Resource Book III: NCD - JICA

Resource Book III: NCD

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Chap t e r 9 CHRONIC NCD

PREVENTION IN KURUNEGALA

Key Messages The provincial vision is a healthier population in the North Western Province that contributes to the nation.

A programme was conducted to determine the status of Chronic NCD among the participants in the Healthy Life Style programme.

Training of trainers (TOT) programmes was conducted on the aspects of healthy life styles.

In June 2007, a review was conducted to identify the lessons learned in TOT programmes.

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9‐3

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9‐4

statistics. NCD accounts for 4 of 10 admissions and more than half of the deaths in Kurunegala government hospitals. ( FIGURE 9‐ 2) At the BH Kuliyapitiya, medical clinics attendance has doubled from about 25,000 in the year 2000 to 40,000 in 2004. The increasing trends in NCD morbidities and mortalities result from a combination of non‐modifiable

factors (ageing), underlying socio‐economic determinants, and health services factors (lack of concern on prevention & health promotion activities) ( Figure 9‐ 3 ).

1IMMR, 2004

NCD41%

Others59%

Causes of Hospital admissions, 2004

NCD54%

Others46%

Causes of Hospital Deaths, 2004

FIGURE 9‐ 2: NCD BURDEN IN KURUNEGALA DISTRICT1


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9.1.3 PROVINCIAL ASPIRATIONS & COMMITMENTS TO ADDRESS NCD

The provincial strategic objectives designed to facilitate the achievement of the provincial goal are in 4 areas – capacity enhancement, primary prevention and health promotion, patient management and rehabilitation, and surveillance system.

Goal:

The increasing trends in priority NCD‐related morbidities, mortalities & disabilities are reversed.

Mission:

To adopt feasible, cost‐effective policies & strategies for the prevention and control of NCDs of major importance to public health in the province

Strategic objectives:

To strengthen provincial/district capacities in developing efficient strategies and models for intervention and in forging working partnerships for the control of major NCDs

To establish primary prevention and health promotion aimed at fostering healthy lifestyles among the population

To improve patient management and rehabilitation of patients with major NCDs

• Ageing of the population • Changes in the social, economic and cultural pattern of living that contribute to elevated risk of NCD

• Unfavorable effects of urbanization, industrialization, mechanization and migration of the people

• Lack of concern on prevention and health promotion strategies

• Inadequate recognition of the impact of NCDs on economic development.

Burden on the health system• Over crowded hospital clinics• Increased Hospital admissions• High health costs ‐drugs, technology, infrastructure,

trained man power • Increased burden on secondary and tertiary care hospitals

• Economic loss to the country

Burden on patients & families•Dependency on treatment• Patient dissatisfaction• Limitations/modifications to the patient’s normal life• Imbalance to the family economy, life style, social and structural disruptions

• Psychiatric illnesses

Increasing trends in NCDmorbidities, mortalities & disabilities

FIGURE 9‐ 3: MAJOR CAUSES AND EFFECTS OF NCD IN KURUNEGALA


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To establish a surveillance system for NCDs and their risk factors within the framework of the National Surveillance System

9.1.4 INITIATIVE AT THE BH KULIYAPITIYA

In 2005, the RDHS Kurunegala initiated the “Reduction of Overcrowding in Medical Clinics in BH Kuliyapitiya due to Chronic LSRD Morbidity in Kurunegala District ‐ Sri Lanka”. The goal of the initiative was to reduce the number of patients coming to the BH with complications; specifically, prevent hypertensive patients from developing strokes and diabetics from getting admitted for ketoacidosis. This could be achieved through 4 major strategies: improvement in the knowledge and skills of the health staff on the prevention programme; establishment of a healthy lifestyle among

patients, health staff and the community; improvement in the life span of patients diagnosed to have diabetes and hypertension by changing their lifestyle and health education; and baseline assessment of the community for hypertension and diabetes. With the financial support from the HSDP, a training programme was designed to combine both learning of theories and practical exercises. An initial 5‐day training course was conducted for the core group of facilitators, who then conducted the subsequent 2‐day training programmes for the other staff of the

hospital, primary care system and other members of the community. Follow up done three months after the onset of the initial training programme showed optimistic results. The following ideas were proposed during a review of the programme:

Assessment of programme impact on biological (e.g. BMI, blood sugar levels; increased muscle endurance, and increased flexibility) and behavioural risk factors (e.g. reduction of sugar consumption, increased vegetable consumption, increased fruit consumption);

Inclusion of primordial prevention to address the underlying determinants;

Development of a surveillance system; Involvement of other stakeholders; and Expansion to settings outside of the BH.

9.1.5 OBJECTIVES

The HLS was carried out in 4 types of settings: hospitals (1 BH, 1 DH, 1 rural hospital and 2 central dispensaries); 10 schools; workplaces (5 hospitals, 10 schools, 1 insurance company, 1 garments factory, and 1 university); and 1 village (Mahimpitiya with 483 population). Figure 9‐ 4, outlines the linkages between the programme goal, purpose and outputs.

