke or heart attack or other noncommunicable
diseases, and that there are behavioral intervention programs that can help minimize this risk. If a
person does not recognize the threat to his/her health, behavior change is not likely to happen. Or
even if the person does recognrze the threat, but does not believe in the benefits of the program,
possibly no action will be done. If the person believes that there is a threat to his/her health and that
there is an effective program to reduce the threat, but the side effects are bad or the regimen is asking
too much, the person is again not likely to act. Changing behavior means dealing with all these
perceptions and then providing information and supporting the person's ability to take action.

Indiaidwal Perceptions tbat Inflwence Bebaaior Cbange

o Perceived susceptibility - one's opinion of chances of getting a condition.
o Perceived threat - one's opinion of how serious a condition is and its consequences.
o Perceived benefits - one's opinion ofthe efficacy of the advised action to reduce the
risk or seriousness of impact.
o Perceived barriers - one's opinion of the tangible and psychological costs of the
advised action.

I'
 In dealing with clients like Aling Marta, it is importantto:
1. Discuss the risks or chances of getting a condition (in Aling Marla's case: risk of
cardiovascular disease and stroke).
2 Specify consequences ofthe risks and condition (heart attack and stroke).
3. Define action to take: how, where, when and clari$' the positive effects or benefits to be
expected.
4. Address possible barriers or what stops an individual to change behavior by giving
reassurance, assistance or incentives.
5. Use strategies like providing reading materials or providing training to make individual or
community to change behavior.

3 Bebaaior change is depend.ent on tbe indioidwal's readiness to change.

Scenario 3

You are launching a physical activity program in your community. You have
invited barangay fficials and members of dffirent households to .join your
" Hataw " Fitness Activity. How are you going to
encourage participation to the
program? Whatfactors do you thinkwill affict your program, in terms of initial
p art i c ip at io n and co nti nuity ?

Individuals are at varying levels of readiness to change. Some may be more ready than others to
initiate change in their behavior. It is important to have strategies targeted at the different stages of
change.

Stages of Change

o Pre-contemplation - unaware of the problem, hasn't

thought about change.
o Contemplation - aware of the problem, thinking about
change.
o Decision -making aplanto change.
o Action -implementationof/doingtheplan.
o Maintenance * continuation ofthe desirable actions.

'l
 Healthy LifestYles

persons who are not aware of the risks of living sedentary lives are not thinking of improving
their physical activity or joining any exercise or fitness program. There are those who might be
u**. that physical activity is important in maintaining health, but do not know howbetoaddressed
start and
maintain their own exercise regimen. These different levels of readiness should
separately to bring or sustain change in behavior.

1. For persons in pre-contemplation stage: Increase awareness of clients on the risks of having
increased blood sugar.
2. For persons in contemplation stage: Provide motivation or encourage client's plans.
a
Fo, p"rrot s who are already deciding to change: Plan with the client how to set goals and
actionplans.
4. During the action and maintenance stage, give client feedback, social support, and
reinforcements.

Knowing the stage of change a person is helps in pacing the actions towards change and avoids
rushine the individual to actions that he/she is not ready for'

/^ Bebaoior cbange is dependent on tbe triadic relationsbip among personal factors,

'T bebaoior and enoironmentalinfluences.

Scenario 4

you want to start a smoking cessation program in the high-school setting, lcnowing that
smoking behavior begins during adolescence and interventions at this stage are very
imporint. What do you think are thefactors that you have to consider inyour campaign to
bi able to successfuIiy change the behuvior of adolescents regarding smoking?

This explains that while the environment causes behavior, an individual uses cognitiveprocesses
to interprei both the environment and his/her behavior. An individual may also change his
given scenario
environinent to have a more favorable behavior outcome. This can be seen on the
either join the behavior as part
wherein an adolescent who belongs to a peer group who smokes can
osf,,pakikisoma" or leave the gro.rp to avoid pressrre on acquiring smoking behavior'

There are two sets of thinking processes that are important in understanding and changing
behavior: outcome expectations and self-fficacy. Outcome expectations include a
person's
interpretations of the of performing the behavior. In the given scenario, an adolescent
"6rrr"q.r.n"es of belonging in a group and smoking behavior
can weigh the positive and negative
"-otrsequ"nces
before he/she can make the dicision. Setf-fficacy is the person's belief in his capabilities
and
in saying
confidence in performing the behavior. If an adolescent has the confidence and capability

I'
 ,a"Ef*/oo

no to "smoking," he/she may even persuade the group to stop smoking and keep this behavior. Sell
efficacy can be improved by enhancing personal skills. For example, smokers need to know how to
stop smoking and maintain quit status.

Smoking behavior is learned through modeling and reinforcement. "Modeling" is learning from
what others are doing or experiencing. People can observe other people to understand the
consequences of specific behaviors. This usually happens when the person being 'oobserved" or
serving as o'model" is considered powerful, respected or "like" the observer. Reidorcement rs a
response to a person's behavior that affects whether or not the behavior is repeated. Positive
reinforcements or rewards increase the chances that behaviors will be repeated. Negative
reinforcements can either be punishment or lack of any response.

Behavior Change Interventions

Strengtbening Indiztidwal Intention to Cbange

The health care setting is a ripe venue for changing health behaviors. Clients who are
cqnsulting for health problems have "intentions to change" to prevent sickness or further
complications. Health workers should look at this as a golden opportunity to change faulty
health behaviors and promote health and wellness. Strengthening individuals' intention to
change can happen through one-on-one patient education or counseling during clinic
consultations or home visits. It can also happen during group sessions, like mothers' class or
community outreach pro grams.

There are many factors that affect behavior such as the influence of significant others, the
availability and accessibility of health care services and the attitude of health care providers and
environmental support. Policies, physical facilities and organrzational structures are needed to
help individuals transform their intentions into actions.

Key strategies in strengthening individual intention to change are based on the principles of
behavior and behavior change. Under each key strategy are specific techniques that can guide the
health worker. These techniques assure a deeper and meaningful connection with the client to
help him/her change and maintain good healthbehavior.

I. Promote IncreasedAwareness and Knowledge

Whether you have only one client or a group of mothers, fathers, children or families, it is
important to know the factors that will likely influence their understanding and acceptance
of ihe concepts you are teaching. However, remember that knowledge, though necessary, is
not enough for behavior change.

o Know your audience; perceptions, values, knowledge, skills, motivation

'l
 Knowing the characteristics of your learners will help you focus on what they
need to learn. You are likely to have mothers who need to know more about
healthy foods and how to prepare affordable meals for their family. You may
have informal sessions with groups like fishermen, farmers and out-of-work
males who need help to quit smoking. You may need to focus your physical
activity session to off,rce workers who lead sedentary lives. You need to know the
common perceptions and attitudes ofthese groups ofpeople so you can anticipate
theirproblems and address these.

