NIROGI Lanka - Phase 1
National Initiative to Reinforce and Organize General diabetes care In Sri Lanka
COMPONENT 3 – Prevention of Diabetes Through Health PromotionObjectives:
To establish a low-cost culturally appropriate health promotional model to prevent diabetes by empowering the public through activities that encourages community and family participation in suburban areas of Colombo district
- Capacity building of health promotion facilitators (HPF) in identified settings to implement programmes to prevent diabetes
- To empower communities in different settings that encourage positive health behaviour (e.g. schools, workplaces and community)
- To identify those at risk and provide preventive care at grass root level
Most of the residents in suburban areas in Colombo district are new settlers who have migrated in search of better schooling and work opportunities. To cater to their needs, these areas have been transformed drastically into highly urban settings with increased availability and accessibility to cheaper yet unhealthy ready-to-eat/cooked food, eating out, improved transport facilities, sedentary occupations and recreation, tobacco and alcohol, stress and inadequate space for being active. The most affected are the low income communities who have inadequate knowledge, less conducive environments to change behaviour and less ability to empower themselves or their families to prevent diabetes. In particular, school children in such areas are prone to unhealthy food habits especially fast food due to parental employment and thus not preparing food at home; less physical activities due to exam oriented school education leading to after school classes, use of public transport for commuting to school; stress prone competitive education and over expectations; and an environment favourable for alcohol and tobacco promotion. Semi urban setting workers too are prone to sedentary lifestyles owing to less active office work, less facilities for physical exercise at work place, use of public transport for work; unhealthy food habits especially fast foods due to lack of time to prepare food at home due to employment of both partners, availability of such food in canteens; stressful work environment; and substance use. Health education alone has failed in changing the behaviour of people at risk of diabetes. Attitudes as well as skills should be developed in them to counter act the unhealthy environment within suburban settings. Health promotion (HP) is defined as “the process of enabling people to increase control over, and to improve their health”. Promotion of health of individuals and families need looking at health holistically and beyond the boundaries of individuals and families. Health Promotion approach has identified five main actions: building healthy public policy, creating supportive environments, strengthening community action, develop personal skills and re-orienting health services. This component intended to establish a low cost, culturally appropriate and sustainable health promotional model to empower suburban apparently healthy residents in suburban settings on healthy lifestyle behaviour.
Pitakotte and Kolonnawa MOH areas representing the suburban areas of Colombo district
- Persons in the formal and informal sectors trained as HPFs and HP activists
- Communities living in the suburban sector in Colombo district
- Work places with more than 1000 workers located in the suburban sector
- Schools located in the suburban sector
To establish a local health promotional model to empower individuals and their families towards healthy lifestyles through community and family participation in a defined suburban area of Colombo district
- 15 health promotion facilitators competent in using the health promotion approach to change behaviour towards prevention of DM
- 15 health promotion activists in each setting competent in using the health promotion approach in changing behaviour conducive of prevention of DM
- 80% of primary target groups and 50% of secondary target groups of different setting having positive behaviour conducive of prevention of DM
Under this programme, a health promotion model was designed to be initiated through the existing public health infra-structure, and formal and informal sector organizations to empower residents on healthy behaviour in two suburban settings, Kolonnawa and Kotte MOH areas. For this purpose, training of lay persons in health promotion, facilitating the HP process in different settings, monitoring and evaluation of their progress were focussed upon.
- Capacity building of lay persons in HP in the identified settings
Training was outsourced to the Foundation for Health Promotion with the collaboration of Rajarata University Health Promotion Degree Programme. These trainers were involved in developing the curriculum, training and evaluation of competencies.
The training was done in several stages along with the implementation of HP process. The initial training was to build capacity of lay persons who would take the leadership to initiate the HP process in different settings (a new term was coined for them as ‘health promotion facilitators’ (HPF)). For this purpose, suitable persons were recruited from community, school and workplace settings in Kolonnawa and Kotte MOH areas. The selection was made by the MOHs of the two areas with the assistance of their staff (based on their experience with the potentially suitable individuals in the area). Five each were selected from each of the three types of setting, amounting to a total number of 30 settings.
The HPFs were trained in a two-day skill-based training workshop. Areas mainly focussed upon were on communication and negotiation skills for recruiting people to engage in the HP process, and the concepts on health and its determinants, with special emphasis on the risk factors of diabetes and CVD.
Within the next two weeks, each HPF recruited a group of 10-15 persons as ‘HP activists’ who were identified as suitable for implementing the HP process within their own settings. The HP process was initiated in each setting by HPFs conducting the first meeting with their group. Thereafter, a two-day second training workshop was conducted for HPFs, during which they were given further inputs on skills in problem solving, strategic planning and finding solutions to address the determinants that underlined their unhealthy behaviour related to diabetes/CVD.