Training Curriculum of HLS Programme at the BH Kuliyapitiya:

Introduction Promoting physical activities

Evaluation of fitness Stretching Aerobics Resistance relaxation

Healthy diet Diet therapy with food exchange list How to use the food exchange list

Stress management


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The increasing trends in priority NCD‐related morbidities, mortalities and

disabilities are reversed.Goal

Participants from the 4 settings adopt healthy lifestyles

Purpose

Policies for healthy settings are enforced

Supportive environment is established

Participants’ competencies are enhanced

Output

FIGURE 9‐ 4: HLSP DIRECTIONS


9 8

9.2 ADVOCACY AND BUILDING A BROAD BASE OF

SUPPORTERS

9.2.1 PRELIMINARY CONSULTATIONS

Involvement of the village and health leaders in the Mahenpitiya division

were organised to identify their needs and priorities. A coordination

meeting with the District Education Department was held and a follow up

meeting was conducted on the 1st

week of September. A one day

conference was organised under the sponsorship of the HSDP to sensitise

local leaders and other stakeholders on some basic concepts on NCD and

their risk factors.

9.2.2 STEERING COMMITTEE

A Steering Committee was set up to provide the leadership and overall

directions for the programme. It has a multi sectoral membership. All the

four settings are represented in the Steering Committee for HLS, which

meets at least once a month.

9.2.3 COMMUNICATION

A logo was developed that depicts the key areas of a HLS ( Figure 9 5) –

physical activity, healthy diet, not using tobacco and not misusing alcohol.

Shirts were distributed to community volunteers, leaders and health staff

who helped in setting up the village based baseline assessment programme.

Several school children participated in a poster making contest. The logo

and winning posters will be used for the production of other

communication materials such as banners and calendars. Additional

communication materials will be developed and produced after the training

on “Communication Materials Development”.

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FIGURE 9 5: EXAMPLES OF COMMUNICATIONMATERIALS

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9‐13

9.4 TRAINING OF TRAINERS Training of trainers (TOT) programmes were conducted on the aspects of healthy life styles. They were aimed at developing a resource pool that can become competent enough to implement programmes on healthy life styles in their own settings. They were conducted with the participation of representatives from the village, hospital, schools and work places with the idea of promoting learning and cross‐ learning between members of all settings

9.4.1 BEHAVIOUR CHANGE COMMUNICATION PROGRAMME (PART 1)

The part 1 of the training programme on BCC) was held from 6th to 10th of November 2006, at the MOH Office Kuliyapitiya. Forty participants representing all the four settings (hospitals, schools, village and work places) including MOH staff took part in the programme. Dr. Kanthi Ariyarathna, Deputy Director, Health Education Bureau and Mr. Bandara Kotagepitiya, HEO from Health Education Bureau were the facilitators. The programme started with an introduction to Information Education and Communication, Behaviour Change and Communication and Behaviour Development and Communication. This helped clarify any doubts the audience had about the definition of the terms. Then the participants were taught how to identify the risk factors to a given problem and categorise them into individual risk factors, biological risk factors, social risk factors and environmental risk factors. Then they participated in a group activity where each group was given a target audience and were instructed to list the problems in that target audience. They engaged in determining the risk factors of one of the main problems they had identified, and categorizing them. The next session was on segmentation of the target groups according to different variables such as gender, educational level, economical status, nutritional habits, civil status, religion, habits (smoking, alcohol) and Body Mass Index. Next, the programme moved on to the definition of communication objective. In this, the participants learnt what goals and objectives are, how to perform desirable behaviours, the seven Cs in communication (Command attention, Clarify the message, Convey a benefit, Create trust in the audience, Consistency counts, Cater to hearts and heads and Call for actions), how to perform SWOT analysis (Strengths, Weaknesses, Opportunities and Threats), and how to design communication material to address a given problem in a target audience. This was conducted as group activities, as well as lecture discussions by the facilitators. Emphasis was given to the fact that all the communication material developed this way should be pre tested, the programme should be followed up and monitored and evaluated using indicators. Process documentation is also of immense value in this kind of proceedings. The participants were trained in applying the knowledge they gained to the four settings. This was done with the help of field visits. The participants were divided into groups and they were sent to the four setting to make their observations of the main problems of the settings and the risk factors.


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Afterwards, each group developed goals and objectives for the identified problems, and action plans for the identified settings. This was followed by development of health messages and identification of suitable communication materials for each setting. Finally, the indicators and methods of monitoring and evaluation were finalized. There followed a session on Focus Group Discussions, where the participants got to know the participants, suitable layout, the roles of each participant including moderator, reporter and observer, the steps in conducting and the principles of report writing in a Focus Group Discussion. This session was conducted in the form of a lecture discussion. From this training programme the participants were given the necessary exposure to become resource persons in improving healthy life styles relevant to chronic NCD prevention and health promotion in the above settings.