Assessment of Learning Needs

1. Who ate the learners? Who will benefit the most?

2. What behavioral components can be changed
more easily?
3. Learning needs of the targetted groups? What are
their knowledge, beliefs, attitudes and skrlls?
4. \X/hat resources/services arc avallable to them?
What are the barriers to behavior change?

You also have to consider the characteristics of groups at different stages of

development. The learning needs of a child is different from those of the adult
and those of older persons. For specific guidelines, refer to Annex 6-1. Since
most of the time, we have adults as learners, it will be helpful for you to know
some assumptions about and how they learn (Refer to Annex 6-2).

Choose the message that should be given to your audience.

The key messages are the "must

knows" rather than the "nice to
knows." What are the key messages
that you want to leave to your
audience? These key messages will
guide you in your discussion with
them, so that you will not forget the
more important points. For
example, some key messages to
change smoking behavior include:
Tips on Making Key Messages:
. Keep the messages SIN{PLE!
o Give POSITIVE messages!
o Lrmrt number of messages to the
MOST USEFUL for the learners!
n I{eep repeating the messagesl

I'
 56-6/.* /o+ :,

> Smoking is related to 40 diseases, which include COPD, lung cancer, ischemic
heart disease, diabetes, stroke and asthma.
-> Smoke contains more than 4000 chemicals and gases which produce harm to the
body. It affects not only active smokers, but also passive smokers.
-> Tobacco use is addicting mainly due to nicotine. This makes quitting difiicult
specially the longer the duration smoked, the more number of cigarettes, the
younger started and the deeper the inhalation.
+ Ifyou have not started smoking, don't start. Ifyou are an occasional smoker, quit
now before it becomes an addiction. If you're a regular smoker, quit now because
you can still reduce your risk!

Knowing the key messages will focus the content and strategies of your health
education. For example, in diabetes and asthma, an important key message is that
these diseases are chronic diseases. There is, therefore, a need for self- management,
life sty le change and re gular medical check-up.

Choose a spokespersonyour audience can relate to.

Choosing a spokesperson is like choosing a product endorser. Think of the prominent

persons in your community who are reliable and respectable to be associated with your
iampaign for promoting a healthy lifestyle. Community leaders can be solicited for
psyChosocial and frnancial support. For example, a popular non-smoking mayor can be
your model for a "No-Smoking" campaign. His credibility as a good leader will make
bthers follow his example. It is important that you choose a reliable and credible
spokesperson. A wrong choice of spokesperson will affect the outcome of your health
e-ducati,on and campaign. Example, a popular athlete can be a good spokesperson for
asthma or an active celebrity for diabetes.

Thinkofhow youwill convey the message.

There are different ways of telling people about health messages. This will depend
on the characteristics ofthe learners, the objective and the message. Choose the best way
by looking at your purpose. Some health messages are relayed with the help of video
materials, some are played over the radio, some are taught with visual aids during group
sessions, some are iiO"a fy a workshop, and some discussed during public fora. For
example, teaching mothers about healthy nutrition would need meal planning and maybe
cooking demonstiations to demonstrate how to limit fat and salt in cooking and increase
fiber arid roughage. For children, a video on harmful effects of smoking on body or use
of comics or diorama for preventing diabetes are more appropriate.

10
I
 Healthy Lifestyles

o Be speciJic.

Focus your health education activity. People are more likely to remember your
health teachings if you maintain only one theme. You will also have enough time to
discuss importint details if you focus on one major topic. Being specific also means:
saying specificthings.
For example, don't just tell your clients "Eat a balanced diet", "Eat more vegetables"'
i'Eat at least 1 cup of cooked vegetables p er day" . It is not enough
It is better to iell them:
that you tell clients to avoid smoking. Tell them to avoid places that are not smoke-free,
and ieach them how to say "Please do not smoke" to persons smoking in their presence.

o Chooseyourtiming.
Timing helps a lot in facilitating the learning process. For example, a group of
women during-prenatal check-up can be taught promoting a healthy diet, increasing
physical activity, and avoiding smoking, to protect themselves and their babies.
For example, if someone just died in the community because of diabetes, this is a
good opportunity to organize a health education. and using the incident to motivate
feople io for testing for diabetes. Another good opportunity_to educate is when
"otn"
persons with asthma come to the health center for nebulization or when they consult for
.
an acute asthmaattack.

. Speakyour audience's language.

Speak in the language that will be best understood by your audience. Speak in their
dialeit if you can. This will limit misunderstanding and help estabH sh great rapport. Us9
words that convey the same meaning . For example, barbecue refers to skewered pork
while in another place, it is a catch-all term for grilled innards like "isaw" (intestines) and
"dugo" (blood). When people say they eat "sinigang," a sour broth dish usually cooked
with vegetables, we may assume wrongly that they eat vegetables. In one island province
in Visayas, "sinigang" is cooked with minimal vegetables compared to the Tagalog
regions.
2. Enhunce Motivation to Change
Increasing knowledge is not enough for people to change their behavior. Motivating them to
change takesi-hem on" .iep closer to a positive lifestyle change. Here are some ways to motivate
our clients.

o (Jnderstand your audience's perceptions and expectations.

Understand your audience's perceptions and expectations to motivate them towards

behavior change. Foster positive expectations and try to revise their negative perception
and expectations. For example, people may attend a health education session expecting
that thby will receive free medicines or other goods. Once they find out that they will
receive nothing, they may get bored and disinterested in the session. It is therefore
important to find out what the people's expectations are before starting and at the same
time, let them know what to expect from the session.

I ,'
 It is also important to understand the circumstances sllrrolrnding a person's inability
to achieve behavior change. For example, a pregnant mother diagnosed with gestational
diabetes may not be able to follow a prescribed diet not because she does not want to but
because she does not have control over the preparation of meal in the family. She might
be living with a dominant mother-in-law who takes charge of cooking and preparationof
food. Rather than focusing solely on the pregnant mother, it may be betteito include the
family in the health education. Making them aware of the problem and pointing out ways
to integrate change in meal preparation may enhance their motivation to undertai<e
suggested action.

E mp ha s ize po s it iv e attitu de s.

Be quick to detect the positive attitudes that your audience is communicating with
you. Capitahze on these attitudes to maintain good rapport and positive reception to
your messages. Also, encourage them to keep on being positive. Remember that there is
no one attitude. It is more of a set of attitudes. Select the positive attitude that you can
build on. Do not overly focus on the negative because this will just alienate and make
your client resistant.

