World Heart Federation


PREVENTING CARDIOVASCULAR DISEASE IN INDIAN INDUSTRIAL WORKSITES

The Initiative for Cardiovascular Health Research in Developing Countries (IC Health) involved over 20,000 people from 10 worksites around India in a study1 on the impact of comprehensive worksite interventions for cardiovascular disease (CVD) prevention. The study showed that workplace interventions in developing countries can reduce workers' CVD risk .

Dramatic increase in CVD prevalence

CVD prevalence in India has risen four-fold in the past four decades. Expected to be the leading cause of death and disability by 2020, CVD already causes 29% of all deaths in the country.  “Indians are succumbing to heart disease and stroke in the most productive years of their lives; about a decade earlier than their western counterparts” said Dr KS Reddy, Chair of the World Heart Federation Foundations’ Advisory Board and President of the Public Health Foundation of India. 

In India, CVD victims are often the sole breadwinner of a large family. Most healthcare costs are covered out of pocket and hospitalizations drive many families into poverty. According to the World Health Organization lost productivity due to premature deaths and disability cost India 9 billion dollars in 2005, a loss projected to amount to 237 billion by 2015.  This is one of the reasons why a risk factor surveillance and risk reduction programme was initiated in 10 Indian industries in 2001. “Cardiovascular and other chronic diseases threaten to undermine our health, our wellbeing, and our economic growth. Both the government and the business community are waking up to this threat.” Dr Reddy concluded.

Surveying CVD risk factors

“We first focused on the workplace because we needed detailed mapping of the CVD risk factor burden and wanted to demonstrate the feasibility of health promotion and prevention. The data we needed wasn’t available in official statistics and existing studies were too varied and limited to give a reliable nationwide picture. As a first step toward closing this information gap, we set up a system for surveillance of CVD risk factors in the Indian industrial workforce” explained Dr Dorairaj Prabhakaran, Executive Director of IC Health. A total 10 companies from around India were chosen to participate in the study. They represented a variety of industries including electronics, aeronautics, tea, pharmaceuticals, tools and textiles. All had 1,500–5,000 employees and the facilities to provide medical follow-up. Partners from universities near the worksites collected data on demographics, individual characteristics associated with CVD risk, medical history, clinical and anthropometric profiles and biochemical parameters: nearly 20,000 people completed the questionnaire survey and fasting blood glucose and lipid profiles were measured in some 10,500. This provided the data for a baseline cross-sectional survey.

Pinpointing problems, determining differences

“We found a high prevalence of CVD risk factors in the population studied,” reported Dr Prabhakaran. “Between a third and a half of them were overweight. Some 30% used tobacco regularly; less than half of the tobacco users smoked and the rest used oral tobacco or snuff. The percentage with hypertension and diabetes was high and more than double that documented by self-report. Between a quarter and more than a third of the participants had metabolic syndrome, depending on the standard used, and rates of dyslipidaemia were also high.”

Panniyammakal Jeemon, Senior Research Fellow at IC Health and Worksite Programme Manager, elaborated: “There was a good deal of variability in risk factors from one region to the next -- not surprising since the regions of India have different cultures, religious customs, cuisines and levels of economic development, and these influence risk factors. In Dibrugarh, which is an underdeveloped area in Assam, in the country’s northeast, 83% of the tea garden workers used tobacco, whereas in Bangalore it was less than 16%. On the other hand, Dibrugarh had less diabetes than other sites -- less than a fifth of the prevalence recorded in Thiruvanathapuram, Kerala. Hypertension prevalence in Hyderabad (Andhra Pradesh) was more than double what it was in Nagpur (Maharasthra). There were also some telling gender differences: fewer women used tobacco than men, for example, and when they did they tended to use snuff rather than smoke or chew.”

Multi-method interventions

With these findings as a baseline, IC Health developed a comprehensive approach combining health promotion/education, environmental/policy change and a high-risk approach to target multiple risk factors. Dr Shifalika Goenka, Assistant Professor at the Indian Institute of Public Health, describes the methodology IC Health used in the programme: “Motivational health promotion/education based on scientific techniques, formative inputs and techniques of marketing advertisements were used to educate, empower and change social/worksite norms.”