TABLE 9‐ 1: BASIC INFORMATION ABOUT THE TRAINING ON BEHAVIOUR CHANGE COMMUNICATION

Objectives

To train the trainees on BDC & BCC methods related to healthy life style in chronic NCD prevention and health promotion in four different settings (School, Work place, Hospital & Village) in MOH Division, Kuliyapitiya

Date & Venue 06‐10 November 2006 MOH Office, Kuliyapitiya

Participants

40 participants 13 MOH staff, 11 from schools, 11 from hospitals and central dispensaries, 2 from other work places and 3 HEOO from RDHS Office, Kurunegala

Programme

The programme was conducted by Dr. Kanthi Ariyaratne, Deputy Director, Health Education Bureau and Mr.Bandara Kotagepitiya, HEO from Health Education Bureau

The programme consisted of the following Introduction to ICE, BDC & BCC Identification of target audiences according to the 4 settings Segmentation of the target audience and identify the different communication roles

Identification of main problems in 4 settings Identification of the existing behaviour and the expected behaviuor

Identification of the risk factors Development of goals and objectives for the identified problems Development of Action Plans for each setting Development of health messages and identification of communicating materials

Identification of the indicators and methods of monitoring and evaluation

In the development of the above process field visits were carried out for each setting

Outputs

Identification of problems and risk factors for HLS in chronic NCD prevention and promotion of health in each setting

Capacity building and skill development of the trainers in BCC and BDC

Trainers were oriented in monitoring indicators

Way forward The participants will act as resource persons in improving healthy lifestyle relevant to chronic NCD prevention and health promotion in the above four settings


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9.4.2 BEHAVIOUR CHANGE COMMUNICATION PROGRAMME (PART 2)

The part 2 of the training programme on BCC was conducted on the 27th and 28th of February 2007, at Janadhipathi Shilpa Shalika Centre, Kuliyapitiya, by Dr. Kanthi Ariyarathna, Deputy Director, Health Education Bureau. It commenced with a brief introduction about the programme and moved on to recapitulating the things done at the previous programme. At the previous programme, action plans for all the four settings‐ hospital, village, schools and work places were prepared. They were revised again. Dr. Ariyarathna explained the components of strategic communication.

Advocacy‐ an action directed at changing the policies, positions or programs of any type of institution.

Social mobilization‐ role of health workers and community workers

Behavioural development communication‐ if the current behaviour and expected behaviour is the same, BDC is used

Behavioral change communication‐ if current behaviour and the expected behaviour are different, BCC is used.

Behavioural development communication and behavioral change communication were described as primary strategies, while advocacy and social mobilization were categorized as secondary strategies.

In strategic health communication there are communication methods, media and target groups. We have to:

Identify risk factors Identify current behaviour Identify expected behavior

The participants identified the risk factors as follows:

Individual‐occupation, education, personality, attitudes Biological‐gender Social‐culture, education level, religion, stigma Environmental‐availability

Two groups of target audiences were mentioned:

Primary group is the group whose change in behaviour is expected

Secondary group is who can have an impact on primary group

The methods used to reach the target group are called communication methods. Examples include:

Interpersonal communication

Trainers will be strengthened further in their capacities in the implementation process

Training in the development of education materials Development of indicators for monitoring and evaluation


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Intrapersonal communication Mass communication

The aids used to reach the target group are called communication media. The participants were able to list out the communication media successfully as follows:

Lectures Handouts Booklets Leaflets Posters Models Specimens Calendars Letters Dramas TV Spots TV Programmes Radio Spots Radio Programmes Magazines Pictures News Letters Banners Book Marks Flags Songs Street Dramas Docudrama


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There followed a group activity where the participants were instructed to do the SWOT analysis on a few of the listed communication media. There was also another group activity where the participants were expected to do a similar SWOT analysis on all three communication methods: interpersonal communication, intrapersonal communication and mass communication. The participants were given the chance to present the results of their discussions to the rest of the groups. A broad discussion followed this. On the whole, the BCC (Part 2) programme received many praise from all the participants. They showed interest and enthusiasm in participating in the group activities and discussions.

9.4.3 TRAINER’S GUIDE ON LIFE SKILLS EDUCATION (LEVEL 1)

The level 1 training programme on life skills was held from 21st to 23rd of November 2006 at Janadhipathi Shilpa Shalika Centre, Kuliyapitiya, with participation representing all four sectors‐ hospitals, village, schools and work places. The Deputy Provincial Director Health Services‐ Kurunegala, Dr. Soma Rajamanthrie was also present to grace the occasion. Consultant Psychiatrist Dr. Neil Fernando, Dr. Uthpala, MO, Health Education Bureau, Dr. Nelly Rajaratne from Family Health Bureau, Mrs. Rathna Weththasinghe from Ministry of Education, DR. P.A.D. Premaratne MO/ NCD, Gampaha and Mr. Suneth HEO, Health Education Bureau participated as facilitators to the programme. The programme commenced with religious activities. A broad introduction to life skills was given by each of the facilitators followed by anecdotes of their own experience. Life skills were described as culturally and socially accepted positive thinking to face the challenges in life, tools which are useful in day to day work etc. These descriptions were punctuated by folk songs and poems which talk about life skills, which, while exemplifying usage of life skills also served to break the monotony. There followed a group activity where each group was instructed to discuss the reasons why life skills are important, and present the results afterwards. Some of the identified reasons were:

Important in decision making Important in problem solving To face challenges To bear stresses To build interpersonal relationships To face social problems To understand others Important in self understanding Important in mutual respect To manage disasters In creative thinking To use modern technology To build‐up peace within the family To bear happiness and sorrow


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For self protection To abstain from smoking and consuming alcohol To reduce the number of suicidal attempts To maintain a healthy life To show empathy For time/ Financial management

The participants were requested to present the incidents (own experiences, things which read/ heard) where the life skills were used. The second session was on participatory learning. The terms traditional learning and participatory learning were introduced and explained. A group activity following this discussed on the advantages of participatory learning over traditional learning.