Identify social norms.

Try to investigate the ways that your audience is used to. For example, initiating a
physical activity program would require keeping in touch with the common activities of
the target audience and working on these for your program. Dancing is oftena favorite in
rural community celebrations. Marathon and fun-run games can be introduced in some
urbancommunity.

The following are some examples ofnorms andpractices:

-> Farmers usually indulge in drinking after their morning's work and usually,
cigarette smoking goes with drinking.
> Fishermen smoke when fishing at nightto keep themselves warm and awake.
+- A place is known for its "balut industry," which needs to be considered when
teaching nutrition.

Olfe r inc e ntiv e s and rew ards. I

Giving incentives and rewards are also part of motivating people. Incentives need I
not be in the form of cash or goods. Additional information, skill and social suppofi
groups are more than enough for people who truly need them. These are considered
rewards in themselves. Other forms of incentives and rewards are recognition (e.g.
Outstanding BNS/BHW), access to services, awarding, discounts and other benefits ol
membership inaclub.

,2
I
 :'.'.::,: '.:i :-,.

Vuorkers on Promoting Healthy Lifestyles

aa)::::a::.:.t ...

. Encouragecommitment.

There are various ways of encouraging cofirmitment. Giving clients monitoring

charts much like the well baby card during their clinic visits can help them keep their
commitment to a healthy lifestyle. Launching programs that monitor the health of the
community encourage ahealthy lifestyle among individuals and families. Making their
commitment and support more concrete is also important.

I For example, launch the program with a simple ceremony and where the local
official will declare his/her support. Establishing a buddy system to encourage each
other to exercise will also make them honor their commitment to exercise more.

3. Teach the Skills Neededto Establish and Maintain Behavior

When teaching specific skills, whether during clinic visits or special trainings and workshop
sessions, it is importantto take note ofthe following activities.

Set achievable goals.

Plan SMART goals: Specific, Measurable, Attainable, Realistic and Time-bound.

Identifu specific goals that will result in attainment of desired skill. Work only on the set
goals rather than adding new ones that might not be as important as previousiy
identified.

For example, a SMART goal for a severely obese patient is to aim for losing 5- 1 0 lbs.
for the first months which is more achievable than aiming for 30 lbs. right away. Once
this person starts to lose weight, he/she will be encouraged and continue with his/her
weight loss program, thus losing more than 10 lbs. eventually.

P r ov i de opp o r tuni t i e s fo r s afe, gui de d p r ac t i c e.

Plan for demonstration of the learned skill. This is not only to check whether they
have learned the skill, but also to develop confidence in their performance of the skill.
t Example of skills that need practice include performing breast self-examination, using
the BMI table to calculate BMI, using the peak flowmeter correctly, learning howto quit
smoking, and even decision-making skills when eating out or going out with friends.

En co ur a ge se lf- mo nit or in g.

Plan with the client self-monitoring actions. For example, obese clients who are on
weight management need self-monitoring tools like weighing regularly and regular BP
takingto encourage compliance withtheir diet andphysical activity/exerciseregimen.

I ,.

t
 ,f*6f"4/"" t/""q(.

o Enhance self_fficacy.

Self-efficacy is. enhanced by teaching client personal skills, whether

how to say no to
smoking, how to limit salt/fat intake, oihow to increase physical
activity. An important
component ofenhancing self-effrcacy is to provide enough opportunities
forpractice.
4. Enhance Readiness to Change

Identify an individual's place in the stages of change.

Address the client's need at_each stage of change. Aperson in the pre-contemplation
stage needs more information about the problem before Le
or she
client in the action.stage needs help in how to implement plan "un
ihink of change. a
for change, mor" tt a'
information about the problem. Foi example,.a p.iron ptanning to quit
information about smoking cessation telhniques und' ho* to go about
,-"kift needs
them, not
information on how harmful smoking is.

Encourage progress from one stage to the next.

.. Addressing each stage means pushing the client to another level of readiness. If the
client is in the contem^plation stage, aware-ofthe problem and thinking
about the change,
helphimlher to plan for change or make decisions. Once the decisio-n
is made and plan
for change is achieved, help in implementing the plan. If client is in the
u"tio",tuge (like
quit smoking), help him /hertomaintainhis/her behavior (plan fo.porrift.
r.tuprly.

Creating a Supportive Envitonment

Strengthening individual intention to change is not enough to guarantee a change in health

-behavior'
.
Creating an environment for change , specifically in promoting structures and policies that
support healthy lifestyles, are very much needed io complanent the str#gies
at the individual level.
peli{es, in rnany cases, the environment will influence positive behivior change even if the
individual may not be motivated nor ready for it.

For example, having a "no smoking" policy at schools, offices and shopping
malls will make
smokers inhibit themselves from smoking while in the smoke-free area.

Creating a supporlive environment and the role ofhealth workers is discussed in

Session 7.

14
1

I
 Promotin g Healthy Lif estyles

Annex 6-1

Learning Needs of Different Client Gtoups

and physiologic maturation' Motivation
Readiness to learn depends on three major aspects: motivation, experience
the client willing to leam behaviors that will have long-term,
refers to aroused interest.' This answers th.equeslion: Is
is about the client's
favorable consequences although the process may be long, tedious or painfut? Motivation
and hisArer willingness to learn'
confidence in himselflherself as a learner, hisArerperception of chances for success,
Thisassesseswhether
Experientialreadinessreferstotheclient'srelevantprepaiatorytrainingorpreviousassociations.
maturation
the client has sufficient bactgior,tta to- previous ixperience to understand the new learning. Physiologic
in tearning' A client who is sick may have diffrculty in learning'
and wellness is also importani

learning needs. Let us examine the

Aside from the three aspects, different client groups have their own specific
child and adolescent, adult leamer, and older adults'

Child andAdolescent

child's
Behavior that brings' pleasure tend to be repeated and are incorporated into the
repertoire of responses. Iiehavior that brings piin and disapproval tends to be suppressed'
also learn through
and behavior thit brings no response tends tb 6e extinguished. Children
imitation, especially inlhe early years of development. When the child is an infant, a toddler
or p*-r"f.tool, much of the information is given through the parents and caregivers' Some
"
slmpte instruciions may be given to a pre-school child, depending on his/her ability to
communicate, to relate tb othe-rs, to perform appropriate tasks, and to follow instructions'

more curious and

School-age children are the ones ready for formal teaching' They are
what, why and how of things. They have longer attention
they welcomelbasic information on
intellect. They have more vocabulary and usually communicate using
ffir, -"*ory and good grooming. They can
their own *o.br. They can be taugLt about personal hygiene and
to healthy eating patterns'
choose nutritious menus when they are given the opporhrnity learn
These are the
Children at this age can be taugtrt about social skills through role-playing'
years when ctrildrJn learn more ibout health and develop their health habits.