Aiming to increase fruit and vegetable consumption and encourage healthy diet, help maintain a healthy body weight, increase physical activity and reduce tobacco use, the four-year intervention was implemented by trained, locally-stationed health personnel in seven of the sites studied. Workplaces organized individual and group counselling sessions, health melas (displays) cooking competitions, and dance classes. IC Health produced colourful posters and banners, handouts, booklets, and real-time videos with simple, catchy messages and translated them into seven Indian languages (see link below). Management and employees initiated changes like increasing salads and decreasing salty or fried foods in canteen menus, and enforcing smoking bans. High-risk individuals identified in screening were referred to health facilities for risk management; if they chose to they could either get one-on-one counselling or attend group sessions.  On-site health staff were trained and given treatment guidelines and targets for risk-factor reduction. The control site referred high-risk individuals for follow-up and banned tobacco use, but implemented no other aspects of the intervention.

Ensuring the buy-in of all stakeholders

Panniyammakal Jeemon explained how the programme worked to get stakeholder buy-in. “At different points in the intervention we used surveys, focus groups and interviews to make sure we got regular feedback from management, employees and other key groups like the unions, which are very important for mobilizing workers in India. Interventions were steered by a group with representatives from human resources, on-site health personnel, the unions and the research centre that coordinated each study. To kick off, the programme started with top management: they were the first to give blood. During the intervention especially motivated workers helped spread messages and encourage participation. Involving all stakeholders created a snowball effect for participation. People started to go for walks on their breaks. Women who had signed up for our dance sessions sought out opportunities to continue at home or in the community. There was over 70% participation in our group counselling sessions. In India, many employers already provide preventive health services and see it both as part of their obligation to workers and as a good business investment, so often it is not hard to get their buy-in and support. In some cases the medical personnel were the ones who took the longest to get on board!”

Worksite interventions work

Almost all of the risk factors decreased in the intervention group and worsened in the control population.

The intervention group:

  • Reduced salt intake
  • Increased fruit and vegetable consumption
  • Increased levels of physical activity
  • Decreased tobacco use
  • Showed a significant relative decline in mean body weight, waist circumference, blood pressure, serum cholesterol, and plasma glucose levels.

“This study shows that in developing countries like India, comprehensive worksite interventions that combine high-risk and population approaches can reduce CVD risk,” concluded Dr Prabhakaran. “Even in the cases where the impact on a particular risk factor is modest, the combined effect of several risk factors being modified at once can magnify impact. When there is such a large population at risk, even small reductions in the population risk-factor profiles should result in large reductions of illness and death, saving millions from disability or death, medical expenses and lost wages.”

Low-cost CVD prevention

“Our programme cost $7.30 per person per year, which could be reduced further if implemented on a larger scale,” Dr Prabhakaran highlighted. “That is with all of the research…without it would have been half that amount. We are still developing a model for cost-impact, but with the high costs of treating or coping with the effects of CVD, we expect to show that the worksite interventions were cost-effective. We would like to do a cluster randomized trial that is needed to really fully convince the medical community of the effectiveness of worksite interventions, but the evidence is already strong enough to act – especially regarding tobacco control and promoting healthy diet at workplaces.  On a more practical level we need more randomized trials of interventions in a wider variety of worksites and workforces. We also need to explore innovative ways to provide insurance so workers have access to the care they need.”

Reaching beyond the organized workplace

Dr Goenka co-authored Powering Health, a manual on health promotion aiming to provide a framework for multi-sectorial partnerships to address the threat of CVD in India. He expanded on the need for better coverage: “The study on industrial worksites highlights the great promise of working through organized workplaces, but we have to go beyond this sector. In India over 85% of the working population works in the informal sector -- people like street vendors, self-employed farmers, or those who work in their own or other peoples’ homes. Most are underprivileged and very poorly served by systems of healthcare and social security. We urgently need to find out how to reach them.” He concluded: “If we are to achieve the healthy, powerful and prosperous India, government and non-government sectors, industries, policy makers, the media, city planners and economists all need to work together, along with the health sector, to engineer India’s growth through health.”

Useful links and further information:



1 Prabhakaran D, Jeemon P, Goenka S, et al. Impact of a Worksite Intervention Program on Cardiovascular Risk Factors: A Demonstration Project in an Indian Industrial Population. JACC 2009;  53: 1718–1728.