Advantages identified were:

Every member in the group can actively participate Can build up a good interpersonal relationship within the group Can gather many facts Opportunity of receiving a feedback Facts can be negotiated with other group members Team work Leadership development Time management More productive Concentrate more to the point which discuss Opportunity to share knowledge and ideas Can develop listening skills Can develop communicating skills Less monotony Encourages innovation and creativity Motivates the participants Facilitate dealing with sensitive issues Enhances self‐esteem More resources available Sharing of responsibility Less opportunity for mistakes

The facilitators and the participants engaged themselves in

identifying various teaching and learning methods:

Discussions in pairs Small group discussions (with 3‐5 participants) Role play/ reverse role Brain storming Lecture discussions Use of black/ white board

In the third session the ten core life skills were introduced to the audience.

Decision making


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Problem solving Creative thinking Critical thinking Effective communication Good interpersonal relationships Self awareness Empathy Coping with emotions Coping with stress

At the end of the first day, according to the evaluation of the days’ proceedings, 38 out of the 50 participants have claimed to be satisfied with the programme and thought it successful. The second day commenced with demonstration of stretching and relaxing exercises. Recapitulation of the previous days’ work was done by four participants, followed by listing out the good and bad events of the previous days’ activities. Here also, songs that talked of different life skills were played from time to time to create interest. Short discussions on the application of life skills as described in the song followed. All of the life skills were taken one by one and various activities which described the skills were undertaken. The first one of the life skills, decision making was described as dealing constructively with decisions about life by assessing different options and there effects. Four activities were engaged to test the participants’ decision making skills. The activities were both interesting and entertaining, and the participants enjoyed taking part in them. Next life skill, problem solving was described as dealing constructively with the problems in our lives. The five steps in problem solving are as follows:

Identify the problem List all the alternatives that will solve the identified problem Select the best alternative Work out the steps needed to solve the problem using the chosen alternative

Look at the result This was followed up by an activity which tried out all of the five steps in solving a problem in a given scenario. Three activities each were prepared for creative thinking and analytical thinking, where all the participants joined eagerly. At the end of the second day of the programme 41 of the participants declared in the evaluation that they were satisfied with the days’ activities. The third and final day of the programme started with activities on effective communication and good inter personal relationships after which followed the activities on empathy and self awareness. Lastly coping with stress and coping with emotions were discussed. At the end of the final day, 44 participants have voted that the programme was a success. They were also given a chance to speak their ideas including areas that needed improvement. All the participants were presented with certificates at the end.


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9.4.4 TRAINER’S GUIDE ON LIFE SKILLS EDUCATION (LEVELS 2 AND 3)

The Levels 2/3 training programme on life skills was held from 14th to 16th of May 2007 at Janadhipathi Shilpa Shalika Centre, Kuliyapitiya, with participation representing all four sectors‐ hospitals, village, schools and work places. The same facilitators who conducted the last programme, Consultant Psychiatrist Dr. Neil Fernando, Dr. Uthpala, MO, Health Education Bureau, Dr. Nelly Rajaratne from Family Health Bureau, Mrs. Rathna Weththasinghe from Ministry of Education, DR. P.A.D. Premaratne MO/ NCD, Gampaha and Mr. Suneth HEO, Health Education Bureau were invited to conduct the programme. The programme commenced as usual with religious activities. The participants and facilitators introduced themselves in a ‘name game’. Then the facilitators discussed their objectives and expectations of the programme. Then a brief account was given of the activities in line up in the three days. Next, the previous Life Skills programme was recapitulated and the participants were given an opportunity to share the instances in their lives where their knowledge in life skills became useful. The first activity involved a role play by 8 participants performed with the guidance of the facilitators. The rest of the participants discussed the scenario dramatized by the role play and what they learnt. They also

Objectives To train the trainers on Life Skills Development regarding NCD prevention and health promotion in 4 different settings (School, Work place, Hospital & Village) in MOH Division, Kuliyapitiya

Date & Venue 21‐23 November 2006 Shilpa Shalika Auditorium, Kuliyapitiya

Participants

38 participants 17 MOH staff, 6 from schools, 9 from hospitals and central dispensaries, 2 from other work places and 4 HEOO from RDHS Office, Kurunegala

Programme

Conducted by Consultant Psychiatrist Dr. Neil Fernando, Dr. Uthpala, Amarasinghe, Community Medical Officer, Health Education Bureau, Dr. Nelee Rajaratne,School medical Officer, Family Health Bureau, Mrs. Rathna Weththasinghe, Master teacher, Ministry of Education, DR. P.A.D. Premaratne MO/ NCD, Gampaha, Mr. Suneth PHI, Health Education Bureau

Programme consisted of the following: Introduction to different types of learning strategies ‐Introduction to life skills‐ 10 basic core life skills ‐Discussion on the use of life skills in day to day activities ‐Activities conducted for each and every life skill

Outputs Successful capacity building and skill development of the trainers in improving life skills