Teaching adolescents requires a different set of competencies,..

It is important to establish a trusting relationship
putti.ipute in a learning p.o""rt. 'Rea{ing between the lines" or being on the lookout for
before an adolescent
"un
topics that the adotesceni ii trying to communicati but cannot is an
important skill for the health caregiver' Adolescents
or counseling can be adopted as a method,of
can be very shy about their body and health concerns. Peer teaching
groups, adolescents are more likely to confront their health problems and consider
reaching them. within
"ppi"priit"
significant changes in health behavior.

Adult Learner

people,s need and capacity for self-direction increases they grow older. Adults are more responsible for their own
as

health and behavior .#;;;;'d; and adolescents. And usually, they make their-own decisions based on
"r,itar"n Healtheducationcanlead
informationgiventottrem. Healtheducationplaysaveryimportantroleiniheirhealthstatus.
their decisions towards healthy behavior and lifestyle'

1,,
 ,6-af.*14+ /.Wq

Adults need to understand why they should leam something before they are willing to leam it. This means that the
importance of what the learning is about should be emphasized. Adults' readiness to learn is associated with their
developmental tasks. They are more interested to leam things that will help them cope with their present circumstances.
They do not want to waste time learning something that do not have direct relevance to their current lives or situations.
They leam better when they are given life-centered or task-centered problems.

It is also important to note that experiences in the life of adults help them leam more. Theories mean nothing unless
illustrated by experiences and applied in real life. This is why the most useful leaming strategies for adults are
discussion, laboratory simulation, field experience, team projects and other action-learning techniques.

The sources of motivation among adults are generally internal driven, such as self-esteem, job satisfaction and
quality of life. They are not usually in favor of increased pressure or demand fiom teacher, but need support on these
sources ofmotivation.

What follows are principles of leaming that can be useful in teaching adults.

Principles ofLearning

l. Focusing intensifies learning.

2. Repetition enhances learning.
3. Learner control increases learning.
4. Active participation is necessary for leaming.
5. Learning styles vary.
6. Organizationpromoteslearning.
7. Association is necessary to learning.
8. Imitation is a method of learning.
9. Motivationstrengthenslearning.
1 0. Spacing new material facilitates learning.
1 l. Recency influences retention.
12. Primary affects retention.
13. Arousal influences attention.
14. Accurate and prompt feedback enhances leaming.
I 5. Application of new learning in a variety of contexts broadens the generalization ofthat learning.
16. The learner's biologic, psychologic, sociologic and cultural realities shape the learner's perception of the
learning experience.

Older Adult

There are physiologic changes that may affect the learning process among older adults. Functional changes in the
neurologic system may result in memory loss, vision and hearing impairments. Symbols, letters and objects that are
small are more diffrcult to distinguish from one another. There are also problems with glare, adapting to dark and light,
and loss of peripheral vision. Hearing diffrculties include inability to hear high tones, sound distortions and difficulty in
following conversations, especially when there is background noise. The presence ofchronic disease/s may also affect
leaming of older persons.

In engaging oider adults in health education classes. it is important to rememberthe following;

1. Print letters big and bold, and use colors.
2. Talk low, slow and loud.
3. Improve memory recall by creating associations or links with experiences.

Older clients are different from younger and middle-aged clients. Each client must be assessed to identify his ot
her particular characteristics and to plan health education that meets his or her needs.

IT
16 I
I
t'"

Annex 6-2
ASSUMPTIONS ON ADULT LEARNING
Assumptions on Adult Learning
Adults have many previous experiences that becomes
an increasing resource for learning.
Adults have a gfeat many preoccupations other than
what you are trying to teach them.
ldults are faced with real decisions to make and real
oroblems to solve.
Adults react to authority by habit according to their
exoeriences.
Adults are proud and self-directing.
Adults have real things to Iose.
As a person mafures, he moves ftom dependencv
towards being a self-directing human being.
His readiness to learn becomes oriented increasingly
to the developmental tasks of his social roie.
His time perspective changes from postponed
application of knowledge to immediac,v of application.
on Promoting Healthy Lifestyles
Considerations in Educating Adults
o Ignoring them cause resistance to learning.
j Emphasis on experimental tecl"rniques
3 Emphasis on practical application
. Do unfteezing activities and process the
learnins ftom these activities.
3 If you waste their tjrne, they will resent it.
o If trarning does not help them with either, it may
be wasted.
I You cannot force someone to iearn
I Learning is most effcient when it is the learner's
idea- and meets his soecific needs.
; Learning must enhance their positron their
esteem, or their self actualization, otherwise there
is too much risk.
Learning climate (phy sical, psy chologcal,
behavior of the teacher) should be the one of
"adultness."
3 Involvement of adult learnets in content
resource, and in self-evaluation the processes of
self-diagnosis of learning needs, planning therr
own learningwith the teacher as a the teaching
procedural gurde and content resource, and in
sel f-evaluation.
TeachingJe4rning transaction is the mutual
responsibiliw oTthe learners and te4qbc!!.
I Timing of learning.
. Tire eroupins of learners.
a The orientation of adult educators.
a The organization of the curriculum.
The desisfl of learnine experlences.
I ,,
 ,6"6/a' f-t

References

U.S. Congress, Offrce of Technolog), Assessment. Adolescent Health - Volume II: Background and the Effectiveness of
Selected Prevention and Treatment Services. l7ashington, DC: U.S. Government Printing Office, 1991.

!7HO Press Release \VHO/46,lZJune 1997. "Obesiry Epidemic Puts N illions at Risk from related Diseases."

Avons P.,James WP. "Energy Expenditure of Young trfen From Obese and Nonobese Families," Human Nutrition: Clinical
Nutrition 7986,10C:259-270. --quotedbyU.S. Congress,Officeof TechnologyAssessment (48,209).

WHO. Diet, Nutrition, and the Prevention of Chronic Diseases. WHO Technical Report Series No 797. Geneva: WHO,
1990.

Committee of Cancer Experts of the Commission of the European Communities. "European Code Against Cancer." --
quoted b1, Arnhold, S/olfgang et al. (46,28).

