COMMUNITY INTERVENTIONS FOR HEALTH IN CHINA: CONFRONTING CHRONIC DISEASE IN THE WORKPLACECircumstances 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 priorityTo 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 actionDr 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 solutionsDr 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.” Common approaches to community action around the worldDr 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:
The studies evaluate impact at two levels:
Fast-changing environments and lifestylesThe 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 worksitesWorksites 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:
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 opportunitiesFiona 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 needsA 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 toolsThe 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 actionThe 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 | |||||||
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