Behavior change of the trainers in promoting healthy life style

Way forward

The participants will act as resource persons in improving healthy life style relevant to chronic NCD prevention and health promotion in the above four settings

Trainers will be strengthened further in their capacities in the implementation process

Life skill development of the recipients in the selected settings

TABLE 9‐ 2: BASIC INFORMATION ABOUT THE LIFE SKILLS TRAINING (LEVEL 1)


9‐21

realized the value of role plying as a learning tool and a communication method. Next, another group activity where the participants were divided into 5 groups and instructed to go through newspapers followed. The participants learnt not to be taken in by the advertisements and about marketing strategies. They also had some first hand experience on how to use social marketing principles and prepare an advertisement on chronic NCD and healthy life styles in the subsequent activity. Amidst the activities there were short sessions where songs were played and discussed among the participants and facilitators. The songs were based on various applications of life skills. The ability of the participants to recognize these were tested. Another game followed these activities. The participants were divided into three groups and while having a lot of fun, they learnt about good team work and good leadership. These games were used to break the monotony as well as teaching life skills. At the end of the first day the participants were asked to make a vote on how they liked the programme. Twenty‐six people voted that they liked the programme and 4 voted for neutral. The second day commenced with the displaying of the votes of the previous day. The first activity focused on the participants’ ability on public speaking. Each of them was given a real life scenario where they had to deliver a speech or conduct a discussion. They were given time to prepare and the others were asked to observe critically and point out the good points and areas that needed improvement after the presentations. In addition, the presentations were videotaped, so that the presenter himself/ herself would be able to view it and not his/ her good points and weaknesses. Next, the attention was focused to inter‐personal relationships. The participants were again divided to groups and instructed to list out the features of healthy and unhealthy relationships. It was followed up by a broad discussion with the facilitators and then short presentation. Another role play involving both the participants and facilitators followed this activity. A discussion about what was conveyed in the role play was conducted afterwards. The participants were again divide into groups and asked to list out the skills that are required to work with adolescents. Discussion within the groups and with the facilitators followed, so ending the second day of the programme. As usual, the participants were asked to vote on the programme. 29 votes were given in favour of the programme and 4 were marked as neutral. On the third day, the participants were divided into four groups and they were assigned to each of the four settings‐ hospital, village fair, school and a work place. A person to lead the group and a person for documentation were selected for each group. A facilitator also accompanied each group. Two hours were allocated for the field visits, and the participants presented their observations to the rest of the groups. The rest of the day was spent in preparing one year action plans for the respective settings according to a given format, with regards to non‐communicablediseases.


9‐22

At the end of the programme, 28 participants voted that the programme was a success, and 4 voted that it was neutral. The participants were given the chance to share their views regarding the progamme.

9.4.5 TRAINING PROGRAMME ON DIET

The training of trainers programme on diet was held on the 22nd and 23rd of March 2007, at Kulityapitiya MOH Office. Dr. Shanthi Gunawardana, Director of Nutrition Coordination Division and Ms. Lakmini Thilakarathna, Nutritionist at the Nutrition Coordination Division were invited to conduct the programme. Once again, the attendants represented all the four settings‐ hospital, village, work places and schools, and included schoolteachers, hospital doctors and nurses, stakeholders from the village, employees of the selected work places and of course the MOH Office staff. All of the participants took a very keen interest in attending the programme. The programme started with a lecture by Dr. Shanthi Gunawardana on Food, Nutrition and Health where all the basics in nutrition were elaborated and the prevalent nutritional problems in the country were discussed in detail. The concept of the food pyramid was introduced and the importance of a balanced diet was highlighted. After the tea break Dr. Gunawardana talked about Nutrition in Various Stages of Life. In this, she discusses about the nutritional needs of pregnant and lactating mothers, infants, preschool children, adolescents and the elderly. She discussed why the nutritional needs differ in each category, and with this the party broke up for lunch. Another lecture discussion on the Food Based Dietary Guidelines for Sri Lankans was the first item after lunch. In this, the six groups of food that should be consumed every day‐ cereals and starchy foods, fruits, vegetables, milk and milk products, fish, pulses, meat and eggs, and fat and sugar were discussed along with the nutritional values of each. The recommended numbers of servings were also given after a thorough explanation on the serving sizes. She emphasized on the importance of having five servings of fruits and vegetables per day and the value of consuming milk and dairy products every day. The lecture went on to describe all the nutrients, their importance and foods and groups of food which contained them. She also explained why fats, sugars and salt should be limited. Dr. Gunawardana then gave some very useful tips on how to improve the nutritional value of some common Sri Lankan staple foods and handed over to Ms. Lakmini to continue with the programme. Ms. Lakmini Thilakarathna captured and horrified the audience with a presentation on Fast Foods and the Reality, where she elaborated on the actual constituents of some of our favourite fast foods. She described in detail, the reasons for the immense popularity of fast foods and the wide spectrum of harmful effects they have on us. She concluded her session by giving some useful hints for healthy eating and living. The first day of the programme came to an end with the invitation from Dr. Gunawardana to the participants to prepare some food items according to the tips given by her earlier, on how to render common staple foods more


9‐23

nutritious and balanced. Several of the participants volunteered to prepare and bring the foods the next day for further discussion. The second day commenced with a broad discussion of the nutritional values, the ease of preparation, and the suitability for school children etc of the foods that were prepared and brought by the participants. First, they described how they prepared the foods, the ingredients they used and their idea of the nutritional value of the food. The facilitators joined the discussion by adding their own ideas and methods of improvement. They also cleared the doubts of the audience on various nutritional issues and myths regarding them.