18
|
 er*6"V a 9,rryaAve, A.r.r*;.*n tnenf,

Utilizing Existing Community Data

Creating Community Awareness

Developing an Action Plan

Fostering and Mobilizing Supportive Social Networks

Establishing a Supportive Physical Environment

Establishing and Enforcing Supportive Policies

tD-@r",, /r" /r/.tqh CA*, ?' I n fr"ining Manualfor Health Workers on Promoting Healthy Lifestyle
 Promoting HealthY Lif estYles

SESSION

a Creating a Supportive Environment

f for Ilealthy LifestYle

"Health is not a commodity that is given. It must be generatedfrom within.

Similarly, health action cannot be an effort from outside and foreign,to the
people;'rather
-peipte it must be a response of the community to the problems that the
'them
in the community perceive, carried out in a way that is acceptable to
and properly supported by an ade quate'"fr otT;:',ry::iu,,,

Pafi S ecretary G neral of the lYoild H ealth O rganilatio n

e

participation
Indeed, the success of any community health action will depend on the 9{ent of
and commitment of the people to the noncommunicable disease (NCD) program' which
incorporates the promotion of a healthy lifestyle'
This session will deal with strategies on creating an environment supportive of a healthy
people to engage in
fifestvle by advocating and implementing measures that will make it easier for
desirable behaviors. These strategies include :
-> Fostering supportive social networks;
> Establitliittgu s,tpportive physical environment; and
+ Establishing and enforcing supportive policies'

Session Objectives
At the end of this session, the health worker will be able to:
1. Explain the importance of creating a supportive environment in relation to promoting
behavior change ofthe PeoPle
2. Discussthe importance ofutilizing existing community datato:
1 . 1 Identify the leading NCD, available resources
and policies
1.2 Describe the social, political, economic and cultural factors that predispose
poPulationtoNCD
1 .3 IdentifY urlnerable groups

3. Identify the different strategies and activities in creating community awareness

in
4" Develop an action plan foireating a supportive_environment for healthy lifestyle
control
their communityreflecting an integr*ed approachforNCD prevention and
4.1 Explain how sociai networki create an environment supportive of healthy
lifestYle
4.2 Discus how a supportive physical environment contribute to healthy lifestyle
4.3 Discuss how supportive pbfi.i.r strengthen intention to change, adopt
and
maintain healthY lifestYle
 ,6"6/.* /"t

Utilizing Existing Community Data

Community dataare generated by a thorough health assessment of the local area. Assessment is
accomplished by identi$zing and studying available records and reports on noncommunicable
diseases and the health risks encountered by the people in the community. Gathering information is
also done directly from the people through surveys and from health care providers through a focus
group discussion. Community-based organizations and individuals like traditional healers, school
teachers and extension workers are likewise sources of information because they understand the
health needs and concerns ofthe community.

Also part of data gathering is developing an inventory of available community resources. This
includes, for example, local health care facilities, community-based organizatrons, transportation
facilities and human resource assets ( e.g. traditional healers, herbalists, midwives). These wealth
of information should be put to good use in our effort to promote and support a program for NCD.
They are important in identifying the community's most important health problems, available
resources and existing health policies.

More than having data at our disposal, their use becomes more meaningful when they are
translated into analysis. A clear description ofthe health risks to which the community is exposed to
is part of the data analysis. Hence, data should be as wide or comprehensive as possible to include
the social, political, economic and cultural factors that predispose population to noncommunicable
diseases. This will help in analyzingthe determinants of health problems as well as identifiing the
vulnerable individuals and groups affected by these factors. Data that went through the process of
analysis becomes the basis for developing health programs for preventing and controlling
noncommunicable diseases as well as forpromoting healthy lifestyle.

,,+ Remember that local statistics and stories about

o
l1
lcQ people's lives generate interest among the
o stakeholders to do somethins about the situation.

20
1
 qF:f fornoting Healthy Lifestyles

The important information from the community that are needed to understand our priorities for
NCD prevention and control are summarized below :

'Vbat are tbe importdnt NCDs
in the comrnunin?
'Wbat
are the risk factors
associated witb NCDs?
Identify those which contribute most heavily to the
burden ofdisease interms of:
+ Mortality
> Morbidity
> Disability
Classify these factors according to:(Hawe, et al., 1990)
+ Individual attitudes, knowledge, values,
beliefs, self-esteem, self-efficacy, health locus
of control, literacy
> Social - role models, social support, social
desirability
-> Environmental physical environment,
pollution, housing, transport routes, water
supply
> Health service availability, accessibility,
sensitivity/acceptability to target group
-> Financial - cost of services or preventive care;
financial incentives for prevention
> Political - political self-efficacy, opportunities
for participation in decision-making, policies on
health and equity
> Legislative - safety regulations, environmental
protection, laws, regulations regarding exposure
to hazardous materials, laws on school safety

'Who are tbe popwlation growPs Identify vulnerable/at risk population groups according
most awlnerable or at risk of to:
deaeloping NCDsi
> Age
-> Gender
> Ethnicity
-> Socio-economic status

Creating CommunitY Awareness

Changing behavior at the community level is very im_portant in health promotion efforts. Its
main goaiis"creating an environment for change, specifically in creating structures and policies that
,,rppJrth"ulthy lifeJtyles. HoweveE it is diffrcultto create change inthe community ifthe people are
,-roi u**. of the riski they are confronted with, the options available to them, and
a support system
necessary for continuation ofdesirable actions.
I 21
I
 Remembe r thatawareness strategies aim to:

$e Communicate relevant information that facilitates behavior

change or reinforces existing behaviors by helping people
reevaluate their values, perceptions, emotions, attitudes or
beliefs.

Empower or enable the people to take action building on the

acquired information and therefore develop self-effrcacy and
self-determination.

Enable the individual to gain practical access to information

or services that can help initiate or reinforce a specific desired
behavior.

In creating awareness about NCD prevention and control, the fsllowing are the important points
that should be communicatedto the people:

1. What are the noncommunicable diseases prevalent in the community? Who are the people
most affected by these conditions?
2. What are the risk factors (social. economic, political and cultural) present in the community
that are associated with NCDs?
J. Which ofthose risk factors can be modified or changed?
A
T. What intervention stratesies will eive the bestresults?

The development of social awareness is a key factor in generating a supportive environment for
improving community health in general and promoting a healthy lifestyle in particular. To optimize
the effects of awareness or communication strategies, efforts are concentrated where they will have
the greatest impact. Focus on a specific group of people who are most likely to hear, interpret and
respond appropriately. They are:

1. The people most affected by the problem but do not believe they have the power to change
their conditions:
2. Leaders of institutions who have the power to mobilize their constituencies
through both formal and informal influence;
a
Community leaders in different sectors; and
4. The community at large.

