COMMUNITY INTERVENTIONS FOR HEALTH IN CHINA: CONFRONTING CHRONIC DISEASE IN THE WORKPLACE

Circumstances are changing fast in China. Economic development and urbanization are altering lifestyle there, and chronic diseases are now the leading cause of death and illness. The World Health Organization estimates that in 10 years, heart disease, stroke and diabetes will cost China $558 billion in foregone national income. 

Cardiovascular disease: the first chronic disease priority

To find suitable strategies to meet the challenge of the growing burden of chronic disease, the Chinese Ministry of Health established the National Non-Communicable Diseases (NCD) Comprehensive Community-based Programme. Involving hundreds of thousands of people in communities from around the country, the programme identified cardiovascular disease (CVD), and its leading risk factor, hypertension, as the main focus for action. 

Barriers to action

Dr Liming Lee, Professor of the Beijing University School of Public Health, is committed to addressing the threats posed by CVD to China’s health and growth  “There are simple solutions that can counter the rise in cardiovascular and other chronic disease,” he said, “but in China there are many barriers to implementing them.”  These include time and monetary restraints, lack of knowledge or perception of risk, differing cultural perspectives on health, relative expense and accessibility of healthy and unhealthy options, and a lack of information among key decision makers.

Finding solutions

Dr Lee works with colleagues Dr Lv and Dr Qingmin Liu to coordinate research for the Community Interventions for Health (CIH) initiative in China. CIH is the action research-arm of the Oxford Health Alliance (OxHA). Its long-term aim is to create environments and policies that reduce exposure to the three main risk factors (tobacco use, unhealthy diet and physical inactivity) for the four leading chronic diseases which account for over 50% of deaths worldwide.  Dr Sara Karrar, CIH Intervention Coordinator at OxHA, highlighted the importance of this work: “There is no dispute that global action is needed in tackling chronic diseases, especially as 80% of the disease burden falls on developing countries where resources are already stretched. CIH provides a solution by focusing and building on comprehensive community-based chronic disease prevention strategies.”

The project in China addresses both chronic disease risk factors and barriers to change, to find better ways to navigate policy change, to find sustainable funding and build community capacity for NCD prevention and control, and to develop systems of surveillance and evaluation that are scientifically sound.

Common approaches to community action around the world

Dr Lee leads one of four ongoing CIH studies: the other three are in India, Mexico and the UK. All of them are two-year intervention pilot studies, carried out in neighbourhoods, schools, workplaces and health centres. Focusing on high-risk communities, the projects use four strategies for change:

1. community coalition building
2. health education
3. media
4. structural change.

The studies evaluate impact at two levels:

• individual level: measuring changes in both knowledge and behaviour together with physical/biological risk factors (blood pressure, lipid profile, hip-to-waist ratio, body mass index and glucose level).
• community level: focusing on policy and environmental changes, measuring these by using GPS technology to conduct an environmental scan that maps neighbourhoods, worksites, health centres and schools to systematically document barriers or opportunities for healthy behaviour.

Fast-changing environments and lifestyles

The Hangzhou Centre for Disease Control (CDC) is spearheading the CIH intervention in three districts of Hangzhou. An industrial city of six million inhabitants, Hangzhou is located in Zheijiang province some 200 kilometres southwest of Shanghai. It is an important manufacturing base and logistics hub for coastal China, and has grown enormously since the early nineties when China opened up. There is a large population of migrant workers – a group whose lives have been changed dramatically by economic changes. “Hangzhou is an ideal place to study the effects of the recent economic, social and demographic changes, and there is a clear need to reduce risk factors there and throughout the province,” remarked Dr Lv Jun.

Working through worksites

Worksites involved in the Hangzhou CIH include a mix of public and private sectors in areas as varied as heavy machinery and administrative enforcement. Thirteen worksites are being studied, four intervention areas and seven controls. The workplaces involved in the programme vary in size with some having 1,000 employees and on-site healthcare providers. Interventions focus on:

• smoke-free policy
• workplace safety
• physical activity
• healthy diet
• health knowledge

They will offer workers health education, coaching, disease management and personalized health-risk assessment, carried out in parallel with efforts to gain managerial support and develop policies and systems to support changes in practice, environment and behaviour. 

Challenges and opportunities

Fiona Wong, Senior Associate at MATRIX Public Health Solutions and CIH Project Research Coordinator, described the specifics in China. “The focus for working with canteens will be on sodium consumption and in portion size. When possible, sports competitions will be organized and dancing, to reach more women, but not all worksites have the facilities for that. Another challenge with physical activity is figuring out how to organize it on-site without impeding productivity. Encouraging active transport can also be difficult: over half the workers live far from the factories and most have shuttle buses to take them directly to work. In some of these huge industrial complexes you can encourage cycling on-site”. All workplaces have pledged to go smoke-free but they still need to strengthen enforcement and find ways to support workers who want to quit: possibly on-site cessation counselling, or they can refer smokers to local cessation clinics. Neither option will offer pharmaceutical aids that make the counselling more effective: it is just too expensive in China. Screening for risk factors, on the other hand should not be too big a challenge because it can be integrated into the annual health checks that the worksites already do.

Leveraging workplaces to meet community needs

A big strength of the CIH approach is that it does not look at the workplace in isolation, but links it to other aspects of the community. “The big economic changes in China are also changing the health system,” said Ms Wong, “and primary care is losing ground as people shift from public to private services, and insurance coverage shapes access to care. This is a huge threat for the community’s capacity to reduce chronic disease; we are looking at how worksites can play a role in reinforcing primary care services in the community.” 

Adapting assessment tools

The studies assess the impact of CIH interventions through a rigorously designed research study. They examine how cultural and community contexts affect both how interventions work and what their impact is. This provides the basis for cross-cultural, comparative analysis between sites. To measure the knowledge and behaviour of adults in worksites, the CIH drew on a number of available tools including, amongst others, the CINDI Health Monitor Questionnaire and WHO STEPS. “Once we developed the adult survey we had to translate and adapt it so that the questions made sense in that cultural and practical context. That was interesting and not always easy,” Ms Wong admitted.

Research to feed action

The CIH initiative plans to use the knowledge gained to develop a “roadmap” to guide action addressing chronic disease risk. A comprehensive international database of intervention processes and outcomes will be established together with research articles to advance the field of risk-factor reduction and chronic disease prevention. “Our approach balances research and action,” summarised Denise Stevens, Director of CIH. We hope that this will help establish health-related productivity as a global community priority.”

Further information:

Oxford Health Alliance: www.oxha.org and http://3four50.com

CIH: www.cih.net

CIH China: www.3four50.com/cih/china.php

MATRIX: http://matrixphs.com/default.aspx