Then the participants were divided into 6 groups and they were instructed to prepare model meals for a given category of people:

For a child of 6 months to 1 year For a pre school child For a child of 5 to 10 years For an adolescent girl or boy For a pregnant/ lactating mother For an elderly person

Participants were instructed to present their preparations, while the nutritional value, practicality of preparation and suitability to the given age group were discussed along with the presentations. Here some novel ideas of preparing attractive foods, rich in nutritional value for small children were given by the presenters. For the rest of the programme, Ms. Lakmini made several presentations on the nutritional management of obesity, diabetes mellitus, hypertension and renal diseases. Regarding obesity, she discussed on the harmful effects to health of obesity, and how nutritional therapy can be made successful. This was followed by many very practical hints on food preparation and consumption for obese persons. The presentations on diabetes, hypertension and renal diseases followed the same lines. Finally, she talked of the importance of motivating and supporting the newly diagnosed with person with a chronic disease. Changing drastically from ones usual eating pattern can be a challenge and an immense stress on a person. Therefore, extensive family support and empathy from the doctors is essential. Ms. Lakmini encouraged the participants to give people with chronic diseases this support.

9.4.6 REDUCING THE USE OF TOBACCO AND ALCOHOL

The programme on reducing the use of tobacco and alcohol was conducted on the 9th and 10th of April 2007 at the Janadhipathi Shilpa Shalika Centre, Kuliyapitiya. Dr Neil Fernando, consultant psychiatrist, Dr. Manoj Fernando, executive director, Mel Medura, Mr. Pubudu Sumanasekara, executive director, ADIC, and Mr. Amaranath, from ADIC conducted the programme as facilitators. After the introduction of the participants and the facilitators, Dr. Neil Fernando made a presentation on coping with stress. He introduced the terms ‘positive’ and ‘negative’ stress and explained how stress can be


9‐24

useful. Threats, changes, extreme demands and relationships were given as the four main sources that give rise to stress. Each was described with simple examples. He concluded the session by mentioning the symptoms of stress and the different ways of coping with stress. An evaluation on the knowledge gained by the session was carried out by means of a questionnaire. A pre test questionnaire consisting of 10 questions was given to the participants. Only one out of 19 (5.26%) had more than 50% correct. A post test after the lecture showed that 18 out of the 19 participants (94.74%) had got more than 50% correct. Copies of the tobacco and alcohol bill, leaflets and fliers designed by ADIC were distributed among the participants. Next in line was an interactive session conducted by Mr. Amaranath. He discussed the different categories of people we could attempt to bring about a change with regards to tobacco and alcohol and what interventions were needed to bring about these changes. This was followed by a group activity where the participants were divided into three groups. They were instructed to write the changes that should occur in a community, with respect to prevention of drug use. They were given 15 minutes to come up with their ideas, and advised not to come up with large issues that cannot be addressed easily. One person in the group was asked to come forward and present the results of their discussion. The pros and cons were discussed by the facilitator during the presentations. Mr. Amaranath also shared some changes that were considered successful by studies.

Reduction of factors that attract tobacco and alcohol to people. Education of people of the ‘real’ harm by tobacco and alcohol Reduction of the privileges given to drunk people Reduction of ‘alcoholisation’ Reduction of industrial strategies Reduction of availability Increased numbers of quitters Good policies

In the second half of the day, Mr. Pubudu Samarasekara conducted a broad discussion on the real harms of alcohol and tobacco. He described how alcohol ultimately limits the enjoyment of life. The audience participated with energy and enthusiasm to this discussion. The second day commenced with recapitulation of the previous days’ work. Dr. Manoj Fernando conducted a group activity during which the groups were asked to discuss what can be done to minimize the violence associated with alcohol in the community they work. The group activity was followed by a presentation by Dr. Fernando on “Problems of Substance Use”. He described the factors that support substance use and the certain ‘privileges’ that are attributed to the users. He also discussed the real harms of substances in detail. Afterwards, the participants were divided into four groups according to the four settings (i.e. schools, work places, villages and hospitals). They were asked to discuss among themselves and write down the characteristics of their respective places in an ideal situation. For example, what are the desirable characteristics of an ideal school, work place, village and hospital).


9‐25

These regarding issues related to tobacco and alcohol. After the presentations each group was assigned to find out the characteristics which were practical and achievable. They were instructed to discuss how these goals can be achieved in four steps. They were asked to write the stages of change achieved at the end of each step. Next they were asked to write down the interventions/ activities necessary for achieving each stage of change. The practicability and other advantages and disadvantages were discussed along with the presentations. The days’ work was concluded with another presentation on “Managing Substance Use Problems”. Dr. Fernando described each of the therapeutic models used in managing substance use problems. A pre test questionnaire of 7 questions on tobacco and alcohol was given to the participants. Ten out of 17 participants (58.81%) got more four or more correct. The post test revealed that all the 17 participants got four or more correct.