22
I
 on Promoting Healthy Lifestyles

There are four steps on how to effectively launch community/public awareness campaign on
NCD prevention and control:

1. Obtain information about your target population. You can create community/public
awareness by providing information which you have gathered from earlier and continuing
assessment activities. Understand how the community views the issue so that you cun
create messages thut relute to their lives . For example, is smoking regarded as a risk factor
to existing NCDs by the people? Do they realize the extent their smoking behavior
contributes to the magnitude ofthe problem?

2. Customize your message to each target group. Since specific groups of people need to be
addressed, the message cannot be common to all. Define the different autliences and tailor
the information campuign to each group to effectively deliver the message to the
community.

In developing messages for target audiences, there are only two important issues that
have to be emphasized:
> The human and economic costs ofNCDs is enormous; but
+ The NCD problem is manageable; and therefore policies and programs to prevent
NCDs will benefit the community.

Focus on simple messages that can be repeated and that can be used with key health
indicators and key policy proposals.

Remember that effective messages are:

o Simple

$e
o Meaningful
o Shocking
c Relevant to daily life
. Culturally suitable
o Able to stir the imaeination

3. Use different approaches and forms ofmedia to communicate your issue.

> Varied venues can be tapped such as the local newspapers, radio and posting in
strategically located bulletin boards and accessible places such as the 'sari-sari' store and
multipurpose halls.
-> { relationship with the media can be established by introducing oneself to local reporters
or broadcasters and other media personnel. Media networking may help in maximizing
radio or television coverage on the health program/campaign providing presentations to
community groups. Remember, media has the power to influence opinion.

t,,
 -> Local officials and policy makers can help create awareness among their constituents as
well as gather support for the program. Choose a spokesperson that the people trust"
respect, believe or can identifu with who can be a role model of the desired behavior.
Invite prominent personalities, local celebrities, sporls figures, business leaders to
endorse or promote the program.
-> However, more formal approaches are needed such as printing and distribution of local
fact sheets, organizing community presentations and meetings which can be
incorporated in community activities such as health and fitness fairs, promotional
campaigns andthe like.
Once convinced ofthe need for ahealthprogram,local officials andpolicymakers canbe
moved to grant funds to community prevention and control efforts related to non-
communicable diseases. Likewise, health care providers will be more conscious of their
responsibility to include risk assessment and screening for NCD when people seek
consultation in health facilities.
4. Evaluate your efforts. Getfeedbuck from the people regarding the effectiveness of the
information campaign and use the information to plan for your next steps.

Developing an Action Plan for Creating a Supportive Environment

What is a supportive environment? In the context of NCD prevention and control, a supportive
environment provides material, human and political resources in order to achieve the ultimate goal of
promoting, adopting and maintaining behavior change towards a healthy lifestyle.

Success towards this endeavor will depend on developing and implementing a plan of action
where the whole community is involved. For the NCD program, the likelihood of success may be
enhancedby:

1. Fostering andmobilizing supporlive social network;

2. Establishing a supportive physical environment; and
3. Establishing and enforcing supporlive policies'

24
1
 :,,: , I
gF::Ptofioting Healthy Lif estyles

1. Fostering and Mobilizing Swpportiae Social Netuorks

According to Roger's Diffusion of Innovation
Theory (1983), social networks and interpersonal
channels have impact that is more profound than
mass media in terms of influencing behavior
change or modification. Social networks refer not
only to formal organizations, alliances or clubs. It
also includes social interactions with family,
friends, neighbors or co-workers.

In the context of NCD prevention and control,

how can social interactions and transactions foster an environment supportive of a healthy
lifestyle among the people?

Social networks provide assistance in the form of:

->- Tangible aid or service like screening procedures, risk assessment activities, nutrition
counseling or exercise testing to atatgetgroup
_n- Timely or appropriate information to disseminate messages about healthy lifestyle
utilizingformal as well as informal means of communication such as in daily, ordinary
" conversations with one's neighbor or friend or relative at home or through the telephone
or even while taking ajeepney ride with a co-worker
+- Constructive criticism, feedback and suggestions or advice to increase people's self-
efficacy

The support provider is characterizedasempathetic and understanding of the people's needs

and situatib.r, *hom the people can identify with and whom they trust. For example, a person
who has successfully quit smoking can be an effective facilitator of a "quit smoking" support
group having undergone similar life experiences with them. A cancer survivor can effectively
advocate cancer u*ir.r"r, program in the community having experienced the agony of coping
with the physiological and psychological consequences ofthe disease.

What one person accomplishes in terms of motivating people to change can be achieved in
greater fold if carried out in the context of an organizatiotwhere there is clear-cut direction in
terms of obj ectives, structures and strate gies'

In the Philippines, putting up organizations for health promotion and NCD prevention and
control is not ieally a-problem. Any existing organization in the community can very well
assume these responsibilities. The problem usually- develops when there are too many
organizations impiementing similur a"ii'trities that people become confused. Then, the issue of
collaboration comes in. Ii is important for organizations to work together in alliances and
coalitions because there really is sirength in numbers. with different views, resources and skills,
goals are not only accomplished; the base of decision-making process is also broadened.

1,,
I
 ,6"6/'*/o*

Successful health improvement efforts depend greatly upon a solid and dynamic partnership
between public and private sectors, consumers and providers. Community coalitions are ideal
partners as they are collaborative groups of individuals and agencies that work together toward a
common goal. Aside from local government groups and agencies, civic and religious
organizations, youth, women and older persons should also be recruited. A coalition with a
membership that comes from different segments of the community is more likely to be
successful.

Whatever segment of the local population is being recruited for a coalition, personal
motivation should be considered. Generally, individuals will participate in coalitions because of
their commitment to alleviating the problem. Others join because they gain a sense of
satisfaction from volunteering and working with other professionals and community workers.
Some people would simply like to share their resources and demonstrate civic responsibilities.

Once partnership has been established in the form of a coalition, it should develop short uncl
Iong-term goals. These goals must be translated into concrete plans and strutegies,which are
formulated in coalition meetings. It is suggested that in the initial stages, a coalition should
engage in noncontroversial strategies. These can be in the form of health fairs and other
community events to promote community awareness. Small successes are very important to
build the confidence and unity of members and leaders. As a coalition develops experience,
members will learn from their mistakes and successes, resulting in easier and more effective
strategizing.