The training of HPFs continued by having monthly one day reviews with HPFs and trainers, focussed on sharing the learning experiences that they had gathered by working in different settings. New inputs were also given, as needed. HP competencies that were developed;
- Knowledge on determinants of health, HP principles and practice
- Skills of community diagnosis, addressing stakeholders with regular updating of skills
- Attitudes of inclusiveness, equity, gender
- Communication on listening skills, empathy and mass awareness strategies
- Resource mobilization through new partners, community mobilization, promoting social capital
- Social marketing to sell the idea
- Program management
- Generate evidence based evidences from assessing outcomes/impact and synthesis
In addition to these competencies, they were exposed to relevant topics such as overview, patho-physiology and prevention of diabetes and other cardiovascular diseases; psychological Issues related to these diseases; nutrition in these diseases; gestational diabetes and its prevention; and childhood diabetes and its prevention.
Thereafter, HP activists met on a regular basis with their HPFs, and by themselves, to discuss and involve in community participation for activities organised at group level. These discussions or their activities were facilitated by providing necessary facilities based on demand. Through this process, the same capacities (knowledge and competencies) were developed in both types of HP workers. Competencies developed in HP activists were the same as for HPFs, so that there was an effective transfer of knowledge and skills to others in the groups.
During this process, there was close monitoring done at central level by the coordinators as well as at field level by the trainers. However, the visits were declined gradually over time to ensure that the knowledge and competencies were well transferred to everyone in the group and thereby to their families. A unique feature was that if any HP activities, showed an interest in forming their own group, it was facilities leading to expansion of the settings in number and size. Furthermore, towards the latter end, some were autonomously functioning settings.
- Advocacy An advocacy package was developed to motivate the policy makers of the division and settings to solicit their support in making healthy policies, developing supportive environments and community empowerment. It consisted of the extent of diabetes and cardiovascular diseases in Sri Lanka, their determinants, prevention and what support is expected from them. They were motivated to form steering committees in each setting with the view of monitoring the progress of the activities. They were advocated once a year in a central meeting to maintain their enthusiasm.
- Community participation through inter-sectoral collaboration Community participation was enhanced by collaborating with already existing networks in the formal and informal sectors. Banking sector with loan schemes were used to motivate participants to be in the program. Periodic reviews with all relevant sectors were conducted to solicit the support of different sectors. Quarterly reviews with different sectors and setting leaders were conducted to review the progress and to find resource to develop a favourable environment such as foot paths for walking, providing exercise equipment, reducing stress in working environments, etc.
- Data / information management system from family to Division A unique health information management system was developed with the assistance of the Computer school of computing, University of Colombo, department of Community Medicine of the Faculty of medicine, Colombo. This information system was capable of obtaining information using online mechanisms with less paper based work, ideal for PHM work in the field and in clinics. It was also able to follow up follow up data from birth to death on NCD and other health conditions. Necessary changes were done to improve the system with the assistance of public health staff, and experts in paediatrics, IT. It was handed over to pilot test it using the Kotte university health project data.
- Monitoring and evaluation system Trainers, HPFs and HP activists were motivated to use the behavioural indicators that are already developed by the Ministry of Health (list of indicators annexed) to evaluate the progress of the project. In addition, they were encouraged to develop their own indicators to assess their progress. Monitoring was also done quarterly to assess the progress. Behavioural Indicators that have been developed by the Ministry of Health An evaluation was conducted by two independent expert reviewers to assess the impact of component 3 in relation to its functionality, perception of the change
- Provide a supportive environment
Group activities were facilitated by the NIROGI Lanka project by providing equipment, educational material and funding for conducting activities. These activities were also well supported by income generated by raising their own funds, thus self-sufficient. Ministry of Health was advocated to develop a supportive environment. Indicators for such environments were developed to assess the extent of the managers and superiors’ support given to prevent diabetes.
- Provision of communication material Several educational materials such as leaflets, posters, wall charts, bill boards, DVD and CDs were developed. Some already developed ones by other health agencies were adopted and reproduced. A guide on initiating the HP process in field settings was produced in both Sinhala and Tamil languages as a guide for any planning to initiate a process in their own setting. Computer based interactive software were developed and made available for all settings.
- Developing a screening facility for diabetes and cardiovascular risks in the Kotte MOH area
Screening facilities were developed at a central place of the project area to conduct screening. It was also conducted in the initial screening of participants in settings to identify the high risk groups and further investigated and necessary advice given individually with the aim of secondary prevention. However, this was not a routine activity to discourage people from screening without resorting to healthy behaviours.