9 26

9.5 REVIEW OF THE HEALTHY LIFESTYLEPROGRAMME

The HLS programme was organized with the

view of educating the public on risk factors

for chronic NCDs and how to avoid them.

The basic plan of the project was to provide

training for selected trainers from different

settings of the community and provide

them with the knowledge and skills

required to implement programmes in their

respective settings to educate the public.

The community was divided in to four

settings comprising of schools, workplace,

hospital and the village.

In June 2007, a review process was conducted to identify the lessons

learned particularly in the conduct of the training of trainers and following

up of participants who are at high risk. Focus group discussions were

facilitated by MoH officials who were not directly involved with the

programme. The groups organised for this purpose were as follows: TOT

participants; high risk participants; members of the Steering Committee for

HLS; MOH staff; hospital staff; and representatives of the target group such

as the village people and workers. Interview instruments were also

developed. An interviewer administered questionnaire was used for the

high risk participants; and self administered ones for the TOT participants

and members of the steering committee.

9.5.1 TRAINING OF TRAINERS

The self administered questionnaires were filled only by the participants

who were present at the eighth and final workshop (Life skills – 02).

A. ATTENDANCE

The attendance at each workshop was variable. Five out of the eight

workshops had been attended by more than 50% of the respondents.

Highest participation has been for the workshop on life skills ( Figure 9

6 ).

The participation was highest from the MOH/Hospitals (66%) for the

workshops. 27% participated from schools and only 7% participated from

the working places.

B. LEVEL OF UNDERSTANDING, USEFULNESS ANDWILLINGNESS TO

PARTICIPATE AGAIN

The majority of the participants, amounting to 87%, have understood

most of the topics discussed at the workshops. The others claimed to

have understood only some of the topics (Figure 9 7)

3%

6%

12%

18% 18%

15%

6%

18%

0

2

4

6

8

10

12

14

16

18

20

OnlyOne

OnlyTwo

OnlyThree

OnlyFour

OnlyFive

OnlySix

OnlySeven

OnlyEigth

Percentage%

FIGURE 9 6: ATTENDANCE FOR TOTWORKSHOPS


9 27

C. KNOWLEDGE RETAINED

The knowledge acquired at the training

work shops was assessed by way of

multiple choice questions based on the

topics that were discussed. A mean mark of

above 70% was observed. Only one

participant had scored below 50% Figure

9 8).

D. EXISTENCE OF NCD AND RISK FACTORS

The respondents were also

assessed with regard to

illnesses they have been

diagnosed with and the

common risk factors. The

results are based on self

reporting by the respondents.

Majority of them had

hypertension. Amongst the risk

factors, limited physical

activities and unhealthy food

patterns were the commonest.

12% of the trainers had

Hypertension and 3% each had

FIGURE 9 7: RESPONSE OF THE PARTICIPANTS

0

2

4

6

8

10

12

Frequency

Marks

FIGURE 9 8:DISTRIBUTION OF MARKS GAINED BY

THE TRAINERS FOR THEMCQ S.

47%

47%

53%

65%

6%

6%

0 10 20 30 40 50 60 70

LimitedStressmanaging

activities

Veg or Fruits<5 serving

Rice>3Cups

Limitedphysical activities

Alcohol

Smoking

Percentage% (n=32)

FIGURE 9 9: RISK FACTORS FOR NCD S AMONGST THE TRAINERS


9 28

high cholesterol and stroke (Figure 9 9 ). None of them had Diabetes,

MI/Angina or cancer as a disease.

E. SUGGESTIONS AND ISSUES RAISED DURING THE FGD

In general all the participants were pleased to be involved in the

programme. They believe that the progamme provided them with an

opportunity to strengthen their bonds with the employees, students or

subordinates.

Schools

According to the heads of the staff there is a difficulty in providing

extra time for the activities as the syllabus has to be covered. It also

revealed that certain canteen owners refused to change their

menus to include more fruits and vegetables, as it differs from their

existing contracts.

For the sustainability of the programme number of the staff

involved could be increased. Teachers felt that students them

selves should be made ambassadors to pass on the message to

address these issues and especially students of grade 1 to 5 are

selected as the most appropriate group to implement the activities

to change food habits. Most of the schools requested for education

and baseline assessment programmes to be held in their settings.

Hospital/ MOH

MO/NCD suggested that there should be room for alterations in the

programme in future as the community trends keep changing with

time. The exercise programme itself was not suitable to the

villagers and the need to change it was emphasized. Apart from

that more trained professionals from the ministry of Sports were

needed for the exercise programme. They believed that media can

be used to educate the public about the project more effectively.

Workplace

They believed that the discussions held in large groups were not

successful and were too lengthy and the productivity can be

increased in small group discussions where all can actively

participate. Furthermore if the feed back is obtained after the

discussion, the productivity will be increased. Another request was

to give printed study materials in Sinhala which would make it

easier for them to understand. According to them in some settings

people are still unaware of the project as expected.

Amongst the common views and suggestions which came up from

all the participants was that the training on prevention of tobacco

and alcohol was inadequate. They also believed that there should

be more emphasis on mental health issues.