Shared decision-making leads to better acceptance of change and support for the process.
The coalition should agree on common broad goals such as helping people change unhealthy,
unsafe or risky behaviors; and decreasing the incidence of preventable conditions that have a
negative impact on the community and equalizing access to health and support services.

The following summarizes the general ideas on howto get started in building organizatronal
I

relationships:

1. It is important to involve all the stakeholders in all the phases of the process in building
or ganizatronal re I ationship s.
2. In working together, people will also have to take risk together; hence, it is important to
know and trust each other.

Mobilization activities ...

graduate ftom simple to mofe complex and effecuve ones ate

those based on the people's level of capablJtty, the urgency of the
issue and the reaction of the t^rgetaudience.

26
1
 Heatthy Lifestyles

3. Clariff the goals each organization wants to accomplish in relation to how each
perceites the problem and how organization relationships could help resolve the
problem.
4. Determine the kind or level of relationship that will best help accomplish the set goals
considering needs, goals and resources.
5. Once the organizations have agreed to work together, formulate ground rules which
will serve as a basis for decision-making. It is importantto take note of the following
points:
a. Listen, listen and listen! Organizational relationships work because the group
makes decisions. These decisions can only be arrived at if information is exchanged.
b. Unity in diversity. Different groups will have diverse opinions on certain issues.
Build on those ideas and determine what the possible points of agreements are. Keep
anopenmind.
c. Don't force organizations to give up their identities. Organizational relationships
should encourage people to work together and make a difference rather than work to
outdo eachother.

Effecting change through community participation means changing the conditions within
the community and ultimately, people's behaviors. Social networks must provide mechanisms
for people to participate in activities that have the potential to impact positively on health,
specifically onNCD prevention and control.

Remember that social networks aim to:

$t Develop the capability of the people to assume greater

responsibility for assessing their health needs and
problems.
Plan and implement solutions that ultimately lead to
behaviorchange.
a Sustain efforts in support ofbehavior changes.
a Evaluate the effectiveness of collective action in
bringing about behavior change in the community.

Activities to motivate community participation can take several forms - from a simple
sending of a petition letter to a target agency, to negotiation and to higher forms such as mass
actionsl forming picket lines or demonstration. On the other hand, motorcades, parades and
other street events create media attention and reach a wide number of people in an entertaining
and stimulating way. This is a good means to reach people who might not ordinarily be reached
throush the more traditional events such as seminars or meetings.

t,
 ,fr"%.'r l.+

In launching a health program, you may invite individuals who are'well-known and
respected in the community and who can bring positive attention to stop or reduce non
communicable diseases. You may suggest popular personalities in sports, entertainment, health
or politics who may call for the start of the "Yosi Kadiri" program or an exercise program in the
workplace. Selecting the place to launch a health program or conducting a health activity is
important. For example, having it in a shopping center or public market or a basketball court can
attract attention ofmany people at one time andmobilize action.

The involvement of the community can be sustained when people know what they can do
and how they can get involved. More importantly, when they know the health, social and
economic benefits that can be derived from taking an active part in the whole health program.

On the part ofthe health care providers, it is necessary that you keep track of the
initial efforts
and plan forfollow-up action. Compile a summary of events; collect newspaper clippings; listen
to radio broadcasts. As a team, review the successes, shortcomings and lessons learned.
Identi$ the challenges and what needs to be followed up. In your review or assessment, you
may askthe following key questions:

How many people did you reach?

How many people participated in health campaigns/activities?
What are the main obstacles?
Howwill you overcome these obstacles?
What factors contributed to vour success?

2. Establisbing a Swpportizse Pbysical Enzsironment

A supportive physical environment consists of all external conditions and influences that
positively affect the life and development of man. It includes land, water and air characteristics
of the community as well as assets and resources that contribute to health promotion and disease
prevention.

Assets are strengths of a community, such as strong family involvement, low crime rate,
alcohol and drug-free schools and cooperative people. Resources are more traditional and
tangible, such as structural facilities inthe local area, human, financial and material support. As
mentioned above, it is essential to be awareofthe resources that exist within the community.

There are two equally important reasons for assessing the community's physical
environment:
> Determine the extent to which the environmental characteristics will either positively or
negatively influence the population's attainment of desired behaviors.
> Determine what approaches/strategies to use in order to:
o Eliminate, modiff or mitigate negative environmental influences or
o Establish, maintainoradvocate forpositive environmental influences.

28
1
 il€Nlthy Lifestytes

Remember that for people to change, adopt and

$t maintain desirable health behaviors, health assets and

resources shouldbe:
o
.
o
o
Available
Accessible
Affordable
Acceptable
Appropriate
'

Here is an example of action area in terms of advocating for a physical environment that is
health promotive and disease preventive:

Physical activity ,l Developmentf creation of facilities that encourage physical

acfl\'1ty
I Parks/playgounds

I Covered courts ,

lmprovement of facilities/structures that minimize hazards '

and encourage walking

'

r Clearing of sidewalks ,

Urban planning to encourage public

transoortation
t. - -

l*
 ,6"Ef.b la"

3. Establisbing and Enforcing Supportiae Policies

For NCD prevention and control campaign to gain ground requires appropriate policies, laws
and rules that will govem how the people in the community will behave. A supportive political
environment means that there exists a political structure where laws and policies supporl a
person's desire to achieve a healthy lifestyle while removing or modifying barriers to achieving a
healthy status. In the Philippines, there are laws or ordinances that aim to prevent environmental
pollution. The Clean Air Act of 1998 is one glaring example of a law which lacks enforcement
simply because of lack ofpolitical will onthe part of local government executives. There are also
local ordinances that prohibit unhealthy practices like smoking in public places, vehicles and
even inside government offices. But what do we commonly observe in public places like the
markets, churches, government offices and public transportation? People smoke without regard
for others health and well-beins.

Healthy pubtc pohcies require political will, the suPport of the government
and a commitment to equity and to ensudng that all membets of society
teceive the health benefits of social changes flWass,1994;2000).

Wass (2000) emphasized that a healthy prrblic policy is central to the promotion of health
without which other health promotion actions are likely to be of limited value.

Vhatispolicy?
A policy tefers to:
o A genetal statement of intentron
o A set of actions by government over a period of time in a

pafiicalzrarea
o A set of standingtules

Public policies therefore are policies afflecting public interest. Most policies are created by
the government but a good many ofthe government's policies are influenced by private interests
espJcially from powerful industries and other sectors. What is the implication of this?
Establishing and enforcing policies is acomplexprocess. It is adynamic, competitive, social and
political pto..5 involving three key players - the public including formal interest groups,
political and bureaucratic policy makers, and the mass media.