Impact assessment and evaluation:
- Competency and progress of HPFs was monitored and evaluated during review meetings that took place centrally on a regular basis.
- Competency and progress of HP activists was monitored by HPFs and trainers using qualitative indicators during group meetings in the local setting. They were expected to maintain a diary of events including difficulties faced by them and actions taken. Diary was used during reviews and subsequent training as a monitoring and learning tool. Empowerment of communities was monitored in the setting using indicators such as enthusiasm, active participation, expansion drive and change in behaviour.
- HP trainers’ work was monitored and evaluated during monthly review meetings with the central technical team.
- At the end of the project, an external review by two independent reviewers was done to evaluate the health promotion process followed, medium/long term outcomes achieved towards empowerment of individuals and groups in the settings and sustainability. Qualitative as well as quantitative methods were used for this purpose. Behavioural indicators related to diet, physical activities, tobacco, alcohol and mental stress, and trends in positive behaviour were used to evaluate these aspects.
- The total number of health promotion settings expanded from 30 primary settings to a total of 133 secondary and tertiary settings in both Kotte and Kollonawa MOH areas during the period from August 2009 to April 2012.
- Of these 133 settings, 101 settings were functional at the end of the project period (84 community settings; 14 work place settings; and 4 school settings).
- Most settings have been developed to function independently (automosly functioning settings) with the guidance of HPFs. All HPFs and HP activitists worked on a voluntary basis.
- The total number of participants in the program expanded from an initial 500 to 6583 individuals, of whom 4962 individuals remained actively involved in the community-based health promotion programmes.
- At individual level, participants showed progress in changing behaviour in relation to diet, physical activity, mental stress, tobacco and alcohol.
- At community level, in msost settings, they empowered the families or peers in return.
- A set of setting specific indicators were developed by activitists and successfully used in the health promotion settings: exercise and physical activity being a part of life, dietary habits, BMI, mental wellbeing, family happiness, reducing alcohol consumption and smoking. As evidenced by the evaluation done on the health promotion programme of component 3, the overall functionality was satisfactory.
- There have been substanial positive changes in individuals and their families mainly in the areas of diet and activity.
- Community particiaption through Capacity building of HPFs and HP activists was successful. A manual was prdoduced to guide them.
- Health eduaction material have been developed, such as leaflets and posters and distributed among the participants. An interactive exhibition kit, food pyramid, quiz, flip charts and buffet table are some of the interactive tools developed in the education on diabetes.
- A health promotion manual has been developed as a guideline for the trainers.
- An evaluation was conducted by two independent expert reviewers to assess the impact of component 3 in relation to its functionality, perception of the change in behaviour of individuals and their families, knowledge on NCD and risk factors, underlying factors that determine behaviour, transfer of skills of motivation and assessing the areas that require strengthening based on secondary data available with trainers, a cross-sectional study, in-depth interviews and focus group discussions.
- Transfer of knowledge and skills through the HP model was successful.
- An efficnet monitoring mechansim at central level and field level was established in which HP Trainers conducted meetings biweekly to oversee the community settings while both Trainers and HPFs were monitored centrally by the NIROGI Lanka team.
- Utilising lay persons to intiaite and maintain the process of HP in school, community and worksettings was proven to be effective.
- The most successful settings have been the community settings, which mainly consisted of housewives. Empowering especially mothers have made a major positive impact on the behaviour of families since they are the decision makers especially in relation to diet.
- Using a bottoms up approach was able to address the core underlying determiannts of negative health in them. These determiannts were found to be different in each settings, indicating that assessing the HP success should not be limited to change in beahviour alone but to chaging their attitudes and competencies.
- With the strengthening of the state health care workers and volunteers as field trainers and better access to schools and workplace settings, this programme could be used as a model to empower communities in the prevention of diabetes, this would increase the amount of participants who would be willing to join.
- Dr Carukshi Arambepola (Senior Lecturer in Community Medicine, University of Colombo) - Coordinator
- Prof Diyanath Samarasingha (Professor in Psychiatry, University of Colombo)
- Prof Pujitha Wikramasingha (Professor in Paediatrics, University of Colombo)
- Dr Sarath Amunugama (Director, Health Education Bureau)
- Dr Manaoj Fernando (Lecturer in Health Promotion, Rajarata University)
- Mr Duminda Guruge (Senior Lecturer in Health Promotion, Rajarata University)
- Prof Rohini Seneviratne (Professor in Community Medicine, University of Colombo)