The main obstacle that everyone felt was the difficulty to change

the attitudes of people. A monetary incentive to the participants


9 29

was identified as not feasible as the sustainability of such an offer

was at question.

9.5.2 IMPACT OF THE TOT PROGRAMME

A. EFFECT OF NCD DUTIES AND RESPONSIBILITIES ONOVERALL JOBPERFORMANCE

Figure 9 10: Performance of the subordinates

following the implementation of the

programme

Majority of the steering committee members

agreed that the performance of their

subordinates have improved since the

implementation of the HLS programme in their

settings. Majority of the favorable responses

were from the schools (Figure 9 10).

B. POST TOT ACTIVITIES IN THE SETTINGS

Implementation of projects by the trainers following the training

programme at the settings has effectively taken place at schools and

workplaces. Although the Hospital / MOH setting has the lowest rate of

implementation (89%),

the number of respondents from this setting was the highest (n=23,

66%). There were only two respondents from the workplace setting

(Figure 9 11).

Majority of the settings have had at least one programme on healthy life

style. Most of them have been on healthy diet.

18%

9%

64%

0%

9%

0

10

20

30

40

50

60

70

Not Applicable No Change Better

performance

Worse

performance

I don't know

Percentage%

100%

100%

89%

93%

82 84 86 88 90 92 94 96 98 100

School

Working Places

MOH/Hospital

Total

Percentage %

FIGURE 9 11: IMPLEMENTATION OF NEW PROJECTS USING

KNOWLEDGE FROMWORKSHOP

6 %

18 %

12 %

18 %

24 %

53 %

35 %

0 10 20 30 40 50 60

None

Behavioral Change

Communication

Life Skills

Stress Management

Tobacco & Alcohol

Diet

Exercise

Percentage %

FIGURE 9 12: PROGRAMMES ON “HLS” ORGANIZED IN THE

COMMUNITY UNDER EACH TOPIC


9 30

The initiative for these

was taken mostly by the

trainers who participated

for the TOT programme

( FIGURE 9 13 ) Steering

committee members have

also taken the initiative in

organizing a considerable

number of events.

C. ENVIRONMENT FOR

HEALTHY LIFESTYLE

Infrastructure and polices favoring a healthy life style proved to be

inadequate in most settings. Majority of the institutes did not have

adequate equipment for physical activities and more than 60% did not

have any specific time allocated for it (Figure 9 14).

Also most of the institutes had

fast food items to be sold at

their canteens ( Figure 9 15 ).

Only canteens from two schools

and one hospital did not have

any such items to be sold.

The Person in

charge

47%

Steering

committee

member

33%

Staff

20%

FIGURE 9 13: INITIATION FOR THE IMPLEMENTATION OF PROGRAMMS

62%(8)

7% (1)

8% (1)

43%(6)

31% (4)

7%(1) 43% (6)

0% 20% 40% 60% 80% 100%

Period allocated

Facilities

Percentages %

None Insufficient Neither

adequate or

insufficient

adequate

None Daily Irregularly

FIGURE 9 14: AVAILABILITY OF PHYSICAL RESOURCES AT THE INSTITUTION

25% (3)

42% (5)

25% (3)

8% (1)

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

None Few Neither few or

Many

Don’t Know

Percentage

%

FIGURE 9 15: AVAILABILITY OF FAST FOOD ITEMS AT THE

CANTEENS


9 31

9.5.3 SYSTEM TO FOLLOW UP PARTICIPANTS AT HIGH RISK

From among the people in the 4 settings whose baseline NCD conditions

were assessed previously and who were at high risk, a stratified random

sampling was conducted to generate a sample of 115 people (89 of whom

responded). The review was carried out with the use of an interviewer

administered questionnaire and a focus group discussion. The following

criteria were used to determine the people who were at high risk (total of

731 people at high risk):

Diagnosed to have hypertension or diabetes;

Systolic blood pressure of 130mmHg; and

Fasting blood sugar of at least 6.1 mmol/l.

A. VISITED AMEDICAL DOCTOR

Among the 89 respondents, only 28% of the respondents had met a

doctor following the referral. Highest rate of compliance was seen from

the school setting with 51%. None from the village setting have

complied with the referral. Less than 20% complied from workplaces and

MOH/hospitals.

74% of the people said that they were unaware that they should meet a

doctor. 6% had no time and 8% said that they thought it’s not important.

12% gave other reasons for the poor compliance.

B. HAVING NCD OR RISK FACTORS

Out of the referred individuals, 44% were diagnosed as having either

diabetes or hypertension.

Amongst the risk factors for NCD, limited physical activities and

unhealthy food patterns were the commonest (Figure 9 16 ).

C. CLINIC ATTENDANCE

Only 38% of the diagnosed patients attended clinics while 15% each

said either its not important or else that they have no time. 31% of

them gave other reasons for not attending the clinics.

0 5 10 15 20

Smoking

Alcohol

Limited Physical

Activities

Rice>3cups

Veg or Fruits <5 servings

Limited Stress Managing

activities

FIGURE 9 16: RISK FACTORS AMONGST THE HIGH RISK PARTICIPANTS

Documents

Resource Book III: NCD - JICA