30l
 on Promoting Healthy Lifestyles

Palmer and Short (1994) summarizes the five stages of policy-making process. The health
worker must be able to identifi, in which stage of the process should they exert pressure in terms
of influencing the key players.

1. Problem identification and agenda setting - recognition of a health problem as an

issue ofpolitical concern; often occurs in response to pressure from interest groups.

2. Policy formation - policy development or redevelopment taking into consideration the

social and political context.

3 . Adoption - formal acceptance of a new policy through legal enactment or approval of an

appropriate body.

4. Policy implementation - a policy is actually put into practice; implementation may

become different as it is affected by budget or other similar situation.

5 . Policy evaluation - policies are evaluated for their impact.

If health workers are to influence the direction of health policies and the policy making
process, then they need to work with other people especially the key players in the policy-
making process. Establishing and enforcing supportive policies are generally the consequences
of successful advocacy work.

'Whatis
adaocacy?

Advocacy is a combrnation of indrvidual and social actions

designed to gain political and commwnity swpport for a
particular health goal or program. Actton may be taken by,
or on behalf of indrviduals and groups to create living
conditions which promote health and healthy lifestyle.
0vHq lee8)

Advocacy work is directed at both policy makers and those who influence the policy making
process - mainly, the media, industry and civil society. Its main goal is to communicate health
issues to powerful individuals or organizations to make substantial changes in the physical,
political and social environment favorable to promoting a healthy lifestyle. Before any aetive
advocacy work is implemented, there is a need to create a flexible plan which is anticipatory of
change. Sometimes, tactics become ineffective because new conditions or opponents surface or
that some allies turn against you. In developing a plan, the following information can be useful:

I,'
 Determine who among these people are considered allies and who are hostile to the
cause.
c Elected government ofhcials (senators, congressmen, local government executives,
barangay officials)
o Healthpolicycommitteemembers
. Key professional organrzattons and leaders
. Key industry organrzattons and leaders
. Health reporters and journalists
-> Determine their interests, priorities and position regarding the issues.
+- Determine the time when decision-making is to be done, when congressional and senate
hearings are to be conducted for health policy making as well as budget hearings.

There are many advocacy tools. Their use depends on the political situation or
characteristics of the targets for advocacy, but what really matters most is for the advocate to
effectively communicate health issues to the target audience. Is it best to work by privately
lobbying with local government officials or policymakers to pass city ordinances about the
smoking ban? Or would it be more productive if advocates create fanfare such as holding
community health fair or having celebrities in TV and radio plugs? What about creating public
outrage by picketing public offices or organtzing mass actions or wearing black bands in the
arms while burning an effi gy of a"foe"?

Advocacy tools include:

. Lobbyingpoliticians
. Building alliances or coalition
r Face-to-facemeetings
o Letter-writing
o Media advocacy

Most often, people look at the government as an enemy and that the best way to deal with
them is through antagonistic or confrontational approaches. There are ways to effectively deal
with government officials but this requires fundamental knowledge on how the government
bureaucracy works and makes decision, the legislative and budgetary processes. The advocates
should look into the so-called "pressure areas or points" for advocacy efforts to become
successful.

s2
I
 on Promoting HealthY LifestYles

plan for advocacy work utilizing any of the advocacy tools must reflect
the
In general, a
following:

1. Define the health problem or issue. Be clear and be focused.

2. Statethehealthstatuschangethatyouwanttoachieveintermsofpolicyoutcomes'
3. Identify targets for advocacy work'
4. Decide on the approaches/tools for advocacy work'
5. Determine the key messages appropriate for each target audience.
that will contribute to
6. Make an inventory of tn. urr"ti urrd r.ro,rr"es in the community
or
the success of the campaign. It will also do well to identify limitation/constraints
obstacles to achieving desired outcomes'
and support in
7. Building and developing the mass base that will serve as the backbone
advancingthe cause.
8. Evaluate-advocacy efforts and make adjustments in the plan when new situation
develoPs.

Conclusion
entails participalion of the people and
Creating a supportive environment for a healthy lifestyle
community' tt begins withthe process of
tooperation among the different groups and sectors in the
community in using existing data to identiff
raising the awaren.rrtirtr. p.op'1" and engaging the
address these NCD problems'
priority healthproblems inNbD. It also i""?i"Jrt. ategizingtohelp

Promoting a healthy lifestyle to curb the rising incidence

of noncommunicable diseases
necessitates an environment that supports individual
hialth actions. It is imperative that individual
that recognizes its strengths, potentials
health actions are expanded to reach the entire community
and indigenorr, ,"ro*r"r. It is a .t"ii;;g. {ra1 garr^J
for devel'oping an. action plan that is
skills, knowledge
implemented by the people themserves.- irt.i"a goal is for the peopre to acquire
l"p..i"nce so that they take greater responsibility for their own health'
"rJ

t,,
 References

Kahssay H.L. and Oakley, P. (1999). Community Involvement in Health Development. A Review of the
Concept and Practice. Geneva: \florld health Organization'

Bensley, R.J and Fisher, J.R. (2001). Community Health Education Methods; A Practitioner's Guide.
Massachusetts: Jones and Bartlett Publishers.

Community Involvement (Supervisory Skills Manual). Vorld He alnh Organization ,1'987 Field Test.

Guidelines for Social Mobilization: Planning world TB D^y. http:/,/www.stoptb.

Orglworld.tb.daylVTBD 2000 guidelines-for-social mobilization.htm

Flawe,P;Dageling,DandHall,J. G99O).EvaluatingHealthPromotion:AHealth'WorkersGuide.Maclennan
and Petty Pty Limited. 80 Reserve Road, Artarmon NS'W 2064. p32

Acting on Noncommunicable Diseases: An Advocacy Guide for the'Western Pacific (Draft). Prepared for
Vorld Health Organization by Prue Bagley and Vivian Lin, School of Public Health, La Trobe University,
Australia.

Promoting Physical Activity: A Guide for Community Action. US Department of Health and Human Services,
Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease
Prevention and Health Promotion, Division of Nutrition and Physical Activity. Champaign, IL: Human Kinetics,
1999.

'$7ass, Andrea. (2000), Promoting health. The Primary Health Care Approach. \flB Saunders, Harcourt
Australia. CAN 0009 10583. P .t7 4-17 5.

lvorld HealthO,rganizatton. (1998). The Vorld Health Report 1998: Life in the 2Lst Century. A Vision for All,
\fl orld Health Organization. Geneva.

Palmer G. and Short S. (1994).Health Care and Public Policy. Macmillan, Melbourne.

s4
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