COMMUNITY INTERVENTIONS FOR HEALTH IN MEXICO: LINKING WORKSITES TO THE COMMUNITYMexico is at the forefront of global health trends that are changing health patterns in developing and middle-income countries. The Community Interventions for Health (CIH) project there integrates worksites into a comprehensive strategy, linking them to neighbourhoods, schools and health facilities in efforts to change policies and other environmental factors that are barriers to healthy behaviour. CIH is the action research-arm of the Oxford Health Alliance (OxHA). Chronic disease primary health threat for Mexicans“With recent economic, demographic, environmental and social changes, chronic diseases have overtaken communicable disease as our biggest health threat,” said Dr Jorge Ramirez Hernandez, InterAmerican Heart Foundation Coordinator of Social and Economic Studies for Latin America. “Cardiovascular disease is the number one killer in the country; nearly a quarter of Mexican adults are smokers and 30% are hypertensive. In 1989 less than 10% of all Mexican adults were overweight; now it is about 68%, and rising rates of overweight and obesity in childhood and youth indicate that the problem is still growing. The Ministry of Health has sounded the alarm that if we do not get diabetes under better control we will bankrupt the healthcare system. This is not only a disaster in terms of health, but it also undermines our productivity: Mexicans die much younger of CVD than their counterparts in wealthy countries. Many die at the ages of 40 or 50 years, when they should still have at least 20 more years of life and over 10 years more work.” Dying in the prime of lifeIn 2000, Dr Ramirez conducted a study on cardiovascular (CVD) risk in Tlalpan, a delegación (or a municipal administration unit) of about 600,000 people in Mexico City. “What we learned from the qualitative component of the study was that in our community and among people that had suffered heart attacks, is that they knew a fair amount about heart disease and its causes, but they did not feel threatened by it personally. Either they saw heart disease and stroke as something that happens to other people or else they said well, you have to die of something. They did not seem to pay attention to the fact that while they have to die, they do not have to do it at 40 or 50, which is what is happening now.” Culture, behaviour, health“Tlalpan has more hospital and medical research institutes than anywhere else in the country – probably even anywhere in Latin America – but these don’t really translate into better health for the population, especially not when you are talking about health problems linked to behaviour. When I realized that the biggest barriers to CVD prevention were culture and psychology, I went back to school to study anthropology.” Exchange and opportunityDr Ramirez, an epidemiologist and health economist, Director for CIH Project in the InterAmerican Health Foundation and senior lecturer at the National University of Mexico and National School of Anthropology, now leads this project in Mexico City. “The opportunity to be involved in the CIH project grew out of World Heart Day events in Mexico City between 2002 and 2003, when I started presenting the results of the study and shared experiences and ideas for action,” he recalled. Policy and environment keyThe CIH project focuses at community level on the structural and environmental factors that shape opportunities for preventing CVD. “Fortunately, Mexico City has a strong public health policy that goes beyond the medical system to affect the factors that shape peoples’ behaviour,” emphasised Dr Beatriz Champagne, Executive Director of the InterAmerican Heart Foundation. “It is the largest city in the world with 100% smoke-free policy, and it has a city policy for increasing physical activity and a good system of health promotion. The CIH project helps us see how well these policies could or do work at community level, and find what else could be done. We look with different stakeholders at factors that have changed peoples’ behaviours: the explosion of supermarket chains and fast food, adults working long hours with little time to shop and cook or ability to control childrens’ intake and activity; the increase of crime that makes jogging or walking unsafe in the city; sedentary electronic entertainment. These changes make it harder to make healthy choices.” Global network of action and researchThe CIH project in Mexico is one of four sites that have been launched by OxHA around the world: the others are located in India, China and the UK. Aiming to reduce tobacco use, increase physical activity, improve diet, reduce hip/waist ration, blood pressure, cholesterol and glucose levels and to change risk factors as a function of exposure to multiple interventions, the studies use a variety of research methods to examine the effectiveness of comprehensive, community-wide interventions that address policy, environment, and economic changes, as well as population knowledge and skills. While intervention priorities and activities are tailored to the needs, practicalities and culture in each setting, all four projects take the same approach and use common measures to evaluate impact, so that results can be compared across settings. Comprehensive change“The CIH project really goes where people live – which is where you need to be to have impact on everyday behaviour” commented Sara Karrar, who coordinates CIH interventions. “It approaches them from different points of view, combining health education with community coalition building, changing policy, and media. Whether you are talking about individual behaviour change or developing political will, any given activity may have a small effect. But when it is combined with others in a comprehensive strategy, the whole impact can be even greater than the sum of the parts.” The workplace: nucleus for CVD prevention in the community“The workplace is one of four key areas where we work,” reported Dr Ramirez; the other three are schools, neighbourhoods and health facilities. When we are working in schools and hospitals or clinics we also approach them as workplaces: smoke-free hospitals help patients, but they also help workers quit – and health professionals who have quit are more effective helping patients quit; healthy lunches for students are also healthy lunches for teachers, and physical activity for students can be designed to include teachers. Also, what you do in workplaces can be designed to strengthen communities, hospitals: from the worksite you can get people more involved in preventive care offered in clinics, or in community sporting facilities or activities to promote physical activity.
Reaching out to the informal sectorDr Ramirez emphasized the importance of extending workplace initiatives beyond formal work settings to include the unorganized or informal sector: those who are self-employed and work at home, or as street vendors. “It is very important to reach out to this group, which is a big sector of the economy and has fewer resources and poor access to primary care services: in our neighbourhood about half of the population do not get social security insurance, for example. To reach these people you have to get out into public places: the streets, markets, parks.” Research shapes communication“In the past, World Heart Day has given us a good ‘hook’ for organizing activities in Tlalpan; we applied epidemiological and social research findings to planning activities by targeting certain groups and used them to tailor messages to address the specific barriers we had found. It was very effective to link our World Heart Day and other awareness activities on this kind of research,” concluded Dr Ramirez. Next year, when he has completed gathering his baseline information, he hopes to integrate World Heart Day into project activities. Further information: | |||||||
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